Minimizing neonatal adverse events associated with the management of red cell alloimunization: A decision analysis

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OF RED CELL ALLOIMUNIZATION: A DECISION ANALYSIS ANGELA SILBER, SERDAR URAL, University of Pennsylvania, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: Compare strategies for managing patients with red cell alloimunization and identify the path that maximizes perinatal survival and outcome. STUDY DESIGN: Using decision analysis, we compared 3 screening strategies: Doppler ultrasound measurements of middle cerebral artery (MCA) peak velocity followed by cordocentesis, serial amniocentesis with determination of amniotic fluid delta-OD450 and no testing. Outcomes included perinatal death and prematurity sequelae, including grade III-IV intraventricular hemorrhage (IVH). Baseline assumptions included procedure-specific and gestational agespecific estimates of perinatal morbidity and mortality. The high pay calculation path was chosen, for survival intact pay off defined as 1, survival with sequelae given pay off 0.5 and for death, 0. RESULTS: The optimal strategy with the highest pay off is MCA Doppler screening. The pay off for MCA Doppler screening reached 0.91; with the amniocentesis protocol the pay off reached 0.71 and for no testing, 0.22. CONCLUSION: The MCA Doppler strategy is the one with the highest pay off, suggesting higher overall and intact neonatal survival when compared to the amniocentesis and no testing strategies. In the absence of randomized controlled trials, this analysis suggests that MCA Doppler strategy is the optimal scheme for managing red cell alloimmunization.