Perinatal mortality in Rh alloimmunized patients

[Anti-D prophylaxis in fetal-maternal erythrocyte incompatibility in Tunisia]

Generalization of postnatal prophylaxis using anti-D immunoglobulins decreased the incidence of erythrocyte fetal-maternal incompatibility (EFMI) in the Rhesus system. Few recent studies have investigated the situation of anti-D prophylaxis in Tunisia and its effects on maternal and neonatal health. The aim of this study was therefore to analyze the situation of anti-D prophylaxis in Tunisia to detect defects and propose solutions. We conducted a retrospective descriptive study of IFME cases in the rhesus system in the Department of Medicine and Neonatal Resuscitation of the Tunis Maternity and Neonatology Center (CMNT) during an 8-year period from 1 January 2006 to 31 December 2015. We collected 51 cases of IFME. The prevalence of IFME was 3.4 per 10 000 live births; 41 % of the patients were transferred in utero and they were from the northwest of the country (17 %). The rate of women with a history of at least one spontaneous miscarriage (SCF) was 45 %. In 42 % of the cases, pregnancies were monitored at local clinics. The search for irregular agglutinins (RAI) was performed in 86 % of the women studied. RAI was positive in 97 % of the cases. Anti-D prophylaxis was correctly performed in only 27 % of the cases. The systematic prophylaxis of the third trimester and a systematic Kleihauer test must be combined with postpartum prophylaxis to better identify dysfunctions and improve the application of the recommendations.

Diagnosis of severe fetal anemia based on perinatal outcomes: a comparative analysis of the current reference values

Objectives. To compare current criteria for severe fetal anemia diagnosis. Methodology. A cohort study analyzed 105 alloimmunized fetuses that underwent cordocentesis due to risk of anemia. Concordance among the diagnostic criteria for severe fetal anemia, hemoglobin deficit >7 g/dL, hemoglobin deficit ≥5 g/dL, and hemoglobin concentration <0.55 MoM, was analyzed using Cohen's Kappa index. Perinatal mortality, fetal hydrops, and fetal acidosis were used to discuss discordances. Results. There was fair concordance among the three criteria analyzed: 0.80 (Kappa index, IC 95%: 0.67 to 0.93) when comparing hemoglobin deficit >7.0 g/dL and hemoglobin concentration <0.55 MoM criteria, 0.63 (Kappa index, IC 95%: 0.47 to 0.69) when comparing hemoglobin deficit ≥5.0 g/dL and hemoglobin deficit >7.0 g/dL reference, and 0.77 (Kappa index, IC 95%: 0.64 to 0.90) when comparing hemoglobin deficit≥5.0 g/dL and hemoglobin concentration <0.55 MoM standards. Eighteen cases were classified differently depending on the criteria used. The cut-off point of hemoglobin deficit ≥5 g/dL was the best criterion to discriminate fetuses with poor perinatal outcome in our study. Conclusions. Relevant discordances in classification of severe fetal anemia were pointed out. Some criteria may underestimate the real gravity of fetal anemia.

Predictive factors of perinatal mortality in transfused fetuses due to maternal alloimmunization: what really matters?

INTRODUCTION

Alloimmunization is the main cause of fetal anemia. There are not many consistent analyses associating antenatal parameters to perinatal mortality in transfused fetuses due to maternal alloimmunization. The study aimed to determine the prognostic variables related to perinatal death.

MATERIAL AND METHODS

A cohort study analyzed 128 fetuses treated with intrauterine transfusion (IUT), until the early neonatal period. Perinatal mortality was associated with prognostic conditions related to prematurity, severity of fetal anemia and IUT procedure by univariated logistic regression. Multiple logistic regression was used to compute the odds ratio (OR) for adjusting the hemoglobin deficit at the last IUT, gestational age at birth, complications of IUT, antenatal corticosteroid and hydrops.

RESULTS

Perinatal mortality rate found in this study was 18.1%. The hemoglobin deficit at the last IUT (OR: 1.26, 95% CI: 1.04-1.53), gestational age at birth (OR: 0.53, 95% CI: 0.38-0.74) and the presence of transfusional complications (OR: 5.43, 95% CI: 142-20.76) were significant in predicting fetal death.

CONCLUSION

Perinatal mortality prediction in transfused fetuses is not associated only to severity of anemia, but also to the risks of IUT and prematurity.