Fetal Hematocrit Research Articles

Maternal melatonin: Effective intervention against developmental programming of cardiovascular dysfunction in adult offspring of complicated pregnancy

Adopting an integrative approach, by combining studies of cardiovascular function with those at cellular and molecular levels, this study investigated whether maternal treatment with melatonin protects against programmed cardiovascular dysfunction in the offspring using an established rodent model of hypoxic pregnancy. Wistar rats were divided into normoxic (N) or hypoxic (H, 10% O2 ) pregnancy±melatonin (M) treatment (5μg·ml-1 .day-1 ) in the maternal drinking water. Hypoxia±melatonin treatment was from day 15-20 of gestation (term is ca. 22days). To control for possible effects of maternal hypoxia-induced reductions in maternal food intake, additional dams underwent pregnancy under normoxic conditions but were pair-fed (PF) to the daily amount consumed by hypoxic dams from day 15 of gestation. In one cohort of animals from each experimental group (N, NM, H, HM, PF, PFM), measurements were made at the end of gestation. In another, following delivery of the offspring, investigations were made at adulthood. In both fetal and adult offspring, fixed aorta and hearts were studied stereologically and frozen hearts were processed for molecular studies. In adult offspring, mesenteric vessels were isolated and vascular reactivity determined by in-vitro wire myography. Melatonin treatment during normoxic, hypoxic or pair-fed pregnancy elevated circulating plasma melatonin in the pregnant dam and fetus. Relative to normoxic pregnancy, hypoxic pregnancy increased fetal haematocrit, promoted asymmetric fetal growth restriction and resulted in accelerated postnatal catch-up growth. Whilst fetal offspring of hypoxic pregnancy showed aortic wall thickening, adult offspring of hypoxic pregnancy showed dilated cardiomyopathy. Similarly, whilst cardiac protein expression of eNOS was downregulated in the fetal heart, eNOS protein expression was elevated in the heart of adult offspring of hypoxic pregnancy. Adult offspring of hypoxic pregnancy further showed enhanced mesenteric vasoconstrictor reactivity to phenylephrine and the thromboxane mimetic U46619. The effects of hypoxic pregnancy on cardiovascular remodelling and function in the fetal and adult offspring were independent of hypoxia-induced reductions in maternal food intake. Conversely, the effects of hypoxic pregnancy on fetal and postanal growth were similar in pair-fed pregnancies. Whilst maternal treatment of normoxic or pair-fed pregnancies with melatonin on the offspring cardiovascular system was unremarkable, treatment of hypoxic pregnancies with melatonin in doses lower than those recommended for overcoming jet lag in humans enhanced fetal cardiac eNOS expression and prevented all alterations in cardiovascular structure and function in fetal and adult offspring. Therefore, the data support that melatonin is a potential therapeutic target for clinical intervention against developmental origins of cardiovascular dysfunction in pregnancy complicated by chronic fetal hypoxia.

Evaluation of sleep quality and restless legs syndrome in adult patients with sickle cell anemia.

To determine the prevalence of poor sleep quality and RLS in adult patients with sickle cell anemia (SCA). The second aim was to identify the risk factors for RLS and impairment of sleep quality in SCA patients. Patients at least 18years old, with hemoglobin electrophoresis confirmation of sickle cell disease, were included. Restless legs syndrome was diagnosed according to the International Restless Legs Syndrome Study Group criteria. The sleep quality of the patients was determined using the Pittsburgh Sleep Quality Index (PSQI) scale. The Epworth Sleepiness Scale (ESS) was used to assess excessive daytime sleepiness. Of 72 patients enrolled in the study, the median totalPSQI score was 5 (R 1-17). The totalPSQI score was significantly associated with increased age and number of acute severe or extremely severe painful crises during the previous year (p< 0.001, r= 0.45; p= 0.013, r= 0.291 respectively). Of 72 patients, 13 (18%) had RLS and 11 (15%) had excessive daytime sleepiness. The presence of RLS was significantly associated with increased age (p= 0.004). The presence of RLS was not associated with fetal hemoglobin, hemoglobin, hematocrit, or ferritin levels (p> 0.05 for all). The prevalence of RLS among this sample ofadult patients with sickle cell anemia was much higher than that previously reported for the general Turkish population. The presence of RLS was an important cause of sleep disturbance in theseadult patients with SCA.

Correlation between Site of Placenta and Umbilical Cord Hematocrit Value

Background: Placenta Previa (PP) is characterized as the unusual implantation of placental tissue over or adjoining the inside cervical os. The commonness of PP is at around 5 for every 1000 pregnancies. It represents roughly 20% of all antepartum drain, front PP was seen as related with unfavorable maternal results including over the top blood misfortune, gigantic transfusion, placenta accreta and hysterectomy. Objective: The purpose of our study was to decide the connection between the site of placenta in pregnant women and the hematocrit (Hct) estimation of umbilical cord blood (CB) of the newborn. Patient and method: This case-control study was carried out at Obstetrics and Gynecology Department, Zagazig University Hospitals and El-Menshawy General Hospital in Tanta during the period from May 2018 to May 2019. The study included 32 pregnant women with various placental site. They were classified into two groups; group 1: women determined to have placenta previa as front or back placenta previa. Group II: women without placenta previa at a similar gestational age as (bunch II). Placenta position was classified as foremost, back and fundal placenta. Results: there was high huge distinction between hemoglobin levels when activity in the placenta previa gathering. Additionally, there was high distinction between the placenta previa gathering and the control group in respect to fetal haematocrit esteem, which was higher among placenta previa gathering. Regarding fetal hematocrit and placenta site, our examination demonstrated that there was high solid critical connection between the placental site and haematocrit esteem. Conclusion: Placental area can decide pregnancy outcome.

The utility of MRI for measuring hematocrit in fetal anemia

Doppler ultrasound measurements of the peak systolic velocity of the middle cerebral artery can be used to noninvasively diagnose fetal anemia but are less precise following fetal blood transfusion and in late gestation. We have previously demonstrated the feasibility of estimating fetal hematocrit invitro using magnetic resonance imaging relaxation times. Here we report the use of magnetic resonance imaging as a noninvasive tool to accurately detect fetal anemia invivo. This study has 2 objectives: (1) to determine the feasibility and accuracy of magnetic resonance imaging in estimating hematocrit in anemic fetuses and (2) to compare magnetic resonance imaging and middle cerebral artery Doppler in detecting moderate to severe fetal anemia. Fetuses undergoing fetal blood sampling or transfusion underwent magnetic resonance imaging examinations prior to and following their procedures at 1.5 Tesla (Siemens Avanto). A modified Look-Locker inversion pulse sequence and T2 preparation sequence were applied for T1 and T2 mapping of the intrahepatic umbilical vein. Estimated fetal hematocrit was calculated using a combination of T1 and T2 values and compared with conventional hematocrit obtained from fetal blood samples and middle cerebral artery Doppler measurements. Twenty-three fetuses were assessed during 33 magnetic resonance imaging scans. The mean absolute difference between the laboratory and magnetic resonance imaging-estimated hematocrit was 0.06± 0.05 with a correlation of 0.77 (P < .001) determined by a multilevel, mixed-effects model adjusting for the repeated measurements from the same participants, multiple gestation pregnancies, and the scan type (ie, before or after transfusion scan). Bland-Altman analysis revealed a systematic bias of -0.03 between the magnetic resonance imaging and fetal blood sampling measurements. Magnetic resonance imaging and middle cerebral artery Doppler had similar sensitivities of approximately 90% to detect moderate to severe anemia. However, magnetic resonance imaging had a higher specificity (93% [13/14], 95% confidence interval, 66-100%) than Doppler (71% [10/14], 95% confidence interval, 42-92%). Moderate to severe fetal anemia can be detected noninvasively by magnetic resonance imaging with high sensitivity and specificity. Our results suggest an adjunct role for magnetic resonance imaging in fetuses with suspected anemia, particularly following previous transfusion and in late gestation.

Correlation of fetal blood vessel Doppler measurements with fetal anemia among Rhesus isoimmunized pregnancies after two intrauterine transfusions.

To assess the correlation between fetal blood vessel Doppler measurements and fetal anemia among Rhesus isoimmunized pregnancies after two intrauterine transfusions as a potential guide to therapy. A prospective observational study was conducted among 30 women who attended a single hospital in India between April 2, 2015 and October 30, 2016. The participants underwent a third intrauterine transfusion based on a middle cerebral artery (MCA) peak systolic velocity (PSV) of greater than 1.50 multiples of the median (MoM). Cordocentesis was performed before the third intrauterine transfusion and hematocrit values correlated with the blood vessel Doppler measurements. The MCA PSV MoM and fetal hematocrit MoM had a correlation coefficient of -0.43 (95% confidence interval -0.68 to 0.08; P=0.017). The sensitivity, specificity, positive predictive value, and negative predictive value were 68%, 57%, 83%, and 33%, respectively. The descending aorta PSV δ and fetal hematocrit δ had a correlation coefficient of -0.54 (95% confidence interval -0.75 to -0.23; P=0.001). An area under the curve of 0.80 (standard error 0.085; P=0.017) had 87% sensitivity and 57% specificity for diagnosing fetal anemia. The descending aorta PSV could offer a useful diagnostic adjunct to MCA PSV after two intrauterine transfusions.

NT-proBNP: A Useful Biochemical Marker for Prognosis in Rh-Isoimmunized Pregnancies.

Rh incompatibility sometimes results in life-threatening conditions in fetus like severe anemia and jaundice, leading to kernicterus and even death. Even after an uneventful intrauterine transfusion (IUT), fetus may not survive despite correction of the fetal anemia. Finding appropriate markers may help in determining the prognosis of such cases. The N-terminal prohormone of brain natriuretic peptide (NT-proBNP) suggests some degree of heart failure. Present study was planned to evaluate its role in predicting the outcome of fetus in Rh-isoimmunized pregnant woman. This prospective study consisted of total 40 pregnant patients: 10 pregnant Rh-isoimmunized women with hydropic fetuses, 10 with non-hydropic fetuses and 20 control group. If the MCA-PSV was > 1.5 MOM, cord blood sampling and IUT was done and sent for fetal hematocrit and NT-proBNP. The levels of NT-proBNP at various periods of gestation in hydropic, non-hydropic and control group fetuses showed positive correlation with the degree of fetal anemia. Correlation of high levels of NT-proBNP to fetal anemia proves that hydrops fetalis is probably due to progressive high cardiac output myocardial failure, increased capillary permeability and perhaps reduced coronary flow.

Fetal middle cerebral artery Doppler to time intrauterine transfusion in red-cell alloimmunization: a randomized trial.

To evaluate whether Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) for timing subsequent intrauterine transfusions (IUTs) in fetuses that had undergone one IUT for anemia secondary to red-cell alloimmunization is non-inferior to timing based on expected decrease in fetal hematocrit (Hct) or fetal hemoglobin level, without compromising infant hemoglobin at birth. This was an international, pragmatic multicenter randomized controlled trial. Women with a pregnancy complicated by fetal anemia secondary to red-cell alloimmunization (due to any antibody alone or in combination), as indicated by the need to undergo a single IUT, were eligible for inclusion. Women were randomized to the determination of timing of further transfusion(s) by Doppler measurement of MCA-PSV (MCA-PSV Group), with a serial upward trend of values >1.5 multiples of the median considered indicative of the need for another IUT, or timing of transfusion by a decrease in fetal Hct (fetal Hct Group), with subsequent IUTs timed according to an estimated fall in fetal Hct of 1% per day or fetal hemoglobin of 0.3 g/dL per day, to maintain fetal hemoglobin level between 7 and 10 g/dL. The primary outcome was infant hemoglobin level measured at birth. A total of 71 women were randomized, 36 to the MCA-PSV Group and 35 to the fetal Hct Group. Median gestational age at randomization was 30.3 weeks, the majority of women were Caucasian and non-smokers, 9.9% of women had Kell alloimmunization, and 14% of fetuses were hydropic at their first IUT. No statistically significant differences between the two treatment groups were observed with regard to mean hemoglobin levels at birth (MCA-PSV Group, 10.36 ± 3.82 g/dL vs fetal Hct Group, 12.03 ± 3.14 g/dL; adjusted mean difference -1.56 g/dL (95% CI, -3.24 to 0.13 g/dL); P = 0.070), or the number of IUTs performed after randomization (MCA-PSV Group, 1.75 ± 1.79 vs fetal Hct Group 1.80 ± 1.32; adjusted relative risk 0.88 (95% CI, 0.61-1.26); P = 0.474). There was no statistically significant difference between the two groups with respect to the risk of adverse infant outcomes related to alloimmunization or procedure-related complications. Both Doppler measurement of MCA-PSV and estimation of the decrease in fetal Hct or hemoglobin can be used to determine the timing of second and subsequent IUTs in fetuses with red-cell alloimmunization. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Fetal hydrops and middle cerebral artery Doppler in prediction degree of fetal anemia and the best timing for therapy

To determine the role of fetal multiples of the median of middle cerebral artery peak systolic velocity (MoM MCA-PSV), in predicting the degree of fetal anemia for determination of the best timing for the second intrauterine intravascular transfusion (IUIVT) in hydropic fetuses with Rh alloimmunization. Prospective study of 30 monofetal pregnancies with maternal Rh D alloimmunization and hydrops fetalis, from 2005 to 2012 that underwent first and second IUIVT were assessed. Thirty IUIVT were performed at 26.9 weeks (standard deviation, SD 4.3). Mean interval to the second procedure was 11.23 (SD 6.21) days and average hematocrit decline rate was 1.45%/day. The study did not demonstrated statistical significance between MCA-MoM-3 before the second IUIVT, and the mean decline rate in fetal hematocrit levels (expressed in percentage/day) r = 0.220; p = 0.242, and between MCA-MoM-3 and the time interval between both procedures (T) r = -0.157; p = 0.408. The measurements fetal MoM-MCA before every IUIVT cannot be useful as predictor for the best timing for the next IUIVT, but it can be useful in predicting severity of fetal anemia.

Clinical and Hematological Evaluation of Patients with Sickle Cell Anemia Before and After Four Years of Using Hydroxyurea

Objective: Evaluating clinical and hematological-clinical parameters of patients with sickle cell anemia (SCA) before and after four years of using hydroxyurea (HU). &#x0D; Method: A retrospective cohort study implementing a quantitative, descriptive and analytical approach developed in two public teaching hospitals located in the Central-West region of Brazil, from November 2010 to October 2011. Data collection was performed through medical records of 32 patients with SCA to assess clinical and hematological parameters before and after HU treatment. The study was approved by the UFMS Ethics Committee under protocol number 1890/2010.&#x0D; Results: All of the 32 patients were homozygous with a mean age in the prescription of hydroxyurea of 19.72±7.58 years, an initial dose of 15.59±4.27 mg/kg/day, and 22.48±5.35 mg/kg/day in the fourth year of treatment. Regarding the use of HU, average values of some hematological parameters presented a significant difference in the fourth year compared to the mean values prior to HU use, such as fetal hemoglobin (14.49±7.52%), red blood cells (2.54±0.38x1012/L), hematocrit (25.30±4.03%) and hemoglobin (9.22±3.34g/dL). &#x0D; Conclusion: Treatment with hydroxyurea showed a significant increase in fetal hemoglobin levels, increased hemoglobin, hematocrit and average corpuscular hemoglobin concentration, with reduced episodes of pain, infection and acute chest syndrome in such a way as to reaffirm its efficiency in treating these patients.&#x0D; Keywords: Hemoglobin; Sickle Cell Anemia; Hydroxyurea.

Actual vs optimal fetal hematocrit measuredwith punctures of cord blood inutero: Relationship with umbilical arteryresistance.

Physiological studies on fetal blood in narrow glass tubes have suggested that fetal optimal hematocrit (hct) might be as high as 60%. Atheoretical 'ideal' hct can also be predicted with atheoretical curve of hematocrit/viscosity (h/η) ratio vs hct constructed with Quemada's model. We used the database of one of our previous papers on fetal hemorheology to reinterpret its results with this concept. Aseries of 28 intrauterine cord punctures (between 19 and 33 weeks gestation) with doppler measurements of resistance in umbilical arteries was studied. The theoretical 'optimal hematocrit' was well correlated to actual (r = 0.857, p < 0.01) but systematically lower (Bland-Altman plot +12.1[8.52-15.7]) than the actual one. Umbilical artery resistance index is correlated with actual hematocrit (r = 0.407, p < 0.05), the discrepancy between ideal and actual (r = - 0.542, p < 0.05) but not predicted ideal hematocrit, suggesting that the discrepancy between ideal and actual may reflect an adaptative decrease aiming at reducing vascular resistance. These findings indicate that prediction of ideal hematocrit with Quemada's equation makes sense in fetal blood, and suggest that a'viscoregulatory mechanism' maintains hematocrit below this theoretical value in order to avoid excess vascular resistance.

Prenatal Alcohol Exposure Alters Fetal Iron Distribution and Elevates Hepatic Hepcidin in a Rat Model of Fetal Alcohol Spectrum Disorders

Background: Prenatal alcohol exposure (PAE) causes neurodevelopmental disabilities, and gestational iron deficiency (ID) selectively worsens learning and neuroanatomical and growth impairments in PAE. It is unknown why ID worsens outcomes in alcohol-exposed offspring.Objective: We hypothesized that PAE alters maternal-fetal iron distribution or its regulation.Methods: Nulliparous, 10-wk-old, Long-Evans rats were mated and then fed iron-sufficient (100 mg Fe/kg) or iron-deficient (≤4 mg Fe/kg) diets. On gestational days 13.5–19.5, dams received either 5.0 g ethanol/kg body weight (PAE) or isocaloric maltodextrin by oral gavage. On gestational day 20.5, maternal and fetal clinical blood counts, tissue mineral and iron transport protein concentrations, and hepatic hepcidin mRNA expression were determined.Results: In fetal brain and liver (P < 0.001) and in maternal liver (P < 0.005), ID decreased iron (total and nonheme) and ferritin content by nearly 200%. PAE reduced fetal bodyweight (P < 0.001) and interacted with ID (P < 0.001) to reduce it by an additional 20%. Independent of maternal iron status, PAE increased fetal liver iron (30–60%, P < 0.001) and decreased brain iron content (total and nonheme, 15–20%, P ≤ 0.050). ID-PAE brains had lower ferritin, transferrin, and transferrin receptor content (P ≤ 0.002) than ID-maltodextrin brains. PAE reduced fetal hematocrit, hemoglobin, and red blood cell numbers (P < 0.003) independently of iron status. Unexpectedly, and also independent of iron status, PAE increased maternal and fetal hepatic hepcidin mRNA expression >300% (P < 0.001).Conclusions: PAE altered fetal iron distribution independent of maternal iron status in rats. The elevated iron content of fetal liver suggests that PAE may have limited iron availability for fetal erythropoiesis and brain development. Altered fetal iron distribution may partly explain why maternal ID substantially worsens growth and behavioral outcomes in PAE.

Congenital Dyserythropoietic Anemia Type 1: A New Variant Pathogenic CDAN1 Mutation

Introduction:Congenital dyserythropoietic anemia (CDA) is a rare autosomal recessive condition that results in dyserythropoiesis and iron overload. Bone marrow evaluation in these patients demonstrates distinctive abnormalities in red cell precursors including multinucleated erythroblasts and chromatin bridges. Dysmorphisms such as distal limb abnormalities, skin pigmentation defects, vertebral malformations, and short stature may also be present. Mutations in the CDAN1/codanin-1 gene underlie the majority of CDA type I cases. We describe a previously unreported pathogenic variant.Case report:The female fetus of a gravida 2 para 1 woman was noted to have hepatomegaly, cardiomegaly, and elevated middle cerebral artery velocity concerning for severe intrauterine anemia at approximately 20 weeks gestation. The parents had one previous pregnancy that resulted in a stillborn male infant with hydrops fetalis and club foot. Given concern for anemia with this pregnancy, percutaneous umbilical cord blood sampling was performed demonstrating a fetal hematocrit of 9%. This severe fetal anemia was initially thought to be secondary to ABO incompatibility as mother was O- with a positive antibody screen and infant was A+. The fetus required four intrauterine transfusions and was delivered at 34 weeks 6 days via cesarean section due to history of previous cesarean. Exam revealed a phenotypically normal female with APGARs of 9/9 and a birth weight of 2130 grams.Following delivery the infant had serial blood counts performed over a 6-week period, which noted a steady decrease in her hematocrit to 16%. A transfusion was given, and a bone marrow evaluation revealed a cellular marrow with red cell hyperplasia and dyserythropoiesis. Next generation sequencing through PreventionGenetics was performed revealing a novel CDAN1 alteration.Results:The patient was found to be heterozygous for two mutations in trans in the CDAN1 gene: c.2072dupT and c.2093A>T.Discussion:We present a patient with severe fetal and infant transfusion dependent anemia who has two novel CDAN1 gene variants not previously described. The sequence variant c.2072dupT is predicted to result in a frameshift and premature protein termination and is expected to be pathogenic. The second variant c.2093A>T is predicted to result in an amino acid substitution (p.Glu698Val). Another amino acid substitution (p.Glu698Lys) was previously reported as pathogenic in an individual with congenital dyserythropoietic anemia. Based upon the clinical picture, morphologic characteristics, and genetic findings, we have concluded that this presentation is consistent with a diagnosis of CDA type I. Through the utilization of improved diagnostic techniques we continue to gain knowledge regarding the molecular underpinnings of CDA type I. DisclosuresNo relevant conflicts of interest to declare.

Delayed cord clamping with and without cord stripping: a prospective randomized trial of preterm neonates

Autologous blood transfusion from the placenta to the neonate at birth has been proven beneficial. Transfusion can be accomplished by either delayed cord clamping or cord stripping. Both are equally effective in previous randomized trials. We hypothesized that combining these 2 techniques would further improve outcomes in preterm neonates. This was a prospective randomized trial for singleton deliveries with estimated gestational ages between 22 and 31 6/7 weeks. The control protocol required a 30-second delayed cord clamping, whereas the test protocol instructed a concurrent cord stripping during the delay. The primary outcome was initial fetal hematocrit. We also examined secondary outcomes of neonatal mortality, length of time on the ventilator, days to discharge, peak bilirubin, number of phototherapy days, and neonatal complication rates. Of the 67 patients analyzed, 32 were randomized to the control arm and 35 were randomized to the test arm. The gestational ages and fetal weights were similar between the arms. Mean hematocrit of the control arm was 47.75%, and the mean hematocrit for the test arm was 47.71% (P = .98). These results were stratified by gestational age, revealing the infants less than 28 weeks had an average hematocrit of 41.2% in the control arm and 44.7% in the test arm (P = .12). In the infants with gestational ages of 28 weeks or longer, the control arm had an average hematocrit of 52.9%, which was higher than the test arm, which averaged 49.5% (P = .04). The control arm received an average of 1.53 blood transfusions, whereas the test arm received 0.97 (P = .33). The control arm had 3 neonatal deaths, and the test arm had none (P = .10). The average number of days until discharge was 71.2 for the control arm and 67.8 for the test arm (P = .66). The average number of days on the ventilator was 4.86 for the control arm and 3.06 for the test arm (P = .34). Adding cord stripping to the delayed cord clamp does not result in an increased hematocrit. Data suggest trends in lower mortality and higher hematocrit in neonates born less than 28 weeks, but these were not statistically significant.

End-tidal carbon monoxide as an indicator of the hemolytic rate.

In the first days of life, low grade jaundice is essentially universal. The source of the elevated bilirubin level giving rise to "physiological jaundice of the newborn" is only partly known. We hypothesized that it is, at least in part, the result of active and specific hemolysis involving a physiological mechanism to lower the high fetal hematocrit, appropriate for the relatively low oxygen environment in utero, to a lower level appropriate for the state of oxygen abundance after birth. We tested this by quantifying end tidal carbon monoxide (ETCO) as a marker of the rate of heme metabolism to bilirubin. We found that ETCO values of 20 neonates and children with known hemolytic disorders were higher than 20 age-matched healthy controls (p<0.0001), indicating that this instrumentation recognizes hemolysis in neonates and children. We also found that ETCO reference intervals were indeed higher in healthy neonates during the first three days after birth (5th to 95th percentile reference range, 1.4 to 1.7ppm) than after 1month of age (all ≤1.0ppm, p<0.0001). These results suggest to us that hemolysis is physiological during the first days after birth. The cellular and molecular mechanisms responsible for transient hemolysis after birth are topics of current investigation.

P21.09: Improving outcome of in utero fetal transfusion by increasing the target fetal hematocrit

Improve fetal outcome and reduce the number of fetal intervention after Rh alloimmunization by reducing the number of inutero transfusion by increasing the target fetal hematocrit. Rh alloimmunization is common in India and western world. To improve the outcome and make it available across the country, we have tried many strategies. One of them is to reduce the number of Inutero transfusion by increasing the target fetal hematocrit to 55 % rather than standard 45%. Other aims are to reduce the over all cost of the IUT so that many more people will be able to afford it. We have analyzed the data of our center (Paras Advanced Center for Fetal Medicine, Ahmedabad, India) between January 2008 to December 2013. We retrospectively analyzed 314 fetal transfusions and found better fetal outcome with this strategy - Group A -74% v/s Group B 86 % (Group A -45% target v/s Group B - 55 %). Over all 21% fetal transfusion rate was reduced. Complications and cost related to IUT was also reduced. While doing inutero fetal transfusion procedure, target of fetal hematocrit should be increased from 45% to 55% ( 20% Approximately). Over all procedure rate and complication rate was reduced and fetal outcome is also improved. Long-term outcome up to 3 years shows NO difference in outcome between 2 groups.

Direct Fetal Intravenous Immunoglobulin Infusion as an Adjunct to Intrauterine Fetal Blood Transfusion in Rhesus-Allommunized Pregnancies: A Pilot Study

Objectives: To study the usefulness of direct fetal intravenous immunoglobulin (IVIG) infusion along with intrauterine transfusion (IUT) in the management of severe fetal anemia in rhesus (Rh) alloimmunized pregnancies. Methods: Thirty-four consecutive Rh-isoimmunized pregnant women who required serial IUTs received either blood alone (control group, n = 16) or IVIG and blood (study group, n = 18). Pregnancies were followed up to delivery, and fetal outcome was recorded. The rate of fall of hematocrit was measured and compared between the two groups. Results: There was a slower rate of fall of hematocrit in the study group (IUT and IVIG) compared to the control group (only IUT). The mean rate of fall was 0.72 ± 0.54% per day in the study group while it was 1.29 ± 0.95% per day in the control group (p = 0.005). Conclusion: Fall of fetal hematocrit was reduced in the study group. The results of this pilot study can be used to time the next transfusion in patients receiving IVIG along with IUT (taking the rate of fall as 0.70%). This may eventually result in decreasing the number of transfusions per fetus.

Ascorbate prevents placental oxidative stress and enhances birth weight in hypoxic pregnancy in rats.

This study isolated the effects of maternal hypoxia independent of changes in maternal nutrition on maternal circulatory and placental molecular indices of oxidative stress and determined whether maternal antioxidant treatment conferred protection. Pregnant rats were subjected to normoxic pregnancy or 13% O2 chronic hypoxia for most of gestation with and without maternal treatment with vitamin C in the drinking water. Maternal hypoxia with and without vitamin C did not affect maternal food or water intake and led to a significant increase in maternal and fetal haematocrit. At gestational day 20, maternal plasma urate and L-cysteine concentrations, and placental levels of 4-hydroxynonenal and heat shock protein 70 were increased while placental heat shock protein 90 levels were decreased in hypoxic pregnancy. The induction of maternal circulatory and placental molecular indices of oxidative stress in hypoxic pregnancies was prevented by maternal treatment with vitamin C. Maternal hypoxia during pregnancy with or without vitamin C increased placental weight, but not total or compartmental volumes. Maternal treatment with vitamin C increased birth weight in both hypoxic and normoxic pregnancies. The data show that maternal hypoxia independent of maternal undernutrition promotes maternal and placental indices of oxidative stress, effects that can be prevented by maternal treatment with vitamin C in hypoxic pregnancy. While vitamin C may not be the ideal candidate of choice for therapy in pregnant women, and taking into consideration differences in ascorbic acid metabolism between rats and humans, the data do underlie that antioxidant treatment may provide a useful intervention to improve placental function and protect fetal growth in pregnancy complicated by fetal hypoxia.

Intrauterine blood transfusion in immune hydrops fetalis, corrects middle cerebral artery Doppler velocimetry very quickly

The aim of our study was to evaluate the middle cerebral artery velocimetry before and after intrauterine blood transfusion in immune hydrops fetalis. The current study was conducted in a tertiary research hospital, from February 2009 to January 2011. Nineteen intrauterine blood transfusions performed during the study period. The factors recorded were age of the mothers, gestational weeks, pre-transfusion fetal hematocrit and post-transfusion fetal hematocrit, and also middle cerebral artery peak systolic velocimetry (MCA-PSV) was detected and recorded before and after intrauterine transfusion. A control group of twenty two cases for normal MCA doppler velocimetry was also included to the study. During the study, a total of eleven rhesus isoimmunized pregnancies underwent intrauterine blood transfusions at our perinatal diagnose unit. Before transfusion seventeen severe and two moderate anemias were detected and mean MoM of MCA-PSV was 1.76±0.38 MoM. Post transfusion mean MoM of MCA-PSV in the patient group and control group were 1.08±0.22 MoM and 0.96±0.21 MoM, respectively. The mean MCA-PSV values were higher in RI fetuses than post transfusion and control group. In current study, we found that MCA-PSV is a valuable parameter in detecting fetal anemia requiring intrauterine transfusion and mean MCA-PSV values is higher than 1.5 MoM in fetuses with anemia. And also decrease in MCA-PSV just after transfusion in anemic fetuses showed the quick response of the fetus to correction of anemia.

Fetomaternal hemorrhage in normal vaginal delivery and in delivery by cesarean section

The objective was to determine the incidence and volume of fetomaternal hemorrhage (FMH) in normal vaginal delivery and in delivery by cesarean section. Determination of these variables would enable optimalization of guidelines for D alloimmunization prophylaxis. In a prospective cohort study, a total of 3457 examinations were performed, 2413 after normal vaginal delivery and 1044 after cesarean delivery. FMH was assessed by flow cytometry. (FMH is fetal red blood cell [RBC] volume; fetal blood volume is double [expected fetal hematocrit is 50%].) The fetal RBC volume diagnosed in maternal circulation after delivery ranged from insignificant FMH of not more than 0.1 mL to excessive FMH of 65.9 mL (median, 0.7; mean, 0.78; SD, 1.48). FMH of more than 2.5 mL (immunoglobulin [Ig] G anti-D insufficient dose 50 µg) was observed in 1.4% (49/3457) and excessive volumes of FMH of more than 5 mL (insufficient dose, 100 µg) in 0.29% (10/3457). Delivery by cesarean section presented a higher risk of incidence of FMH of more than 2.5 mL (odds ratio, 2.2; p = 0.004) when compared with normal vaginal delivery. It did not, however, present a significant risk factor for the incidence of excessive volumes of FMH of more than 5 mL. During normal vaginal delivery as well as during delivery by cesarean section, FMH of less than 5 mL occurs in the great majority of cases, and thus for the prevention of D alloimmunization, an IgG anti-D dose of 100 µg should be sufficient. Contrarily, only rarely does greater FMH occur and delivery by cesarean section does not present a risk factor.

395: Isoimmunization to minor red blood cell antigens in pregnancy: management, monitoring and outcomes

in pregnancy: management, monitoring and outcomes Sharmilee Thota, Srinivas Ketharaju, Carolyn Salafia, Aleksandr Fuks Bronx-Lebanon Hospital Center, OB/GYN, Bronx, NY, Bronx-Lebanon Hospital Center, OB/GYN, Bronx, NY, New York Methodist Hospital Cornell Presbyterian, OB/GYN, Pathology, Pediatrics, Brooklyn, NY, Queens Hospital Center, OB/GYN, Queens, NY OBJECTIVE: To examine fetal and neonatal outcomes of pregnancies complicated by isoimmunization to minor red blood cell (RBC) antigens and managed by serial antibody titer and MCA-peal systolic velocity (MCA-PSV) assessments. STUDY DESIGN: Retrospective cohort study of all patients isoimmunized to minor RBC antigens managed at Bronx-Lebanon Hospital Center, 2008-2011. Inclusion criteria: live singleton gestataion, presence of minor RBC antibodies, gestational age 24 0/7 36 0/7 weeks. Exclusion criteria: multiple gestations, Kell and major RBC antibodies, fetal malformations and chromosomal abnormalities. All patients were managed with serial antibody titer and MCA-PSV assessments. Outcome parameters were assessed: birthweight, fetal bilirubin concentration, cord gas base excess, fetal hematocrit, NICU stay duration. RESULTS: 24 patients fit study inclusion criteria. Demographic and outcome parameters are summarized in the Table below. None of the patients in the study had MCA-PSV values in the range of severe fetal anemia requiring PUBS and in-utero transfusion. None of the neonates required RBC transfusion and only 2 newborns were Coombs positive and required phototherapy. CONCLUSION: Patients with alloimmunization to minor RBC antigens and antibody titers less than critical value (1:32) do not appear to be at risk for sever fetal anemia. In those patients, serial MCA-PSV assessments do not influence management decisions and outcomes of pregnancy and forgoing such evaluation might be suitable.