Use of Photoacoustic Imaging to Study the Effects of Anemia on Placental Oxygen Saturation in Normoxic and Hypoxic Conditions

We aimed to evaluate fetal and placental oxygen saturation (sO2) in anemic and non-anemic pregnant rats throughout gestation using photoacoustic imaging (PAI). Female Sprague-Dawley rats were fed an iron-restricted or iron-replete diet before and during pregnancy. On gestational days 13, 18, and 21, PAI was coupled with high resolution ultrasound to measure oxygenation of the fetus, whole placenta, mesometrial triangle, as well as the maternal and fetal faces of the placenta. PAI was performed in 3D, which allowed sO2 to be measured within an entire region, as well as in 2D, which enabled sO2 measurements in response to a hypoxic event in real time. Both 3D and 2D PAI were performed at varying levels of FiO2 (fraction of inspired oxygen). Iron restriction caused anemia in dams and fetuses, a reduction in fetal body weight, and an increase in placental weight, but overall had minimal effects on sO2. Reductions in FiO2 caused corresponding reductions in sO2 which correlated to the severity of the hypoxic challenge. Regional differences in sO2 were evident within the placenta and between the placenta and fetus. In conclusion, PAI enables non-invasive measurement of sO2 both rapidly and with a high degree of sensitivity. The lack of overt changes in sO2 levels between control and anemic fetuses may suggest reduced oxygen extraction and utilization in the latter group, which could be attributed to compensatory changes in growth and developmental trajectories.

An Exploratory Investigation into Optimal Indicators and Thresholds for Anemia Diagnosis Through Abdominal CT Plain Scans

Objective

This study aimed to assess the diagnostic utility and optimal thresholds of abdominal CT plain scans in identifying various degrees of anemia.

Methods

We included 40 participants in each of the mild, moderate, and severe anemia groups, totaling 120 participants, along with 40 healthy controls. We measured CT values of several abdominal structures, including the abdominal aorta (AA), inferior vena cava (IVC), liver, bilateral kidneys, spleen, and lumbar spinal cord (LSC), in both the normal and anemia groups. Additionally, we calculated the difference and ratio of CT values between AA and LSC and IVC and LSC. We analyzed the correlation between these parameters and hemoglobin (Hb) concentration. The most effective indicators and thresholds for diagnosing varying degrees of anemia using abdominal CT plain scans were identified.

Results

Significant differences were observed in hemoglobin concentration, CT values of AA, CT values of IVC, liver CT values, kidney CT values, and the ratios of CT values between AA and LSC, as well as IVC and LSC, among the four groups (P < .05). However, no significant differences were found in spleen CT values and CT values of LSC between the groups (P > .05). The CT values of AA, IVC, the ratios of AA to LSC, and IVC to LSC displayed significant positive linear correlations with hemoglobin concentration. Optimal thresholds for diagnosing mild, moderate, and severe anemia in AA were found to be 35.43, 33.2, and 30.2 HU, respectively, while for IVC, they were 34.18, 31.27, and 28.1 HU, respectively.

Conclusions

Among the various parameters obtained from abdominal CT plain scans, the CT value of the abdominal aorta demonstrated the highest diagnostic efficacy in distinguishing between different degrees of anemia.

Anaemia is associated with higher disease activity in axial spondyloarthritis but is not an independent predictor of spinal radiographic progression: data from the Swiss Clinical Quality Management Registry

OBJECTIVE

As anaemia represents a biomarker for increased radiographic damage in rheumatoid arthritis, we aimed to investigate whether it independently predicts spinal radiographic progression in axial spondyloarthritis (axSpA).

METHODS

AxSpA patients with available haemoglobin levels from the prospective Swiss Clinical Quality Management Registry were included for comparison of patients with and without anaemia. Spinal radiographic progression was assessed according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) in patients with ankylosing spondylitis (AS) if ≥ 2 sets of spinal radiographs were available every 2 years. The relationship between anaemia and progression (defined as an increase ≥ 2 mSASSS units in 2 years) was analysed with generalized estimating equation models after adjustment for the Ankylosing Spondylitis Disease Activity Score (ASDAS) and potential confounding, as well as after multiple imputations of missing values.

RESULTS

A total of 212/2522 axSpA patients presented with anaemia (9%). Anaemic patients had higher clinical disease activity, higher acute phase reactants and more severe impairments in physical function, mobility and quality of life. In the subgroup of patients with AS (N = 433), a comparable mSASSS progression was found in anaemic and non-anaemic patients (OR 0.69, 95% CI 0.25 to 1.96, p = 0.49). Age, male sex, baseline radiographic damage and ASDAS were associated with enhanced progression. The results were confirmed in complete case analyses and with progression defined as the formation of ≥ 1 syndesmophyte in 2 years.

CONCLUSION

Although anaemia was associated with higher disease activity in axSpA, it did not additionally contribute to the prediction of spinal radiographic progression. Key Points • Anaemia is associated with higher disease activity and more severely impaired physical function, mobility and quality of life in axSpA. • Anaemia does not provide an additional value to ASDAS for prediction of spinal radiographic progression.

Prediction of Anemia From Cerebral Venous Sinus Attenuation on Deep-Learning Reconstructed Brain Computed Tomography Images

OBJECTIVE

The aim of the study is to evaluate whether the prediction of anemia is possible using quantitative analyses of unenhanced cranial computed tomography (CT) with deep learning reconstruction (DLR) compared with conventional methods.

METHODS

This cross-sectional retrospective study included 116 participants (76 males; mean age, 66.7) who had hemoglobin (Hb) levels obtained within 24 hours of unenhanced cranial CT, which included 2 reconstruction methods: DLR and hybrid iterative reconstruction. Regions of interest were the confluence of sinuses (CoS) and the right and left transverse sinuses. In addition, edge rise distance of cerebrospinal fluid and venous was measured.

RESULTS

Spearman rank correlation coefficient demonstrated a positive association between Hb levels and sinus attenuation values. Among these, the CoS in DLR had the best correlation ( r = 0.703, P < 0.001). For the prediction of anemia (Hb < 11 g/dL), the area under the curve of CoS in DLR (area under the curve = 0.874; 95% confidence interval, 0.798-0.949; P < 0.001) was the highest; however, there were no significant differences among reconstruction method and sinus. The attenuation values of DLR were significantly higher than those of hybrid iterative reconstruction ( P < 0.001, paired t test), and the differences between the 2 methods were 4.1 (standard deviation [SD], 1.6) for CoS, 5.2 (SD, 2.2) for right transverse sinuses, and 5.8 (SD, 2.4) for left transverse sinuses. The signal-to-noise ratio ( P < 0.001, paired t test) and edge rise distance ( P < 0.001, Wilcoxon signed rank test) of DLR was significantly higher.

CONCLUSIONS

Higher CT attenuation values should be considered for predicting anemia based on brain DLR images.

Intrauterine Blood Transfusion for Parvo B19-Induced Fetal Anemia: Neuroimaging Findings and Long-Term Neurological Outcomes

INTRODUCTION

We aimed to evaluate the neuroimaging findings and long-term neurodevelopmental outcomes of fetuses and children following intrauterine blood transfusion (IUT) for parvo B19 infection-induced anemia compared to those with RBC alloimmunization.

METHODS

We conducted a retrospective cohort study including women who underwent an IUT due to fetal anemia between 2006 and 2019 in a tertiary, university-affiliated medical center. The cohort was divided into two groups: a study group - fetuses affected by congenital parvo B19 infection; and a control group - fetuses affected by RBC alloimmunization. Retrospective data such as antenatal sonographic evaluations, fetal brain MRI results, and short-term fetal and neonatal outcomes were collected. All children underwent a neurodevelopmental evaluation after birth using a Vineland questionnaire. Primary outcome was defined as the presence or absence of neurodevelopmental delay. Secondary outcome was defined as the presence of abnormal fetal neuroimaging findings such as cerebellar hypoplasia, polymicrogyria, intracranial hemorrhage, or severe ventriculomegaly.

RESULTS

Overall, 71 fetuses requiring at least one IUT were included in the study. Of these, 18 were affected by parvo B19 infection and 53 by RBC alloimmunization with various associated antibodies. Fetuses in the parvo B19 group presented at an earlier gestational age (22.91 ± 3.36 weeks vs. 27.37 ± 4.67 weeks, p = 0.002) and were more affected by hydrops (93.33% vs. 16.98%, p < 0.001). Three fetuses out of the 18 (16.67%) fetuses in the parvo B19 group died in utero following the IUT. Abnormal neuroimaging findings were detected in 4/15 (26.7%) of the parvo B19 survivors versus 2/53 (3.8%) of fetuses affected by RBC alloimmunization (p = 0.005). There was no difference in long-term neurodevelopmental delay rates between the children in the study and control groups, as assessed at the average age of 3.65 and 6.53 years, accordingly.

CONCLUSION

Fetal anemia due to parvo B19, treated with IUT, might be associated with increased rates of abnormal neurosonographic findings. The correlation between those findings and long-term adverse neurodevelopmental outcomes requires further investigation.

Fetal Cardiac Inflow Characteristics in Response to Fetal Anemia: Based on Fetal Hemoglobin Bart's Disease at Mid-Pregnancy

OBJECTIVES

To identify the inflow (filling time fraction [FTF] and E/A ratio) characteristics of fetuses with anemia, and to evaluate the performance of the inflow markers in predicting the affected fetuses.

METHODS

Fetuses at risk of hemoglobin (Hb) Bart's disease at 17-22 weeks were prospectively recruited to undergo echocardiography before diagnostic cordocentesis. Cardiac Doppler images were digitally stored for off-line blinded measurements of FTF and E/A ratio.

RESULTS

A total of 428 fetuses at risk of Hb Bart's disease were analyzed, including 88 affected fetuses (20.6%). The mean gestational age at the time of diagnosis was 19.43 ± 1.5 weeks. The FTFs in both sides were significantly lower in the affected fetuses, whereas the E/A ratios of both sides were significantly higher in the affected group. According to the receiver operating characteristic curves, the performance of the FTF of the right side in predicting affected fetuses was slightly better than that of the left side (area under curve: 0.707 versus 0.680, P < .001). Likewise, the performance of the E/A ratio of the tricuspid valve was slightly better than that of the mitral valve. Also, FTF was superior to E/A ratio in predicting the affected fetuses.

CONCLUSIONS

New insights leading to a better understanding of the fetal cardiac response to anemia are: 1) the FTFs in both sides were significantly decreased, suggesting some degree of diastolic ventricular dysfunction; 2) the E/A ratios of both sides were significantly increased, indicating volume load; and 3) The inflow parameters may be useful as a new predictor of fetal anemia, especially among pregnancies at risk.

Fetal Hemodynamic Response to Anemia in Early Gestation: Using Hemoglobin Bart's Disease as a Study Model

OBJECTIVE

 To assess fetal hemodynamic changes in response to anemia in early gestation, using fetal Hb Bart's disease as a study model.

METHODS

 A prospective study was conducted on pregnancies at risk for fetal Hb Bart's disease at 12-14 weeks of gestation. Fetal hemodynamics were comprehensively assessed by 2D ultrasound, Doppler velocity, and cardio-STIC just prior to the invasive procedure for diagnosis. The various hemodynamic parameters of the affected and unaffected fetuses were compared.

RESULTS

 Of 56 fetuses at risk, 17 had Hb Bart's disease and 39 were unaffected. The right and combined ventricular cardiac outputs (CO) were significantly higher in the affected fetuses (0.993 vs. 1.358; p < 0.001 and 1.010 vs. 1.236; p < 0.001, respectively), whereas the left CO tended to be higher but not significantly (1.027 vs. 1.113; p = 0.058). Cardiac dimensions, middle-cerebral artery peak systolic velocity, Tei index, and isovolemic contraction time were significantly increased, while the global sphericity index was significantly decreased. Interestingly, cardiac preload, ventricular wall thickness, shortening fraction, isovolemic relaxation time, and fetal heart rate were unchanged. Four fetuses had hydropic changes, but all cardiac functions were normal.

CONCLUSION

 Fetal anemia induces hypervolemia and increases cardiac output to meet the tissue oxygen requirement, resulting in an increase in size without hypertrophy, volume load without pressure load, and a decrease in the globular sphericity index. The heart works very well but works harder, especially systolic ventricular load. Hydrops fetalis due to anemia appears not to be caused by heart failure as previously believed but rather by volume load with high vascular permeability at least in early pregnancy.

Qualitative analysis of Doppler assessment used for surveillance of alloimmunized individuals

OBJECTIVES

To summarize image quality variables for alloimmunized women at risk for fetal anemia. To investigate the association between image quality with the highest and median middle cerebral artery peak systolic velocity (MCA-PSV) at the last visit and fetal anemia based on hemoglobin.

STUDY DESIGN

This study was a qualitative retrospective analysis of 192 Doppler ultrasound images used in the detection of fetal anemia in 26 alloimmunized women seen in a Minneapolis hospital over the past 3 years. Images were graded on seven criteria found in literature.

RESULTS

Of the images analyzed, 23 (12.0%) of the 192 met all seven image quality criteria. Using the highest MCA-PSV value, the sensitivity, and specificity were 55.6% and 94.1%, respectively. Using the median MCA-PSV value, the sensitivity, and specificity were 44.4% and 94.1%, respectively.

CONCLUSIONS

Only a minority of Doppler images meet all suggested image criteria. This could negatively impact the accuracy of the MCA-PSV measurements as indicated by the decreased sensitivity in our evaluations.

A Low-Cost Test for Anemia Using an Artificial Neural Network

BACKGROUND

Anemia during pregnancy can complicate maternal and neonatal health and even lead to fatal consequences if not diagnosed early on. Around 99% of women who face maternal mortality are from middle or low-income countries. Early screening of anemia could facilitate improved health outcomes in pregnant women. Point of care techniques are preferred due to their ability to provide results rapidly and because they can be used by personnel with minimal or no training. Such techniques are especially useful in resource-constrained settings like rural parts of developing countries.

OBJECTIVES

The aim of the study was to develop a tool using an Artificial Neural Network (ANN) to estimate hemoglobin values using color information recorded from blood sample images. Our method utilizes inexpensive consumables and a simple image acquisition setup that can be assembled easily.

METHODS

This study explores a neural network model to estimate the hemoglobin content in an individual's blood sample. Blood samples were collected from 86 volunteers and the images of blood drops were obtained using an image acquisition setup designed by the team. The color intensity values calculated from the blood drop images were used as feature descriptors for the samples. The features obtained from our samples were consequently fed to the Artificial Neural Network.

RESULTS

Our neural network that gives the best result has the architecture of 11 neurons in each of the 5 layers. The best model gave estimated hemoglobin levels by analyzing color of blood samples with an accuracy of ±1.8 g/dl Limits of agreement (LOA) and bias 0.03 g/dl (with mean error of 0.75 g/dl). The model was subsequently tested with a validation set prepared from an additional 65 samples. The estimated hemoglobin levels gave an accuracy of +2 g/dl to -1.9 g/dl Limits of agreement (LOA) and bias 0.06 g/dl (with mean error of 0.78 g/dl).

CONCLUSION

Optimization of sensitivity and specificity has been able to achieve the sensitivity and specificity values as 95.5% and 52% respectively. These results are at par with the contemporary measurement techniques indicating that our method can be used as a workable screening technique itself.

Low-dose CT from myocardial perfusion SPECT/CT allows the detection of anemia in preoperative patients

BACKGROUND

To assess whether low-dose CT for attenuation correction of myocardial perfusion single-photon emission computed tomography (SPECT) allows for identification of anemic patients and grading anemia severity.

METHODS AND RESULTS

Patients who underwent a preoperative blood-test and low-dose CT scan, as a part of a cardiac SPECT exam, between 01 January 2015 and 31 December 2017 were enrolled in this retrospective study. Hemoglobin (Hb) levels and hematocrit were derived from clinical records. CT images were visually assessed (qualitative analysis) for the detection of inter-ventricular septum sign (IVSS) and aortic rim sign (ARS) and quantitative analysis were performed. The diagnostic accuracy for detecting anemia was compared using Hb values as the standard of reference. A total of 229 patients were included (110 with anemia; 57 mild; 46 moderate; 7 severe). The AUC of IVSS and ARS were 0.830 and 0.669, respectively (p<0.0001). The quantitative analysis outperformed ARS and IVSS; (AUC of 0.893, p=0.29). The optimal anemia cut-off using Youden index was 4.5 HU.

CONCLUSION

Quantitative analysis derived from low-dose CT images, as a part of cardiac SPECT exams, have a diagnostic accuracy similar to that of hematocrit for the detection of anemia and may allow discriminating different anemia severities.

Association of Maternal and Child Anemia With Brain Structure in Early Life in South Africa

Importance

Anemia affects millions of pregnant women and their children worldwide, particularly in low- and middle-income countries. Although anemia in pregnancy is a well-described risk factor for cognitive development, the association with child brain structure is poorly understood.

Objective

To explore the association of anemia during pregnancy and postnatal child anemia with brain structure in early life.

Design, Setting, and Participants

This neuroimaging nested cohort study was embedded within the Drakenstein Child Health Study (DCHS), a population-based birth cohort in South Africa. Pregnant individuals were enrolled into the DCHS between 2012 and 2015 from 2 clinics in a periurban setting. Mother-child pairs were assessed prospectively; follow-up is ongoing. A subgroup of children had brain magnetic resonance imaging (MRI) at age 2 to 3 years from 2015 to 2018. This study focused on the 147 pairs with structural neuroimaging and available hemoglobin data. Data analyses were conducted in 2021 and 2022.

Exposures

Mothers had hemoglobin measurements during pregnancy, and a subgroup of children had hemoglobin measurements during early life. Anemia was classified as hemoglobin levels less than 11 g/dL based on World Health Organization guidelines; children younger than 6 months were classified using local guidelines.

Main Outcomes and Measures

Child brain volumes of global, subcortical, and corpus callosum structures were quantified using T1-weighted MRI. Linear regression models were used to analyze the associations between maternal and child anemia with child brain volumes, accounting for potential confounders.

Results

Of 147 children (mean [SD] age at MRI, 34 [2] months; 83 [56.5%] male) with high-resolution MRI scans, prevalence of maternal anemia in pregnancy was 31.3% (46 of 147; median [IQR] gestation of measurement: 13 [9-20] weeks). Maternal anemia during pregnancy was significantly associated with smaller volumes of the child caudate bilaterally (adjusted percentage difference, -5.30% [95% CI, -7.01 to -3.59]), putamen (left hemisphere: -4.33% [95% CI, -5.74 to -2.92]), and corpus callosum (-7.75% [95% CI, -11.24 to -4.26]). Furthermore, antenatal maternal hemoglobin levels were also associated with brain volumes in the caudate (left hemisphere: standardized β = 0.15 [95% CI, 0.02 to 0.28]; right hemisphere: β = 0.15 [95% CI, 0.02 to 0.27]), putamen left hemisphere (β = 0.21 [95% CI, 0.07 to 0.35]), and corpus callosum (β = 0.24 [95% CI, 0.09 to 0.39]). Prevalence of child anemia was 52.5% (42 of 80; median [IQR] age of measurement: 8.0 [2.7 to 14.8] months). Child anemia was not associated with brain volumes, nor did it mediate the association of maternal anemia during pregnancy with brain volumes.

Conclusions and Relevance

In this cohort study, anemia in pregnancy was associated with altered child brain structural development. Given the high prevalence of antenatal maternal anemia worldwide, these findings suggest that optimizing interventions during pregnancy may improve child brain outcomes.

Systemic retinal biomarkers

PURPOSE OF REVIEW

Systemic retinal biomarkers are biomarkers identified in the retina and related to evaluation and management of systemic disease. This review summarizes the background, categories and key findings from this body of research as well as potential applications to clinical care.

RECENT FINDINGS

Potential systemic retinal biomarkers for cardiovascular disease, kidney disease and neurodegenerative disease were identified using regression analysis as well as more sophisticated image processing techniques. Deep learning techniques were used in a number of studies predicting diseases including anaemia and chronic kidney disease. A virtual coronary artery calcium score performed well against other competing traditional models of event prediction.

SUMMARY

Systemic retinal biomarker research has progressed rapidly using regression studies with clearly identified biomarkers such as retinal microvascular patterns, as well as using deep learning models. Future systemic retinal biomarker research may be able to boost performance using larger data sets, the addition of meta-data and higher resolution image inputs.

Twelve Weeks of Reversed Umbilical Flow in a Fetal Growth Restriction Case Associated with Severe Periconceptional Maternal Anemia

We present a case of a patient diagnosed with severe intrauterine growth restriction and periconceptional severe anemia, where the fetal well-being features, including reversal of umbilical artery end-diastolic flow and abnormal cerebroplacental ratio, remained stationary for 12 weeks. We are not aware of reports with similar findings, and the professionals should take into consideration the possibility of a "frozen" fetal well-being for a long time. Possibly, in our case, the evolution may be due to the prompt correction of the chronic severe maternal anemia. This approach may offer the opportunity to prolong the pregnancy, even in cases with apparently imminent delivery, as the association of reversal of umbilical artery end-diastolic flow.

Detection of anaemia from retinal fundus images via deep learning

Owing to the invasiveness of diagnostic tests for anaemia and the costs associated with screening for it, the condition is often undetected. Here, we show that anaemia can be detected via machine-learning algorithms trained using retinal fundus images, study participant metadata (including race or ethnicity, age, sex and blood pressure) or the combination of both data types (images and study participant metadata). In a validation dataset of 11,388 study participants from the UK Biobank, the fundus-image-only, metadata-only and combined models predicted haemoglobin concentration (in g dl-1) with mean absolute error values of 0.73 (95% confidence interval: 0.72-0.74), 0.67 (0.66-0.68) and 0.63 (0.62-0.64), respectively, and with areas under the receiver operating characteristic curve (AUC) values of 0.74 (0.71-0.76), 0.87 (0.85-0.89) and 0.88 (0.86-0.89), respectively. For 539 study participants with self-reported diabetes, the combined model predicted haemoglobin concentration with a mean absolute error of 0.73 (0.68-0.78) and anaemia an AUC of 0.89 (0.85-0.93). Automated anaemia screening on the basis of fundus images could particularly aid patients with diabetes undergoing regular retinal imaging and for whom anaemia can increase morbidity and mortality risks.

Overcoming Hurdles in Nanoparticle Clinical Translation: The Influence of Experimental Design and Surface Modification

Nanoparticles are becoming an increasingly popular tool for biomedical imaging and drug delivery. While the prevalence of nanoparticle drug-delivery systems reported in the literature increases yearly, relatively little translation from the bench to the bedside has occurred. It is crucial for the scientific community to recognize this shortcoming and re-evaluate standard practices in the field, to increase clinical translatability. Currently, nanoparticle drug-delivery systems are designed to increase circulation, target disease states, enhance retention in diseased tissues, and provide targeted payload release. To manage these demands, the surface of the particle is often modified with a variety of chemical and biological moieties, including PEG, tumor targeting peptides, and environmentally responsive linkers. Regardless of the surface modifications, the nano-bio interface, which is mediated by opsonization and the protein corona, often remains problematic. While fabrication and assessment techniques for nanoparticles have seen continued advances, a thorough evaluation of the particle's interaction with the immune system has lagged behind, seemingly taking a backseat to particle characterization. This review explores current limitations in the evaluation of surface-modified nanoparticle biocompatibility and in vivo model selection, suggesting a promising standardized pathway to clinical translation.

Role of fetal intertwin difference in middle cerebral artery peak systolic velocity in predicting neonatal twin anemia-polycythemia sequence

OBJECTIVES

To evaluate the relationship between the fetal intertwin difference in middle cerebral artery peak systolic velocity (MCA-PSV) and intertwin difference in hemoglobin (Hb) concentration at birth in monochorionic diamniotic (MCDA) twin pregnancies in order to assess its potential role in the prediction of twin anemia-polycythemia sequence (TAPS).

METHODS

This was a retrospective cohort study of MCDA twin pregnancies delivered between January 2012 and January 2018. All pregnancies with measurements of MCA-PSV within 7 days prior to delivery and in which neonatal Hb concentration was available were included. The correlation between fetal intertwin difference in MCA-PSV, expressed in multiples of the median (MoM), and neonatal intertwin difference in Hb concentration was investigated. Receiver-operating characteristics (ROC) curve analysis was used to assess the performance of fetal intertwin difference in MCA-PSV for predicting intertwin difference in Hb > 90^th centile at birth.

RESULTS

A total of 154 out of 256 MC twin pregnancies fulfilled the inclusion criteria. Fetal intertwin difference in MCA-PSV MoM correlated positively with neonatal intertwin difference in Hb concentration (r = 0.79; P < 0.001). The 90^th centile for intertwin difference in Hb was 7.25 g/dL. There were 15 (9.7%) cases with a Hb difference ≥ 7.25 g/dL at birth. ROC curve analysis showed a high accuracy of fetal intertwin MCA-PSV MoM difference for the prediction of neonatal intertwin Hb difference ≥ 7.25 g/dL at birth (area under the ROC curve, 0.976 (95% CI, 0.935-0.993); P = 0.012). The optimal cut-off for intertwin MCA-PSV MoM difference was 0.373, with a sensitivity of 93.3% (95% CI, 68.1-99.8%) and a specificity of 95.7% (95% CI, 90.8-98.4%). The positive predictive value was 70% (95% CI, 45.7-88.1%) and the negative predictive value was 99.3% (95% CI, 95.9-100%).

CONCLUSION

Our findings show that fetal intertwin MCA-PSV MoM difference is a good predictor of neonatal intertwin Hb concentration difference > 90^th centile and potentially of TAPS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Improved prediction of twin anemia-polycythemia sequence by delta middle cerebral artery peak systolic velocity: new antenatal classification system

OBJECTIVES

To investigate the diagnostic accuracy of delta middle cerebral artery peak systolic velocity (MCA-PSV) > 0.5 multiples of the median (MoM) and compare its predictive value with that of the current MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient, for the diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic twin pregnancy.

METHODS

This was a retrospective consecutive cohort study comprising all uncomplicated monochorionic twin pregnancies and twin pregnancies with a postnatal diagnosis of TAPS managed between 2003 and 2017 in the Dutch national referral center for fetal therapy. Cases with incomplete MCA-PSV Doppler measurements 1 week prior to delivery or with incomplete hemoglobin measurements within 1 day after birth were excluded. The postnatal diagnosis of TAPS was based on an intertwin hemoglobin difference > 8 g/dL and at least one of the following: reticulocyte count ratio > 1.7 or presence of minuscule anastomoses on the placental surface. We compared the predictive accuracy of the current diagnostic method using MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient with that of a new method based on intertwin difference in MCA-PSV > 0.5 MoM for prediction of TAPS.

RESULTS

In total, 45 uncomplicated and 35 TAPS monochorionic twin pregnancies were analyzed. The sensitivity and specificity of the cut-off MCA-PSV values (donor > 1.5 MoM, recipient < 1.0 MoM) to predict TAPS was 46% (95% CI, 30-62%) and 100% (95% CI, 92-100%), respectively; positive predictive value was 100% (95% CI, 81-100%) and negative predictive value 70% (95% CI, 58-80%). Delta MCA-PSV showed a sensitivity of 83% (95% CI, 67-92%) and a specificity of 100% (95% CI, 92-100%); the positive and negative predictive values were 100% (95% CI, 88-100%) and 88% (95% CI, 77-94%), respectively. Of the 35 cases with TAPS diagnosed postnatally, 13 twin pairs showed a delta MCA-PSV > 0.5 MoM but did not fulfill the cut-off MCA-PSV criteria. Of these 13 TAPS twins, nine donors and four recipients had normal MCA-PSV values. There was a high correlation between delta MCA-PSV and intertwin difference in hemoglobin level (R = 0.725, P < 0.01).

CONCLUSION

Delta MCA-PSV > 0.5 MoM has a greater diagnostic accuracy for predicting TAPS compared to the current MCA-PSV cut-off criteria. We therefore propose a new antenatal classification system for TAPS. In monochorionic twin pregnancies with delta MCA-PSV > 0.5 MoM on Doppler ultrasound, but normal MCA-PSV values in the donor or recipient, obstetricians should be aware of the therapeutic implications and neonatal morbidities associated with TAPS. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Clinical characteristics and prognosis of idiopathic pulmonary hemosiderosis in pediatric patients

OBJECTIVE

This study aimed to analyze the clinical characteristics and prognosis of pediatric idiopathic pulmonary hemosiderosis (IPH).

METHODS

Pediatric IPH cases that were diagnosed at West China Second University Hospital, Sichuan University between 1996 and 2017 were reviewed. Follow-up data from 34 patients were collected.

RESULTS

A total of 107 patients were included (42 boys and 65 girls). The median age was 6 years at diagnosis. The main manifestations of the patients were as follows: anemia (n = 100, 93.45%), cough (n = 68, 63.55%), hemoptysis (n = 61, 57%), fever (n = 23, 21.5%), and dyspnea (n = 23, 21.5%). There were relatively few pulmonary signs. The positive rates of hemosiderin-laden macrophages in sputum, gastric lavage fluid, and bronchoalveolar lavage fluid were 91.66%, 98.21%, and 100%, respectively. Seventy-nine patients were misdiagnosed. A total of 105 patients were initially treated with glucocorticoids, among whom 102 survived and three died. Among the followed up patients, two died and 32 survived, among whom 10 presented with recurrent episodes.

CONCLUSIONS

The classic triad of pediatric IPH is not always present. The rates of misdiagnosis and recurrence of IPH are high. Early recognition and adequate immunosuppressive therapy are imperative for improving prognosis of IPH.

Contribution of fetal brain MRI in management of severe fetal anemia

INTRODUCTION

Intrauterine transfusion (IUT) has changed fetal anemia prognosis. However, long-term neurodevelopmental outcome is altered in 5% of children. Our objective was to study the contribution of fetal MRI to diagnosis brain lesions in case of fetal anemia.

MATERIAL AND METHODS

Retrospective monocentric descriptive study from 2005 to 2016, including all patients followed for fetal anemia requiring IUT. The indications for MRI were: hydrops fetalis and / or hemoglobin <5 g / dL and / or more than 3 IUTs and / or acute severe anemia and / or ultrasound abnormality. Fetal and neonatal outcome and pediatric neurological monitoring were studied.

RESULTS

89 patients were followed for fetal anemia with IUT and 28 (29.1%) had fetal MRI, 12 of which were abnormal. Two out of twelve had abnormal ultrasound. Seven out of twelve had poor neurological prognosis: 2 medical terminations of pregnancy were performed; 2 children had severe developmental delay and 3 children had schooling difficulties. Five out of twelve children had favorable neurological prognosis.

CONCLUSION

MRI of the fetal brain makes it possible to better detect brain lesions than ultrasound does in the management of severe fetal anemia and seems particularly appropriate in cases of acute anemia.

Real time visualization may be advisable to exclude aspiration in patients undergoing capsule endoscopy examination

Capsule endoscopy (CE) is currently considered as a first line diagnostic tool for small bowel examination. Some patients find swallowing the capsule difficult. However, capsule aspiration is relatively uncommon and is only reported in isolated cases. The majority of these cases are male (39/41; 95.1%) with an age ranging from 56-93 years and only 4 (9.8%) patients had a recorded history of dysphagia. Twenty-four out of 41 (58.5%) patients experienced symptoms of capsule aspiration. The aspiration self-resolved in 11/41 patients and the CE was retrieved during bronchoscopy in the other cases. We present the case of a 75 year old man with a history of chronic anemia who was referred for CE.

Contrasting resting-state fMRI abnormalities from sickle and non-sickle anemia

Sickle cell disease (SCD) is a chronic blood disorder that is often associated with acute and chronic cerebrovascular complications, including strokes and impaired cognition. Using functional resting state magnetic resonance images, we performed whole-brain analysis of the amplitude of low frequency fluctuations (ALFF), to detect areas of spontaneous blood oxygenation level dependent signal across brain regions. We compared the ALFF of 20 SCD patients to that observed in 19 healthy, age and ethnicity-matched, control subjects. Significant differences were found in several brain regions, including the insula, precuneus, anterior cingulate cortex and medial superior frontal gyrus. To identify the ALFF differences resulting from anemia alone, we also compared the ALFF of SCD patients to that observed in 12 patients having comparable hemoglobin levels but lacking sickle hemoglobin. Increased ALFF in the orbitofrontal cortex and the anterior and posterior cingulate cortex and decreased ALFF in the frontal pole, cerebellum and medial superior frontal gyrus persisted after accounting for the effect of anemia. The presence of white matter hyperintensities was associated with depressed frontal and medial superior frontal gyri activity in the SCD subjects. Decreased ALFF in the frontal lobe was correlated with decreased verbal fluency and cognitive flexibility. These findings may lead to a better understanding of the pathophysiology of SCD.

Cryptogenic multifocal ulcerous stenosing enteritis: Radiologic features and clinical behavior

AIM

To investigate the characteristic radiologic findings of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) which can be differentiated from other similar bowel disease and to assess their clinical behavior.

METHODS

Twenty pathologically and clinically confirmed CMUSE patients (males:females = 8:12; mean age: 40.4 years) between March 2002 and August 2015 from seven academic centers in South Korea were retrospectively reviewed. We evaluated small bowel series (SBS; n = 25), computed tomography (CT) enterography (n = 21), magnetic resonance (MR) enterography (n = 2), and abdominopelvic CT (n = 18) images, focusing on enteric and perienteric manifestations. Any change in radiologic features during follow-up period was recorded. We evaluated clinical data including presenting symptoms, laboratory finding and presence of relapse from electronic medical records. Histopathologic findings were also evaluated.

RESULTS

The main symptoms were abdominal pain (n = 12) and anemia (n = 10). All patients showed small bowel strictures (n = 52, mean: 2.6 per patient) on initial CT/MR, located in the ileum (n = 47) or jejunum (n = 5). Strictures showed short-length (mean: 10.44 mm) and circumferential bowel wall thickening (mean: 5.56 mm) with layered enhancement (n = 48) that were also noted on initial SBS (n = 36) with shallow ulcers (n = 10). Some ulcerative lesions or wall thickening progressed into strictures on follow-up SBS/CT, and some strictures revealed recurrent ulceration on follow-up SBS. There were no penetrating disease features like fistula or abscess and no gastrointestinal tract involvement except the small bowel. Nine patients experienced disease recurrence (median relapse-free period: 32 mo) even post-operatively. Histopathologic features of surgically resected specimens were characterized as multiple superficial ulcerations confined to mucosa or submucosa and multiple strictures.

CONCLUSION

Under characteristic radiologic findings with multiple short-segmental strictures and/or shallow ulcers of the small intestine, CMUSE should be considered when assessing patients with recurrent abdominal pain and anemia.

The effect of red blood cell transfusion on the microcirculation of anemic children

Red blood cell transfusion can improve but also might temporarily reduce the microcirculation. The buccal microcirculation was visualized and total vessel density (TVD) determined with sidestream dark field imaging in 19 pediatric anemic (Hb 7.2 g/dL, 95 % CI 6.5-7.9) oncology or hematology patients receiving red blood cell transfusions (Tx) and in 18 age-matched healthy non-anemic controls. After transfusion, Hb (8.0 g/dL, 95 % CI 7.3-8.6) and TVD increased (14.7 ± 1.7 versus 16.6 ± 2.0 mm/mm(2)) significantly with a concomitant decrease in RBC velocity in medium-sized vessels (pre-Tx 711 ± 199 versus post-Tx 627 ± 163 μm/s). Compared to the controls, pre-Tx TVD (17.5 ± 1.3 mm/mm(2)) was lower and RBC velocity (476 ± 77 μm/s) was significantly higher. After transfusion, TVD and RBC velocity remained significantly lower and higher, respectively. In a subgroup, analysis of the transfused children with infection of TVD at baseline was lower with a larger increase after transfusion compared to anemic children without infection (ΔTVD 3.4 ± 2.6 versus ΔTVD 1.3 ± 1.5 mm/mm(2)).

CONCLUSION

With the rise of hemoglobin after transfusion, significant improvements of tissue perfusion were demonstrated but differences to non-anemic controls persisted. In particular, the microcirculation of anemic oncology patients with infection improved after transfusion.

WHAT IS KNOWN

• Transfusions can improve but also temporarily reduce the microcirculation. • In neonates, transfusion significantly increases total vessel density. What is New: • Pretransfusion, the microcirculation of the anemic children differed significantly from the controls. • After transfusion, the microcirculation improved but still differed from the controls. • These changes were most profound in anemic patients with concurrent infection, therefore transfusion threshholds might need to be higher.

Review of the correlation between blood flow velocity and polycythemia in the fetus, neonate and adult: appropriate diagnostic levels need to be determined for twin anemia-polycythemia sequence

Twin anemia-polycythemia sequence (TAPS) is recognized increasingly antenatally by the demonstration of an anemic twin and a polycythemic cotwin using the middle cerebral artery peak systolic velocity (MCA-PSV). While the MCA-PSV has been shown to correlate well with anemia in singleton fetuses, the evidence to support its use to diagnose fetal polycythemia appears to be less clear-cut. We aimed to evaluate fetal, neonatal and adult literature used to support the use of MCA-PSV for the diagnosis of polycythemia. Comprehensive literature searches were performed for ultrasound evidence of polycythemia in the human fetus, neonate and adult using key search terms. Only manuscripts in the English language with an abstract were considered for the review, performed in June 2014. Fifteen manuscripts were found for the human fetus, including 38 cases of TAPS. Nine of these defined fetal polycythemia as MCA-PSV < 0.8 multiples of the median (MoM), five used < 1.0 MoM and one used 0.8-1.0 MoM. Only two studies, involving a total of 15 cases, proposed a diagnostic level, acknowledging false-positive and -negative cases, though neither reported sensitivities or specificities. Six neonatal studies (96 neonates) demonstrated evidence of decreased cerebral velocities in polycythemia and a consequent increase with hemodilution. In the adult, five studies (57 polycythemic adults) demonstrated increased flow or velocity with hemodilution. Neither neonatal nor adult studies conclusively defined levels for screening for polycythemia. Despite widespread adoption of a cut-off of < 0.8 MoM in the published literature for the polycythemic fetus in TAPS, this is based upon minimal evidence, with unknown sensitivity and specificity. We recommend caution in excluding TAPS based purely upon the absence of a reduced MCA-PSV.

Reliability of Doppler Assessment of the Middle Cerebral Artery in the Near and Far Fields in Healthy and Anemic Fetuses

OBJECTIVES

The purpose of this study was to assess the reliability of the middle cerebral artery pulsatility index (PI) and peak systolic velocity (PSV) at the proximal portions of the near- and far-field vessel sites in healthy and anemic fetuses.

METHODS

The middle cerebral artery PSV and PI were prospectively assessed in 50 normal singleton pregnancies. The Doppler waveforms for the middle cerebral artery PI and the PSV were recorded independently by 2 operators at the most proximal portions of the near- and far-field sites. Data for the PSV and PI at the proximal portions of both the near- and the far-field sites were also retrospectively collected in 7 anemic fetuses.

RESULTS

No significant difference between the operators was detected for the middle cerebral artery PSV (P = .60) and PI (P = .88) measured in the conventionally used near-field proximal site in the 50 healthy fetuses. No significant difference between the proximal portions of the near- and far-field sites was detected for the PSV (P = .53) and PI (P = .23) in healthy or anemic fetuses.

CONCLUSIONS

The findings of this study suggest that the use of the far-field vessel is an acceptable alternative for measurement of the middle cerebral artery PI and PSV when investigation of the near-field vessel is technically difficult.

Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence

OBJECTIVE

To evaluate the diagnostic accuracy of middle cerebral artery peak systolic velocity (MCA-PSV) Doppler measurements in prediction of hemoglobin levels in twin anemia-polycythemia sequence (TAPS).

METHODS

This study involved a consecutive cohort comprising monochorionic twin pregnancies complicated by TAPS managed at three European fetal medicine centers between 2005 and 2013. The accuracy of MCA-PSV, measured immediately prior to fetal hemoglobin (Hb) measurement by fetal or cord blood sampling, for prediction of anemia and polycythemia was assessed using 2 × 2 tables.

RESULTS

A total of 116 measurements (74 recorded in donors and 42 in recipients) from 43 twin pregnancies complicated by TAPS were available for analysis. MCA-PSV multiples of the median (MoM) values correlated well with Hb levels (r = - 0.86; P < 0.001). The sensitivity of MCA-PSV ≥ 1.5 MoM to predict severe anemia (Hb deficit > 5 SD below the mean) in TAPS donors was 94% (95% CI, 85-98%); specificity was 74% (95% CI, 62-83%); positive and negative predictive values were 76% (95% CI, 65-85%) and 94% (95% CI, 83-98%), respectively. The sensitivity of MCA-PSV ≤ 1.0 MoM to predict polycythemia (Hb level > 5 SD above the mean) in TAPS recipients was 97% (95% CI, 87-99%); specificity was 96% (95% CI, 89-99%); positive and negative predictive values were 93% (95% CI, 81-97%) and 99% (95% CI, 93-100%), respectively.

CONCLUSION

MCA-PSV measurement has high diagnostic accuracy for predicting abnormal Hb levels in fetuses with TAPS.

Correlation between cardiac tissue Doppler and peripheral vascular Doppler in the anemic fetus - an additional method to determine the transfusion threshold?

PURPOSE

To examine the relationship between cardiac tissue Doppler and peripheral vascular Doppler measurements in fetal anemia.

MATERIALS AND METHODS

We analyzed high frame rate cardiac Tissue Doppler Imaging (TDI) data files of 26 anemic fetuses. The peak systolic tissue velocity (PSV), peak systolic displacement (PD), and peak systolic strain (PS) were determined in the mid-segment of the ventricular walls (ROI 1 right ventricle (RV), ROI 2 left ventricle (LV)) and in the basal segment of the ventricular walls (ROI 3 tricuspid annulus, ROI 4 mitral annulus). TDI parameters were correlated with established fetal vascular Doppler parameters (peak systolic blood flow velocity (Vmax) in the middle cerebral artery (MCA), pulsatility index (PI) in the MCA, in the umbilical artery (UA), and in the venous duct (DV)).

RESULTS

The PSV in the LV correlated significantly negatively with the PI in the MCA. Both the PSV and PD in the LV correlated significantly negatively with the PI in the UA. The PS in the RV correlated significantly negatively with the PI in the UA. The left ventricular PSV and PD correlated significantly positively with the PI in the DV. The Vmax in the MCA did not correlate with any systolic myocardial TDI parameter.

CONCLUSION

In fetal anemia, peak systolic myocardial TDI parameters correlate with vascular Doppler parameters, confirming that TDI is a promising method to evaluate myocardial function in the anemic fetus. This suggests combining both techniques to quantify fetal myocardial function in anemia even more accurately, possibly allowing for the determination of the indication for intrauterine transfusion.

Middle cerebral artery Doppler in prediction degree of fetal anemia and the best timing for the second intrauterine intravascular transfusion in red cell alloimmune disease

AIM

To determine the role of fetal multiples of the median of middle cerebral artery peak systolic velocity (MoM MCA-PSV), predicts the rate of decline in fetal hematocrit (Hct) for determination of the best timing for the second intrauterine intravascular transfusion (IUIVT) in fetuses with Rh alloimmunisation.

MATERIALS AND METHOD

Retrospective study of 59-monofetal alloimmunized pregnancies from 2005 to 2012 that underwent first and second IUIVT were assessed in Department of Gynecology and Obstetrics, Belgrade, Serbia.

RESULT

There was an inverse statistically significant correlation between measurements MCA MoM-1 and fetal Hct-1 before the first IUIVT r = -0.622; p = 0.001 and MCA-MoM-3 and Hct-3 before the second IUIVT r = -0.381; p = 0.001, also as the significant correlation between the interval between both procedures (expressed in day) and measurement MCA-MoM-3, before the second IUIVT r = -0.284; p = 0.029.

CONCLUSION

The measurements MoM-MCA before every IUIVT can be useful for prediction of the best timing for the next IUIVT.

Spontaneous rectus sheath hematoma: two variant cases

We present two variant cases of spontaneous rectus sheath hematoma (SRSH). A 71-year-old woman presented with ST elevation myocardial infarction and was found to have multivessel coronary artery disease. She was treated with aspirin, clopidogrel, eptifibatide, and heparin. Heparin was continued while preoperative workup for coronary artery bypass grafting was done. She developed a large 20x10 cm actively bleeding SRSH while on heparin. It was surgically evacuated. The second case represents an atypical cause of SRSH. A 64-year-old woman with Wegener's Granulomatosis presented with anemia and abdominal pain. Abdominal CT showed a large 22 cm SRSH without active bleeding that was treated conservatively. Both patients did well on follow-up. The incidence of SRSH is likely to increase in the coming years with the increasing use of antithrombotic agents for many disease processes. Clinicians should be aware of typical and atypical presentations of SRSH and its variant management options.

Laser surgery as a management option for twin anemia-polycythemia sequence

OBJECTIVE

To evaluate the effectiveness of laser treatment for antenatally detected twin anemia-polycythemia sequence (TAPS) compared with intrauterine transfusion or expectant management.

METHODS

All monochorionic twin pregnancies with TAPS managed between 2005 and 2013 in two European fetal therapy centers were evaluated. The outcomes of TAPS cases treated primarily with laser surgery were compared with the outcomes of cases managed expectantly or treated with intrauterine transfusion.

RESULTS

In this retrospective study 52 cases of TAPS were detected antenatally and were managed with either laser surgery (n=8; 15%) or intrauterine blood transfusion (n=17; 33%) or expectantly (n=27; 52%). Perinatal survival in the laser group was 94% (15/16) vs 85% (29/34) in the intrauterine-transfusion group and 83% (45/54) in the expectant-management group (P=0.30). The rates of severe neonatal morbidity in liveborn neonates in the laser, intrauterine-transfusion and expectant-management groups were 7% (1/15), 38% (12/32) and 24% (12/50), respectively (P=0.17). There was a significant reduction in respiratory distress syndrome in cases treated by laser. No severe postnatal hematological complications were detected in the laser group compared with 72% (23/32) in the intrauterine-transfusion group and 52% (26/50) in the expectant-management group (P<0.01). Median time between diagnosis and birth was 11 weeks in the laser group compared to 5 weeks after intrauterine transfusion and 8 weeks after expectant management (P<0.01). After injection of colored dye no residual anastomoses were found in the laser group.

CONCLUSIONS

Laser surgery for TAPS appears to improve perinatal outcome by prolonging pregnancy and reducing respiratory distress syndrome. Larger, adequately controlled studies are needed to reach firm conclusions on the optimal management of TAPS.

The PhysioFlow thoracic impedancemeter is not valid for the measurements of cardiac hemodynamic parameters in chronic anemic patients

The aim of the present study was to test the validity of the transthoracic electrical bioimpedance method PhysioFlow® to measure stroke volume in patients with chronic anemia. Stroke volume index (SVI), as well as cardiac index (CI) obtained by transthoracic electrical bioimpedance method and doppler echocardiography were compared in healthy subjects (n = 25) and patients with chronic anemia (i.e. mainly with sickle cell anemia; n = 32), at rest. While doppler echocardiography was able to detect difference in SVI between the two populations, the Physioflow® failed to detect any difference. Bland & Altman analyses have demonstrated no interchangeability between the two methods to assess CI and SVI in anemic patients and healthy subjects. While doppler echocardiography displayed a good concordance for SVI results with those obtained in the literature for anemic patients, the Physioflow® did not. Finally, in contrast to doppler echocardiography: 1) the CI obtained with the Physioflow® was not correlated with the hemoglobin level and 2) the stroke volume determined by the Physioflow® was highly influenced by body surface area. In conclusion, our findings indicate that the Physioflow® device is inaccurate for the measurement of SVI and CI in patients with chronic anemia and has a poor accuracy for the measurement of these parameters in African healthy subjects.

A prospective cross-sectional study of fetal middle cerebral artery peak systolic velocity in a normal obstetric population attending an Indian Medical College

PURPOSE

Fetal middle cerebral artery peak systolic velocity (MCA-PSV) is now an established method of noninvasive diagnosis of moderate to severe fetal anemia of different origins. This being a population-based parameter, it may have different values in individuals from different locations. A standard local reference range of normal individuals specific to each geographic locality is therefore needed.

MATERIALS AND METHODS

Fetal MCA-PSV was measured in 1,015 healthy pregnant women attending the antenatal ultrasound clinic at least once between 12 and 40 weeks of gestation (35 patients per week of gestation). Statistical analysis was done using the SPSS 12 software.

RESULTS

A positive correlation between MCA-PSV and gestational age was found. MCA-PSV was seen to increase with advancing gestational age. The Tukey-Kramer multiple comparisons test showed a normal distribution that was highly significant (p < 0.01). The multiples of median values of fetal MCA-PSV to label a fetus as severely anemic were consistently and significantly lower than internationally accepted values.

CONCLUSIONS

A normal reference range of fetal MCA-PSV for local use was thus scientifically and successfully constructed. Significant differences between local values and internationally accepted value were found.

Fetal myocardial peak systolic strain before and after intrauterine red blood cell transfusion--a tissue Doppler imaging study

OBJECTIVES

The purpose of this study is to evaluate the cardiac function in anemic fetuses by tissue Doppler imaging (TDI) measuring the myocardial peak systolic strain (PS) in fetuses before and after intrauterine transfusion (IUT) of red blood cells.

METHODS

In our prospective clinical study in anemic fetuses, high-frame-rate TDI data files from a four-chamber view of fetal hearts pre- and post-IUT were analyzed. The biventricular PS parameters of the mid-segment of the ventricular walls [region of interest (ROI) 1 right ventricle, ROI 2 left ventricle] and the basal segment of the ventricular walls (ROI 3 tricuspid annulus, ROI 4 mitral annulus) were compared with the PS data of the normal controls.

RESULTS

We analyzed the pre-/post-data sets from the 15 hearts of anemic fetuses and from the 17 controls. The threshold of statistical significance was set to P≤0.05. Compared with the controls, in anemic fetuses the left ventricular longitudinal myocardial PS (ROI 2, P=0.001) and PS in the basal segment of the right ventricle (ROI 3 P=0.009) was significantly increased (absolute amount). Compared with pre-IUT, post-IUT PS decreased significantly in both ventricles (ROI 1 P=0.025, ROI 2 P=0.02). Compared with the controls, post-IUT left ventricular PS was still higher (absolute amount) (ROI 2, P=0.026; ROI 4, P=0.009).

CONCLUSIONS

The increase in myocardial PS due to severe fetal anemia is partially normalized by IUT. In anemic fetuses, assessment of TDI fetal myocardial PS is feasible.

[Anti-D isoimmunization severe in a twin pregnancy. Case report]

Perinatal hemolytic disease occurs secondary to a hemolytic phenomenon of immune origin resulting in fetal or neonatal anemia. A 38-year-old pregnant woman was referred to the Department of high risk Obstetrics, Hospital Universitario La Paz Madrid because of presenting a dichorionic diamniotic twin pregnancy spontaneously, pre-pregnancy diabetes poorly controlled and severe alloinmunization anti-D. Her first pregnancy ended in a normal delivery at term; in the period of 4 years, she has three newborn with 36, 34 and 40 weeks respectively, who die with a week of life. After that, two intrauterine fetal death occur at 26 weeks of gestation. The patient who is RhD negative, suffers anti-D inmunization with a antibody titration of 1/1024 with 14 weeks of gestation. Twelve plasmapheresis, eight doses of anti-D inmunoglobulins and intrauterine transfusions has been the treatment received. A severe anemia is found during the ultrasound control of the middLe cerebral artery peak systolic velocity in both twins since the 16th week. It remains stable thanks to the treatment. Finally at the 28th week of gestation, pregnancy is terminated with a cesarean section. The twins are born alive and premature, but with good general state. The measurement of the middle cerebral artery peak systolic velocity predicts moderate-severe fetal anemia cases, which are the most important in the clinical management because of the need of active treatment or finish the pregnancy.

[Intrauterine blood transfusion in case of placental chorangioma]

The paper presents a case of placental tumor causing hemodynamic changes. Doppler studies and fetal echocardiography allowed the diagnosis of hyperkinetic circulation in the course of fetal anemia. Cordocentesis has been performed and confirmed fetal anemia. The treatment used, intrauterine blood transfusion, allowed the compensation of hemodynamic and hematological disorders. Paper presents a detailed diagnostic and therapeutic procedures in the event chorangioma in pregnancy.

Regional myocardial function and response to acute afterload increase in chronically anemic fetal sheep: evaluation by two-dimensional strain echocardiography

We hypothesized that in chronic fetal anemia, remodeling of the myocardium is related to abnormalities in regional wall motion and acutely increased afterload further disturbs myocardial strain. Chronic anemia was induced in one fetus of each of seven sheep twin pregnancies. The fetuses were studied by two-dimensional (2-D) strain echocardiography at baseline and during increased afterload via angiotensin II (AT II) infusion. At baseline, the peak systolic longitudinal, radial and circumferential strains in the left ventricular lateral wall in anemic fetuses were lower than those in the controls (all p<0.05). During AT II, the circumferential strain of right ventricular free wall decreased significantly both in the control and anemic fetuses. Left ventricular free wall systolic strains were not affected by AT II. Fetal myocardial remodeling in chronic anemia decreases left ventricular systolic free wall strains. The myocardial adaptation does not change ventricular responses to acutely increased afterload.

Clinical and placental characteristics in four new cases of twin anemia-polycythemia sequence

We report and analyze four new cases of spontaneous twin anemia-polycythemia sequence (TAPS) and discuss antenatal management by fetoscopic laser coagulation for this uncommon form of chronic intertwin transfusion. The clinical course and placental characteristics of four pairs of monochorionic-diamniotic (MCDA) twins with spontaneous TAPS, of which one was treated with fetoscopic laser surgery, are described. For the three cases that did not undergo intrauterine intervention, serial Doppler measurement revealed a gradual increase in the middle cerebral artery peak systolic velocity (MCA-PSV) in the donor and a concomitant decrease in the recipient. These twins were born at between 32 and 34 weeks' gestation by Cesarean section. At birth, the donor twins were severely anemic and the recipient twins were polycythemic. Placental injection studies revealed a few small arteriovenous (AV) and venoarterial anastomoses. In the fourth case, because of the high suspicion of TAPS on MCA-PSV data at 24 weeks' gestation, fetoscopic laser coagulation of three small AV anastomoses was successfully performed. No hematological abnormalities were detected at birth. TAPS is a newly described form of chronic twin-to-twin transfusion associated with chronic anemia in the donor and polycythemia in the recipient, without twin oligo-polyhydramnios sequence (TOPS). The monitoring of MCDA pregnancies should include measurement of MCA-PSV in both fetuses even in the absence of intertwin discordance in amniotic fluid volume. Early detection of TAPS could indicate fetoscopic laser coagulation of AV anastomoses.

Role for serial prenatal anti-Vel quantitative serologic monitoring with 2-ME serum treatment during pregnancy: case report

Anti-Vel is an uncommon antibody to a high-prevalence antigen. Its clinical significance and management in the prenatal setting are not well characterized. We present a case that demonstrates the utility of serial prenatal anti-Vel quantitative serologic monitoring with 2-ME serum treatment during pregnancy. The patient is a 23-year-old Hispanic woman with history of prior pregnancy and prior transfusion who was discovered to have an antibody to the high-prevalence Vel antigen in the first trimester (week 7) of her second pregnancy. Interval measurements of the serologic antibody titers were performed during the next 26 weeks. The untreated serum (IgM and IgG) titer increased from a baseline of 4 to 16 during that interval, while the 2-ME (presumed IgG component) titer remained stable at 4. Responding to ultrasound findings suspicious for fetal anemia, the child was delivered without complications at 34 weeks' gestation. At birth, the DAT was negative and there was no evidence of HDN. Placed in the context of other similar reports, this case demonstrates the importance of separately reporting the IgG fraction (after either DTT treatment or 2-ME treatment) from the untreated (IgM and IgG) fraction and the importance of correlating the treated serum titer with potential clinical significance.

[Estimation of diagnostic value of the middle cerebral artery peak systolic velocity in prediction of fetal anemia in pregnancies complicated by alloimmunisation]

The use of the middle cerebral artery peak systolic velocity (PSV) for the noninvasive diagnosis of fetal anemia in pregnancies complicated by alloimmunisation has the potential to reduce the number of invasive procedures.

OBJECTIVES

The study was undertaken to determine the detection of fetal anemia by fetal middle cerebral artery peak systolic velocity (MCA PSV).

MATERIAL AND METHODS

31 fetuses with red cell alloimmunisation were evaluated with Doppler ultrasongraphy. On the basis of ROC (AUC) analysis the cutoff point of MoM=1.215 with the highest sensitivity and specificity was established. We examined the relation between MoM=1.215 and neonatal hemoglobin level and the maternal antibody titre in the indirect antiglobulin test. Sensitivity specificity positive and negative value and statistical significance were calculated.

CONCLUSIONS

Data reported to date suggest that a threshold of 1.215 multiples of the median can be used to better diagnostic of fetal anemia.

Middle cerebral artery peak systolic velocity and ductus venosus velocity in the investigation of nonimmune hydrops

PURPOSE

This study was performed to investigate the cause of nonimmune hydrops fetalis by measuring the peak systolic velocity (PSV) in the middle cerebral artery (MCA) and velocity waveforms of the ductus venosus (DV) with Doppler.

METHODS

This cross-sectional study was done on 19 pregnancies referred to three university teaching hospitals for further investigation of nonimmune hydrops fetalis in 2007 and 2008. The MCA-PSV and DV velocity waveforms were recorded in all fetuses. Anemia was investigated in cases with MCA-PSV values greater than 1.50 MoM (multiple of the median). Cardiovascular causes and chromosomal abnormalities were investigated in fetuses with abnormal DV velocity.

RESULTS

Four of 19 fetuses had MCA-PSV values greater than 1.50 MoM. The causes of anemia were cytomegalovirus, parvovirus B19 infections, congenital heart disease, and Turner syndrome. Four cases had reversed flow in the DV; three of them had congenital heart disease on echocardiography; and one had a normal echocardiogram, but an abnormal karyotype was detected.

CONCLUSION

Assessment of the MCA-PSV and DV velocity waveforms during sonographic examination of fetuses with nonimmune hydrops fetalis may improve our knowledge about the etiology of this condition.

Interobserver variability in the measurement of fetal middle cerebral artery peak systolic velocity in a tertiary fetal medicine unit

OBJECTIVES

To investigate the interobserver variability of fetal middle cerebral artery (MCA) peak systolic velocity (PSV) Doppler measurements in a tertiary fetal medicine unit.

METHODS

This was a prospective cohort study of pregnant women between 22 and 34 weeks of gestation who underwent fetal MCA-PSV Doppler velocimetry by a paired combination of operators. A set protocol was followed; ease of scanning was recorded and three quality assurance parameters were analyzed. The interobserver variability was determined. In addition, individual operator characteristics were determined by analyzing the variation of each operator relative to all his/her paired colleagues, and their quality assurance parameters.

RESULTS

Two hundred and eighty-five women had completed paired fetal MCA-PSV Doppler measurements. Eighty-three (29%) of the ultrasound examinations requested were for suspected fetal anemia and 202 (71%) were for other obstetric indications. The interobserver variation was less than 10% in 78% of the paired MCA-PSV Doppler measurements whereas 99% had less than 15% variation. The intraclass correlation coefficient of each operator when compared with all his/her colleagues ranged from 0.82 to 0.95. The overall mean variability of the MCA-PSV recorded by a given operator, relative to all his/her paired colleagues, ranged from + 5.26% to - 6.47% in all but one operator whose value was + 13.5% (standard deviation factor, 1.13-1.22). Logistic regression analysis, using a 10% or greater variation in MCA-PSV as a binary outcome variable, showed a significant difference when inappropriate angle correction was detected (P < 0.001).

CONCLUSIONS

Clinically acceptable interobserver variability was obtained in fetal MCA-PSV Doppler measurements. Inappropriate angle correction was found to be a significant predictive factor for increased interobserver variability. Analysis of mean variation identified operators who were outliers enabling quality assurance within the unit.

Midgut volvulus with hemorrhagic ascites: a rare cause of fetal anemia

Fetal intestinal volvulus is a rare life-threatening condition usually manifesting after birth. It appears on prenatal ultrasound imaging as a twisting of the bowel loops around the mesenteric artery, leading to mechanical obstruction and ischemic necrosis of the bowel. Vascular compromise can result in bowel infarction and eventual perforation of the necrotic bowel, with the development of hemorrhagic fetal ascites and fetal anemia. We report a case of intrauterine midgut volvulus, suspected when ultrasound imaging revealed dilated bowel loops at 31 weeks' gestation, with fetal anemia also suspected on measurement of increased middle cerebral artery peak systolic velocity by Doppler ultrasound examination. Volvulus should be considered in the differential diagnosis when ultrasound imaging demonstrates dilated loops of bowel, especially in association with fetal ascites.

Intrauterine fetal transfusions in the management of fetal anemia and fetal thrombocytopenia

During the past 40 years, rhesus alloimmunization has gone from being one of the major causes of perinatal mortality to an almost eradicated disease. The unraveling of the pathophysiology, the development of reliable diagnostic tools, a very effective prophylaxis program, and for those (nowadays rare) cases slipping through the prevention system the availability of treatment by intrauterine blood transfusions, together constitute one of the great triumphs in modern medicine. Although Rh-D alloimmunization remains the most common indication for fetal blood transfusion therapy, an increasing percentage of these procedures is used to treat other causes of fetal anemia such as Kell alloimmunization and parvovirus B19 infection. Apart from transfusing blood, the same technique can be used to transfuse platelets to thrombocytopenic fetuses. This chapter describes the technique of fetal transfusion, and reviews the current management of fetal anemia and fetal thrombocytopenia.

Discordant Middle Cerebral Artery Peak Systolic Velocity Doppler Studies in a Fetus With RhD Alloimmunization

BACKGROUND

Doppler measurement of the fetal middle cerebral artery peak systolic velocity is a valuable tool in detecting the presence of fetal anemia in Rh-sensitized pregnancies. We present a case in which discordant left and right middle cerebral artery Dopplers complicated clinical management.

CASE

An RhD-alloimmunized patient had middle cerebral artery Dopplers at 30 weeks of gestation, which showed an elevated peak systolic velocity in the left middle cerebral artery, greater than 1.55 multiples of the mean, but the right middle cerebral artery was within the normal range. The amniotic fluid change in optical density at a wavelength of 450 nm was consistent with the right middle cerebral artery Doppler. When both Dopplers were greater than or equal to 1.5 multiples of the mean, fetal blood sampling revealed a hematocrit of 28%. Postnatal cranial ultrasound examination showed normal architecture, but there was persistent discordant Dopplers in the left versus the right middle cerebral artery.

CONCLUSION

Measurement of both left and right middle cerebral artery peak systolic velocities may identify patients with intrinsic variations in cranial blood vessels resulting in abnormal Doppler flows.

Middle cerebral artery peak systolic velocity of healthy fetuses in the first half of pregnancy

OBJECTIVE

The purpose of this study was to establish normative data of middle cerebral artery (MCA) peak systolic velocity (PSV) in the first half of normal pregnancies (11-22 weeks).

METHODS

A prospective cross-sectional descriptive study was conducted in which low-risk pregnant women whose pregnancies were singleton with accurate gestational age were recruited into the study. All neonates were subsequently proven to be healthy at birth. The sonographic measurements of MCA PSV were performed by the same examiner with a high-resolution machine.

RESULTS

The total number of measurements was 410, and the number of measurements for each gestational week ranged from 30 to 40. The best regression model between gestational week and placental thickness was observed to be a linear function, and reference curves were constructed. The results showed a continuous increase in MCA PSV over the period from 11 to 22 weeks. During the period of study, 3 fetuses with hemoglobin Bart disease in the first half of pregnancy were encountered, and all of them had PSV of greater than the 95th percentile as well as 1.5 multiples of the median for each gestational week.

CONCLUSIONS

A nomogram of MCA PSV for each gestational age from 11 to 22 weeks was constructed. These reference ranges may be useful noninvasive tools in risk assessment for fetal anemia in early pregnancy, especially due to hemoglobin Bart disease.

Hemodynamic changes in the fetal arteries during the second half of pregnancy assessed by Doppler velocimetry

The applicability of Doppler velocimetry has been well established regarding intrauterine growth restriction and fetal hypoxia. This method can also be used to determine fetal anemia and cardiac malformations. The main fetal arteries evaluated by Doppler velocimetry are the middle cerebral artery and the umbilical artery. However, the fetal aorta is responsible for the distribution of blood flow to the upper and lower extremities of the human body and should also be properly valued. In order to characterize abnormalities in the arteries of high-risk fetuses, it is necessary to know the hemodynamic modifications of normal fetuses. On this basis, the authors performed a review of fetal hemodynamics evaluated by Doppler velocimetry in the fetal aorta and middle cerebral and umbilical arteries during the second half of pregnancy. The study of fetal vessels by Doppler velocimetry indirectly evaluates the hemodynamic changes occurring in fetuses at risk. In this respect, we emphasize the changes in Doppler velocimetry occurring in fetal anemia, in restricted intrauterine growth, and in normal fetuses.