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Jiandani F, Bhalerao A, Somalwar S, Chindhalore P, Jaiswal Y. Maternal isoimmunization associated fetal anemia: A case report. J Family Med Prim Care 2024; 13:2507-2510. [PMID: 39027853 PMCID: PMC11254084 DOI: 10.4103/jfmpc.jfmpc_1705_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 07/20/2024] Open
Abstract
Maternal isoimmunization occurs when a pregnant woman develops an immune reaction due to the inheritance of a red-cell antigen, which is paternally derived and can result in fetal anemia, hemolysis, fetal death, and hydrops fetalis as the antibodies might travel through the placenta and get adhered to the antigens present in the erythrocytes of the fetus. This report highlights a rare case of Rh isoimmunization leading to fetal anemia in a 26-year-old female and evaluates the impact of intrauterine transfusion (IUT) in terms of the gestational age at delivery along with the mode of delivery, procedural complications, and overall survival rate of the fetus. In conclusion, the most frequent cause of fetal anemia is Rh alloimmunization, which should be taken into consideration while making a differential diagnosis throughout the assessment. Improvements in IUT procedures and earlier detection of the MCA-PSV by Doppler ultrasonographic examination have also contributed to better results.
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Affiliation(s)
- Farah Jiandani
- Department of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India
| | - Anuja Bhalerao
- Department of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India
| | - Savita Somalwar
- Department of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India
| | - Prajakta Chindhalore
- Department of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India
| | - Yashika Jaiswal
- Department of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India
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Zamprakou A, Söderhult I, Ferm‐Widlund K, Ajne G, Johnson J, Herling L. Automated quantitative evaluation of fetal atrioventricular annular plane systolic excursion before and after intrauterine blood transfusion in pregnancies affected by red blood cell alloimmunization. Acta Obstet Gynecol Scand 2024; 103:313-321. [PMID: 37984405 PMCID: PMC10823390 DOI: 10.1111/aogs.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/15/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Maternal red blood cell alloimmunization during pregnancy can lead to hemolysis and various degrees of fetal anemia, which can be treated with intrauterine blood transfusion (IUT) to prevent adverse outcomes. Knowledge about fetal myocardial function and adaptation is limited. The aim of the present study was to measure fetal atrioventricular plane displacement before and after IUT and compare these measurements with previously established reference ranges. MATERIAL AND METHODS An observational study was conducted on pregnant women affected by red blood cell alloimmunization. Fetal echocardiography was performed before and after IUT. The atrioventricular plane displacement of the left and right ventricular walls and interventricular septum, described as mitral, septal, and tricuspid annular plane systolic excursion (MAPSE, SAPSE, and TAPSE, respectively), was assessed using color tissue Doppler imaging with automated analysis software. A Mann-Whitney U test was used to compare the z scores to the normal mean before and after IUT. RESULTS Twenty-seven fetuses were included. The mean z score for pre-IUT MAPSE was significantly increased compared with the reference ranges, +0.46 (95% confidence interval [CI] +0.17 to +0.75; p = 0.039), while the mean z scores for post-IUT SAPSE and TAPSE were significantly decreased, -0.65 (95% CI -1.11 to -0.19; p < 0.001) and -0.60 (95% CI -1.04 to -0.17; p = 0.003), respectively. The difference in atrioventricular plane displacement z scores before and after IUT was statistically significant in all three locations. The median difference between the pre-IUT and post-IUT z scores was -0.66 (95% CI -1.03 to -0.33, p < 0.001) for MAPSE, -1.05 (95% CI -1.43 to -0.61, p < 0.001) for SAPSE, and -0.60 (95% CI -1.19 to -0.01, p = 0.046) for TAPSE. CONCLUSIONS This study suggests that atrioventricular plane displacement, when determined using automated analysis software, may represent a quantitative parameter, describing fetal myocardial function and adaptation before and after IUT.
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Affiliation(s)
- Aikaterini Zamprakou
- Center for Fetal Medicine, Pregnancy Care and DeliveryKarolinska University HospitalStockholmSweden
- Division of Obstetrics and Gynecology, Department of Clinical Sciences, Intervention and Technology (CLINTEC)Karolinska InstitutetStockholmSweden
| | - Ingrid Söderhult
- Center for Fetal Medicine, Pregnancy Care and DeliveryKarolinska University HospitalStockholmSweden
| | - Kjerstin Ferm‐Widlund
- Center for Fetal Medicine, Pregnancy Care and DeliveryKarolinska University HospitalStockholmSweden
| | - Gunilla Ajne
- Division of Obstetrics and Gynecology, Department of Clinical Sciences, Intervention and Technology (CLINTEC)Karolinska InstitutetStockholmSweden
- Pregnancy Care and DeliveryKarolinska University HospitalStockholmSweden
| | - Jonas Johnson
- Center for Fetal Medicine, Pregnancy Care and DeliveryKarolinska University HospitalStockholmSweden
- Division of Obstetrics and Gynecology, Department of Clinical Sciences, Intervention and Technology (CLINTEC)Karolinska InstitutetStockholmSweden
| | - Lotta Herling
- Center for Fetal Medicine, Pregnancy Care and DeliveryKarolinska University HospitalStockholmSweden
- Division of Obstetrics and Gynecology, Department of Clinical Sciences, Intervention and Technology (CLINTEC)Karolinska InstitutetStockholmSweden
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董 淼, 姜 梅. [Clinical Efficacy and Nursing Care of Fetal Intrauterine Blood Transfusion: Previous Experience Review]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:843-847. [PMID: 37545084 PMCID: PMC10442628 DOI: 10.12182/20230760504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Indexed: 08/08/2023]
Abstract
Objective To summarize the clinical efficacy and nursing experience of intrauterine blood transfusion (IUT) treatment for fetal anemia cases. Methods The clinical data of 4 fetal anemia cases receiving IUT in Beijing Obstetrics and Gynecology Hospital, Capital Medical University between 2020 and 2022 were collected. Four pregnant women aged 24-38 years were included in the study. They carried fetuses with anemia of unknown causes. The four pregnant women developed anxiety after they were informed of the diagnosis of fetal anemia. One-on-one psychological counseling before the IUT procedure and one-on-one companionship over the course of the surgery were provided for the pregnant women. In addition, they were closely monitored for blood transfusion reactions. Postprocedural observation of the puncture site and 24-hour monitoring of the newborns were also conducted. Results The four pregnant women underwent 1-3 times of IUT in the second and third trimesters, with the minimum gestational age at the time of IUT being 25 + weeks and the blood transfusion volume being 20-107 mL/time. Two pregnant women experienced irregular uterine contractions during IUT in the third trimester. Other than that, all other IUT treatments were successful. After IUT, there was a significant improvement in fetal hemoglobin, peak systolic velocity of the middle cerebral artery (MCA-PSV), and cardiothoracic area ratio. One case did not give birth in our hospital and the outcome of the fetus was not known. The other three fetuses achieved good outcomes. Conclusion Positive preprocedural psychological counseling for pregnant women, close intraoprocedural and postprocedural pregnancy monitoring, and the prevention of maternal and fetal complications are the key to improving the clinical efficacy of IUT and achieving a good fetal outcome.
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Affiliation(s)
- 淼 董
- 首都医科大学附属北京妇产医院/北京妇幼保健院 特需门诊 (北京 100026)Specialist Consultation Outpatient Service, Beijing Obstetrics and Gynecology Hospital, Capital Medical University/Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - 梅 姜
- 首都医科大学附属北京妇产医院/北京妇幼保健院 特需门诊 (北京 100026)Specialist Consultation Outpatient Service, Beijing Obstetrics and Gynecology Hospital, Capital Medical University/Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
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Abstract
Rhesus incompatibility in pregnancy may result in haemolytic disease of the fetus and newborn (HDFN). This review discusses the fetal, neonatal and long-term consequences of HDFN and its management. Untreated, the fetal and neonatal prognosis of HDFN is poor. Provision of intravascular intrauterine transfusion (IUT) in a dedicated referral centre significantly reduces perinatal loss. Early-onset, severe fetal anaemia carries a greater risk of adverse fetal and neonatal outcomes and is less amenable to treatment with IUT. Interventions to prevent and treat severe, early onset disease have been investigated, however evidence from randomised controlled trials is required. Neonatal consequences of Rhesus haemolytic disease include early and late postnatal anaemia, and hyperbilirubinaemia leading to bilirubin-induced neurological dysfunction. Neurodevelopmental impairment and adult cardiovascular disease are long-term complications that have been reported in association with severe fetal anaemia. Strategies to prevent fetal hydrops, and further research into the long-term impacts of fetal anaemia may improve health outcomes for adult survivors of HDFN.
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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: 11] [Impact Index Per Article: 2.8] [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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Benavides A, Conrad AL, Brumbaugh JE, Magnotta V, Bell EF, Nopoulos P. Long-term outcome of brain structure in female preterm infants: possible associations of liberal versus restrictive red blood cell transfusions. J Matern Fetal Neonatal Med 2019; 34:3292-3299. [PMID: 31722594 DOI: 10.1080/14767058.2019.1683157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preterm infants who receive differential red blood cell (RBC) transfusions at birth may show brain structure differences across development, including abnormalities in white matter (WM) structure and organization. This study investigated long-term outcomes of brain structure in female infants born preterm, at an average age of 13 years old, who received red blood cell (RBC) transfusions in the neonatal period according to a liberal or restrictive approach. Results from this study will increase understanding of the effects of transfusion on the developing brain. STUDY DESIGN AND METHODS This follow-up study included female preterm infants who participated in a clinical trial and had been randomized at birth to either a liberal or restrictive hematocrit threshold. Brain structures were measured in childhood using structural magnetic resonance imaging (MRI) scans. Due to the low number of females in the restrictive transfusion group at follow-up, additional females were recruited for inclusion. Main outcome measures included cerebral and subcortical brain region volumes. RESULTS Total intracranial volume was significantly decreased in females who were randomized to higher average hematocrit levels at birth. Infants in the liberal transfusion group had proportionately smaller volumes in all measures of regional cerebral WM and subcortical brain volumes, reaching significance for temporal lobe WM and caudate volumes. CONCLUSION Female premature infants who received a liberal transfusion threshold at birth had decreased WM volumes, which suggests the potential long-term neurodevelopmental risks associated with liberal transfusion practices.
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Affiliation(s)
- Amanda Benavides
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Amy L Conrad
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Jane E Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Edward F Bell
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Peggy Nopoulos
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
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Anesthesia for predelivery procedures: ex-utero intrapartum treatment/intrauterine transfusion/surgery of the fetus. Curr Opin Anaesthesiol 2019; 32:291-297. [PMID: 31045636 DOI: 10.1097/aco.0000000000000718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the current literature on anesthesia for predelivery procedures and to summarize recent findings on anesthesiological methods used. RECENT FINDINGS Ex-utero intrapartum treatment (EXIT)-procedures are performed to secure the newborn's oxygenation in case of severe airway obstruction due to multiple conditions. A key feature of EXIT is continued intactness of the maternofetal circulation by uterine relaxation achieved by general anesthesia with high doses of anesthetic gases. A dose reduction may be achieved by combining inhaled anesthesia with propofol. After intrauterine transfusion the anesthesia team needs to be prepared for a potential need of emergency cesarean section. Temporary fetal endoluminal tracheal occlusion and laser coagulation for twin-to-twin transfusion syndrome may be either performed in monitored anesthesia care or neuraxial anesthesia. Neuraxial anesthesia also is a method of choice for fetal valvuloplasty and amniotic band release. Fetal myelomenigocele repair requires general anesthesia with tocolysis. SUMMARY Predelivery procedures require a differentiated anesthesia approach depending on the invasiveness of the intervention. Anesthesia ranges from monitored care to neuraxial anesthesia and general anesthesia. Depending on the procedure uterine relaxation and fetal immobilization are crucial for technical success. Interdisciplinary consultation optimizes the anesthesia plan for complex procedures.
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Prefumo F, Fichera A, Fratelli N, Sartori E. Fetal anemia: Diagnosis and management. Best Pract Res Clin Obstet Gynaecol 2019; 58:2-14. [PMID: 30718211 DOI: 10.1016/j.bpobgyn.2019.01.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
Fetal anemia has been known for many years as a dangerous complication of pregnancy. Its most common causes are maternal alloimmunization and parvovirus B19 infection, although it can be associated with many different pathological conditions including fetal aneuploidies, vascular tumors, and arteriovenous malformations of the fetus or placenta and inherited conditions such as alpha-thalassemia or genetic metabolic disorders. Doppler ultrasonographic assessment of the peak velocity of systolic blood flow in the middle cerebral artery for the diagnosis of fetal anemia and intravascular intrauterine transfusion for its treatment are the current practice standards. Live birth rates as high as 95% have been reported in recent years. The additional role of intravenous immunoglobulin therapy and the long-term consequences of the condition are the subjects of active ongoing research.
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Affiliation(s)
- Federico Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy.
| | - Anna Fichera
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
| | - Enrico Sartori
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
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Davis L, Musso J, Soman D, Louey S, Nelson JW, Jonker SS. Role of adenosine signaling in coordinating cardiomyocyte function and coronary vascular growth in chronic fetal anemia. Am J Physiol Regul Integr Comp Physiol 2018; 315:R500-R508. [PMID: 29791204 DOI: 10.1152/ajpregu.00319.2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fetal anemia causes rapid and profound changes in cardiac structure and function, stimulating proliferation of the cardiac myocytes, expansion of the coronary vascular tree, and impairing early contraction and relaxation. Although hypoxia-inducible factor-1α is sure to play a role, adenosine, a metabolic byproduct that increases coronary flow and growth, is implicated as a major stimulus for these adaptations. We hypothesized that genes involved in myocardial adenosine signaling would be upregulated in chronically anemic fetuses and that calcium-handling genes would be downregulated. After sterile surgical instrumentation under anesthesia, gestationally timed fetal sheep were made anemic by isovolumetric hemorrhage for 1 wk (16% vs. 35% hematocrit). At 87% of gestation, necropsy was performed to collect heart tissue for PCR and immunohistochemical analysis. Anemia increased mRNA expression levels of adenosine receptors ADORA 1, ADORA2A, and ADORA2B in the left and right ventricles (adenosine receptor ADORA3 was unchanged). In both ventricles, anemia also increased expression of ectonucleoside triphosphate diphosphohydrolase 1 and ecto-5'-nucleotidase. The genes for both equilibrative nucleoside transporters 1 and 2 were expressed more abundantly in the anemic right ventricle but were not different in the left ventricle. Neither adenosine deaminase nor adenosine kinase cardiac levels were significantly changed by chronic fetal anemia. Chronic fetal anemia did not significantly change cardiac mRNA expression levels of the voltage-dependent L-type calcium channel, ryanodine receptor 1, sodium-calcium exchanger, sarcoplasmic/endoplasmic reticulum calcium transporting ATPase 2, phospholamban, or cardiac calsequestrin. These data support local metabolic integration of vascular and myocyte function through adenosine signaling in the anemic fetal heart.
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Affiliation(s)
- Lowell Davis
- Center for Developmental Health, Oregon Health & Science University , Portland, Oregon.,Department of Obstetrics and Gynecology, Oregon Health & Science University , Portland, Oregon
| | - James Musso
- Center for Developmental Health, Oregon Health & Science University , Portland, Oregon
| | - Divya Soman
- Center for Developmental Health, Oregon Health & Science University , Portland, Oregon.,Knight Cardiovascular Institute, Oregon Health & Science University , Portland, Oregon
| | - Samantha Louey
- Center for Developmental Health, Oregon Health & Science University , Portland, Oregon.,Knight Cardiovascular Institute, Oregon Health & Science University , Portland, Oregon
| | - Jonathan W Nelson
- Knight Cardiovascular Institute, Oregon Health & Science University , Portland, Oregon
| | - Sonnet S Jonker
- Center for Developmental Health, Oregon Health & Science University , Portland, Oregon.,Knight Cardiovascular Institute, Oregon Health & Science University , Portland, Oregon
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Ree IMC, Smits-Wintjens VEHJ, van der Bom JG, van Klink JMM, Oepkes D, Lopriore E. Neonatal management and outcome in alloimmune hemolytic disease. Expert Rev Hematol 2017; 10:607-616. [DOI: 10.1080/17474086.2017.1331124] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Isabelle M. C. Ree
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
- Sanquin Blood Supply, Clinical Transfusion Research, Leiden, Zuid-Holland, The Netherlands
| | | | - Johanna G. van der Bom
- Sanquin Blood Supply, Clinical Transfusion Research, Leiden, Zuid-Holland, The Netherlands
| | | | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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