Pune: A 36-year-old woman with 27-weeks of pregnancy was admitted to the Fetal Medicine Department of a city-based hospital. The child was diagnosed with extralobar pulmonary sequestration (PS), which is a mass of non-functional lung tissue separate from the normal lung inside the pleural cavity and having a distinctive blood supply.
A large mass can often cause severe heart failure, hydrops (fluid accumulation in the foetus), mechanical compression on the heart and major blood vessels. It could result in stillbirth. With prompt intervention by doctors, the child was delivered through elective caesarean and is now healthy.
The pregnant women underwent a detailed foetal ultrasound evaluation, which revealed generalised swelling around the foetus with severe fluid accumulation around the left lung. The condition was severe enough to displace the heart of the child to the right side of the chest. The abnormality was diagnosed as extralobar pulmonary sequestration (PS).
Talking about the complexity of the case, Dr Bhupendra Avasthi, Founder and MD of the Surya Hospitals, said pulmonary lobectomy is surgical removal of the sequestrated lobe of the lung and it is a treatment of choice.
“The chance of survival in a preterm baby with a large PS is reported to be as low as 20 to 25 per cent. Most of them may not even survive to undergo definitive surgery. The family was explained about the prognosis for survival and long-term outcomes,” said Dr Avasthi.
He said there was an urgent need of drainage of the pleural fluid, which was considered necessary to relieve the mechanical compression of the heart and attempt to salvage the foetus in-utero for longer period of gestation.
“After a detailed joint consultation with the feto-maternal medicine specialist and the neonatology team, a shared decision for pleural fluid aspiration was undertaken and 90 ml of pleural fluid was tapped under ultrasound guidance. However, the pleural fluid re-accumulated within 24 hours of the foetal intervention. Hence, it was planned to deliver the infant by the caesarean section before further foetal compromise,” said Dr Avasthi.
He said a decision was made after a series of discussions over choosing the right procedure.
Dr Vandana Bansal, Director, Fetal Medicine Department, Surya Hospitals said the doctors zeroed down on repeating the procedure of pleural tapping just prior to delivery.
“We very carefully took this call in order to improve the neonatal resuscitative measures and provide time for the neonatal intubation and inter-costal drain placement,” said Dr Bansal.
The patient then underwent an elective caesarean delivery after a repeat procedure of pleural tapping.
The patient gave birth to a boy weighing 1.675 kg, of which 600 gms was estimated to be fluid related weight, with generalised swelling all over the body. The baby did not cry immediately after birth and was ventilated in the delivery room and immediately transferred to the neonatal intensive care unit (NICU) at the hospital, said Bansal.
Dr Nandkishor Kabra, Director NICU, Surya Hospitals said the infant required high frequency ventilation, surfactant and insertion of chest drains within the first 30 minutes of age to expand the lungs. “We conducted a CT scan of the chest as required to confirm the abnormality and also to establish the location and blood supply of the mass prior to surgery. After initial stabilisation in the NICU, the baby underwent surgery (thoracotomy) on the 8th day of life for resection of the sequestrated lung mass,” said Dr Kabra.
Dr Jui Mandke, Paediatric Surgeon, Surya Hospitals said the baby requires a timely thoracic operation with removal of the abnormal lobe of the lung.
“This requires a highly skilled, precise surgery because if the delicate blood vessels of the lobe get avulsed, there is a torrential blood loss, resulting in loss of life in such a precariously placed baby,” said Dr Mandke. At present, the infant’s growth is normal.
