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Prescott B, Jackson DE. Effective management of foetal anaemia in Rh(D) alloimmunised pregnant women with intrauterine transfusion: a Systematic Review. Hematol Transfus Cell Ther 2024; 46:289-299. [PMID: 38278670 DOI: 10.1016/j.htct.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/27/2023] [Accepted: 07/24/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Foetal anaemia is caused by a severe pregnancy complication, haemolytic disease of the foetus and newborn. Intrauterine transfusions (IUTs) are performed to treat foetal anaemia in alloimmunised pregnant women. If left untreated hydrops can develop thereby reducing the chance of survival. Survival rates have improved but the procedure is not without complications. Procedure-related complications can be associated with early gestational age, hence delaying IUT could improve outcomes. This review aims to determine the effectiveness and safety of IUTs by examining survival and mortality rates, procedure-related complications with associated foetal mortality and the influence of hydrops. STUDY DESIGN AND METHOD A systematic review was conducted by searching keywords in four scientific databases from January 2000 to April 2022. A meta-analysis was performed with the OpenMeta-Analyst software using an arcsine transformed proportion with the binary random-effects model and maximum likelihood method. RESULTS Fifteen studies were identified as eligible and used in the meta-analysis. The forest plots all showed statistically significant outcomes with heterogeneity of data. Results indicated a greater foetal survival rate with IUT to treat anaemic foetuses, a low foetal mortality rate, and low risk of procedure-related complications associated with foetal loss but a higher risk of foetal mortality when hydrops is present. CONCLUSION The findings of this systematic review and meta-analysis provide evidence that IUT is a safe and effective treatment for foetal anaemia in the absence of hydrops when experienced personnel perform the procedure to minimise the risk of procedure-related complications.
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Affiliation(s)
- Brittany Prescott
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Denise E Jackson
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia.
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2
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Ahmed M, Jackson DE. The role of measuring peak systolic velocity of the middle cerebral artery blood flow and anti-K1 titre during pregnancy to detect foetuses with severe anaemia, foetal hydrops, and the requirement of intrauterine transfusion: A systematic review and meta-analysis. Hematol Transfus Cell Ther 2024:S2531-1379(24)00035-X. [PMID: 38429195 DOI: 10.1016/j.htct.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 09/04/2023] [Accepted: 02/02/2024] [Indexed: 03/03/2024] Open
Abstract
The clinical manifestation of foetal anaemia caused by maternal Kell alloantibodies differs from that caused by non-Kell alloantibodies. Severe anaemia develops in the foetus in the early weeks of gestation; therefore, proper management and early intervention are important. A systematic review and meta-analysis was performed to determine whether the anti-K1 titre can determine the sequelae of Kell alloimmunised pregnancies. Prospective and retrospective cohort studies were used to conduct a systematic review following a comprehensive literature search, in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Studies were screened based on a defined set of inclusion and exclusion criteria. A total of 5143 potential articles were identified. Ten studies were used in the meta-analysis of pregnancy outcomes for a specific anti-K1 titre cut-off. The meta-analysis identified statistical significance for intrauterine transfusion (ARD: 0.351; 95 % CI: 0.593-0.109; p-value = 0.004), hydrops (ARD: 0.808; 95 % CI: 1.145-0.472; p-value <0.001), intrauterine foetal death (ARD: 0.938; 95 % CI:1.344 to -0.533; p-value <0.001) and intrauterine transfusion for Doppler middle cerebral artery >1.5 MoM (ARD: 0.381; 95 % CI:1.079 to -0.317; p-value = 0.285). It was concluded that there is no correlation between anti-K1 titre and Kell sensitised pregnancy outcomes, but monitoring the anti-K1 titre is important to manage the pregnancy and it helps clinicians determine the need for intrauterine transfusions. Doppler middle cerebral artery peak systolic velocity is strongly correlated with foetal anaemia and is an efficient routine method for determining the need for intrauterine transfusions in pregnancies affected by anti-K1.
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Affiliation(s)
- Mufleha Ahmed
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences-STEM College, RMIT University, Bundoora, Victoria, Australia
| | - Denise E Jackson
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences-STEM College, RMIT University, Bundoora, Victoria, Australia.
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3
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Crowe EP, Hasan R, Saifee NH, Bakhtary S, Miller JL, Gonzalez-Velez JM, Goel R. How do we perform intrauterine transfusions? Transfusion 2023; 63:2214-2224. [PMID: 37888489 DOI: 10.1111/trf.17570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Intrauterine transfusion (IUT) is an invasive but critical and potentially life-saving intervention for severe fetal anemia with demonstrated improvement in outcomes. The fetus is vulnerable to hemodynamic alterations and transfusion-related adverse events; therefore, special consideration must be given to blood component selection and modification. There is widespread IUT practice variability, and existing guidance primarily relies on expert opinion and single center experiences. STUDY DESIGN AND METHODS Experts in Maternal Fetal Medicine, Pediatric Hematology, and Transfusion Medicine from centers across the United States, collectively performing about 120 IUT annually, offer a multidisciplinary perspective on the performance of IUT and preparation of blood components. This perspective includes strategies for identifying an at-risk fetus, communicating between disciplines, determining the necessary blood volume, selecting and processing blood components, documenting the procedure in medical record, and managing the neonate. RESULTS Identifying an at-risk fetus relies on review of the clinical history, non-invasive monitoring, and laboratory evaluation. We recommend the use of relatively fresh, group O, cytomegalovirus-safe, freshly irradiated, red blood cells (RBC) that are Hemoglobin S negative and antigen-negative for any maternal antibody, if indicated. These RBC units should be concentrated to remove additives and increase the hematocrit thus minimizing fluctuations in fetal volume status. The units intended for IUT should be labeled clearly and the documentation of transfusion differentiated in the maternal medical record. DISCUSSION An awareness of the technical, logistical, and regulatory considerations for IUT performance will facilitate improved communication and patient care, especially when rare units of RBC are required.
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Affiliation(s)
- Elizabeth P Crowe
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rida Hasan
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Department of Laboratory Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Department of Laboratory Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jena L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Juan M Gonzalez-Velez
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Ruchika Goel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Corporate Medical Affairs, Vitalant, Scottsdale, Arizona, USA
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de Winter DP, Kaminski A, Tjoa ML, Oepkes D, Lopriore E. Hemolytic disease of the fetus and newborn: rapid review of postnatal care and outcomes. BMC Pregnancy Childbirth 2023; 23:738. [PMID: 37853331 PMCID: PMC10583489 DOI: 10.1186/s12884-023-06061-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Advances in postnatal care for hemolytic disease of the fetus and newborn (HDFN) have occurred over the past decades, but little is known regarding the frequency of postnatal treatment and the clinical outcomes of affected neonates. Most studies reporting on HDFN originate from high-income countries or relatively large centers, but important differences between centers and countries may exist due to differences in prevalence and available treatment options. We therefore aimed to evaluate the postnatal treatment landscape and clinical outcomes in neonates with Rhesus factor D (Rh(D))- and/or K-mediated HDFN and to provide recommendations for future research. METHODS We conducted a rapid literature review of case reports and series, observational retrospective and prospective cohort studies, and trials describing pregnancies or children affected by Rh(D)- or K-mediated HDFN published between 2005 and 2021. Information relevant to the treatment of HDFN and clinical outcomes was extracted. Medline, ClinicalTrials.gov and EMBASE were searched for relevant studies by two independent reviewers through title/abstract and full-text screening. Two independent reviewers extracted data and assessed methodological quality of included studies. RESULTS Forty-three studies reporting postnatal data were included. The median frequency of exchange transfusions was 6.0% [interquartile range (IQR): 0.0-20.0] in K-mediated HDFN and 26.5% [IQR: 18.0-42.9] in Rh(D)-mediated HDFN. The median use of simple red blood cell transfusions in K-mediated HDFN was 50.0% [IQR: 25.0-56.0] and 60.0% [IQR: 20.0-72.0] in Rh(D)-mediated HDFN. Large differences in transfusion rates were found between centers. Neonatal mortality amongst cases treated with intrauterine transfusion(s) was 1.2% [IQR: 0-4.4]. Guidelines and thresholds for exchange transfusions and simple RBC transfusions were reported in 50% of studies. CONCLUSION Most included studies were from middle- to high-income countries. No studies with a higher level of evidence from centers in low-income countries were available. We noted a shortage and inconsistency in the reporting of relevant data and provide recommendations for future reports. Although large variations between studies was found and information was often missing, analysis showed that the postnatal burden of HDFN, including need for neonatal interventions, remains high. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2021 CRD42021234940. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021234940 .
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Affiliation(s)
- Derek P de Winter
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.
| | - Allysen Kaminski
- OPEN Health, Bethesda, MD, USA (Currently The George Washington University, Washington, DC, USA
| | | | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
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Ghesquière L, Leroy J, Deken V, Tournier A, Vaast P, Subtil D, Delsalle A, Alluin G, Garabedian C, Houfflin-Debarge V. Anti-RH1 alloimmunization: At what maternal antibody threshold is there a risk of severe fetal anemia? Transfusion 2023; 63:629-637. [PMID: 36734370 DOI: 10.1111/trf.17264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 12/16/2022] [Accepted: 12/27/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND To define a threshold of maternal antibodies at risk of severe fetal anemia in patients followed for anti-RH1 alloimmunization (AI). STUDY, DESIGN, AND METHODS We conducted a retrospective study of patients followed for anti-RH1 AI at the Lille University Hospital. The first group, severe anemia, included patients who received one or more in utero transfusions (IUT) or who were induced before 37 weeks of pregnancy for suspected severe fetal anemia. The second group, absence of severe anemia, corresponded to patients without intervention during pregnancy related to AI. Sensitivities, specificities, and positive and negative predictive values for screening for severe fetal anemia were calculated for the antibody thresholds of 3.5 and 5 IU/ml for the quantification. RESULTS Between 2000 and 2018, 207 patients were included 135 in the severe anemia group and 72 in the no severe anemia group. No severe anemia was observed for an antibody titer below 16. For an antibody threshold of 3.5 IU/ml, the sensitivity was 98.2%, with 30.2% false positives. All severe anemias were detected in the second trimester; two cases of severe anemia were not detected in the third trimester. For an antibody threshold of 5 IU/ml, the sensitivity was lower at 95.6%, with five cases of severe anemia not detected. CONCLUSION The antibody threshold of 3.5 IU/ml for the quantification and 16 for the titration allow targeting patients requiring close monitoring by an experienced team in case of anti-RH1 AI.
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Affiliation(s)
- Louise Ghesquière
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ. Lille, CHU Lille, ULR 2694 - METRICS - Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Julie Leroy
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
| | - Valérie Deken
- Univ. Lille, CHU Lille, ULR 2694 - METRICS - Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
- Department of Biostatistics, CHU Lille, Lille, France
| | - Alexane Tournier
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
| | - Pascal Vaast
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
| | - Damien Subtil
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ. Lille, CHU Lille, ULR 2694 - METRICS - Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Anne Delsalle
- French Blood Establishment, Nord Pas de Calais, France
| | | | - Charles Garabedian
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ. Lille, CHU Lille, ULR 2694 - METRICS - Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Véronique Houfflin-Debarge
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ. Lille, CHU Lille, ULR 2694 - METRICS - Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
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de Winter DP, Kaminski A, Tjoa ML, Oepkes D. Hemolytic disease of the fetus and newborn: systematic literature review of the antenatal landscape. BMC Pregnancy Childbirth 2023; 23:12. [PMID: 36611144 PMCID: PMC9824959 DOI: 10.1186/s12884-022-05329-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/21/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Prevention of pregnancy-related alloimmunization and the management of hemolytic disease of the fetus and newborn (HDFN) has significantly improved over the past decades. Considering improvements in HDFN care, the objectives of this systematic literature review were to assess the prenatal treatment landscape and outcomes of Rh(D)- and K-mediated HDFN in mothers and fetuses, to identify the burden of disease, to identify evidence gaps in the literature, and to provide recommendations for future research. METHODS We performed a systematic search on MEDLINE, EMBASE and clinicaltrials.gov. Observational studies, trials, modelling studies, systematic reviews of cohort studies, and case reports and series of women and/or their fetus with HDFN caused by Rhesus (Rh)D or Kell alloimmunization. Extracted data included prevalence; treatment patterns; clinical outcomes; treatment efficacy; and mortality. RESULTS We identified 2,541 articles. After excluding 2,482 articles and adding 1 article from screening systematic reviews, 60 articles were selected. Most abstracted data were from case reports and case series. Prevalence was 0.047% and 0.006% for Rh(D)- and K-mediated HDFN, respectively. Most commonly reported antenatal treatment was intrauterine transfusion (IUT; median frequency [interquartile range]: 13.0% [7.2-66.0]). Average gestational age at first IUT ranged between 25 and 27 weeks. weeks. This timing is early and carries risks, which were observed in outcomes associated with IUTs. The rate of hydrops fetalis among pregnancies with Rh(D)-mediated HDFN treated with IUT was 14.8% (range, 0-50%) and 39.2% in K-mediated HDFN. Overall mean ± SD fetal mortality rate that was found to be 19.8%±29.4% across 19 studies. Mean gestational age at birth ranged between 34 and 36 weeks. CONCLUSION These findings corroborate the rareness of HDFN and frequently needed intrauterine transfusion with inherent risks, and most births occur at a late preterm gestational age. We identified several evidence gaps providing opportunities for future studies.
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Affiliation(s)
- Derek P. de Winter
- grid.508552.fDepartment of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands ,grid.417732.40000 0001 2234 6887Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Allysen Kaminski
- OPEN Health, Bethesda, MD USA ,grid.253615.60000 0004 1936 9510Present address: The George Washington University, Washington, DC, USA
| | - May Lee Tjoa
- grid.497530.c0000 0004 0389 4927Janssen Pharmaceuticals, Raritan, NJ USA
| | - Dick Oepkes
- grid.10419.3d0000000089452978Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, K-06-35, PO Box 9600, Leiden, 2300 RC The Netherlands
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Riordan SL, Ryan GA, Cathcart B, Hughes H, Higgins S, Fitzgerald J, Corcoran S, Walsh J, Mahony R, Carroll S, Mcauliffe FM, Mcparland P. The Rate of Decline in Fetal Hemoglobin following Intrauterine Blood Transfusion in the Management of Red Cell Alloimmunization. Eur J Obstet Gynecol Reprod Biol 2022; 271:93-96. [DOI: 10.1016/j.ejogrb.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/31/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
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Yu M, Tang T, Zheng R, Situ M, Feng J. A comparative study on perinatal outcomes of red blood cell-alloimmunized pregnancies with anti-RhD in combination and anti-RhD alone in China. Vox Sang 2021; 117:268-274. [PMID: 34111300 DOI: 10.1111/vox.13161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 05/05/2021] [Accepted: 05/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES The advent of intrauterine transfusion (IUT) has improved the survival of severe foetal anaemia. The aim of this study was to compare the perinatal outcomes of red blood cell (RBC)-alloimmunized pregnancies with anti-RhD in combination and anti-RhD alone in China. MATERIALS AND METHODS A retrospective study was conducted involving RBC-alloimmunized pregnancies with anti-RhD in combination and anti-RhD alone admitted to The First Affiliated Hospital, Sun Yat-sen University, between January 2007 and December 2019. Obstetric data and neonatal outcomes were compared. RESULTS A total of 165 alloimmunized pregnancies were identified, with 32 pregnancies in the anti-RhD-in-combination group (25 pregnancies with anti-RhD + anti-RhC and 7 pregnancies with anti-RhD + anti-RhE) and 133 pregnancies in the anti-RhD-alone group. The anti-RhD-in-combination group had significantly higher frequency of IUTs than the anti-RhD-alone group (59.4% [19/32] vs. 30.1% [40/133]; p < 0.01). The postnatal frequency of top-up transfusions was significantly higher in the anti-RhD in combination group than the anti-RhD-alone group (90.6% [29/32] vs. 70.7% [94/133]; p = 0.02). There was no significant difference in the frequency of exchange transfusions (ETs) between the two groups (15.6% [5/32] vs. 17.3% [23/133]; p = 0.82). CONCLUSIONS Compared to alloimmunized pregnancies with anti-RhD alone, pregnancies with anti-RhD in combination with anti-RhC or anti-RhE have an increased requirement for antenatal IUTs and postnatal top-up transfusions but do not have an increased need for ETs.
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Affiliation(s)
- Muxue Yu
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tonghui Tang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rujiang Zheng
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Miaoqiong Situ
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiali Feng
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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9
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Li S, He Z, Luo Y, Ji Y, Luo G, Fang Q, Gao Y. Distribution of maternal red cell antibodies and the risk of severe alloimmune haemolytic disease of the foetus in a Chinese population: a cohort study on prenatal management. BMC Pregnancy Childbirth 2020; 20:539. [PMID: 32938441 PMCID: PMC7493166 DOI: 10.1186/s12884-020-03235-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 09/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Haemolytic disease of the foetus and newborn (HDFN) is the most common aetiology of haemolytic anaemia and hyperbilirubinaemia in foetuses and neonates. Studies on the distribution of antibodies that cause haemolytic disease of the foetus (HDF) in China are limited, and the effects of multiple antibodies on the severity of HDF need further evaluation. METHODS An observational cohort study from January 2005 to December 2019 was conducted in two hospitals affiliated with Sun Yat-sen University. Maternal red cell alloimmunization was identified by the Guangzhou Blood Centre. In total, 268 pregnant woman-foetus pairs were divided into four groups according to the type of maternal alloantibodies: anti-D, anti-D combined with other antibodies, other single-antibody and other multiple antibodies. The obstetric history, antibody characteristics, incidence of severe HDF and foetal outcomes were collected and compared. Logistic regression analysis of the risk factors for HDF and survival analysis of the severe HDF-free interval were conducted. RESULTS Anti-D was the most common cause of HDF, followed by anti-M. No anti-K- or isolated anti-c-associated HDF was found. The incidence of severe HDF was higher in the group with anti-D combined with other antibodies than in the group with anti-D alone (P = 0.025), but no significant difference was found in haemoglobin level and reticulocyte count in the anaemic foetuses between these two groups. Foetuses in the other single-antibody group had a lower reticulocyte count (P = 0.007), more IUTs (P = 0.007) and an earlier onset of severe HDF (P = 0.012). The maximum antibody titre was significantly lower in the other single-antibody group than in the anti-D group (P < 0.001). A high maternal antibody titre (P < 0.001), multiple affected pregnancies (P < 0.001) and other single-antibody (P = 0.042) were independent risk factors for HDF. A higher reticulocyte count (P = 0.041) was an independent risk factor for severe HDF in anaemia foetuses affected by Rh(D) alloimmunization. CONCLUSIONS The distribution of HDF-associated antibodies in China is different from that in Western countries. Other single non-Rh(D) antibodies could increase the risk of HDF, and anti-D combined with other antibodies would not influence the severity of foetal anaemia compared with anti-D alone.
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Affiliation(s)
- Si Li
- Department of Obstetrics, the Sixth Affiliated Hospital of Sun Yat-sen University, 510655, Guangzhou, Guangdong, China
- Foetal Medicine Centre, Department of Obstetrics and Gynaecology, the First Affiliated Hospital of Sun Yat-sen University, Guangdong, 51000, Guangzhou, China
| | - Zhiming He
- Foetal Medicine Centre, Department of Obstetrics and Gynaecology, the First Affiliated Hospital of Sun Yat-sen University, Guangdong, 51000, Guangzhou, China
| | - Yanmin Luo
- Foetal Medicine Centre, Department of Obstetrics and Gynaecology, the First Affiliated Hospital of Sun Yat-sen University, Guangdong, 51000, Guangzhou, China
| | - Yanli Ji
- Insititute of Clinical Blood Transfusion, Guangzhou Blood Centre, 510095, Guangzhou, China
| | - Guangping Luo
- Insititute of Clinical Blood Transfusion, Guangzhou Blood Centre, 510095, Guangzhou, China
| | - Qun Fang
- Foetal Medicine Centre, Department of Obstetrics and Gynaecology, the First Affiliated Hospital of Sun Yat-sen University, Guangdong, 51000, Guangzhou, China.
| | - Yu Gao
- Department of Obstetrics, the Sixth Affiliated Hospital of Sun Yat-sen University, 510655, Guangzhou, Guangdong, China.
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10
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Castleman JS, Kilby MD. Red cell alloimmunization: A 2020 update. Prenat Diagn 2020; 40:1099-1108. [PMID: 32108353 DOI: 10.1002/pd.5674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 12/27/2022]
Abstract
Management of maternal red cell alloimmunization has been revolutionized over the last 60 years. Advances in the prevention, screening, diagnosis, and treatment of alloimmune-induced fetal anemia make this condition an exemplar for contemporary practice in fetal therapy. Since survival is now an expectation, attention has turned to optimization of long-term outcomes following an alloimmunized pregnancy. In this review, the current management of red cell alloimmunization is described. Current research and future directions are discussed with particular emphasis on later life outcomes after alloimmune fetal anemia.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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11
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Sun JB. The prenatal intervention of pregnancy complicated with anti-Kell isoimmunization: a review. J Matern Fetal Neonatal Med 2019; 34:2893-2899. [PMID: 31571493 DOI: 10.1080/14767058.2019.1671330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Since the first case of the hemolytic disease of the fetus and newborn (HDFN) caused by anti-K was reported in 1946, the fetal diagnosis of K-HDFN has made rapid progress from invasive immunological and biochemical tests to noninvasive Doppler ultrasound and molecular biology techniques. However, its treatment, especially prenatal intervention, has developed slowly compared with RhD-HDFN. This review attempts to clarify the current key points and explore the direction of the next phase by systematically reviewing the development of diagnosis and treatment of this disease, which involving multidisciplinary participation.
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Affiliation(s)
- Jun-Bo Sun
- Department of Blood Transfusion, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
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12
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Zwiers C, Oepkes D, Lopriore E, Klumper FJ, de Haas M, van Kamp IL. The near disappearance of fetal hydrops in relation to current state-of-the-art management of red cell alloimmunization. Prenat Diagn 2018; 38:943-950. [PMID: 30187936 PMCID: PMC6282502 DOI: 10.1002/pd.5355] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 11/16/2022]
Abstract
Objective In this study, we aim to evaluate trends in the condition of fetuses and neonates with hemolytic disease at the time of first intrauterine transfusion (IUT) and at birth, in relation to routine first‐trimester antibody screening, referral guidelines, and centralization of fetal therapy. Method We conducted a 30‐year cohort study including all women and fetuses treated with IUT for red cell alloimmunization at the Dutch national referral center for fetal therapy. Results Six hundred forty‐five fetuses received 1852 transfusions between 1 January 1987 and 31 December 2016. After the introduction of routine first‐trimester antibody screening, the hydrops rate declined from 39% to 15% (OR 0.284, 95% CI, 0.19‐0.42, P < 0.001). In the last time cohort, only one fetus presented with severe hydrops (OR 0.482, 95% CI, 0.38‐0.62, P < 0.001). Infants are born less often <32 weeks (OR 0.572, 95% CI, 0.39‐0.83, P = 0.004) and with higher neonatal hemoglobin (P < 0.001). Neonatal hemoglobin was positively independently associated with gestational age at birth, fetal hemoglobin, and additional intraperitoneal transfusion at last IUT. Conclusion Severe alloimmune hydrops, a formerly often lethal condition, has practically disappeared, most likely as a result of the introduction of routine early alloantibody screening, use of national guidelines, and pooling of expertise in national reference laboratories and a referral center for fetal therapy. What's already known about this topic?
Severe alloimmune hydrops is associated with impaired outcome on both the short term and the long term.
What does this study add?
With routine early alloantibody screening, national guidelines, and pooling of expertise in national reference laboratories and a referral center for fetal therapy, severe alloimmune hydrops has almost disappeared. Survival of hydrops cases no longer differs from hemolytic disease of the fetus and newborn cases without hydrops. Children treated with intrauterine transfusions are now in better condition at birth.
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Affiliation(s)
- Carolien Zwiers
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.,Immunohematology Diagnostic Services, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - Inge L van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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13
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Phung TV, Houfflin-Debarge V, Ramdane N, Ghesquière L, Delsalle A, Coulon C, Subtil D, Vaast P, Garabedian C. Maternal red blood cell alloimmunization requiring intrauterine transfusion: a comparative study on management and outcome depending on the type of antibody. Transfusion 2018; 58:1199-1205. [DOI: 10.1111/trf.14542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 01/11/2018] [Accepted: 01/13/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Thanh-Vy Phung
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
| | - Véronique Houfflin-Debarge
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
| | - Nassima Ramdane
- Department of Biostatistics; EA 2694, UDSL, CHU Lille; Lille France
| | - Louise Ghesquière
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
| | - Anne Delsalle
- Etablissement français du Sang, Nord Pas de Calais; France
| | - Capucine Coulon
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
| | - Damien Subtil
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
| | - Pascal Vaast
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
| | - Charles Garabedian
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille; Lille France
- Perinatal Environment and Growth; EA 4489, University of Lille North of France; Lille France
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14
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Zwiers C, van Kamp I, Oepkes D, Lopriore E. Intrauterine transfusion and non-invasive treatment options for hemolytic disease of the fetus and newborn – review on current management and outcome. Expert Rev Hematol 2017; 10:337-344. [DOI: 10.1080/17474086.2017.1305265] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Carolien Zwiers
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Inge van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Enrico Lopriore
- Divison of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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15
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Walsh CA, Doyle B, Quigley J, McAuliffe FM, Fitzgerald J, Mahony R, Higgins S, Carroll S, McParland P. Reassessing critical maternal antibody threshold in RhD alloimmunization: a 16-year retrospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:669-673. [PMID: 24706487 DOI: 10.1002/uog.13383] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/02/2014] [Accepted: 03/26/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine the critical maternal antibody threshold for specialist referral in cases of RhD alloimmunization. METHODS This was a retrospective cohort study, covering a 16-year period at the national tertiary fetal medicine center for management of alloimmunization. Data concerning RhD alloimmunized pregnant women were extracted from an institutional database and maternal anti-D antibody levels were cross-checked with the national reference laboratory. Fetal hemoglobin (Hb) levels were determined only at the first intrauterine transfusion (IUT) and were compared with the pretransfusion maternal anti-D antibody level (IU/mL). Sensitivity, specificity and positive and negative predictive values of maternal antibody thresholds for detecting moderate to severe (Hb ≤ 0.64MoM) fetal anemia were calculated. RESULTS Between 1996 and 2011, 66 women underwent a first IUT for RhD alloimmunization at our institution. The highest serum anti-D antibody level was extracted for 208 RhD alloimmunized women who did not require IUT during the last 10 years of the study period. The traditional maternal antibody threshold of > 15 IU/mL failed to detect 20% of cases of moderate to severe fetal anemia. The ≥ 4 IU/mL threshold had 100% sensitivity but a 45% false-positive rate. The optimal anti-D antibody threshold for specialist referral in our population was ≥ 6 IU/mL; at this level, no case of moderate to severe anemia was missed and specificity was 61%. Use of this threshold would have eliminated 10% of referrals to our fetal medicine unit without compromising fetal outcomes. CONCLUSIONS Setting the critical maternal RhD antibody level at >15 IU/mL does not provide sufficient sensitivity. The lower threshold of ≥ 4 IU/mL, though sensitive, is associated with a 45% false-positive rate. In our population, a threshold of ≥ 6 IU/mL minimizes false-positive referrals while maintaining 100% sensitivity for moderate to severe fetal anemia.
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Affiliation(s)
- C A Walsh
- Fetal Medicine Unit, National Maternity Hospital, Dublin, Ireland
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