Fetal Blood Analysis Research Articles

Trial of labor after caesarean section in low risk pregnancies: is it risky?

To evaluate the influence of a previous caesarean section on adverse composite maternal and perinatal outcome in women who attempted a trial of labor. This historical cohort study analyzed maternal and perinatal outcome in women with otherwise low risk pregnancies at term who underwent a trial of labor after a caesarean section (TOLAC). The primary outcome measure was the adverse composite outcome. Secondary outcome measures were amongst others the caesarean section rate and the mode of vaginal delivery. The adverse composite outcome was more frequently in the previous caesarean section group compared to women with no previous caesarean Sect.(22.3% vs. 15.6%, p < 0.0001). The percentage of caesarean Sect.(15.4% vs. 8.2%, p < 0,0001), uterine rupture (1.0% vs. 0.02%, p < 0.0001), placental abruption (1.1% vs. 0.3%, p = 0.0014), vaginal operative delivery (16.0% vs. 8.6%, p < 0.0001), pH < 7.10 (3.7% vs. 2.5%, p = 0.0151), base excess < -12 (3.2% vs. 2.2%, p = 0.0297), abnormal cardiotocography (22.5% vs. 13.9%, p < 0,0001) and fetal blood analysis (6.2% vs. 2.6%, p < 0.0001) was significantly higher in women with a previous caesarean section. Taking the parity into account, these differences could only been seen in women without a previous vaginal delivery. In parous women with a previous vaginal delivery and a caesarean section in history, the adverse composite did not differ between the groups. Only the rate of pH < 7.1 was higher in women after a caesarean Sect.(4.5% vs. 1.8%, p = 0.0436). Trial of labor after caesarean in otherwise low risk pregnancies is associated with a higher rate of complications especially if there is no history of vaginal delivery.

Accidental discovery of copy number variation on chromosome 1 in a fetus with high risk of trisomy 13 suggested by NIPT

To validate a fetus with high risk for trisomy 13 suggested by non-invasive prenatal testing (NIPT). The fetus was selected as the study subject after the NIPT detection at Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences on February 18, 2019. Clinical data of the pregnant woman was collected. Fluorescence in situ hybridization (FISH), chromosomal karyotyping analysis and chromosomal microarray analysis (CMA) were carried out on amniotic fluid and umbilical cord blood and the couple's peripheral blood samples. Copy number variation sequencing (CNV-seq) was also performed on the placental and amniotic fluid samples following induced labor. The pregnant woman, a 38-year-old G4P1 gravida, was found to have abnormal fetal development by prenatal ultrasonography. NIPT test suggested that the fetus has a high risk for trisomy 13. Chromosomal karyotyping analysis of fetal amniotic fluid and umbilical cord blood were 46,XN,add(13)(p10). The result of CMA was arr[hg19]1q41q44(223937972_249224684)×3, with the size of the repeat fragment being approximately 25.29 Mb, the fetal karyotype was thereby revised as 46,XN,der(13)t(1;13)(q41;p10). Chromosomal karyotyping analysis and CMA of the parents' peripheral blood samples showed no obvious abnormality. The CNV-seq analysis of induced placenta revealed mosaicisms of normal karyotype and trisomy 13. The CNV-seq test of induced amniotic fluid confirmed a duplication of chr1:22446001_249220000 region spanning approximately 24.75 Mb, which was in keeping with the CMA results of amniotic fluid and umbilical cord blood samples. NIPT may yield false positive result due to placenta mosaicism. Invasive prenatal diagnosis should be recommended to women with a high risk by NIPT test. And analysis of placenta can explain the inconsistency between the results of NIPT and invasive prenatal diagnosis.

Microbial Analysis of Umbilical Cord Blood Reveals Novel Pathogens Associated with Stillbirth and Early Preterm Birth.

ABSTRACTStillbirths account for half of all perinatal mortality, but the underlying cause of a significant portion of the cases remains unknown. We set out to test the potential role and extent of microbial infection in stillbirth through a case-control analysis of fetal cord blood collected from the multisite Stillbirth Collaborative Research Network. Cases (n = 60) were defined as stillbirths at >20 weeks of gestation, and controls (n = 176) were live births. The bacterial presence, abundance, and composition were analyzed by endpoint PCR of full-length 16S rRNA and the V4 amplicon sequence variants (ASVs). The results demonstrate that bacterial prevalence and abundance were both significantly increased in stillbirth, even after adjusting for maternal age, race, body mass index, number of pregnancies, gestational age, and multiple gestations. Composition of bacterial communities in the cord blood also differed significantly. Using a group of 25 ASVs differentially abundant between the two groups, a Random Forest classification model achieved an accuracy score of 0.76 differentiating stillbirth and live birth, with Group B Streptococcus as the most enriched species in stillbirth. Positive PCR was also significantly associated with early preterm birth. A group of oral anaerobes, including Actinomyces, Campylobacter, Fusobacterium, Peptostreptococcus, Porphyromonas, and Prevotella, were enriched in live early preterm birth, suggesting possible oral origin of infection. Our ASV-based microbiome analysis revealed specific candidate pathogens associated with infections in stillbirth and early preterm birth. The cord blood microbial signatures may be markers of adverse pregnancy outcomes. Our study will help identify possible mechanism of infection and improve our ability to prevent stillbirth and early preterm birth.

Case Report of Transient Abnormal Myelopoiesis in New-born with Down’s Syndrome

Introduction: A unique white cell abnormality called transient abnormal myelopoiesis [TAM] is found in approximately 10% of neonates with Down’s syndrome. Material &amp; method: Medical record of a case of confirmed TAM in Down’s syndrome was reviewed in retrospect at Desai Metropolis laboratory. The co-relation of prenatal ultrasonographic findings, maternal screen results, fetal blood analysis, flow cytometry, karyotyping and the postnatal clinical course were done. Result: A case of TAM associated with Down’s syndrome was confirmed in November 2021. A complete blood count done on 2nd day of life showed abnormal leukocytosis with blast cells. TAM spontaneously resolved after 15 days of birth. Conclusion: Fetal TAM is a self-limiting condition which requires supportive care. In the neonatal period, most cases of TAM have a favorable outcome from this preleukemic condition, but some progress to leukemia. Investigation of TAM will continue to strongly influence basic and clinical research into development of hematological malignancies.

Maternal Anti-αIIb Antibodies Target Fetal Hematopoietic Stem Cells and May Lead to Pancytopenia and Miscarriage in Fnait

Background: Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a devastating disorder characterized by an aberrant maternal immune response against paternally inherited polymorphisms on fetal platelet antigens. Affected fetuses can experience severe bleeding (e.g. intracranial hemorrhage; ICH), neurological sequelae and death. The targeted platelet antigens are located predominantly on platelet surface receptor αIIbβ3 integrin. It is estimated that 0.5-1.5/1000 live neonates are born with FNAIT although this incidence may largely underestimate the prevalence of the disease due to miscarriage. We have previously demonstrated that anti-β3 alloantibodies can target not only fetal platelets but also the β3 subunit on endothelial cells leading to ICH and placental vascular pathologies (J Clin Invest. 2015; Nat Commun. 2017). Although the number of polymorphisms in the αIIb subunit is similar to the β3 subunit, reported incidences of anti-β3 mediated FNAIT are far greater. It is currently unknown whether this due to miscarriage in anti-αIIb mediated FNAIT. αIIb was previously considered to be exclusively expressed on platelets, however hematopoietic stem cells (HSCs) and their early progenitors can express αIIbβ3 during embryonic development and αIIb is one of the earliest markers of hematopoietic commitment. Throughout gestation, HSCs migrate from yolk sac to the aorta-gonadal-mesonephros, placenta, fetal liver and finally bone marrow. We hypothesize that miscarriage is prevalent in anti-αIIb mediated FNAIT and that maternal anti-αIIb antibodies may target HSCs resulting in decreased blood cell counts, increased bleeding and fetal death.Methods: We established an animal model of anti-αIIb mediated FNAIT by immunizing αIIb-/- mice with 108 wild-type (WT, αIIb+/+) platelets. Immunized αIIb-/- mice were then bred with WT males. We used non-immunized (naïve) αIIb-/- x WT breeding pairs as a control. Sera of immunized and naïve mice were collected prior to breeding and ultrasound was used to detect fetal death. Mice were sacrificed at E14.5 and fetuses, placentas and fetal livers were weighed. Cell suspensions were prepared from these tissues as well as fetal blood and analyzed with flow cytometry. Fluorescent markers were used to identify HSCs (CD34+/CD117+/Lin- or CD34+/CD45+) and blood cell counts for T cells (CD3+,CD4+,CD8+), B cells (CD19+), myeloid lineage cells (CD11b+) and megakaryocytes (GPIbα+).Results: Sera of immunized mice showed a significant anti-αIIb immune response. Pups of immunized mice had low platelet counts, reduced body weight and bleeding diathesis. Ultrasound revealed miscarriage occurred mainly at E14.5 of immunized αIIb+/- fetuses. The miscarriage rate in our anti-αIIb mediated FNAIT model appeared significantly higher than the anti-β3 model. At E14.5, our results showed live fetuses of immunized mice had significantly lower body and liver weight although no significant difference in placental weight was observed. We found fetal liver HSCs have increased maternal antibody binding when incubated with sera from immunized αIIb-/- mice versus naïve αIIb-/- mice in vitro, suggesting that maternal anti-αIIb antibodies target fetal HSCs in vivo . Preliminary data also demonstrated that fetuses in the immunized group had reduced overall HSCs as well as αIIb+ HSC subsets in the placenta, liver and yolk sac. Fetal blood analysis showed reduced hematopoietic lineage cells in the immunized group, particularly T cells (CD3+), B cells and megakaryocytes.Conclusions: We established an anti-αIIb mouse model of FNAIT and revealed a high rate of miscarriage, which may explain the paucity of reported human cases. Our results indicate maternal anti-αIIbantibodies may bind and target fetal HSCs during embryonic development, which contributes significantly to impaired placental and fetal liver development, and fetal death. Destruction of early αIIb+ HSC progenitors may explain the decrease in HSCs (both αIIb+ and αIIb-) and account for the pancytopenia in FNAIT fetuses. Further experiments are in progress to elucidate the mechanism by which destruction of αIIb+ HSCs contributes to fetal pathology.*J.S. and B.E.O contributed equally to this work DisclosuresNo relevant conflicts of interest to declare.

The Changing Trends in Prenatal Diagnosis of Hemoglobinopathies in India: The Quest of a Single Center to Reduce the Burden of Disease over Three Decades

The β-thalassemias and sickle cell disorders pose a considerable health burden in India. Of the more than 10,000 annual births of children with a severe hemoglobinopathy, only around 10.0% are managed optimally. Thus, genetic counseling and prenatal diagnosis (PND) is a valid option for a large and diverse country. Our center was one of the first to initiate PND and we present our experience over 30 years to evaluate the impact of awareness in changing the trends of PND of hemoglobinopathies. Both second and first-trimester diagnoses were undertaken by fetoscopy/cordocentesis and globin biosynthesis/high-performance liquid chromatography (HPLC) analysis of fetal blood and chorionic villus sampling (CVS) and DNA analysis. Over 30 years, 3478 couples (first trimester: 2475; second trimester: 1003) from all over India were offered PND. The number of couples coming in the first trimester increased significantly over each decade and couples coming prospectively increased from 2.5 to 18.4%. A cost-effective stepwise approach was used for molecular analysis. Eight hundred and one fetuses (23.0%) were affected and all except three couples opted for termination of these pregnancies. Genetic counseling and PND is the only way to reduce the burden of disease. With awareness, there was a shift from second trimester to first trimester PND over each decade, with an increasing number of couples coming during the first pregnancy. There are only 15 to 20 centers in India offering PND. We have compared our study with other reports on PND from different regions in India.

Induction of Labour In Growth Restricted and Small for Gestational Age Fetuses - A Historical Cohort Study

Induction of labour for small-for-gestational-age (SGA) foetus or intrauterine growth restriction (IUGR) is common, but data are limited. The aim of this trial was therefore to compare labour induction for SGA/IUGR with cases with normal fetal growth beyond the 10th percentile. This historical multicentre cohort study included singleton pregnancies at term. Labour induction for SGA/IUGR (IUGR group) was compared with cases of fetal growth beyond the 10th percentile (control group). Primary outcome measure was caesarean section rate. The caesarean section rate was not different between the 2 groups (27.0 vs. 26.2%, p=0.9154). In the IUGR group, abnormal CTG was more common (30.8 vs. 21.9%, p=0.0214), and fetal blood analyses were conducted more often (2.5 vs. 0.5%, p=0.0261). There were more postpartum transfers to the NICU in the IUGR group (40.0 vs. 12.8%, p<0.0001), too. Induction of labour for fetal growth restriction was not associated with an increased rate of caesarean section.

Confined placental mosaicism of trisomy 16 detected by non-invasive prenatal testing and multiple abnormalities

This study aimed to investigate a case of confined placental trisomy 16 mosaicism (CPM16) with abnormal amniotic fluid, placental lake, and other abnormalities. Maternal serum screening was performed to assess the risk of foetal aneuploidy, and massively parallel sequencing was used to detect cell-free fetal DNA. The abnormalities of the fetus, amniotic fluid, and placenta were detected by ultrasonic inspection. Maternal serum screening indicated a high risk for trisomy 21, and the non-invasive prenatal testing (NIPT) result was positive for trisomy 16. The pregnancy was terminated and karyotype analysis of fetal heart blood revealed a 46, XX karyotype. Copy number variation (CNV) sequencing of placental tissues indicated that CPM16 is the main cause of false-positive NIPT results and intrauterine growth retardation (IUGR) diagnoses. Combining molecular genetics technologies, such as CNV sequencing, can be complementary, and provide an effective strategy to determine the cause of such abnormalities.

Prenatal Diagnosis of HbE-β-Thalassemia: Experience of a Center in Western India.

The clinical presentation of HbE-β-thalassemia is extremely variable, however, many cases are severe and transfusion dependent. We offered prenatal diagnosis to 108 couples, 20 of whom came prospectively. CVS was done in 93 cases (9.5-13weeks of gestation) while amniocentesis/cordocentesis was done for 15 cases in the second trimester. Diagnosis was done by reverse dot blot hybridization, ARMS, DNA sequencing and in a few cases by HPLC analysis of fetal blood. The genetic combinations in the couples at-risk were the following: HbE trait/β-thal trait-95, HbE-thal/HbE trait-5, HbE homozygous/β-thal trait-3, HbE-thal/β-thal trait-3, HbE Lepore/β-thal trait-1, HbE trait/HbDPunjab trait-1. IVS1-5(G>C) was the commonest β-thalassemia mutation followed by codon15(G>A), codon30(G>C), codons41/42(-CTTT), the 619bp deletion and codon8/9(+G) in the β-thalassemic parent. However, several rare mutations seen in India like -90(C>T), -88(C>T),codon15(-T), IVS1-129(A>C), IVS1-130(G>C), IVSII-1(G>A), IVSII-837(C>T) and IVSII 848(C>A) were also encountered. Twenty-one fetuses were affected (HbE-β-thal-20, β-thal major-1) and all the couples opted for termination of the pregnancies. Couples with affected children wish to undergo prenatal testing for HbE-β-thal in subsequent pregnancies. More regional centers are needed for these services, particularly in West Bengal and the North-East where HbE is very common.

Evaluation of Malondialdehyde, Superoxide Dismutase and Catalase Activity in Fetal Cord Blood of Depressed Mothers.

ObjectiveThe umbilical cord consists of two arteries and one vein and it functions in the transport between the maternal and fetal circulation. Biochemical analysis of fetal cord blood (FCB) during delivery could be beneficial in terms of understanding the fetal environment. In this study, we aimed to investigate oxidative parameters like malondialdehyde (MDA), superoxide dismutase (SOD), and catalase (CAT) levels in FCB during delivery.MethodsWe collected FCB samples during caesarean section. Our study included 33 depressed mothers and 37 healthy controls. We investigated MDA, SOD, and CAT levels in FCB samples.ResultsWe found no significant difference between groups in terms of MDA (p=0.625), SOD (p=0.940), and CAT (p=0.413) levels.ConclusionOur study reveals probable protective effects of the placenta from oxidative stress. Future studies should include larger samples.

Analysis of blood from Zika virus-infected fetuses: a prospective case series

Zika virus has spread through the Americas and the Caribbean since early 2015 and was rapidly declared a Public Health Emergency of International Concern by WHO because of the potential association with fetal anomalies. We analysed fetal and maternal fluids and tissues in fetuses with confirmed Zika virus infection prospectively monitored in Martinique, a French Caribbean island. Since the beginning of the Zika virus outbreak in Martinique, all pregnant women undergo monthly fetal ultrasound examination surveillance. In this study, we prospectively studied all patients with fetal anomalies and a positive amniotic fluid for Zika virus by RT-PCR. Maternal and fetal blood, urine, amniotic fluid, placenta, and fetal tissues were tested for Zika virus by RT-PCR. Fetal blood was analysed to identify haematological and biological anomalies. Between Jan 1, 2016, and Nov 10, 2016, we recruited eight cases of Zika virus infection. All but two cases were symptomatic during the first trimester. Fetal anomalies were only detected after 20 weeks' gestation. After an initial positive result, amniocentesis became negative in two cases and fetal blood was transiently Zika virus-positive in six cases. Fetal blood analyses showed a cholestatic pattern, anaemia, and infectious response. Normalisation of amniotic fluid and fetal blood for Zika virus, as well as maternal blood and urine, shows the limitations of the performance of these investigations, due to the possibility of false negative results. Abnormal fetal blood needs to be investigated further to establish prognostic factors of severe Zika virus infections. None.

Diagnosis and treatment of dystrophic epidermolysis bullosa

Dystrophic epidermolysis bullosa (DEB) is a severe type of hereditary epidermolysis bullosa (EB) . At present, the type VII collagen gene COL7A1 has been found to be related to the pathogenesis of DEB. Clinical phenotypes of DEB are associated with sites and forms of COL7A1 gene mutations. Besides invasive amniocentesis, non-invasive prenatal diagnosis techniques for DEB have been improving, including ultrasonic examination, isolation of fetal nucleated red blood cells and analysis of cell-free fetal DNA from maternal blood. Recently, new progress has been made in treatments targeting molecular defects in DEB. Key words: Epidermolysis bullosa dystrophica; Genes; Prenatal diagnosis; Therapeutic uses; Prognosis

Increasing fetal ovine number per gestation alters fetal plasma clinical chemistry values.

Intrauterine growth restriction (IUGR) is interconnected with developmental programming of lifelong pathophysiology. IUGR is seen in human multifetal pregnancies, with stepwise rises in fetal numbers interfering with placental nutrient delivery. It remains unknown whether fetal blood analyses would reflect fetal nutrition, liver, and excretory function in the last trimester of human or ovine IUGR. In an ovine model, we hypothesized that fetal plasma biochemical values would reflect progressive placental, fetal liver, and fetal kidney dysfunction as the number of fetuses per gestation rose. To determine fetal plasma biochemical values in singleton, twin, triplet, and quadruplet/quintuplet ovine gestation, we investigated morphometric measures and comprehensive metabolic panels with nutritional measures, liver enzymes, and placental and fetal kidney excretory measures at gestational day (GD) 130 (90% gestation). As anticipated, placental dysfunction was supported by a stepwise fall in fetal weight, fetal plasma glucose, and triglyceride levels as fetal number per ewe rose. Fetal glucose and triglycerides were directly related to fetal weight. Plasma creatinine, reflecting fetal renal excretory function, and plasma cholesterol, reflecting placental excretory function, were inversely correlated with fetal weight. Progressive biochemical disturbances and growth restriction accompanied the rise in fetal number. Understanding the compensatory and adaptive responses of growth‐restricted fetuses at the biochemical level may help explain how metabolic pathways in growth restriction can be predetermined at birth. This physiological understanding is important for clinical care and generating interventional strategies to prevent altered developmental programming in multifetal gestation.

Feasibility of predicting the outcome of fetal infection with cytomegalovirus at the time of prenatal diagnosis

Congenital cytomegalovirus infection occurs in 0.7% of live births with 15-20% of infected children developing long-term disability including hearing loss and cognitive deficit. Fetal cytomegalovirus infection is established by viral DNA amplification by polymerase chain reaction in amniotic fluid obtained by amniocentesis following maternal seroconversion or after the diagnosis of ultrasound features suggestive of fetal infection. Severe brain ultrasound anomalies are associated with a poor prognosis. The prognosis of an infected fetus showing either no ultrasound features or nonsevere ultrasound anomalies is difficult to establish up until late in the second or third trimester of pregnancy. We sought to evaluate the prognostic value of fetal ultrasound, amniotic fluid, and fetal blood analysis at the time of prenatal diagnosis of fetal infection. We reviewed all cases of fetal cytomegalovirus infection with a sample of amniotic fluid positive for viral DNA and/or fetal blood analyzed in our laboratory from 2008 through 2013. Prenatal ultrasound features along with cytomegalovirus DNA loads in amniotic fluid and in fetal blood and fetal platelet counts were reviewed in relation to gestational age at maternal infection, neonatal examination, and postnatal follow-up or postmortem examination. In all, 82 fetuses were infected following maternal infection mainly in the first trimester. At the time of prenatal diagnosis at a median of23 weeks, 19, 22, and 41 fetuses showed severe brain ultrasound abnormalities, nonsevere ultrasound features, and normal ultrasound examination, respectively. Nonsevere ultrasound features, higher DNA load in amniotic fluid, fetal platelet count ≤114,000/mm(3), and DNA load ≥4.93 log10 IU/mL in fetal blood were associated with a symptomatic status at birth in univariate analysis (P < .001, P= .001, and P= .018, respectively). Bivariate analysis combining ultrasound results and either adjusted viral load in amniotic fluid or fetal blood profile showed that these were independent prognostic factors of a symptomatic status at birth. Both fetal blood parameters were better predictors than amniotic fluid viral load. At the time of prenatal diagnosis, the ultrasound negative predictive valuefor symptoms at birth or at termination of pregnancy was 93%. The combined negative predictive values of ultrasound and viral load in amniotic fluid and that of ultrasound and fetal blood parameters were 95% and 100%, respectively. In fetuses presenting with nonsevere ultrasound features, the positive predictive values of ultrasound alone and in combination with amniotic fluid viral load or with fetal blood parameters were 60%, 78%, and 79%, respectively. Risk assessment of infected fetuses for being symptomatic at birth is possible as early as the time of diagnosis by using a combination of targeted ultrasound examination along with viral load in amniotic fluid and in fetal blood together with platelet count. The advantage of using amniotic fluid is that it is available at prenatal diagnosis. One may wonder if increasing the negative predictive value of the overall assessment of an infected fetus from 95-100% is worth the additional risk of cordocentesis for fetal blood sampling. This can only be an individual decision made by well-informed women and it seems therefore appropriate to use the figures presented here and their confidence intervals for counseling.

Analysis of Fetal Blood: Is There Still a Role for Prenatal Diagnosis of Thalassemia?

The aim of the present study was to report the use of analysis of fetal blood in prenatal diagnosis (PND) of β- and α-thalassemia (β- and α-thal), at a Chinese tertiary, maternity center. All cases undergoing invasive testing for PND of thalassemias from 1 January 2010 to 31 December 2014 were included. The main clinical characteristics of these invasive procedures were retrieved from the database software used for analysis. One thousand, nine hundred and six invasive PNDs were carried out for thalassemia, including 904 cases for β-thal and 1002 for α-thal. In the 904 PNDs for β-thal, chorionic villus sampling (CVS) was done in 321 cases and amniocentesis in 583 cases. No fetal blood analysis was used for cases at-risk for β-thal. In the 1002 PNDs for α-thal, CVS was done in 724 cases, amniocentesis in 137 cases and fetal blood analysis in 141 cases. All the 278 cases sampled by amniocentesis or fetal blood analysis were found to be affected by Hb Bart’s (γ4) disease. Currently, fetal blood analysis is considered only in relatively late gestation when Hb Bart’s disease has already been identified by ultrasound in a fetus at-risk for α-thal.

Clinical Features of 10 Fetuses With Prenatally Diagnosed Parvovirus B19 Infection and Fetal Hydrops

Objectives: To evaluate the clinical features of fetuses with prenatally diagnosed parvovirus B19 infection and fetal hydrops. Methods: Parvovirus infection was diagnosed by PCR analysis of amniotic fluid or fetal blood. Fetal anemia was assessed by Doppler measurements of the middle cerebral artery peak systolic velocity (MCA-PSV) and confirmed by fetal blood. Intrauterine transfusions (IUT) were performed only if the MCA-PSV was > 1.5°MoM. Results: In our study population 10 cases of parvovirus infection which were associated with fetal hydrops were reviewed. The median gestational age at diagnosis was 21 (16.3–24.2) weeks. Five of our cases received IUT and four fetuses survived. The remaining five cases were managed conservatively and two fetuses survived. Conclusions: The survival rate for parvovirus infection associated with fetal hydrops was 60%. MCA-PSV and IUT are useful for the management and treatment of fetal anemia due to parvovirus infection.

Beta thalassemia - a review

Thalassemia is a globin gene disorder that results in a diminished rate of synthesis of one or more of the globin chains. About 1.5% of the global population (80 to 90 million people) are carriers of beta Thalassemia. More than 200 mutations are described in beta thalassemia. However not all mutations are common in different ethnic groups. The only effective way to reduce burden of thalassemia is to prevent birth of homozygotes. Diagnosis of beta thalassemia can be done by fetal DNA analysis for molecular defects of beta thalassemia or by fetal blood analysis. Hematopoietic stem cell transplantation is the only available curative approach for Thalassemia. Many patients with thalassemia in underdeveloped nations die in childhood or adolescence. Programs that provide acceptable care, including transfusion of safe blood and supportive therapy including chelation must be established.DOI: http://dx.doi.org/10.3126/jpn.v4i8.11609 Journal of Pathology of Nepal; Vol.4,No. 8 (2014) 663-671

Introducing routine fetal scalp blood analysis (FSBA) for suspicious or pathologic fetal heart rate – effect on mode of delivery, fetal and maternal outcome

Introduction: Despite a good sensitivity (80 – 91%) for fetal hypoxia or acidosis, specificity of fetal heart rate (FHR) analysis is low (9 – 63%). Fetal scalp blood analysis (FSBA) is a complementary tool for the interpretation of pathologic FHR. However FSBA is an invasive procedure and could lead to complications.

Medico-Legal Issues with CTG Interpretation

Electronic fetal monitoring is the recommended method of intrapartum fetal surveillance in high risk pregnancies and the cardiotocography (CTG) forms an integral part of intrapartum care on most modern labour wards. Despite the questions about its efficacy and controversy regarding increased rates of operative delivery associated with its use, continuous CTG remains the predominant method of intrapartum fetal monitoring. Although CTG is sensitive in detecting abnormalities of fetal heart rate (FHR), its specificity for detection of fetal hypoxia is low and therefore confirmatory tests such as fetal scalp blood sampling or analysis of fetal electrocardiography (ECG) become necessary. The intrapartum CTG trace forms a central piece of documentary evidence in litigations related to adverse perinatal outcomes which are alleged to have arisen due to events that took place during the labour and/or delivery of the baby. The main reasons for litigation are not just for recovery of costs determined by injury, pain, loss and future care of a brain damaged child; but the parents also want to know what happened and why, and expect the healthcare staff to be held accountable for their actions. Majority of medico-legal cases have similar problems which can be laid down to a few factors such as - a) inability to interpret FHR trace, b) inappropriate action, c) technical aspects and d) record keeping. Not only can litigations have long-term consequences for the working lives of midwives or obstetricians but they have been influential in changing practice trends such as rising caesarean rates. Unfortunately obstetric litigation with its huge costs is a growing problem and for the foreseeable future, the CTG is here to stay. The best defence against litigation is good clinical practice with adherence to evidence based guidelines and regular mandatory training in the interpretation of CTG for all labour ward staff. There should be a mechanism for the rapid review of adverse obstetric events and dissemination of key learning points to all staff. Keywords: CTG, fetal, hypoxia, intrapartum, medico-legal, monitoring, surveillance.

Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway.

To examine whether the introduction of advanced diagnostic technology in maternity care has led to less variation in type of delivery between hospitals in Norway. The Medical Birth Registry of Norway provided detailed medical information for 1.7 million deliveries from 1967 to 2005. Information about diagnostic technology was collected directly from the maternity units. The data were analyzed using a two-level binary logistic model with Caesarean section as the outcome measure. Level one contained variables that characterized the health status of the mother and child. Hospitals are level two. A heterogeneous variance structure was specified for the hospital level, where the error variance was allowed to vary according to the following types of diagnostic technology: two-dimensional ultrasound, cardiotocography, ST waveform analysis, and fetal blood analyses. There was a marked variation in Caesarean section rates between hospitals up to 1973. After this the variation diminished markedly. This was due to the introduction of ultrasound and cardiotocography. Diagnostic technology reduced clinical uncertainty about the diagnosis of risk factors of the mother and child during delivery, and variation in type of delivery between hospitals was reduced accordingly. The results support the practice style hypothesis.