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Mari G, Norton ME, Stone J, Berghella V, Sciscione AC, Tate D, Schenone MH. Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline #8: the fetus at risk for anemia--diagnosis and management. Am J Obstet Gynecol 2015; 212:697-710. [PMID: 25824811 DOI: 10.1016/j.ajog.2015.01.059] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We sought to provide evidence-based guidelines for the diagnosis and management of fetal anemia. METHODS A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through May 2014. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology was used for defining the strength of recommendations and rating the quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS We recommend the following: (1) middle cerebral artery peak systolic velocity (MCA-PSV) measured by ultrasound Doppler interrogation be used as the primary technique to detect fetal anemia; (2) amniotic fluid delta OD450 not be used to diagnosis fetal anemia; (3) MCA-PSV assessment be reserved for those patients who are at risk of having an anemic fetus (proper technique for MCA-PSV evaluation includes assessment of the middle cerebral artery close to its origin, ideally at a zero degree angle without angle correction); (4) if a fetus is deemed at significant risk for severe fetal anemia (MCA greater than 1.5 multiples of the median or hydropic), fetal blood sampling be performed with preparation for an intrauterine transfusion, unless the pregnancy is at a gestational age when the risks associated with delivery are considered to be less than those associated with the procedure; (5) if a fetus is deemed at significant risk for severe fetal anemia, the patient be referred to a center with expertise in invasive fetal therapy; (6) MCA-PSV be considered to determine the timing of a second transfusion in fetuses with anemia, and, alternatively, a predicted decline in fetal hemoglobin may be used for timing the second procedure; and (7) pregnancies with a fetus at significant risk for fetal anemia be delivered at 37-38 weeks of gestation unless indications develop prior to this time.
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Molad M, Waisman D, Rotschild A, Auslander R, Kessel I, Soloviechick M, Goldberg Y, Shabad E. Nonimmune hydrops fetalis caused by G6PD deficiency hemolytic crisis and congenital dyserythropoietic anemia. J Perinatol 2013; 33:490-1. [PMID: 23719252 DOI: 10.1038/jp.2012.116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We present a case of a female neonate who had a nonimmune hydrops fetalis and severe hemolytic anemia due to a rare combination of glucose-6-phosphate dehydrogenase (G6PD) deficiency and congenital dyserythropoietic anemia. We conclude that in severe cases with persistent anemia one should search after delivery for a second reason other than G6PD deficiency alone.
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Affiliation(s)
- M Molad
- Department of Neonatology, Carmel Medical Center and Faculty of Medicine, Technion-ITT, Haifa, Israel
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3
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Fermo E, Bianchi P, Notarangelo LD, Binda S, Vercellati C, Marcello AP, Boschetti C, Barcellini W, Zanella A. CDAII presenting as hydrops foetalis: molecular characterization of two cases. Blood Cells Mol Dis 2010; 45:20-2. [PMID: 20381388 DOI: 10.1016/j.bcmd.2010.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 02/05/2010] [Indexed: 11/16/2022]
Abstract
We report two patients with very severe congenital dyserythropoietic anemia presenting with hydrops foetalis, previously classified as "atypical" CDAs since they presented CDAII-like erythroblastic morphological features lacking other diagnostic CDAII markers. Molecular characterization of SEC23B gene, recently described as responsible of CDAII, revealed the presence of Glu109Lys/Arg701Cys and Glu109Lys/Cys66Tyr mutations, respectively. This finding leads to a re-classification of these cases and underlines phenotypic heterogeneity of CDAII, demonstrating for the first time that CDAII may be associated with hydrops foetalis and intrauterine death.
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Affiliation(s)
- Elisa Fermo
- UO Ematologia 2, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
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Abstract
Placental pathology continues to be an underutilized, undertaught, and inadequately handled surgical subspecialty. The requests for placental pathology are soaring, due partly to demands from obstetricians and to the litigious environment in which they practice, and to improved obstetrical care leading to pregnancies in medically challenging situations. Evaluation of the placenta requires a good understanding of the questions and issues concerning both the fetus/infant and the mother. Information from placental pathology can be critical in early neonatal care and in reproductive planning for the family, and it can provide risk assessment for neurologic outcome of the infant. A comfortable interaction among the obstetric staff, mothers, and pathologists often obviates need for legal intervention in unexpected pregnancy outcomes. Some critical pathologic features that involve maternal and fetal management are illustrated herein. A template for gross examination and a few critical histopathologic diagnostic features with clincopathologic correlation are included.
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Affiliation(s)
- Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02115, USA.
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Roberts DJ, Oliva E. Clinical significance of placental examination in perinatal medicine. J Matern Fetal Neonatal Med 2006; 19:255-64. [PMID: 16753764 DOI: 10.1080/14767050600676349] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Complete pathologic evaluation of the placenta provides valuable information for perinatal care for the obstetrician, neonatologist, pediatrician, and family. The histopathology of the placenta can answer specific questions about in utero insults, give insight into management of subsequent pregnancies, and provide an assessment of the newborn risk. Placental pathology has been a key litigious informant in inferring timing of insults. Despite these well known advantages of placental pathologic examination, it remains an under-utilized part of perinatal medicine. This stems from a historically under-taught part of surgical and autopsy pathology resulting in inadequate reporting. This review will focus on the utility of the placental examination for fetal and maternal well-being. This review will be restricted to singleton births.
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Affiliation(s)
- Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Abstract
The congenital dyserythropoietic anaemias (CDAs) are a heterogeneous group of diseases in which the anaemia is predominantly caused by dyserythropoiesis and marked ineffective erythropoiesis; three major (types I, II and III) and several minor subgroups have been identified. Additional information on the natural history of these conditions, the beneficial role of splenectomy in CDA type II and efficacy of interferon-alpha in type I have recently been reported. A disease gene has been localised to a chromosomal segment in the three major types and in CDA type I, a disease gene has been identified (CDANI). Mutations have been detected in both familial and sporadic cases but the predicted protein structure gives few clues as to its function. In both type I and II, there are cases unlinked to the identified localisations, suggesting genetic heterogeneity.
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Souka AP, Bower S, Geerts L, Huggon I, Nicolaides KH. Blackfan-Diamond anemia and dyserythropoietic anemia presenting with increased nuchal translucency at 12 weeks of gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2002; 20:197-199. [PMID: 12153674 DOI: 10.1046/j.1469-0705.2002.00753.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Blackfan-Diamond anemia is a congenital hypoplastic anemia with a birth prevalence of about 1 in 200,000, usually presenting in the first few months of life and commonly associated with cardiac, urogenital and digital anomalies. Congenital dyserythropoietic anemias are a group of rare congenital anemias characterized by ineffective erythropoiesis. We report on two cases of congenital fetal anemia, one with Blackfan-Diamond anemia and one with dyserythropoietic anemia, presenting with increased nuchal translucency at 12 weeks of gestation.
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Affiliation(s)
- A P Souka
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, Denmark Hill, London,UK
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Okajima K, Ito T, Wakita A, Suzuki Y, Nagahama M, Shamoto M, Eguchi M, Wada Y. Male siblings with dyserythropoiesis, microcephaly and intrauterine growth retardation. Clin Dysmorphol 2002; 11:107-11. [PMID: 12002139 DOI: 10.1097/00019605-200204000-00006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Male siblings with intrauterine growth retardation, hydrops, mild liver dysfunction, chronic diarrhoea, failure to thrive and microcephaly are reported. In both patients, the intrauterine growth retardation was detected in the second trimester of pregnancy. Relatively severe early onset neonatal jaundice, microcytosis, anisocytosis and abnormal iron metabolism were also seen. Bone marrow examination in the second sibling showed marked ringed sideroblasts and multilobulated erythroblasts in late developmental stages. The brain was very small with enlarged cerebrospinal fluid space, a reduced number of gyri and a thin cortex. The clinical and laboratory findings in these patients appear to be unique.
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Affiliation(s)
- K Okajima
- Department of Pediatrics, Nagoya City University Medical School, Mizuho Nagoya, Japan.
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Kato K, Sugitani M, Kawataki M, Ohyama M, Aida N, Koga N, Ijiri R, Imaizumi K, Kigasawa H, Tanaka Y, Itani Y. Congenital dyserythropoietic anemia type 1 with fetal onset of severe anemia. J Pediatr Hematol Oncol 2001; 23:63-6. [PMID: 11196275 DOI: 10.1097/00043426-200101000-00016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a patient with congenital dyserythropoietic anemia type 1 with characteristic anomalies and two novel clinicopathologic presentations: intrauterine onset of severe anemia resulting in cardiac failure and relatively mild dyserythropoietic features on bone marrow aspiration in contrast to severity of anemia. After repeated transfusions and a trial of erythropoietin administration, the patient died from respiratory infection at age 7 months. Autopsy revealed characteristic dyserythropoietic features of the bone marrow by light microscopy and electron microscopy, which confirmed a diagnosis of congenital dyserythropoietic anemia type 1.
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Affiliation(s)
- K Kato
- Division of Pathology, Kanagawa Children's Medical Center, Yokohama, Japan.
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Shalev H, Tamary H, Shaft D, Reznitsky P, Zaizov R. Neonatal manifestations of congenital dyserythropoietic anemia type I. J Pediatr 1997; 131:95-7. [PMID: 9255198 DOI: 10.1016/s0022-3476(97)70130-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Congenital dyserythropoietic anemia type I is a rare inherited bone marrow disorder characterised by macrocytic anemia with pathognomonic morphological ultrastructural features in erythroid precursors. The disease is usually not diagnosed in the neonatal period. In a retrospective study of 31 patients we found that 17 were first seen in the neonatal age with significant anemia (birth hematocrit 0.34 +/- 0.07); 14 of the 17 infants also had early jaundice. Six infants were small for gestational age and two had syndactyly. Although rare, congenital dyserythropoietic anemia type I should be considered in the differential diagnosis of neonatal anemia.
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MESH Headings
- Anemia, Dyserythropoietic, Congenital/blood
- Anemia, Dyserythropoietic, Congenital/classification
- Anemia, Dyserythropoietic, Congenital/diagnosis
- Anemia, Dyserythropoietic, Congenital/genetics
- Anemia, Dyserythropoietic, Congenital/pathology
- Anemia, Macrocytic/pathology
- Anemia, Neonatal/diagnosis
- Blood Transfusion
- Bone Marrow Diseases/blood
- Bone Marrow Diseases/genetics
- Bone Marrow Diseases/pathology
- Diagnosis, Differential
- Erythrocyte Indices
- Erythrocytes/pathology
- Erythroid Precursor Cells/pathology
- Erythroid Precursor Cells/ultrastructure
- Follow-Up Studies
- Hematocrit
- Humans
- Infant, Newborn
- Infant, Small for Gestational Age
- Jaundice, Neonatal/blood
- Jaundice, Neonatal/pathology
- Microscopy, Electron
- Reticulocyte Count
- Retrospective Studies
- Syndactyly/pathology
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Affiliation(s)
- H Shalev
- Division of Pediatrics, Soraka Medical Center, Beer Sheva, Israel
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Abstract
Hydrops fetalis is a morbid condition caused by a wide variety of fetal, placental, and maternal diseases. Mortality is high and depends on the gestational age at the time of occurrence and underlying etiology. Although the condition was described more than 300 years ago, recent advances in obstetric ultrasound, prenatal diagnostics have made it possible to differentiate various etiologies involved. It is also possible to treat some of these fetuses prenatally. In utero medical and surgical therapy is presently done in some centers. However, the majority of cases diagnosed remain untreatable. Early diagnosis of untreatable cases allows parents to make informed choices about subsequent management. Recent advances are covered in this review.
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Affiliation(s)
- I Forouzan
- Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, Philadelphia, USA
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13
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Abstract
The congenital dyserythropoietic anemias (CDAs) are a group of relatively rare inherited anemias that share in common ineffective erythropoiesis and morphologic abnormalities of mature red blood cells and their precursors. Three major types of CDA and a number of variants have been described. The diagnosis and categorization of these disorders are facilitated by microscopic examination of the blood and bone marrow and by serologic testing. Management of patients currently consists of observation and supportive care. Because patients with CDAs may be at significant risk for secondary hemochromatosis, they require monitoring for this condition. Splenectomy may be of benefit in certain cases in which the anemia is particularly severe. Over the past few years advances have been made in understanding the pathogenesis of these disorders, and it now appears that CDA II results from enzymatic defects in the cellular glycosylation pathway.
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MESH Headings
- Anemia, Dyserythropoietic, Congenital/classification
- Anemia, Dyserythropoietic, Congenital/diagnosis
- Anemia, Dyserythropoietic, Congenital/enzymology
- Anemia, Dyserythropoietic, Congenital/genetics
- Anemia, Dyserythropoietic, Congenital/therapy
- Blood Proteins/metabolism
- Carbohydrate Sequence
- Diagnosis, Differential
- Erythrocytes, Abnormal/metabolism
- Female
- Genes, Dominant
- Genes, Recessive
- Glycoproteins/metabolism
- Glycosylation
- Humans
- Infant, Newborn
- Male
- Mannosidases/deficiency
- Mannosidases/genetics
- Molecular Sequence Data
- N-Acetylglucosaminyltransferases/deficiency
- N-Acetylglucosaminyltransferases/genetics
- N-Acetylglucosaminyltransferases/metabolism
- Protein Processing, Post-Translational
- alpha-Mannosidase
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Affiliation(s)
- P W Marks
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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