Induced Abortion and the Risk of Rh Sensitization

Importance

While population-level data suggest Rh immunoglobulin is unnecessary before 12 weeks' gestation, clinical evidence is limited. Thus, guidelines vary, creating confusion surrounding risks and benefits of Rh testing and treatment. As abortion care in traditional clinical settings becomes harder to access, many people are choosing to self-manage and need to know if ancillary blood type testing is necessary.

Objective

To determine how frequently maternal exposure to fetal red blood cells (fRBCs) exceeds the most conservative published threshold for Rh sensitization in induced first-trimester abortion.

Design, Setting, and Participants

Multicenter, observational, prospective cohort study using high-throughput flow cytometry to detect circulating fRBCs in paired maternal blood samples before and after induced first-trimester abortion (medication or procedural). Individuals undergoing induced first-trimester abortion before 12 weeks 0 days' gestation were included. Paired blood samples were available from 506 participants who underwent either medical (n = 319 [63.0%]) or procedural (n = 187 [37.0%]) abortion.

Exposure

Induced first-trimester abortion.

Main Outcomes and Measures

The primary outcome was the proportion of participants with fRBC counts above the sensitization threshold (125 fRBCs/5 million total RBCs) after induced first-trimester abortion.

Results

Among the 506 participants, the mean (SD) age was 27.4 (5.5) years, 313 (61.9%) were Black, and 123 (24.3%) were White. Three of the 506 participants had elevated fRBC counts at baseline; 1 of these patients had an elevated fRBC count following the abortion (0.2% [95% CI, 0%-0.93%]). No other participants had elevated fRBC counts above the sensitization threshold after induced first-trimester abortion. The median change from baseline was 0 fRBCs, with upper 95th and 99th percentiles of 24 and 35.6 fRBCs, respectively. Although there was a strong association between the preabortion and postabortion fRBC counts, no other baseline characteristic was significantly associated with postabortion fRBC count.

Conclusions and Relevance

Induced first-trimester abortion is not a risk factor for Rh sensitization, indicating that Rh testing and treatment are unnecessary before 12 weeks' gestation. This evidence may be used to inform international guidelines for Rh immunoglobulin administration following first-trimester induced abortion.

Fetal and Neonatal Reticulocyte Count Response to Intrauterine Transfusion for the Treatment of Red Blood Cell Alloimmunization

Management of hemolytic disease of the fetus and newborn relies on monitoring of maternal antibody titers, fetal ultrasound, and fetal middle cerebral artery peak systolic velocity studies and is generally treated by intrauterine transfusion (IUT). Few studies have explored fetal and neonate physiological responses to IUT. Our objective was to examine fetal erythropoietic response and to examine neonatal erythropoietic effects after treatment. Thirty-six patients treated from 2005 to 2015 were identified retroactively. The time course of treatment, including gestational age and number of IUT, and timing of delivery were reviewed. Fetal reticulocyte count and neonatal hemoglobin and reticulocyte counts were analyzed for each IUT. For each gestational week, reticulocyte count decreased by ∼8.6% (95% confidence interval [CI]: 5.3-12.0). In the neonatal period, there was significant correlation between hemoglobin at birth and number of transfusions (Spearman correlation 0.473, 95% CI: 0.113-0.715, P =0.01) as well as reticulocyte count at birth and number of transfusions (Spearman correlation: 0.393, 95% CI: 0.058-0.642, P =0.02). IUT appears to have a direct and measurable effect on fetal reticulocyte production which persists in neonates.

Hemolytic disease of the fetus and newborn due to Rh(D) incompatibility: A preventable disease that still produces significant morbidity and mortality in children

In the mid-20th century, Hemolytic Disease of the Fetus and Newborn, caused by maternal alloimmunization to the Rh(D) blood group antigen expressed by fetal red blood cells (i.e., "Rh disease"), was a major cause of fetal and neonatal morbidity and mortality. However, with the regulatory approval, in 1968, of IgG anti-Rh(D) immunoprophylaxis to prevent maternal sensitization, the prospect of eradicating Rh disease was at hand. Indeed, the combination of antenatal and post-partum immunoprophylaxis is ~99% effective at preventing maternal sensitization to Rh(D). To investigate global compliance with this therapeutic intervention, we used an epidemiological approach to estimate the current annual number of pregnancies worldwide involving an Rh(D)-negative mother and an Rh(D)-positive fetus. The annual number of doses of anti-Rh(D) IgG required for successful immunoprophylaxis for these cases was then calculated and compared with an estimate of the annual number of doses of anti-Rh(D) produced and provided worldwide. Our results suggest that ~50% of the women around the world who require this type of immunoprophylaxis do not receive it, presumably due to a lack of awareness, availability, and/or affordability, thereby putting hundreds of thousands of fetuses and neonates at risk for Rh disease each year. The global failure to provide this generally acknowledged standard-of-care to prevent Rh disease, even 50 years after its availability, contributes to an enormous, continuing burden of fetal and neonatal disease and provides a critically important challenge to the international health care system.

Sensitivity of fetal RHD screening for safe guidance of targeted anti-D immunoglobulin prophylaxis: prospective cohort study of a nationwide programme in the Netherlands

OBJECTIVE

 To determine the accuracy of non-invasive fetal testing for the RHD gene in week 27 of pregnancy as part of an antenatal screening programme to restrict anti-D immunoglobulin use to women carrying a child positive for RHD DESIGN:  Prospectively monitoring of fetal RHD testing accuracy compared with serological cord blood typing on introduction of the test. Fetal RHD testing was performed with a duplex real time quantitative polymerase chain reaction, with cell-free fetal DNA isolated from 1 mL of maternal plasma The study period was between 4 July 2011 and 7 October 2012. The proportion of women participating in screening was determined.

SETTING

 Nationwide screening programme, the Netherlands. Tests are performed in a centralised setting.

PARTICIPANTS

 25 789 RhD negative pregnant women.

MAIN OUTCOME MEASURES

 Sensitivity, specificity, false negative rate, and false positive rate of fetal RHD testing compared with serological cord blood typing; proportion of technical failures; and compliance to the screening programme.

RESULTS

 A fetal RHD test result and serological cord blood result were available for 25 789 pregnancies. Sensitivity for detection of fetal RHD was 99.94% (95% confidence interval 99.89% to 99.97%) and specificity was 97.74% (97.43% to 98.02%). Nine false negative results for fetal RHD testing were registered (0.03%, 95% confidence interval 0.01% to 0.06%). In two cases these were due to technical failures. False positive fetal RHD testing results were registered for 225 samples (0.87%, 0.76% to 0.99%). Weak RhD expression was shown in 22 of these cases, justifying anti-D immunoglobulin use. The negative and positive predictive values were 99.91% (95% confidence interval 99.82% to 99.95%) and 98.60% (98.40% to 98.77%), respectively. More than 98% of the women participated in the screening programme.

CONCLUSIONS

 Fetal RHD testing in week 27 of pregnancy as part of a national antenatal screening programme is highly reliable and can be used to target both antenatal and postnatal anti-D immunoglobulin use.

Neonatal outcome after fetal anemia managed by intrauterine transfusion

In-utero transfusion is now well under control and improves the survival of foetuses monitored for fetal anemia with a survival rate of more than 80 %. The aim was to evaluate short-term neonatal outcome after fetal severe anemia managed by intrauterine transfusions. We did a retrospective study of all neonates born after management of severe fetal anemia (n = 93) between January 1999 and January 2013 in our regional center. The two main causes of anemia were maternal red blood cell alloimmunization (N = 81, 87 %) and Parvovirus B19 infection (N = 10, 10.8 %). In the alloimmunization group, phototherapy was implemented in 85.2 % of cases with a maximum level of bilirubin of 114.4 ± 60.7 (mg/dl). Transfusion and exchange transfusion were, respectively, required in 51.9 % and in 34.6 % of cases. One neonate presented a convulsive episode, and we observed three neonatal deaths. In the parvovirus group, none of the child had anemia at birth and no management was necessary.

CONCLUSION

Contemporary management of Rhesus disease is associated with encouraging neonatal outcomes. In case of Parvovirus infection, no specific management is necessary at. But, in all cases of fetal anemia, children should be followed up with particular attention to neurologic development.

WHAT IS KNOWN

• In-utero transfusion is now well under control and improves the survival of fetuses monitored for fetal anemia. • Limited studies are available on the effect of IUT on postnatal outcome in infants with a history of fetal anemia. What is New: • Contemporary management of severe Rhesus disease is associated with encouraging neonatal outcomes. • The majority of infants can be managed with phototherapy and a limited number of top-up transfusions and exchange transfusions. In case of Parvovirus infection, the short-term neonatal outcome is excellent.

[Maternal blood intrauterine transfusions in the therapy of red-cell alloimmunization performed in three difficult cases]

Maternal alloimmunization can lead to hemolytic anemia, hydrops fetalis and even fetal or neonatal death. Intrauterine treatment is possible and effective even though it is associated with some risk. We present a rare method of maternal blood intrauterine transfusions in the therapy of three difficult cases of erythroblastosis fetalis. The aim of this report was to present an alternative to volunteer donors. In severe cases, i.e. in the absence of matching blood types from the donor in the presence of multiple alloantibodies in the pregnant woman or if multiple transfusions are required, this can be the only therapeutic option. To the best of our knowledge, this has been the first publication on maternal blood donation for intrauterine transfusion in the Polish literature.

Therapeutic management of fetal anemia: review of standard practice and alternative treatment options

Fetal anemia, mainly due to red cell alloimmunization, is still a significant cause of fetal and neonatal mortality and morbidity. The focus of current clinical research has shifted from an invasive approach to non-invasive management and treatment of affected pregnancies, and the progress in this field is associated with a major improvement in perinatal outcome. During the last 50 years, intrauterine red cells transfusion (IUT), fi rst via the intraperitoneal route and later directly to fetal circulation, is the standard practice in most centers, with survival rates that exceed 90 % , particularly if anemia is diagnosed early and treated in a timely manner. In addition, plasmapheresis and intravenous administration of highdose immunoglobulin have been implicated in the treatment of pregnancies complicated with early-onset severe red cell alloimmunization, alone or in combination with IUTs before the 20(th) week of pregnancy, but there are still issues to be clarified further. This review article aims to provide an overview of the current standard therapeutic management and alternative treatment modalities in pregnancies complicated by fetal anemia.

Techniques of intrauterine fetal transfusion for women with red-cell isoimmunisation for improving health outcomes

BACKGROUND

Red-cell alloimmunisation can occur when there are incompatibilities between a woman's blood type and that of her unborn baby. This can cause the baby to become anaemic (low red blood cell count), which may require treatment during the pregnancy by blood transfusion while the baby remains within the uterus (called an intrauterine blood transfusion).

OBJECTIVES

To compare, using the best available evidence, the benefits and harms of different techniques of intrauterine fetal blood transfusion for women with red-cell alloimmunisation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 June 2012).

SELECTION CRITERIA

We considered randomised controlled trials comparing different techniques of intrauterine fetal blood transfusion (either alone or in combination with another technique) for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials under consideration for appropriateness for inclusion and methodological quality, without consideration of their results according to the prestated eligibility criteria. We planned to use a fixed-effect meta-analysis for combining study data if we judged the trials to be sufficiently similar. We planned to investigate statistical heterogeneity using the I² statistic; if this indicated a high degree of statistical heterogeneity, we planned to use a random-effects model.

MAIN RESULTS

Our search strategy identified four reports of three studies for consideration, of which two met the inclusion criteria, involving 44 women. We identified a single trial comparing the use of intrauterine fetal blood transfusion and intravenous immunoglobulin versus intrauterine fetal blood transfusion alone, and a single trial comparing the use of atracurium and pancuronium. There were no statistically significant differences identified for any of the reported outcomes.

AUTHORS' CONCLUSIONS

There is little available high quality information from randomised controlled trials to inform the optimal procedural technique when performing fetal intrauterine fetal blood transfusions for women with an anaemic fetus due to red cell alloimmunisation. Further research evaluating the benefits and harms associated with different techniques is required.

[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.

Desferrioxamine treatment of iron overload secondary to RH isoimmunization and intrauterine transfusion in a newborn infant

Intrauterine transfusion is the standard of care in the management of severe Rh isoimmunization. Desferrioxamine has been used for the treatment of iron overload secondary to hemolysis and intrauterine transfusions in Rh isoimmunization cases. Here, we report a preterm infant born at 34 weeks of gestational age who had formerly received intrauterine transfusions for Rhesus hemolytic disease and presented with severe hyperferritinemia and elevated liver enzymes in the first week of life. Desferrioxamine treatment was started due to a ferritin level of 28,800 ng/ml and continued for 13 weeks. Although the treatment was successful, we observed resistant leukopenia which resolved after the cessation of treatment. In conclusion, iron overload secondary to intrauterine transfusions can be treated successfully with desferrioxamine; however, neonatologists must be aware of the possible side effects of this drug which has been used in only a limited number of newborns.

Necrotizing enterocolitis in a term neonate following intravenous immunoglobulin therapy

A term baby with severe BO isoimmunization was treated with intravenous immunoglobulin. Shortly after the completion of the infusion, the baby developed clinical and radiological signs of necrotizing enterocolitis, with intestinal perforation and massive hemorrhagic ascites, resulting in the death of the baby.

Early intrauterine transfusion in severe red blood cell alloimmunization

OBJECTIVE

To determine perinatal outcome in pregnancies with early severe red blood cell (RBC) alloimmunization.

METHODS

This was a retrospective analysis of 30 patients requiring their first intrauterine transfusion (IUT) at < 22 weeks of gestation. Timing of the first IUT was based on evaluation of either the middle cerebral artery peak systolic velocity (MCA-PSV) or development of ascites.

RESULTS

Thirty-three per cent of the patients had experienced a previous intrauterine fetal death as a result of RBC alloimmunization. Of these alloimmunized pregnancies, 26 (87%) were associated with anti-D, four (13%) with anti-Kell and 12 had more than one antibody type involved. The antibody titers before the first IUT ranged from 1:128 to 1:8024. All fetuses were severely anemic before the first IUT with a median hemoglobin (Hb) level of 37 (range, 3-81) g/L. The nine hydropic fetuses had a lower Hb level compared with non-hydropic fetuses (median 15 g/L vs. 42 g/L, P = 0.016). However, 15 (71%) non-hydropic fetuses had an Hb level of < 50 g/L before the first IUT. The median gestational age at the first IUT was 20.4 (range, 16-22) weeks, and between one and nine transfusions were needed during pregnancy. Transfusion was via the intrahepatic vein (IHV) (n = 19), umbilical vein (n = 6) or umbilical artery (n = 2), or was intracardiac (n = 2) or intraperitoneal (n = 1). Overall perinatal survival rate was 80% and did not differ between hydropic and non-hydropic fetuses. Median gestation at delivery, after exclusion of six intrauterine fetal deaths, was 36.7 (range, 27.8-38.4) weeks.

CONCLUSIONS

In early severe RBC alloimmunization, fetuses can be severely anemic without hydrops, and prognosis cannot be predicted by the presence or absence of hydrops. Early IUT followed by serial transfusions is associated with a perinatal survival rate of about 80%.

Techniques of intrauterine fetal transfusion for women with red-cell isoimmunisation for improving health outcomes

BACKGROUND

Red-cell alloimmunisation can occur when there are incompatibilities between a woman's blood type and that of her unborn baby. This can cause the baby to become anaemic (low red blood cell count), which may require treatment during the pregnancy by blood transfusion while the baby remains within the uterus (called an intrauterine blood transfusion).

OBJECTIVES

To compare, using the best available evidence, the benefits and harms of different techniques of intrauterine fetal blood transfusion for women with red-cell alloimmunisation.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2010).

SELECTION CRITERIA

We considered randomised controlled trials comparing different techniques of intrauterine fetal blood transfusion (either alone or in combination with another technique) for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials under consideration for appropriateness for inclusion and methodological quality, without consideration of their results according to the prestated eligibility criteria. We planned to use a fixed-effect meta-analysis for combining study data if we judged the trials to be sufficiently similar. We planned to investigate statistical heterogeneity using the I(2) statistic; if this indicated a high degree of statistical heterogeneity, we planned to use a random-effects model.

MAIN RESULTS

Our search strategy identified four reports of three studies for consideration, of which two met the inclusion criteria, involving 44 women. We identified a single trial comparing the use of intrauterine fetal blood transfusion and intravenous immunoglobulin versus intrauterine fetal blood transfusion alone, and a single trial comparing the use of atracurium and pancuronium. There were no statistically significant differences identified for any of the reported outcomes.

AUTHORS' CONCLUSIONS

There is little available high quality information from randomised controlled trials to inform the optimal procedural technique when performing fetal intrauterine fetal blood transfusions for women with an anaemic fetus due to red cell alloimmunisation. Further research evaluating the benefits and harms associated with different techniques is required.

[Red-cell alloimmunization: prevention and management]

Although very rare, red-cell immunization is a main factor of hemolytic fetal anemia and severe neonatal jaundice. We emphasize on the prevention of immunization in different situations of feto maternal bleeding by early intravenous injection of 200 at 300 IU or more depending on the term of pregnancy, the circumstances and results of the Kleihauer's test. Prophylaxis corresponds a systematic intramuscular injection of 300 IU immunoglobulin (Natead ) at 28 WA, is performed in many countries. This measure implies information and rigor from Perinatal's professional. If this systematic prophylaxis was conducted, it is not necessary to repeat the IAR until the birth. But if the patient has not received the injection of 28 WA, IAR of the 8th month must be maintained.

Mechanisms of anti-D action in the prevention of hemolytic disease of the fetus and newborn

Anti-D is routinely and effectively used to prevent hemolytic disease of the fetus and newborn (HDFN) caused by the antibody response to the D antigen on fetal RBCs. Anti-D is a polyclonal IgG product purified from the plasma of D-alloimmunized individuals. The mechanism of anti-D has not been fully elucidated. Antigenic epitopes are not fully masked by anti-D and are available for immune system recognition. However, a correlation has frequently been observed between anti-D-mediated RBC clearance and prevention of the antibody response, suggesting that anti-D may be able to destroy RBCs without triggering the adaptive immune response. Anti-D-opsonized RBCs may also elicit inhibitory FcgammaRIIB signaling in B cells and prevent B cell activation. The ability of antigen-specific IgG to inhibit antibody responses has also been observed in a variety of animal models immunized with a vast array of different antigens, such as sheep RBCs (SRBC). This effect has been referred to as antibody-mediated immune suppression (AMIS). In animal models, IgG inhibits the antibody response, but the T-cell response and memory may still be intact. IgG does not mask all epitopes, and IgG-mediated RBC clearance or FcgammaRIIB-mediated B-cell inhibition do not appear to mediate the AMIS effect. Instead, IgG appears to selectively disrupt B cell priming, although the exact mechanism remains obscure. While the applicability of animal models of AMIS to understanding the true mechanism of anti-D remains uncertain, the models have nevertheless provided us with insights into the possible IgG effects on the immune response.

Intravenous immune globulin reduces the need for exchange transfusions in Rhesus and AB0 incompatibility

AIM

To conduct a quality control review of a single institution experience with intravenous immune globulin in the treatment of Rhesus and AB0 incompatibility.

METHODS

Intravenous immune globulin as treatment for Rhesus and AB0 incompatibility was introduced in our hospital in 1998. We performed a chart review of 176 infants with Rhesus or AB0 incompatibility treated in our hospital between 1993 and 2003, divided into a historical control group (1993-1998) and a treatment group (1999-2003). The project was approved through institutional ethics procedures.

RESULTS

The use of exchange transfusion as a therapeutic modality was significantly reduced in the cohort treated with intravenous immune globulin (OR 0.11; 95% CI 0.046-0.26, p < 0.001). We found no difference between the intravenous immune globulin group and the infants receiving only exchange transfusion as far as the duration of phototherapy. Infants with Rhesus incompatibility had a higher need for top-up transfusions than those with AB0 incompatibility.

CONCLUSION

This study supports the evidence from previous studies suggesting that intravenous immune globulin significantly reduces the need for exchange transfusion in infants with Rhesus and AB0 incompatibility.

Rhesus haemolytic disease of the newborn: Postnatal management, associated morbidity and long-term outcome

Rhesus haemolytic disease of the newborn can lead to complications such as hyperbilirubinaemia, kernicterus and anaemia. Postnatal management consists mainly of intensive phototherapy, exchange transfusion and blood transfusion. During the last decades, significant progress in prenatal care strategies for patients with Rhesus haemolytic disease has occurred. New prenatal management options have led to a remarkable reduction in perinatal mortality. As a result of the increase in perinatal survival, attention is now shifting towards short-term and long-term morbidity. This review focuses on the management of neonatal and paediatric complications associated with Rhesus haemolytic disease, discusses postnatal treatment options and summarizes the results of studies on short-term and long-term outcome.

Pediatric outcome in Rhesus hemolytic disease treated with and without intrauterine transfusion

OBJECTIVE

To study the short-term morbidity in Rhesus hemolytic disease of infants treated either with or without intrauterine transfusions (IUT).

STUDY DESIGN

All term and near term infants (gestational age > or = 36 weeks) with neonatal Rhesus hemolytic disease admitted to our center between January 2000-March 2005 were retrospectively included in the study. We recorded the duration of phototherapy, the need of exchange transfusions, and the need of top-up red blood cell transfusions until 6 months of age.

RESULTS

A total of 89 infants were included, of whom 52 received at least one IUT. Duration of phototherapy in the IUT and no-IUT group was 3.8 and 5.1 days, respectively (P = .01). The percentage of infants requiring an exchange transfusion in the IUT group was 71% compared to 65% in the no-IUT group (P = .64). The percentage of infants requiring a top-up transfusion in the IUT and no-IUT group was 77% and 26.5%, respectively (P < .01).

CONCLUSION

Infants with Rhesus hemolytic disease treated with IUT required less days of phototherapy and more top-up red blood cell transfusions than neonates without IUT. However, the need for exchange transfusion was similar in both groups.

Intraperitoneal Transfusion in Severe, Early-Onset Rh Isoimmunization

OBJECTIVE

To describe the management of five women with severe, early-onset Rh isoimmunization with a series of intraperitoneal transfusions.

METHODS

Intraperitoneal transfusions were started at 15 to 16 weeks of pregnancy, with small volumes of blood given weekly until the umbilical cord could be successfully entered and further transfusions given intravascularly.

RESULTS

The initial range of anti-D immune globulin levels was 24-244 international units, and all women had severe Rh isoimmunization complicating previous pregnancies. No fetus was severely anemic at the first intravascular transfusion (lowest hemoglobin 8.9 g/dL), and there were no fetal losses. Middle cerebral artery peak systolic velocity responded to treatment with intraperitoneal transfusions, suggesting that even at 15 to 16 weeks of gestation it correlates with fetal hemoglobin.

CONCLUSION

This series shows that intraperitoneal transfusions can be used to successfully treat severe, early-onset Rhesus disease.

Relationship between obstetric history and Rh(D) alloimmunization severity

BACKGROUND

To evaluate the relationship between obstetric history and Rh(D) alloimmunization severity, employing the gestational age at the first intrauterine fetal transfusion (IUT) as an indicator of this severity.

METHODS

From 1996 to 2006, Rh(D) alloimmunized pregnancies submitted to IUT had their data assessed. Gestational age at the first IUT was modeled as a linear outcome. The associations between obstetric history variables, anti-Rh(D) antibodies titer and gestational age at the first IUT were analyzed. Statistics are presented with 95% confidence intervals (P < 0.05).

RESULTS

A total of 82 non-hydropic anemic fetuses, ensuing in 92.7% (n = 76) of perinatal survival, were submitted to IUT. Nineteen (23,2%) pregnant women did not present with any previous stillbirth, neonatal death, IUT, hydrops or neonatal exchange transfusion (group 1); and 63 (76.8%) reported at least one of these events (group 2). Gestational age at the first IUT differed significantly between the groups (P = 0.0001). For group 1, it ranged from 24 to 35 weeks (median 32.5 weeks), whereas for group 2 it ranged from 19 to 34 weeks (median 27 weeks). In the multivariated analysis, previous neonatal death (P = 0.040), previous IUT (P = 0.000) and previous neonatal exchange transfusion (P = 0.036) were independently associated with the gestational age at the first IUT.

CONCLUSIONS

The evaluation of the obstetrical history is an important diagnostic tool for predicting Rh(D) alloimmunization severity. Alloimmunized pregnant women who reported previous neonatal death(s), neonatal exchange transfusion(s) or IUT(s) should receive a closer fetal surveillance due to the risk of a higher rate of fetal hemolysis and the need of an earlier IUT.

Fetal hematocrit decrease after repeated intravascular transfusions in alloimmunized pregnancies

BACKGROUND

The aim of this study is to evaluate the fetal hematocrit (Hct) decrease along repeated intravascular intrauterine fetal transfusions (IUTs) and test the hypothesis that, after consecutive IUTs, there is a lower Hct drop off.

METHODS

From July 1996 to June 2006, pregnancies submitted to IUT for fetal hemolytic anemia treatment had their data assessed. The daily rate of decrease in fetal Hct was calculated by dividing the difference between the posttransfusion Hct of the previous IUT and the pretransfusion Hct of the current IUT, by the number of days between the transfusions. Fetuses with other abnormalities or submitted to intraperitoneal transfusions were excluded.

RESULTS

Eighty-one women were submitted to IUT during the alluded period, ensuing 296 intrauterine transfusions. The perinatal survival was 89.9% (n = 80), with 92.0% (n = 69) of nonhydropic fetuses survival. Hydropic fetuses showed higher hematocrit drop off than nonhydropic ones (P < 0.01). Compared to the interval between the first and second IUT, the daily fetal Hct decline was lower after the third one (P < 0.05). Stratifying by the presence of hydrops, nonhydropic fetuses showed a smaller decrease at the third and fourth intervals (P < 0.01 and P < 0.05, respectively). Among hydropic fetuses, there is a trend of smaller Hct decrease along successive IUTs (interval 3, P = 0.08; interval 4, P = 0.07; and interval 5, P = 0.10).

CONCLUSIONS

Following some IUTs, fetal hematocrit decrease is lower and larger intervals between the transfusions could be accomplished. Multicenter studies should investigate an algorithm for timing subsequent IUTs, considering Doppler values, estimated fetal hematocrit decline and other parameters.

Perinatal mortality in Rh alloimmunized patients

OBJECTIVE

Evaluate and compare the perinatal mortality of Rh-negative pregnancies managed at São Paulo Federal University during a 9-year period, using either amniocentesis or middle cerebral artery peak systolic velocity.

METHOD

Descriptive observational study involving 291 consecutive Rh-negative pregnancies managed between January 1995 and January 2004. The perinatal mortality of 99 alloimmunized patients was compared with 192 Rh-negative unimmunized patients (control group). The perinatal mortality of patients managed with amniocenteses was compared to those managed with Doppler studies.

RESULTS

There were 74 patients managed with amniocenteses and 25 managed with Doppler studies. Perinatal mortality was significantly higher in the 99 Rh-negative isoimmunized patients than in the 192 unimmunized patients (12.1% versus 1%, p=0.0001) and did not differ according to the management protocol used (amniocentesis 13.5% versus cerebral Doppler 8.0%, p=0.725). Mean gestational age and mean weight at birth in pregnancies managed with amniocenteses (35.7 weeks and 2586 g) did not differ significantly from those managed with Doppler (36.3 weeks and 2647 g).

CONCLUSIONS

Perinatal mortality in Rh-negative alloimmunized patients remains high and does not differ whether pregnancies are managed through amniocentesis or cerebral Doppler evaluation.

Combined plasmapheresis and intravenous immune globulin for the treatment of severe maternal red cell alloimmunization

OBJECTIVE

The objective of the study was to report the maternal and perinatal outcome in patients with severe red cell alloimmunization in pregnancy who were treated with immunomodulation therapy.

STUDY DESIGN

This was a retrospective multicenter case series. Patients with a history of early second-trimester fetal loss secondary to severe maternal red cell alloimmunization or patients with markedly elevated maternal antired cell titers felt to be consistent with poor fetal outcome were offered treatment. Therapy consisted of serial plasmapheresis followed by weekly infusions of intravenous immune globulin (IVIG). Maternal titers were measured before and after plasmapheresis.

RESULTS

Pregnant patients with either a history of a previous perinatal loss (n = 7) or markedly elevated maternal antibody titers (n = 2) were treated with combined plasmapheresis and IVIG. All 9 fetuses subsequently required intrauterine transfusions (median 4; range 3-8). All infants survived with a mean gestational age at delivery of 34 weeks (range 26-38 weeks). Maternal antired cell titers were significantly reduced after plasmapheresis (P < .01) and remained decreased during IVIG therapy. Serial peak middle cerebral artery velocities remained below the threshold for moderate to severe fetal anemia during therapy.

CONCLUSION

Combined immunomodulation with plasmapheresis and IVIG represents a successful approach to the treatment of severe maternal red cell alloimmunization.

Prediction of severe fetal anemia in red blood cell alloimmunization after previous intrauterine transfusions

OBJECTIVE

This study was undertaken to determine the detection of fetal anemia and false-positive rates by fetal middle cerebral artery peak systolic velocity (MCA-PSV) and the estimated daily decrease of hemoglobin (Hb) in red blood cell alloimmunized pregnancies that had previous fetal transfusions.

STUDY DESIGN

We examined the relation between MCA-PSV measured before cordocentesis, and fetal Hb at the time of the second (n = 42) and third (n = 31) intrauterine blood transfusions. In addition, the daily Hb drop between the transfusions was calculated.

RESULTS

The MCA-PSV provided significant prediction of severe anemia (Hb deficit > or = 6 g/dL) for the second but not for the third transfusion. Detection of 95% of severely anemic fetuses was achieved with a false-positive rate of 37% for the second transfusion and 90% for the third, compared with 14% in our previous study for the first transfusion. In patients who had received 2 previous transfusions, the only significant predictor of fetal anemia was the estimation of the Hb from the measured posttransfusion Hb after the second transfusion and the assumption that the rate of decrease in fetal Hb is 0.3 g/dL per day.

CONCLUSION

Prediction of severe fetal anemia after one transfusion is less accurate than in nontransfused fetuses. The MCA-PSV is not useful in predicting severe anemia in fetuses that already had 2 previous transfusions.

Fetal Intravenous Immunoglobulin Therapy in Rhesus Hemolytic Disease

Intrauterine blood transfusion is the mainstay of treatment of fetal rhesus hemolytic anemia with optimal perinatal outcome. Postnatal immunoglobulin therapy has been successfully used in the management of alloimmunized neonates and has shown to decrease the need for exchange transfusion. We report the first case series of fetal immunoglobulin therapy in the antenatal management of severe Rh incompatibility.

[Management of rhesus alloimmunisation by spectrophometry: about one case at the Yopougon Teaching Hospital, Côte-d'Ivoire]

The authors report a care management of a patient presenting a severe alloimmunisation treated by spectrophotometry, a very efficient method but difficult of access in developing countries. Beyond the restrictive paraclinical exams which do not allow an efficient monitoring of this pathology, the lack of alloimmunisation prevention during illegal abortions and the lack of information about patients'medical files are highly responsible for the difficult management of Rhesus- negative patients. However the authors remind that only the scan at best combined with the Doppler, are effective exams helping to avoid the constraints of spectrophotometry. Although quite well-known this pathology induces very severe foetal consequences and may involve the obstetric prognosis of young women. The caesarian section will still remain for a long time the only means to prevent foetus from alloimmunisation complications in developing countries.

A case of severe Rh (D) alloimmunization treated by intensive plasma exchange and high-dose intravenous immunoglobulin

BACKGROUND

In extremely severe Rh (D) alloimmunization, during pregnancy, early diagnosis and treatment is essential to avoid hydrops fetalis. Intrauterine transfusion (IUT) is of utmost importance in the prevention of fetal anemia but it is usually feasible only after 20 weeks of pregnancy. Therefore, additional treatment options in early pregnancy are needed.

STUDY DESIGN AND METHODS

A 27-year-old severely D+C immunized woman was admitted at 8 weeks of gestation in her fifth pregnancy with an extremely high concentration of anti-D. Her first pregnancy was uneventful but resulted in D+C alloimmunization. The next two pregnancies were unsuccessful, because of hydrops fetalis resulting in fetal death in pregnancy week 20 and 24, respectively, despite treatment with high-dose intravenous immunoglobulin (IVIG) and IUT treatment. A fourth pregnancy was terminated with legal abortion. The patient was eager and persistent to accomplish a successful pregnancy. Therefore, a combination of treatments consisting of plasma exchange (PE) three times/week and IVIG 100g/week was started in pregnancy week 12. PE was performed 53 times and totally 159L of plasma was exchanged.

RESULTS

The anti-D concentration was 12mug/mL (IAT titer 2000) before start of treatment by PE and IVIG in pregnancy week 12. The concentration of anti-D was gradually reduced to approximately 3mug/mL after only two weeks of treatment and was maintained at that level until pregnancy week 22. In pregnancy week 26 and 27, signs of hydrops were detected by ultrasonography and IUT were performed at each occasion. Sectio was inevitable at pregnancy week 28+1 and a male baby was born: Hb 58g/L (cord sample) and 68g/L (venous sample); weight 1385g; Apgar score=4-5-7; Bilirubin 56-150mmol/L (4h). Exchange transfusion was performed on day two and day five. Phototherapy was also implemented for eight days. The newborn's recovery thereafter was uneventful and complete.

CONCLUSION

A combination of PE and IVIG may be an efficient treatment possible to start in early pregnancy in patients with extremely severe Rh (D) alloimmunization, with a history of hydrops fetalis in previous pregnancies.

ACOG Practice Bulletin No. 75: Management of Alloimmunization:

When any fetal blood group factor inherited from the father is not possessed by the mother, antepartum or intrapartum fetal-maternal bleeding may stimulate an immune reaction in the mother Maternal immune reactions also can occur from blood product transfusion. The formation of maternal antibodies, or"alloimmunization,' may lead to various degrees of transplacental passage of these antibodies into the fetal circulation. Depending on the degree of antigenicity and the amount and type of antibodies involved, this transplacental passage may lead to hemolytic disease in the fetus and neonate. Undiagnosed and untreated, alloimmunization can lead to significant perinatal morbidity and mortality. Advances in Doppler ultrasonography have led to the development of noninvasive methods of management of alloimmunization in pregnant women. Together with more established protocols, Doppler ultrasound evaluation may allow for a more thorough and less invasive workup with fewer risks to the mother and fetus. Prevention of alloimmunization is addressed in another Practice Bulletin (1).

An Audit of Outcome in Intravascular Transfusions Using the Intrahepatic Portion of the Fetal Umbilical Vein Compared to Cordocentesis

INTRODUCTION

Maternal red cell alloimmunization is a potential cause of perinatal morbidity and mortality. The outcome of severe disease has been transformed by the use of in-utero and particularly, fetal intravascular transfusion. In the majority of instances this is performed by cordocentesis. However, this cohort study represents the experience in a large tertiary referral centre in performing fetal intravascular transfusions via the intrahepatic vein (IHV).

METHODS

Over an 8-year period, 1997-2004, 221 in-utero transfusions (IUT) were performed for rhesus disease in 66 pregnancies. 86% had severe fetal anaemia caused by anti-D, 10.6% by anti-Kell and 3.4% by anti-c. The median maternal age of the cohort was 31 years (range 19-43). The median gestation at initial IUT was 25 weeks (interquartile range (IQR) 23-29 weeks).

RESULTS

A median number of three IUT were performed in each fetus (IQR 2-5) with a median haemoglobin at first fetal blood sampling of 7.3 g% (IQR 4.6-8.8 g%) (73% < or =5 SD and 27% < or =2 SD). Of the total intravascular transfusions, 170 were performed via the IHV (71.7%), 33 via cordocentesis (13.9%) and 1 by intracardiac puncture (0.5%). There were 'transient' bradycardias complicating 4.1% of all transfusions and amniorrhexis following 1.4%. 92% of babies were live born at a median gestation of 34 weeks (range 21-38) with a birth weight centile of 50 (range 3-90). There was no significant difference in intravascular transfusion complication rate when the procedure was performed via the IHV (7.6%) as compared to cord root puncture (3.0%) (Fisher's exact test, p < 0.47).

CONCLUSION

IUT performed by fetal IHV puncture is safe and carries no excess morbidity when performed for severe rhesus disease.

Prevalence of new maternal alloantibodies after intrauterine transfusion for severe Rhesus disease

Limited information is published on the frequency of new maternal alloantibodies found in patients treated for isoimmunization. The purpose of this study was to determine the prevalence of additional maternal red cell alloantibodies, found after the initiation of treatment for Rhesus (Rh) disease. A retrospective review of all patients treated for severe Rh disease was undertaken. Rh disease requiring intrauterine blood transfusion was defined as severe. Gravidas with alloantibodies in addition to Rh were included, but those without Rh antibodies were excluded. New alloantibodies were defined as antibodies absent in previous pregnancies and on initial pregnancy screening, and found after the onset of invasive treatment. There were a total of 84 intrauterine blood transfusions performed in 31 gravidas with severe Rh disease. Seven patients (23%) were found to develop additional red cell alloantibodies after treatment during the pregnancy. Induction of additional maternal red cell alloantibodies after treatment for severe Rh disease is relatively common. This may have significant implications for future pregnancies in this high-risk population.

Correlation between middle cerebral artery peak systolic velocity and fetal hemoglobin after 2 previous intrauterine transfusions

OBJECTIVE

The middle cerebral artery peak systolic velocity (MCA-PSV) has been successfully used for timing the first 2 transfusions in fetuses at risk for anemia because of maternal red cell alloimmunization. The objective of this study was to assess whether the correlation between the MCA-PSV and fetal hemoglobin is maintained in fetuses that had undergone 2 previous intrauterine transfusions.

STUDY DESIGN

Doppler measurement of MCA-PSV was performed before cordocentesis in 39 fetuses. The timing of the third transfusion was based on traditional criteria. The values of MCA-PSV and hemoglobin were expressed as multiples of the median (MoM). Anemia was defined as mild (hemoglobin <0.84 MoM for a given gestational age, moderate (hemoglobin <0.65 MoM), and severe (hemoglobin <0.55 MoM). Regression analysis was used to assess the correlation between the MCA-PSV MoM and fetal hemoglobin MoM.

RESULTS

Gestational age at Doppler study ranged from 22 to 35 weeks. Six fetuses (15%) had normal hemoglobin concentration; 21 (53%) had mild anemia; 7 (20%) had moderate anemia; and 5 (12%) had severe anemia. There was a linear correlation between fetal hemoglobin (y) and the MCA-PSV (x): y = 1.185 - 0.341x.

CONCLUSION

Previously, concerns have been expressed about the accuracy of Doppler prediction of anemia after previous transfusions. Our data suggest that there is a good correlation between the MCA-PSV and fetal hemoglobin in fetuses that have undergone 2 previous transfusions. Our findings expand the clinical situation in which Doppler can be used to monitor red cell alloimmunized pregnancies.

Fetal Intravascular Transfusion for Hydropic Disease due to Rhesus Isoimmunization

OBJECTIVE

To evaluate the management of hydropic fetuses, due to rhesus isoimmunization, with fetal intrauterine intravascular transfusions.

MATERIAL AND METHODS

This is a retrospective analysis of 18 rhesus-negative pregnant women presenting at our hospital with fetal hydrops during a 7-year period. All cases were managed with serial intrauterine intravascular transfusions with the goal of delivery by cesarean section beyond 33 weeks of gestation. All patients received prophylactic ampicillin and ritodrine for 4 days after the procedure.

RESULTS

There were 11 mildly and 7 severely hydropic fetuses. All fetuses with mild hydrops and 5 of the 7 with severe hydrops were delivered alive after 32 weeks of gestation in a good condition. Two fetuses both with severe hydrops died in utero, at 28 weeks of gestation. Intrauterine reversal of hydrops occurred in 90.9% of fetuses with mild hydrops and in 57.1% of severely hydropic fetuses.

CONCLUSIONS

The survival rate for the hydropic fetuses in our study was 88.9% and it was associated with the severity of fetal hydrops.

Red Blood Cell Alloimmunization in Pregnancy

Red blood cell (RBC) alloimmunization in pregnancy continues to occur despite the widespread use of both antenatal and postpartum Rhesus immune globulin (RhIG), due mainly to inadvertent omissions in administration as well as antenatal sensitization prior to RhIG given at 28 weeks' gestation. Additional instances are attributable to the lack of immune globulins to other RBC antigens. Evaluation of the alloimmunized pregnancy begins with the maternal titer. Once a critical value [32 for anti-Rh(D) and other irregular antibodies; 8 for anti-K and -k] is reached, fetal surveillance using serial Doppler ultrasound measurements of the peak velocity in the fetal middle cerebral artery (MCA) is standard. In the case of a heterozygous paternal phenotype, amniocentesis can be performed to detect the antigen-negative fetus that requires no further evaluation. MCA velocities greater than 1.5 multiples of the median necessitate cordocentesis, and if fetal anemia is detected, intrauterine transfusion therapy is initiated. A perinatal survival of greater than 85% with normal neurologic outcome is now expected. Future therapies will target specific immune manipulations in the pregnant patient.

The effects of serial intravascular transfusions in ascitic/hydropic RhD-alloimmunized fetuses

OBJECTIVE

To evaluate the effects of serial intravascular transfusions on RhD-alloimmunized fetuses with ascites/hydrops at the time of the first transfusion by measuring multiple hematological/biochemical blood variables.

METHODS

Thirty-one singleton pregnancies were referred for management of RhD alloimmunization. Seven fetuses had hydrops on presentation and were transfused immediately. The remainder underwent weekly ultrasound examinations, and fetal blood sampling and transfusion were performed on development of ascites. In the 104 samples collected overall from the 31 fetuses, glucose, uric acid, urea, creatinine, total protein, total and direct bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase, alkaline phosphatase, lactic dehydrogenase, amylase, pseudocholinesterase (PCHE), creatine kinase, triglycerides and cholesterol were measured and compared with a reference range for non-anemic fetuses.

RESULTS

The median gestational age at first transfusion was 26 (range, 18-34) weeks. There were three fetal losses after the first transfusion, two of which were due to procedure-related complications; one further loss occurred. At the first transfusion fetal hematocrit, pO2, total protein, PCHE, creatinine and urea concentrations were significantly decreased compared to reference data, while total and direct bilirubin, AST, ALT, amylase, triglyceride and uric acid concentrations were increased. In all surviving fetuses ascites/hydrops had disappeared by the second transfusion. Fetal pO2, total protein, AST, ALT and PCHE concentrations had normalized by the third transfusion. Correction of fetal anemia did not affect the other variables.

CONCLUSIONS

RhD-alloimmunized fetuses with ascites/hydrops at the time of the first transfusion had a survival rate of 87%. Alterations of several biochemical fetal blood indices are present at the first sampling/transfusion, but most variables normalize with intravascular transfusions.

Intrauterine fetal transfusion

The incidence of perinatal death resulting from rhesus Rh isoimmunization has dropped dramatically since the introduction of Rh immunoglobulin. However, Rh sensitization continues to be one of the leading causes of fetal anemia. Our patient is a 38-year-old woman; she gives a history of 2 uneventful pregnancies followed by 5 consecutive stillbirths. Investigations revealed an anti-D titre of 1/2048 and anti-C titre of 1/256. Ultrasound examination revealed fetal ascites at 18 weeks gestation. The fetus had a total of 9 successful intrauterine transfusions. She was delivered by an elective cesarean section at 34 weeks gestation; outcome was a healthy female baby weighing 2060 g. Examination at 9 month of age showed normal growth and neurodevelopment.

Prevention and management of RhD isoimmunization

An Rh-negative woman is at risk for developing Rh isoimmunization upon exposure to RhD antigens from her Rh-positive baby through fetal-maternal hemorrhage. The incidence of Rh isoimmunization and fetal hemolytic disease has decreased substantially since Rh immune globulin was introduced in 1968. When RhD sensitization does occur, careful follow-up of these mothers and judicious intervention can result in good outcomes for most pregnancies. Both Doppler assessment of middle cerebral artery peak systolic velocity and spectral analysis of amniotic fluid at 450 nm (DeltaOD 450) are useful in the diagnosis and management of fetal anemia.

Fetal hemolytic disease due to anti-Rh17 alloimmunization

OBJECTIVE

To delineate clinical features of a case of fetal hemolytic disease due to anti-Rh17, along with a review of relevant studies published in English and Japanese.

METHODS

We present clinical features of a -D-/-D- phenotype woman with anti-Rh17 alloimmunization during pregnancy. Relevant English literature in the MEDLINE database was reviewed, while Japanese studies were searched in the Japana Centra Revuo Medicina database.

RESULTS

A Japanese -D-/-D- woman with anti-Rh17 (Hro) was treated during pregnancy. Serial ultrasonography, antibody titers, amniocenteses, and cordocenteses were conducted for perinatal management. Amniocentesis results demonstrated a high delta optical density level of 450 in the amniotic fluid, while cordocentesis revealed alloimmunization between the mother and the fetus as well as fetal hemolytic anemia. Blood flow velocity in the middle cerebral artery indicated a rapid development of fetal anemia. The newborn demonstrated severe anemia and hyperbilirubinemia, which were successfully treated with exchange transfusions. Two cases of prenatally diagnosed fetal hemolytic disease due to anti-Rh17 were found published in English and 5 in Japanese.

CONCLUSION

A -D-/-D- phenotype patient with anti-Rh17 was successfully managed during pregnancy and a good outcome for the neonate was achieved. Our results and a review of related literature led to the following suggestions. The first pregnancy in a -D-/-D- woman may be affected, an anamnestic immune response can easily occur during pregnancy, the level of anti-Rh17 titer is indicative of the degree of fetal hemolysis, and appropriate intrauterine intervention is warranted for achievement of a good outcome.

A retrospective review of isoimmunized pregnancies managed by middle cerebral artery peak systolic velocity

OBJECTIVE

The purpose of this study was to determine the clinical outcome of isoimmunized pregnancies managed primarily by middle cerebral artery peak systolic velocity.

STUDY DESIGN

A retrospective chart review was conducted of isoimmunized pregnancies that underwent ultrasound examinations from January 1, 2001, through May 1, 2003. Ultrasound reports, laboratory tests, and maternal and neonatal charts were reviewed.

RESULTS

Women with a clinically significant red blood cell antibody and titer value were included. The study population consisted of 39 women (40 pregnancies, 42 fetuses). Patients with a middle cerebral artery peak systolic velocity of > or =1.5 MoM were offered amniocentesis. Seven pregnancies had an abnormal middle cerebral artery peak systolic velocity. Three of these infants had significant anemia. Six of the 7 pregnancies required an exchange transfusion. None of the 33 pregnancies (35 neonates) with normal middle cerebral artery peak systolic velocity measurements resulted in a neonate with significant anemia or severe hyperbilirubinemia.

CONCLUSION

The clinical outcome of these pregnancies supports the use of middle cerebral artery peak systolic velocity measurements in the management of isoimmunized pregnancies.

Recent developments in fetal medicine

Several advances have been made in the field of fetal medicine since the last BMJ review on the subject. This review covers advances in prenatal screening, imaging techniques, management of multiple pregnancies, and fetal therapy

The Peritoneal Route as a Safe Pathway for Early in utero Therapies: Illustration by a 12-Year Follow-Up after Conservative Management of Severe Rhesus Allo-Immunization

OBJECTIVE

We report a case of an extremely severe Rhesus allo-immunization treated very early in pregnancy 12 years ago.

METHODS AND RESULTS

After chorionic villus sampling at 12 weeks for fetal blood phenotyping, two intraperitoneal transfusions at 14 and 15 weeks were given followed by two intravascular and seven exchange transfusions. A girl weighing 2,940 g was delivered vaginally at term after external cephalic version for breech presentation. To date her neurological and social development is normal.

CONCLUSIONS

Since the success of haematopoietic stem cell transplantations for the treatment of congenital haematologic diseases could imply early and repetitive procedures, this observation enlightens the technical feasibility of such an invasive approach and its relative safety for subsequent development.

Management of Pregnancies Complicated by Anti-c Isoimmunization

OBJECTIVE

To review cases of anti-c isoimmunization and determine the most appropriate management strategies.

METHODS

We performed a review of 102 pregnancies managed at The Ohio State University from 1967 to 2001 for anti-c isoimmunization. Of these, 55 had complete data and are included in this report. Information collected included serum titers, deltaOD450 values, Liley zones, fetal and neonatal hemoglobin levels and antigen typing, neonatal direct antiglobulin test, and neonatal outcomes. The appropriateness of traditional management was then evaluated.

RESULTS

Of the 55 pregnancies, 46 had fetuses with positive direct antiglobulin test, and nine pregnancies had unaffected fetuses. Of the affected neonates, 12 (26%) had serious hemolytic disease of the newborn. Of these 12, 8 required fetal transfusion, and the remaining 4 newborns had hemoglobin levels of less than 10 g/dL at the time of delivery. A titer of 1:32 or greater or the presence of hydrops fetalis identified all such fetuses. There were 58 amniocenteses performed for deltaOD450 When plotted on modified Liley graphs, deltaOD450 values corresponded to disease severity. There were no perinatal deaths attributable to anti-c hemolytic disease of the newborn.

CONCLUSION

Anti-c isoimmunization might cause significant fetal and newborn hemolytic disease. A titer of 1:32 or greater or evidence of hydrops fetalis identified all the serious hemolytic disease at our institution. The significance of antibody titers and deltaOD450 values was similar to Rh-D sensitized pregnancies, and management by the same modalities is appropriate.