Challenges of Retained Thoracoamniotic Shunts in the Neonatal Period

Challenges of Retained Thoracoamniotic Shunts in the Neonatal Period | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF comment Challenges of Retained Thoracoamniotic Shunts in the Neonatal Period Alejandro Madurga, María Victoria Lopez-Canelada, María Velayos, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8397321/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 4 You are reading this latest preprint version Abstract Background Thoracoamniotic shunting (TAS) is a well-established fetal therapy for severe pleural effusions complicated by hydrops. Although survival in selected cases exceeds 60%, retained or migrated shunts can pose significant postnatal management challenges. Case presentation : We report a neonate with intrathoracic migration of a Somatex® shunt placed at 26 weeks’ gestation for hydropic pleural effusion. Although initially asymptomatic, the infant developed recurrent pleural effusions requiring multiple readmissions. Thoracoscopic retrieval on day 76 of life allowed safe removal despite dense adhesions, leading to complete clinical resolution. Discussion Retained thoracoamniotic shunts may remain asymptomatic or cause recurrent effusions, pneumothorax, or other complications. This case highlights the limitations of conservative management in the presence of clinical deterioration and supports timely surgical removal. Standardized criteria for intervention are lacking and urgently needed. Conclusion In infants with retained TAS, recurrence of effusions or respiratory compromise should prompt active removal. Thoracoscopic retrieval is a safe and effective minimally invasive option. Thoracoamniotic shunting fetal pleural effusion retained shunt shunt migration neonatal thoracoscopy recurrent pleural effusion minimally invasive surgery Figures Figure 1 Figure 2 1. Introduction Thoracoamniotic shunting (TAS) is an established fetal therapy for severe pleural effusions complicated by hydrops, aiming to decompress the thoracic cavity, promote lung development, and improve perinatal outcomes (1). Reported survival rates in appropriately selected hydropic fetuses exceed 60%, making TAS a life-saving intervention (2). Nevertheless, TAS carries inherent risks, including obstruction, occlusion, and migration, with intrathoracic displacement occurring in up to 20% of cases (3,4). Postnatally, retained or migrated shunts present a management dilemma. While many series advocate conservative observation in asymptomatic infants, serious complications such as recurrent effusions, pneumothorax, or hilar strangulation have been reported (5,6). Currently, there are no standardized guidelines for postnatal management, and practice varies considerably across centers. We present a neonate with intrathoracic migration of a Somatex® shunt, who developed recurrent pleural effusions necessitating thoracoscopic removal. This case highlights the clinical reasoning that justified active intervention and contributes to the ongoing debate regarding conservative versus surgical management of retained TAS. 2. Case Report A 26-year-old primigravida with no relevant medical history was noted at 21 + 6 weeks’ gestation to have a fetus with bilateral hydrothorax, more pronounced on the left. Fetal thoracentesis and amniodrainage were performed, and fluid analysis revealed a cloudy, yellow exudate with 2510 nucleated cells/mm³, exhibiting a marked neutrophilic predominance (94%, 2359/mm³), scarce lymphocytes (1%), and occasional macrophages (5%). QF PCR and array analysis were negative for CMV and B19 Parvovirus, without finding pathogenic mutations (PTPN11 negative). Serial ultrasounds demonstrated progression to hydrops at 26 + 2 weeks, prompting placement of a left-sided Somatex® shunt. Subsequently, pleural effusions improved, and at 39 + 3 weeks a full-term vaginal delivery occurred. Our Obstetrics department performed weekly ultrasounds remarking increasing polyhydramnios and diaphragmatic flattening, following with a full hydrops picture at 26 + 2 weeks. Although the were no signs of heart failure, after discussing the case in our prenatal surgery committee, due to worsening fetal condition and parental wishes to continue the pregnancy, we chose thoraco - amniotic shunt placement as the best option. In this scenario and according to our previous experiences, we decided to insert a left Somatex® shunt under ultrasound guidance. Follow up ultrasounds confirmed proper shunt placement and complete resolution of fetal hydrothorax. Weekly ultrasound evaluations after surgery were stablished to determine the proper placement and functioning of the shunt. We first had doubts about migration of the device just two weeks after the intervention at 29 + 6 weeks. However, at 30 + 4 weeks we found a stable right pleural effusion with minimal left effusion, dismissing shunt malfunction. At 37 + 4 weeks, pleural effusions were nearly resolved. Finally, at 39 + 3 weeks the baby was vaginally delivered, being a full-term newborn appropriate for gestational age. Weight: 3320 g (59th percentile), length: 51 cm (80th percentile), head circumference (HC): 35.8 cm (84th percentile) At birth, the shunt was not visible at the chest wall. Chest radiography confirmed intrathoracic migration. The neonate was stable, with only mild transient respiratory distress. Echocardiography was normal. Following two days of observation in the neonatal intensive care unit (NICU), the infant was discharged for outpatient follow-up. During the first two months, recurrent pleural effusions required drainage and two NICU readmissions. After the final episode, surgical removal was scheduled and performed one week later, on day 76 of life. The patient was placed in the right lateral decubitus position, and general anesthesia was induced. A monitor was placed over the patient’s head. We placed a 12mm camera port in the 5th intercostal space aligned with midaxillary line. Two additional 5mm ports were inserted following a proper triangular arrangement. Carbon dioxide insufflation of 4 mmHg was achieved through one irrigation channel of the ports. However, serious fibrous adhesions hindered identification of the TAS. We gently performed blunt adhesiolysis using a thoracoscopic instrument. After careful inspection of the thoracic cavity, we located the shunt outside the parenchyma lying on the oblique fissure and extracted it using an endoscopic grasping forceps inserted through the 5mm port. The removal of the device was conducted without any complications. Follow-up radiographs demonstrated the complete absence of the shunt, accompanied by satisfactory pulmonary re-expansion. The patient was discharged after a four-day hospitalization. Following discharge, the patient was monitored over a two-year period, during which regular control radiographs were performed. Throughout this follow-up period, there were no recurrent pleural effusions observed, nor was there any indication of the development of pulmonary pathologies. Consequently, it was determined that the patient could be discharged from our outpatient clinic. 3. Discussion Thoracoamniotic shunting has become an established prenatal intervention for large fetal pleural effusions, particularly when associated with hydrops, as it aims to restore cardiopulmonary physiology and prevent progressive pulmonary hypoplasia. Despite its widespread use, the postnatal management of retained thoracoamniotic shunts remains poorly standardized, largely due to the rarity of reported complications and the absence of prospective studies. Most available evidence derives from retrospective series and isolated case reports, resulting in heterogeneous recommendations regarding observation versus elective removal. Early neonatal outcomes after thoracoamniotic shunting can vary significantly, and assessing the initial postnatal findings is crucial for guiding further management. Variations in respiratory transition, the persistence or resolution of effusions, and the position of the shunt at birth all offer important insight into the effectiveness of the fetal intervention and the potential risk of subsequent complications. Insertion of a Somatex® thoracoamniotic shunt at 26 weeks’ gestation led to resolution of fetal hydrops and a favorable pregnancy course, resulting in term vaginal delivery. This outcome supports the efficacy of thoracoamniotic shunting (TAS) in selected cases, as previously reported with survival rates above 60% in hydropic fetuses (1,2). Although TAS offers significant benefits, it may also cause obstruction, occlusion, or migration, with intrathoracic migration occurring in up to 20% of cases (3,4). Even with the Somatex® shunt—designed to reduce displacement—migration can still occur. (5,6). In our case, postnatal imaging confirmed migration into the left hemithorax. The newborn was initially asymptomatic, justifying conservative management (3,4). However, two episodes of recurrent pleural effusion within the first two months indicated clinical deterioration, prompting surgical removal. Similar reports describe retained shunts causing persistent effusions, pneumothorax, or even hilar strangulation (7–9). Postnatal management strategies for retained intrathoracic shunts range from expectant observation in asymptomatic neonates to early surgical retrieval. Conservative management has traditionally been favored in clinically stable infants, based on earlier reports suggesting minimal long-term risk. However, this approach relies heavily on the assumption that retained devices remain inert. Increasing evidence challenges this assumption, as delayed complications may develop after an initial period of apparent stability, making exclusive reliance on early postnatal findings potentially misleading. Thoracoscopic removal was successfully performed despite dense adhesions. This approach is supported by increasing evidence showing that minimally invasive retrieval is both safe and effective, offering low morbidity and rapid recovery (7,10,11). Consistent with these findings, the patient remains asymptomatic with normal pulmonary development at two-year follow-up. This case contributes to the ongoing discourse regarding the optimal management of retained thoracoamniotic shunts (TAS). While earlier retrospective studies suggest that shunts can remain in place without long-term harm (3), more recent evidence highlights the risk of delayed complications, including recurrent effusions, pneumothorax, and life-threatening events associated with long-term device retention. Two perspectives are evident in the current literature. On one hand, large retrospective series suggest that retained intrathoracic shunts may remain in situ without adverse outcomes, with follow-up extending into early adulthood in some cases (3). On the other hand, more recent reports highlight the potential for delayed and unpredictable complications—including recurrent effusions, pneumothorax, and even life-threatening events—associated with long-term device retention (7–9). Our case supports the latter approach. Following the onset of recurrent pleural effusions, conservative management was no longer appropriate in our case and surgical removal led to complete clinical resolution. These findings emphasize the importance of timely surgical intervention in appropriately selected cases. Our case highlights that the postnatal course of infants with retained thoracoamniotic shunts can change rapidly, and that relying solely on initial stability may delay necessary treatment. Systematic follow-up with the use of predefined clinical and radiological checkpoints, would help detect early signs of deterioration and guide timely referral for removal. Developing standardized criteria for intervention based on accumulated clinical experience and reported complications would reduce variability between centers and support earlier, evidence-based decision-making. From a clinical perspective, the development of standardized postnatal surveillance protocols incorporating predefined clinical and radiological criteria could reduce variability between centers and facilitate earlier, evidence-based decision-making. Future research should focus on multicenter registries and long-term outcome studies to better define risk factors for delayed complications, clarify the optimal timing for elective removal, and establish consensus guidelines for postnatal management of retained thoracoamniotic shunts. 4. Conclusions Retained or migrated shunts pose complex postnatal management challenges. Conservative observation may suffice in some infants, but recurrence of effusions or other complications should prompt active removal. Thoracoscopic extraction offers a safe, minimally invasive, and definitive solution. Importantly, initial postnatal clinical stability does not preclude later deterioration, and delayed complications may arise after an apparently uneventful neonatal course. Our case highlights the need to develop standardized postnatal management guidelines, incorporating clinical and radiological follow-up criteria, that better identify which patients are most likely to benefit from early and proactive surgical intervention. Future multicenter studies and registries are warranted to refine risk stratification and optimize decision-making in this rare but clinically relevant setting. Abbreviations The following abbreviations are used in this manuscript: TAS Thoracoamniotic Shunting NICU Neonatal Intensive Care Unit Declarations Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. Institutional Review Board Statement The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Hospital Universitario La Paz (protocol code 2025.4537 at 20/05/2025).” for studies involving humans. Informed Consent Statement : Informed consent was obtained from all subjects involved in the study as well as written informed to publish this paper. Conflicts of Interest: The authors declare no conflicts of interest Funding: This research received no external funding Author Contribution A.M. conceptualized the study and wrote the main manuscript text. M.V.L.C. and M.V. contributed to patient management and data collection. C.D.T. participated in data interpretation and clinical follow-up. E.A.A. contributed to the prenatal and obstetric management of the case. J.L.E. provided senior surgical input and critically revised the manuscript. M.A.B. supervised the study, provided overall guidance, and critically reviewed the manuscript for important intellectual content. All authors reviewed and approved the final manuscript. References Sepulveda W, et al. Thoracoamniotic shunts for the management of fetal hydrothorax: a comparative review of Harrison, Rocket, and Somatex devices. Prenat Diagn. 2020. Imai K, Tano S, Fuma K, Matsuo S, Ushida T, Kajiyama H, et al. Impact of cytokine concentrations on long-term neurological outcomes in fetal pleural effusions managed with thoracoamniotic shunt. JMA J. 2025;8(1):288–92. Abbasi N, Windrim R, Keunen J, Seaward PGR, Van Mieghem T, Kelly EN, et al. Perinatal outcome in fetuses with dislodged thoraco-amniotic shunts. Fetal Diagn Ther. 2021;48(6):430–9. Chung MY, Leung WC, Tse WT, et al. The use of Somatex shunt for fetal pleural effusion: a cohort of 8 procedures. Fetal Diagn Ther. 2021;48:440–7. Tan APP, Tan B, Wright A, Kong JY. Management dilemma in thoracoamniotic shunt migrations. BMJ Case Rep. 2023;16:e255760. Chan VYT, Tse WT, Chan MC, Wong KKY, Leung WC, Leung TY. Pneumothorax associated with a displaced thoracoamniotic Somatex shunt in an infant with congenital pulmonary airway malformation: a case report. Hong Kong Med J. 2025;31(1):68–71. Sham GT, Chung PH, Chan IM, Leung WC, Wong KKY. Thoracoscopic removal of a displaced thoracoamniotic shunt in a newborn with antenatal pleural effusion: a case report. Transl Pediatr. 2020;9(5):702–6. Muta Y, Odaka A, Inoue S, Takeuchi Y, Beck Y. Thoracoscopic removal with fluoroscopic radiographic guidance of thoracoamniotic shunting catheters in newborns. Surg Today. 2022;52:1504–8. Law BH, Bratu I, Jain V, Landry MA. Refractory tension pneumothorax as a result of an internally displaced thoracoamniotic shunt in an infant with congenital pulmonary airway malformation. BMJ Case Rep. 2016;2016:bcr2016216324. Katsura D, Inatomi A, Tokoro S, Tsuji S, Murakami T. Catheter displacement into the amniotic cavity by fetal movement after thoracoamniotic shunting. Cureus. 2024;16(9):e70570. Muntean I, et al. The long-term outcome following thoracoamniotic shunting for congenital malformations. J Pediatr Surg. 2023;58(2):213–7 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 22 Dec, 2025 Editor assigned by journal 21 Dec, 2025 Submission checks completed at journal 21 Dec, 2025 First submitted to journal 18 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8397321","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"comment","associatedPublications":[],"authors":[{"id":562515999,"identity":"046f8b3f-51ca-4c79-941c-586d5592a31f","order_by":0,"name":"Alejandro 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1","display":"","copyAsset":false,"role":"figure","size":248166,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8397321/v1/15537014a2c1a630644735f6.png"},{"id":98780909,"identity":"df0182d2-97cf-4b0d-befa-0f6f606b2f94","added_by":"auto","created_at":"2025-12-22 12:31:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":568253,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8397321/v1/3b22262205422d9e224b0dd5.png"},{"id":98786130,"identity":"e5619de8-79f7-4cd1-b74b-fbe85dbaef0f","added_by":"auto","created_at":"2025-12-22 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Introduction","content":"\u003cp\u003eThoracoamniotic shunting (TAS) is an established fetal therapy for severe pleural effusions complicated by hydrops, aiming to decompress the thoracic cavity, promote lung development, and improve perinatal outcomes (1). Reported survival rates in appropriately selected hydropic fetuses exceed 60%, making TAS a life-saving intervention (2). Nevertheless, TAS carries inherent risks, including obstruction, occlusion, and migration, with intrathoracic displacement occurring in up to 20% of cases (3,4). Postnatally, retained or migrated shunts present a management dilemma. While many series advocate conservative observation in asymptomatic infants, serious complications such as recurrent effusions, pneumothorax, or hilar strangulation have been reported (5,6). Currently, there are no standardized guidelines for postnatal management, and practice varies considerably across centers. We present a neonate with intrathoracic migration of a Somatex\u0026reg; shunt, who developed recurrent pleural effusions necessitating thoracoscopic removal. This case highlights the clinical reasoning that justified active intervention and contributes to the ongoing debate regarding conservative versus surgical management of retained TAS.\u003c/p\u003e"},{"header":"2. Case Report","content":"\u003cp\u003eA 26-year-old primigravida with no relevant medical history was noted at 21\u0026thinsp;+\u0026thinsp;6 weeks\u0026rsquo; gestation to have a fetus with bilateral hydrothorax, more pronounced on the left. Fetal thoracentesis and amniodrainage were performed, and fluid analysis revealed a cloudy, yellow exudate with 2510 nucleated cells/mm\u0026sup3;, exhibiting a marked neutrophilic predominance (94%, 2359/mm\u0026sup3;), scarce lymphocytes (1%), and occasional macrophages (5%). QF PCR and array analysis were negative for CMV and B19 Parvovirus, without finding pathogenic mutations (PTPN11 negative).\u003c/p\u003e \u003cp\u003eSerial ultrasounds demonstrated progression to hydrops at 26\u0026thinsp;+\u0026thinsp;2 weeks, prompting placement of a left-sided Somatex\u0026reg; shunt. Subsequently, pleural effusions improved, and at 39\u0026thinsp;+\u0026thinsp;3 weeks a full-term vaginal delivery occurred.\u003c/p\u003e \u003cp\u003eOur Obstetrics department performed weekly ultrasounds remarking increasing polyhydramnios and diaphragmatic flattening, following with a full hydrops picture at 26\u0026thinsp;+\u0026thinsp;2 weeks. Although the were no signs of heart failure, after discussing the case in our prenatal surgery committee, due to worsening fetal condition and parental wishes to continue the pregnancy, we chose thoraco\u003cb\u003e-\u003c/b\u003eamniotic shunt placement as the best option. In this scenario and according to our previous experiences, we decided to insert a left Somatex\u0026reg; shunt under ultrasound guidance.\u003c/p\u003e \u003cp\u003eFollow up ultrasounds confirmed proper shunt placement and complete resolution of fetal hydrothorax. Weekly ultrasound evaluations after surgery were stablished to determine the proper placement and functioning of the shunt. We first had doubts about migration of the device just two weeks after the intervention at 29\u0026thinsp;+\u0026thinsp;6 weeks. However, at 30\u0026thinsp;+\u0026thinsp;4 weeks we found a stable right pleural effusion with minimal left effusion, dismissing shunt malfunction. At 37\u0026thinsp;+\u0026thinsp;4 weeks, pleural effusions were nearly resolved.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFinally, at 39\u0026thinsp;+\u0026thinsp;3 weeks the baby was vaginally delivered, being a full-term newborn appropriate for gestational age. Weight: 3320 g (59th percentile), length: 51 cm (80th percentile), head circumference (HC): 35.8 cm (84th percentile)\u003c/p\u003e \u003cp\u003eAt birth, the shunt was not visible at the chest wall. Chest radiography confirmed intrathoracic migration. The neonate was stable, with only mild transient respiratory distress. Echocardiography was normal. Following two days of observation in the neonatal intensive care unit (NICU), the infant was discharged for outpatient follow-up. During the first two months, recurrent pleural effusions required drainage and two NICU readmissions. After the final episode, surgical removal was scheduled and performed one week later, on day 76 of life.\u003c/p\u003e \u003cp\u003e The patient was placed in the right lateral decubitus position, and general anesthesia was induced. A monitor was placed over the patient\u0026rsquo;s head. We placed a 12mm camera port in the 5th intercostal space aligned with midaxillary line. Two additional 5mm ports were inserted following a proper triangular arrangement. Carbon dioxide insufflation of 4 mmHg was achieved through one irrigation channel of the ports. However, serious fibrous adhesions hindered identification of the TAS. We gently performed blunt adhesiolysis using a thoracoscopic instrument. After careful inspection of the thoracic cavity, we located the shunt outside the parenchyma lying on the oblique fissure and extracted it using an endoscopic grasping forceps inserted through the 5mm port.\u003c/p\u003e \u003cp\u003eThe removal of the device was conducted without any complications. Follow-up radiographs demonstrated the complete absence of the shunt, accompanied by satisfactory pulmonary re-expansion. The patient was discharged after a four-day hospitalization. Following discharge, the patient was monitored over a two-year period, during which regular control radiographs were performed. Throughout this follow-up period, there were no recurrent pleural effusions observed, nor was there any indication of the development of pulmonary pathologies. Consequently, it was determined that the patient could be discharged from our outpatient clinic.\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eThoracoamniotic shunting has become an established prenatal intervention for large fetal pleural effusions, particularly when associated with hydrops, as it aims to restore cardiopulmonary physiology and prevent progressive pulmonary hypoplasia. Despite its widespread use, the postnatal management of retained thoracoamniotic shunts remains poorly standardized, largely due to the rarity of reported complications and the absence of prospective studies. Most available evidence derives from retrospective series and isolated case reports, resulting in heterogeneous recommendations regarding observation versus elective removal.\u003c/p\u003e \u003cp\u003eEarly neonatal outcomes after thoracoamniotic shunting can vary significantly, and assessing the initial postnatal findings is crucial for guiding further management. Variations in respiratory transition, the persistence or resolution of effusions, and the position of the shunt at birth all offer important insight into the effectiveness of the fetal intervention and the potential risk of subsequent complications.\u003c/p\u003e \u003cp\u003eInsertion of a Somatex\u0026reg; thoracoamniotic shunt at 26 weeks\u0026rsquo; gestation led to resolution of fetal hydrops and a favorable pregnancy course, resulting in term vaginal delivery. This outcome supports the efficacy of thoracoamniotic shunting (TAS) in selected cases, as previously reported with survival rates above 60% in hydropic fetuses (1,2).\u003c/p\u003e \u003cp\u003eAlthough TAS offers significant benefits, it may also cause obstruction, occlusion, or migration, with intrathoracic migration occurring in up to 20% of cases (3,4). Even with the Somatex\u0026reg; shunt\u0026mdash;designed to reduce displacement\u0026mdash;migration can still occur. (5,6). In our case, postnatal imaging confirmed migration into the left hemithorax. The newborn was initially asymptomatic, justifying conservative management (3,4). However, two episodes of recurrent pleural effusion within the first two months indicated clinical deterioration, prompting surgical removal. Similar reports describe retained shunts causing persistent effusions, pneumothorax, or even hilar strangulation (7\u0026ndash;9).\u003c/p\u003e \u003cp\u003ePostnatal management strategies for retained intrathoracic shunts range from expectant observation in asymptomatic neonates to early surgical retrieval. Conservative management has traditionally been favored in clinically stable infants, based on earlier reports suggesting minimal long-term risk. However, this approach relies heavily on the assumption that retained devices remain inert. Increasing evidence challenges this assumption, as delayed complications may develop after an initial period of apparent stability, making exclusive reliance on early postnatal findings potentially misleading.\u003c/p\u003e \u003cp\u003eThoracoscopic removal was successfully performed despite dense adhesions. This approach is supported by increasing evidence showing that minimally invasive retrieval is both safe and effective, offering low morbidity and rapid recovery (7,10,11). Consistent with these findings, the patient remains asymptomatic with normal pulmonary development at two-year follow-up.\u003c/p\u003e \u003cp\u003eThis case contributes to the ongoing discourse regarding the optimal management of retained thoracoamniotic shunts (TAS). While earlier retrospective studies suggest that shunts can remain in place without long-term harm (3), more recent evidence highlights the risk of delayed complications, including recurrent effusions, pneumothorax, and life-threatening events associated with long-term device retention. Two perspectives are evident in the current literature. On one hand, large retrospective series suggest that retained intrathoracic shunts may remain in situ without adverse outcomes, with follow-up extending into early adulthood in some cases (3). On the other hand, more recent reports highlight the potential for delayed and unpredictable complications\u0026mdash;including recurrent effusions, pneumothorax, and even life-threatening events\u0026mdash;associated with long-term device retention (7\u0026ndash;9). Our case supports the latter approach. Following the onset of recurrent pleural effusions, conservative management was no longer appropriate in our case and surgical removal led to complete clinical resolution. These findings emphasize the importance of timely surgical intervention in appropriately selected cases.\u003c/p\u003e \u003cp\u003eOur case highlights that the postnatal course of infants with retained thoracoamniotic shunts can change rapidly, and that relying solely on initial stability may delay necessary treatment. Systematic follow-up with the use of predefined clinical and radiological checkpoints, would help detect early signs of deterioration and guide timely referral for removal. Developing standardized criteria for intervention based on accumulated clinical experience and reported complications would reduce variability between centers and support earlier, evidence-based decision-making.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, the development of standardized postnatal surveillance protocols incorporating predefined clinical and radiological criteria could reduce variability between centers and facilitate earlier, evidence-based decision-making. Future research should focus on multicenter registries and long-term outcome studies to better define risk factors for delayed complications, clarify the optimal timing for elective removal, and establish consensus guidelines for postnatal management of retained thoracoamniotic shunts.\u003c/p\u003e"},{"header":"4. Conclusions","content":"\u003cp\u003eRetained or migrated shunts pose complex postnatal management challenges. Conservative observation may suffice in some infants, but recurrence of effusions or other complications should prompt active removal. Thoracoscopic extraction offers a safe, minimally invasive, and definitive solution. Importantly, initial postnatal clinical stability does not preclude later deterioration, and delayed complications may arise after an apparently uneventful neonatal course. Our case highlights the need to develop standardized postnatal management guidelines, incorporating clinical and radiological follow-up criteria, that better identify which patients are most likely to benefit from early and proactive surgical intervention. Future multicenter studies and registries are warranted to refine risk stratification and optimize decision-making in this rare but clinically relevant setting.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eThe following abbreviations are used in this manuscript:\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"524\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracoamniotic Shunting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eDisclaimer/Publisher’s Note:\u003c/strong\u003e The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eInstitutional Review Board Statement\u003c/h2\u003e \u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Hospital Universitario La Paz (protocol code 2025.4537 at 20/05/2025).\u0026rdquo; for studies involving humans.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed Consent\u003c/strong\u003e \u003cb\u003eStatement\u003c/b\u003e: Informed consent was obtained from all subjects involved in the study as well as written informed to publish this paper.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e \u003cp\u003eThe authors declare no conflicts of interest\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research received no external funding\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.M. conceptualized the study and wrote the main manuscript text. M.V.L.C. and M.V. contributed to patient management and data collection. C.D.T. participated in data interpretation and clinical follow-up. E.A.A. contributed to the prenatal and obstetric management of the case. J.L.E. provided senior surgical input and critically revised the manuscript. M.A.B. supervised the study, provided overall guidance, and critically reviewed the manuscript for important intellectual content. All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSepulveda W, et al. Thoracoamniotic shunts for the management of fetal hydrothorax: a comparative review of Harrison, Rocket, and Somatex devices. Prenat Diagn. 2020.\u003c/li\u003e\n\u003cli\u003eImai K, Tano S, Fuma K, Matsuo S, Ushida T, Kajiyama H, et al. Impact of cytokine concentrations on long-term neurological outcomes in fetal pleural effusions managed with thoracoamniotic shunt. JMA J. 2025;8(1):288–92.\u003c/li\u003e\n\u003cli\u003eAbbasi N, Windrim R, Keunen J, Seaward PGR, Van Mieghem T, Kelly EN, et al. Perinatal outcome in fetuses with dislodged thoraco-amniotic shunts. Fetal Diagn Ther. 2021;48(6):430–9.\u003c/li\u003e\n\u003cli\u003eChung MY, Leung WC, Tse WT, et al. The use of Somatex shunt for fetal pleural effusion: a cohort of 8 procedures. Fetal Diagn Ther. 2021;48:440–7.\u003c/li\u003e\n\u003cli\u003eTan APP, Tan B, Wright A, Kong JY. Management dilemma in thoracoamniotic shunt migrations. BMJ Case Rep. 2023;16:e255760.\u003c/li\u003e\n\u003cli\u003eChan VYT, Tse WT, Chan MC, Wong KKY, Leung WC, Leung TY. Pneumothorax associated with a displaced thoracoamniotic Somatex shunt in an infant with congenital pulmonary airway malformation: a case report. Hong Kong Med J. 2025;31(1):68–71.\u003c/li\u003e\n\u003cli\u003eSham GT, Chung PH, Chan IM, Leung WC, Wong KKY. Thoracoscopic removal of a displaced thoracoamniotic shunt in a newborn with antenatal pleural effusion: a case report. Transl Pediatr. 2020;9(5):702–6.\u003c/li\u003e\n\u003cli\u003eMuta Y, Odaka A, Inoue S, Takeuchi Y, Beck Y. Thoracoscopic removal with fluoroscopic radiographic guidance of thoracoamniotic shunting catheters in newborns. Surg Today. 2022;52:1504–8.\u003c/li\u003e\n\u003cli\u003eLaw BH, Bratu I, Jain V, Landry MA. Refractory tension pneumothorax as a result of an internally displaced thoracoamniotic shunt in an infant with congenital pulmonary airway malformation. BMJ Case Rep. 2016;2016:bcr2016216324.\u003c/li\u003e\n\u003cli\u003eKatsura D, Inatomi A, Tokoro S, Tsuji S, Murakami T. Catheter displacement into the amniotic cavity by fetal movement after thoracoamniotic shunting. Cureus. 2024;16(9):e70570.\u003c/li\u003e\n\u003cli\u003eMuntean I, et al. The long-term outcome following thoracoamniotic shunting for congenital malformations. J Pediatr Surg. 2023;58(2):213–7\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Thoracoamniotic shunting, fetal pleural effusion, retained shunt, shunt migration, neonatal thoracoscopy, recurrent pleural effusion, minimally invasive surgery","lastPublishedDoi":"10.21203/rs.3.rs-8397321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8397321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThoracoamniotic shunting (TAS) is a well-established fetal therapy for severe pleural effusions complicated by hydrops. Although survival in selected cases exceeds 60%, retained or migrated shunts can pose significant postnatal management challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e: We report a neonate with intrathoracic migration of a Somatex® shunt placed at 26 weeks’ gestation for hydropic pleural effusion. Although initially asymptomatic, the infant developed recurrent pleural effusions requiring multiple readmissions. Thoracoscopic retrieval on day 76 of life allowed safe removal despite dense adhesions, leading to complete clinical resolution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRetained thoracoamniotic shunts may remain asymptomatic or cause recurrent effusions, pneumothorax, or other complications. This case highlights the limitations of conservative management in the presence of clinical deterioration and supports timely surgical removal. Standardized criteria for intervention are lacking and urgently needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn infants with retained TAS, recurrence of effusions or respiratory compromise should prompt active removal. Thoracoscopic retrieval is a safe and effective minimally invasive option.\u003c/p\u003e","manuscriptTitle":"Challenges of Retained Thoracoamniotic Shunts in the Neonatal Period","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 10:25:57","doi":"10.21203/rs.3.rs-8397321/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-22T16:16:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-22T01:18:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-22T01:18:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-18T15:11:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"940f05b9-99a6-4eff-b1ff-e1b2d804f28c","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T08:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 10:25:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8397321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8397321","identity":"rs-8397321","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}