Fetal Cardiac Collapse Diagnosed By Umbilical Venous Flow Volume After Thoraco-Amniotic Shunting for Severe Pleural Effusion

Abstract

Objective

Although thoraco-amniotic shunting (TAS) for severe pleural effusion is an effective fetal treatment, there are some cases in which it deteriorates, showing circulatory collapse. To evaluate the usefulness of umbilical venous blood flow volume (UVFV) for predicting deterioration, we analyzed the fetal low UVFV situation.

Methods

In 22 cases of fetal severe pleural effusion, we measured UVFV/fetal estimated birth weight (mL/minute/kg) prospectively before and after TAS by ultrasonography. We defined low UVFV/kg as < 50 mL/minute/kg (2.5 percentile) and compared subgroups based on their UVFV value and analyzed the outcome after birth.

Results

Total survival rate was 59% at 6 months. Seven cases in the low group before delivery (UVFV/kg 19.5) showed poor prognoses, such as fetal/neonatal death and longer neonatal intensive care unit management (100% vs. the normal UVFV group 40%, p = 0.017). The low group also showed umbilical artery absent end-diastolic velocity (71%); edema resolved in 50%, suggesting hypo inflow from the placenta and fetal hypocardiac output status, revealing fetal cardiac collapse.

Conclusion

UVFV analyses would be a new marker of fetal management of severe pleural effusion, suggesting low UVFV after TAS seems to be hypovolemic cardiac collapse and shows poor prognosis, and we had better consider immediate delivery to prevent death even after TAS.

Keywords

thoraco-amniotic shunting - fetal pleural effusion - hydrops fetalis - cardiac collapse - cardiac failure - UVFV - chylothorax - Frank–Starling's law

Data Available on Request from the Authors

The data that support the findings of this study are available from the corresponding author (Y.T.) upon reasonable request.

Publication History

Received: 28 June 2025

Accepted: 13 August 2025

Accepted Manuscript online:
08 September 2025

Article published online:
16 September 2025

• References

• 1 Rodeck CH, Fisk NM, Fraser DI, Nicolini U. Long-term in utero drainage of fetal hydrothorax. N Engl J Med 1988; 319 (17) 1135-1138
• 2 Longaker MT, Laberge JM, Dansereau J. et al. Primary fetal hydrothorax: natural history and management. J Pediatr Surg 1989; 24 (06) 573-576
• 3 Nicolaides KH, Azar GB. Thoraco-amniotic shunting. Fetal Diagn Ther 1990; 5 (3–4): 153-164
• 4 Deurloo KL, Devlieger R, Lopriore E, Klumper FJ, Oepkes D. Isolated fetal hydrothorax with hydrops: a systematic review of prenatal treatment options. Prenat Diagn 2007; 27 (10) 893-899
• 5 Rustico MA, Lanna M, Coviello D, Smoleniec J, Nicolini U. Fetal pleural effusion. Prenat Diagn 2007; 27 (09) 793-799
• 6 Takahashi Y, Ishii K, Ishikawa H, Imai K, Baba K, Sago H. National registry of thoracoamniotic shunting using a double-basket catheter: a post-marketing surveillance registry of 295 patients with fetal hydrothorax. Prenat Diagn 2024; 44 (08) 971-978
• 7 Takahashi Y, Kawabata I, Sumie M. et al. Thoracoamniotic shunting for fetal pleural effusions using a double-basket shunt. Prenat Diagn 2012; 32 (13) 1282-1287
• 8 NICE guidelines IPG 190.2006. Insertion of pleuro-amniotic shunt for fetal pleural effusion. National Institute for Health and Clinical Excellence: London.
• 9 Gill RW, Trudinger BJ, Garrett WJ, Kossoff G, Warren PS. Fetal umbilical venous flow measured in utero by pulsed Doppler and B-mode ultrasound. I. Normal pregnancies. Am J Obstet Gynecol 1981; 139 (06) 720-725
• 10 Acharya G, Wilsgaard T, Rosvold Berntsen GK, Maltau JM, Kiserud T. Reference ranges for umbilical vein blood flow in the second half of pregnancy based on longitudinal data. Prenat Diagn 2005; 25 (02) 99-111
• 11 Figueras F, Fernández S, Hernández-Andrade E, Gratacós E. Umbilical venous blood flow measurement: accuracy and reproducibility. Ultrasound Obstet Gynecol 2008; 32 (04) 587-591
• 12 Chiba Y, Kobayashi H, Kanzaki T, Murakami M. Quantitative analysis of cardiac function in non-immunological hydrops fetalis. Fetal Diagn Ther 1990; 5 (3–4): 175-188
• 13 Flo K, Wilsgaard T, Acharya G. Agreement between umbilical vein volume blood flow measurements obtained at the intra-abdominal portion and free loop of the umbilical cord. Ultrasound Obstet Gynecol 2009; 34 (02) 171-176
• 14 Gungor S, Glosemeyer P, Huber A, Hecher K, Baschat AA. Umbilical venous volume flow in twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2008; 32 (06) 800-806
• 15 Baschat AA, Gungor S, Glosemeyer P, Huber A, Hecher K. Changes in umbilical venous volume flow after fetoscopic laser occlusion of placental vascular anastomoses in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 2010; 203 (05) 479.e1-479.e6
• 16 DeVore GR, Horenstein J. Ductus venosus index: a method for evaluating right ventricular preload in the second-trimester fetus. Ultrasound Obstet Gynecol 1993; 3 (05) 338-342
• 17 Baschat AA, Güclü S, Kush ML, Gembruch U, Weiner CP, Harman CR. Venous Doppler in the prediction of acid-base status of growth-restricted fetuses with elevated placental blood flow resistance. Am J Obstet Gynecol 2004; 191 (01) 277-284
• 18 Huhta JC. Right ventricular function in the human fetus. J Perinat Med 2001; 29 (05) 381-389
• 19 Hofstaetter C, Hansmann M, Eik-Nes SH, Huhta JC, Luther SL. A cardiovascular profile score in the surveillance of fetal hydrops. J Matern Fetal Neonatal Med 2006; 19 (07) 407-413
• 20 Kiserud T, Ebbing C, Kessler J, Rasmussen S. Fetal cardiac output, distribution to the placenta, and impact of placental compromise. Ultrasound Obstet Gynecol 2006; 28 (02) 126-136