Fetal Middle Cerebral Artery Peak Systolic Velocity Research Articles

RETRACTED: Peak systolic velocity of fetal middle cerebral artery to predict anemia in Red Cell Alloimmunization in un-transfused and transfused fetuses

Abstract objectiveTo assess the accuracy of middle cerebral artery peak systolic velocity (MCA-PSV) in prediction of severe fetal anemia resulting from Red Cell Alloimmunization (Anti-D) in un-transfused and transfused fetuses. In addition to comparing the accuracy of MCA-PSV and the estimation of the daily decline of fetal hemoglobin (Hb), to determine the appropriate time of subsequent transfusions. Study designThis was a retrospective study of a series of 84 anaemic fetuses due to Red Cell alloimmunization. During each in-utero transfusion session, measurements of (1)MCA-PSV, (2)pre- and (3)post-transfusion Hb levels were recorded. Receiveroperating characteristics (ROC) curves, negative and positive predictive values of MCA-PSV in predicting severe fetal anemia were calculated. Regression analysis assesses the correlation between fetal HB and MCA-PSV, and between observed and expected fetal hemoglobin levels. ResultsEighty four anemic fetuses were included in the study and had an in-utero transfusion. The positive predictive value (PPV) of MCAPSV decreased sharply from 86.0 % at the first IUT, to 52.0 % and 52.1 % at the second and third IUTs respectively. According to the ROC curves, setting the cut-off at 1.70 MoM would provide the best performance of MCA-PSV with respect to the timing of the second and third IUT. Setting a higher threshold of 1.70 MoM for the 2nd and 3rd transfusions would increase the PPV from 52.0 % to 96.4 % at the second IUT, and from 52.1%–99.8 % at the third IUT. ConclusionIn this study we suggest that a higher MCA-PSV (MoM 1.7 in compared to 1.5MOM) can accurately predict the recurrence of severe fetal anemia requiring serial IUTs. In transfused fetuses, MCAPSV accuracy to detect severe anemia decline slightly with increase number of IUT. In addition to that, the mean projected daily decrease in fetal hemoglobin has a similar accuracy to MCA-PSV in predicting moderate to severe fetal anemia.

Gestational Diabetes Mellitus and Early Hemodynamic Changes in Fetus.

Background:Gestational diabetes mellitus (GDM) incidence can increase up to 14%. GDM creates a risk for developing type 2 diabetes mellitus after pregnancy. Umbilical artery (UA) and fetal middle cerebral artery (MCA) changes in GDM have been studied before. The previous studies have contradictory results. In the current study, we aim to detect and define the impairment of color Doppler ultrasound (CDUS) characteristics in UA and MCA for the pregnant with GDM.Methods:US examinations were all performed at 18–22 weeks of gestation with a 3.5 MHz convex transducer. We recorded peak systolic velocity (PSV), end diastolic velocity, pulsatility index, resistive index, and systole/diastole ratio values of both UA and MCA at 18–22 weeks of gestation. GDM diagnosis was created according to the American Diabetes Association guidelines.Results:Sixty GDM patients and 61 healthy controls were included into the study. Median MCA PSV value was lower in GDM group (28 cm/s vs. 32 cm/s, P = 0.37). Among UA CDUS parameters, we cannot find any significant difference. In GDM group, we could not detect any significant correlation between CDUS parameters and HbA1C values.Conclusion:GDM changes fetal brain hemodynamics and the change can be detected at 18–22 weeks of gestation. Decreased fetal MCA PSV values can serve as an early warning for GDM.

The Limitations of Middle Cerebral Artery Peak Systolic Velocity and the Need for Certification [38A

INTRODUCTION: In fetuses at risk for anemia, middle cerebral artery-peak systolic velocity (MCA-PSV) may have a 12% false-positive rate. Guidelines suggest MCA-PSV is superior to amniocentesis for detection of anemia, provided the correct technique is used. We aim to describe the limitations of MCA-PSV in the diagnosis of fetal anemia and the need for MCA-PSV certification for tertiary care fetal centers. METHODS: This is a university based single-center retrospective study of 47 sensitized pregnancies suspected to have fetal anemia that underwent amniocentesis. Fetal anemia was suspected on elevated MCA-PSV >1.5 MoM. Amniotic fluid ΔOD450 was measured in all pregnancies. Fetuses with amniotic fluid ΔOD450 in zone 3 on Liley's chart, underwent cordocentesis for the assessment of fetal anemia. Intrauterine fetal transfusion (IUT) was performed in fetuses confirmed with anemia. Fetal anemia indicating IUT was defined as ≥5 SD below the mean for GA and Hematocrit ≤30%. RESULTS: Among sensitized pregnancies with elevated fetal MCA-PSV, 19 (40.4%) had elevated ΔOD450 measurements. Of these 19 fetuses, 15 (78.9%) required IUT. In 28/47 (59.6%) with normal ΔOD450, elevated MCA-PSV incorrectly predicted fetal anemia, increasing the amniocentesis related risks. This is much higher than the published false positive results of 12%. CONCLUSION: The decreased specificity of MCA-PSV for fetal anemia diagnoses may be associated with user variability. While MCA-PSV has clinical benefit for the initial workup, the additional amniocentesis confirmation reduced the need for cordocentesis. Amniocentesis also has risks and to further reduce the need for invasive diagnostic testing, we recommend a Certification for MCA-PSV Doppler sonography.

The Effect of Betamethasone on Middle Cerebral Artery Doppler Flow in Fetuses With Elevated Peak Systolic Velocities [27Q

INTRODUCTION: Administration of betamethasone (BMZ) has been shown to decrease the morbidity and mortality associated with preterm birth, and is given to patients with a variety of complications such as preterm labor, PPROM, fetal growth restriction, and alloimmunization, among others. As middle cerebral artery (MCA) Dopplers are used to monitor fetal hemodynamics in patients with many of these conditions, we sought to determine if administration of betamethasone is associated with changes in MCA Doppler parameters in fetuses with an abnormally elevated MCA peak systolic velocity (PSV). METHODS: A retrospective longitudinal study was conducted including women with a fetal MCA PSV greater than 1.3 MoM that had an MCA Doppler assessment within one week before and one week after betamethasone administration. Pre- and post-BMZ MCA PSV were compared using a repeated measures t-test. RESULTS: 20 fetuses met inclusion criteria with diagnoses of alloimmunization (13), parvovirus infection (3), fetal growth restriction (2), and twin-twin transfusion (2). The pre-BMZ PSV of 1.60±0.16 MoM was significantly lower than the post-BMZ PSV of 1.41±0.16 MoM (p < 0.0001). 13 of the 20 fetuses had a second post-BMZ MCA Doppler performed with a PSV of 1.5±0.24 MoM which was not significantly different from the initial post-BMZ MCA PSV (p=0.231). CONCLUSION: Our data suggest that maternal betamethasone administration lowers the MCA PSV in fetuses with an initially elevated MCA PSV. This should be taken into account when using MCA Dopplers to monitor fetal hemodynamics in patients receiving BMZ.

Determination of optimal timing of serial in-utero transfusions in red-cell alloimmunization.

To assess the performance of middle cerebral artery peak systolic velocity (MCA-PSV) and of the expected daily decrease in fetal hemoglobin in determining the timing of serial in-utero transfusions (IUT) in red-cell alloimmunization. This was a retrospective study of a continuous series of suspected anemic fetuses undergoing IUT between June 2003 and December 2012. Doppler measurement of MCA-PSV and pre- and post-transfusion hemoglobin levels were recorded at the time of the first, second and third IUT. Receiver-operating characteristics (ROC) curves and negative and positive predictive values of MCA-PSV in the prediction of severe fetal anemia were calculated. The daily decrease of fetal hemoglobin (Hb) between IUTs was calculated. Regression analysis was used to assess the correlation between pretransfusion fetal hemoglobin and MCA-PSV, and between observed and expected (by projection of daily decreases) pretransfusion fetal hemoglobin levels. One hundred and eleven fetuses required an IUT, of which 96 and 67 received a second and third IUT, respectively. The area under the ROC curve for MCA-PSV in the prediction of severe fetal anemia was not different for each rank of transfusion. The positive predictive value of MCA-PSV decreased from 75.3% at the first IUT, to 46.7% and 48.8% at the second and third IUTs, respectively, while the negative predictive value for a 1.5-MoM threshold remained high (88.9% at the second and 91.7% at the third IUT). The mean daily decrease in hemoglobin following each transfusion was 0.45, 0.35 and 0.32 g/dL, respectively. There was a persistent linear correlation between fetal hemoglobin and MCA-PSV and between observed and expected fetal hemoglobin levels. Both MCA-PSV and projection of daily decrease in hemoglobin are reliable means of diagnosing fetal anemia following previous IUTs. The high negative predictive value of MCA-PSV could allow subsequent IUTs to be postponed in selected cases.

The Effect of the Pressure Exerted on the Maternal Abdominal Wall by the US Probe on Fetal MCA Peak Systolic Velocity.

Purpose To quantify the pressure exerted on the maternal abdominal wall during ultrasound examination and evaluate its effect on the fetal middle cerebral artery (MCA) peak systolic velocity (PSV). Materials and Method Gravid women with singleton pregnancies in their 2nd-3 rd trimester undergoing fetal sonographic evaluation for various indications were recruited. Each subject underwent transabdominal US measuring fetal distance from the probe, abdominal thickness, amniotic fluid index and biophysical profile. The applied pressure was measured simultaneously using an electronic pressure sensor attached directly to the US probe. For each subject baseline values of the pressure required for proper visualization were obtained. Fetal MCA was then demonstrated using color Doppler US. The PSV was measured at different pressure ranges with each subject used as her own control. Care was taken not to exceed the baseline pressure for each subject. Results 29 women were recruited. 24 subjects (82.7 %) demonstrated a statistically significant positive correlation between the pressure exerted and MCA-PSV (R-0.37, p < 0.0001). Of these, 4 subjects (13.8 % of study population) demonstrated elevation of PSV values above 1.29 MOM and 5 subjects (17.2 %) demonstrated elevation of PSV values above 1.5 MOM for gestational age with increasing pressure. Intotal, 9 subjects (31 %) demonstrated significant changes in the MCA-PSV measurements (owing to increase in pressure applied) that could potentially falsely influence clinical obstetric diagnosis and management. Conclusion The pressure exerted on the maternal abdominal wall during US examination is an important parameter, producing clinically significant measurable changes in fetal MCA hemodynamics. Further study is needed in order to demonstrate the potential effect of pressure as a parameter influencing the diagnostic accuracy of the MCA-PSV in the setting of fetal anemia.

An Untold Story of Indian Fetal Middle Cerebral Artery Peak Systolic Velocities

ABSTRACTAlthough noninvasive diagnosis of anemia in fetus by measuring the middle cerebral artery peak systolic velocity (MCA-PSV) is practised and extensively researched in the developed world, such studies from the developing world are rare. India is the home for many hemoglobinopathies and cases of Rh alloimmunization are also reported here. Hence, it is expected that fetal anemias will be quite common. So in addition to an awareness about the correct method of measuring MCA-PSV and knowledge about changes that occur in the waveforms with advancing gestational age, it is important to know the normal values at various gestational ages in an Indian setting. Demonstrating these normal values was the primary goal of the current study.ContextFetal anemia can be adequately tackled only if it is diagnosed on time. Fetal MCA-PSV has the potential to reliably predict fetal anemia. Scientific studies across the globe are a testimony to this fact. As such studies from rural setups are lacking, this study was initiated.AimsTo demonstrate the normal values of fetal MCA-PSV at various gestational ages in an Indian setting by using the standard internationally accepted protocol.Settings and designThe ultrasound wing of radiodiagnosis department of a rural medical college was the site of this study. Permission from institutional research cell and ethical committee was obtained for study on fetal MCA-PSV. Written informed consent from every pregnant mother who participated in the study was also obtained. A cross-sectional and prospective observational study was conducted over the last 9 months.Materials and methodsA total of 60 measurements of fetal MCA-PSV were conducted in normal 20 pregnant women referred for routine obstetric scan at 12, 24, and 36 weeks of gestation respectively, by a single radiologist on color Doppler ultrasound machine. In each fetus the proximal MCA, soon after its origin, was evaluated.Statistical analysisThe observations were entered in Microsoft Excel sheet and statistical analysis was done by using SPSS statistical software version 12. The relation between fetal MCAPSV and gestational age was studied using the Karl Pearson's correlation coefficient. The significance of difference was studied using the t-test.ResultsMCA-PSV increased with increasing gestational age, suggesting positive correlation between the two. Better waveforms and increasing PSV were visualized with advancing gestational age.ConclusionFetal anemia can be accurately predicted only if the MCA-PSV is scientifically measured and compared with normal values in a given setting. This study demonstrates the normal values at various gestational ages in an Indian setting.How to cite this articleKachewar S, Gandage SG, Pawar HJ. An Untold Story of Indian Fetal Middle Cerebral Artery Peak Systolic Velocities. Int J Infertil Fetal Med 2014;5(1):8-11.

Non-invasive diagnosis of fetal anemia: Multicentric nationwide input for a worldwide output

PurposeTo perform a nationwide multicentric validatation of the nomogram of fetal middle cerebral artery peak systolic velocity (MCA-PSV); previously constructed by us and to compare and contrast it with similar studies in the world for an effective output. Materials and methodsFetal MCA-PSV was measured in normal 1015 pregnant women attending the antenatal ultrasound clinic at least once between 12 and 40 weeks of gestation (35 patients per week of gestation), at this institute and a nomogram was constructed. MCA-PSV in 30 patients each at 12, 24 and 36 weeks of gestation (GA) were measured at multiple centers [other institutes by different observers] in this nation. Their mean values were compared with the mean values mentioned in the nomogram prepared by us. Similarly the linear correlation diagrams as well as the regression equations of this large local study were compared with those from other worldwide published studies. Statistical analysis was done using the SPSS 12 software. ResultsA nationwide comparison of the mean and standard deviation (SD) values of MCA-PSV at 12, 24 and 36 weeks of gestation calculated at 95% confidence interval, in our study with studies from different other centers, using ANOVA the calculated F value was far too high than the table value. So, null hypothesis that the nomogram previously prepared by us at this center can be comfortably followed at other centers in this nation is rejected. Comparative analysis of linear correlation between GA (weeks) and MCA-PSV (cm/s) in our study and other studies also displayed a disparity. ConclusionsA significant difference was found between local study and multicentric nation wide studies, as well as between local values and worldwide values. A multicentric nationwide input for a worldwide output thus enabled us not only to construct and compare normal local reference range of fetal MCA-PSV but also to validate it effectively and to realize its limitations. Hence it is time to say goodbye to the “One Size Fits All Theory” of fetal MCA-PSV and to welcome efforts to scientifically construct regional reference range all over the world.

A Study of Fetal Middle Cerebral Artery Peak Systolic Velocity to Diagnose Fetal Anemia in Rural Obstetric Population

ABSTRACTGlobally, fetal middle cerebral artery peak systolic velocity (MCA-PSV) is used for noninvasive diagnosis of fetal anemia. Although, incidence of anemia is common in rural setup, scientific studies describing utilization of this modality are lacking. This study throws light on how the use of fetal MCAPSV to diagnose fetal anemia can help in the decision-making process even in a rural setup.ContextFetal anemia can be adequately tackled only if it is diagnosed on time. Fetal MCA-PSV has the potential to reliably predict fetal anemia. Scientific studies across the globe are testimony to this fact. As such studies from rural setups are lacking, this study was initiated.AimsA study of fetal middle cerebral artery peak systolic velocity to diagnose fetal anemia in rural obstetric population.Settings and designThe study was conducted in the ultrasound section of a rural medical college. Clearance from institutional ethical and research committee was obtained. Written informed consent was obtained from the pregnant mother. A prospective observational study was conducted over the last 12 months.Materials and methodsFetal MCA-PSV was measured in 26 pregnant women referred for ultrasound due to clinical suspicion of fetomaternal abnormality. Middle cerebral artery peak systolic velocity was measured by a single experienced radiologist on color Doppler ultrasound machine.Statistical analysis usedThe observations were entered in Microsoft Excel sheet, and statistical analysis was done by comparing with internationally accepted values at that gestational age. Karl Pearson's correlation coefficient was used to study the relation between fetal MCA-PSV and gestational age. Standard t-test was used to study the significance of difference.ResultsThere was a steady increase in MCA-PSV with rising gestational age suggestive of positive correlation between them. When compared with internationally accepted values, significantly raised fetal MCA-PSV values were seen in six patients. These patients were followed up and the cause of fetal anemia in each was identified.ConclusionFetal MCA-PSV can be successfully used to evaluate for anemia in fetuses in a rural setup provided correct methods are followed. An attempt to measure fetal MCA-PSV in face of every fetomaternal adversity is recommended so that none of the cases of fetal anemia go undiagnosed.Key messagesProper knowledge and routine measurement of fetal MCA-PSV value can be a life saving noninvasive practice to diagnose fetal anemia in a rural setup.How to cite this articleKachewar S, Gandage SG, Pawar HJ. A Study of Fetal Middle Cerebral Artery Peak Systolic Velocity to Diagnose Fetal Anemia in Rural Obstetric Population. Int J Infertility Fetal Med 2013;4(3):83-87.

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

Fetal middle cerebral artery peak systolic velocity (MCA-PSV) is now an established method of noninvasive diagnosis of moderate to severe fetal anemia of different origins. This being a population-based parameter, it may have different values in individuals from different locations. A standard local reference range of normal individuals specific to each geographic locality is therefore needed. Fetal MCA-PSV was measured in 1,015 healthy pregnant women attending the antenatal ultrasound clinic at least once between 12 and 40 weeks of gestation (35 patients per week of gestation). Statistical analysis was done using the SPSS 12 software. A positive correlation between MCA-PSV and gestational age was found. MCA-PSV was seen to increase with advancing gestational age. The Tukey-Kramer multiple comparisons test showed a normal distribution that was highly significant (p < 0.01). The multiples of median values of fetal MCA-PSV to label a fetus as severely anemic were consistently and significantly lower than internationally accepted values. A normal reference range of fetal MCA-PSV for local use was thus scientifically and successfully constructed. Significant differences between local values and internationally accepted value were found.

Fetal middle cerebral artery peak systolic velocities in a local Indian scenario

Measurement of fetal middle cerebral artery peak systolic velocity (MCA-PSV) is now universally recommended for noninvasive assessment and follow-up of fetal anemia. However, a literature review suggests that the fetal MCA-PSV range is different for Asian and non-Asian populations. A study was therefore undertaken to compare and contrast MCA-PSV values in the local obstetrical population with those of previously published studies done elsewhere. Fetal MCA-PSV was measured in normal 100 pregnant women attending the outpatient antenatal clinic using Doppler ultrasonography, which was performed at least once between 12 and 40 weeks of gestation. A positive statistically significant (P < 0.05) correlation was seen between gestational age and MCA-PSV. The 5th (17.0 vs. 24.9 cm/s), 50th (23.0 vs. 32.4 cm/s), and 95th (38.0 vs. 41.1 cm/s) percentile values of MCA-PSV at 25 weeks of gestation in the present study were consistently lower than those cited in other studies. The results indicate that a local fetus would be anemic even before its MCA-PSV rises to the internationally accepted standard of fetal anemia. Hence, by the time the MCA-PSV value of the local fetus rises to the point where it is deemed severely anemic as per values mentioned in other published literature, it might be too late for intervention and the fetal health as well as life might be at stake. Each geographic locality should therefore develop its own standard values.

Reliability of Fetal Middle Cerebral Artery Velocity Measurements

The purpose of this study was to determine the reliability of fetal middle cerebral artery (MCA) peak systolic velocity (PSV) measurements at a tertiary care center and to evaluate the effect of targeted training for sonographers. Six sonographers were randomized to training modules for fetal MCA PSV or amniotic fluid volume (AFV) measurements. Six fetuses of uncomplicated pregnancies were selected for participation. Middle cerebral artery and AFV measurements were obtained before and after a training module. The intraobserver and interobserver variability (reliability) was calculated with intraclass correlation coefficients and was compared between groups. Administration of the MCA training module increased the number of technically adequate MCA images obtained (odds ratio, 3.95; 95% confidence interval, 1.07-14.65). The intraobserver and inter-observer variability for MCA measurements was significantly reduced after the targeted training module (P = .05). The reliability of fetal MCA PSV measurements improved after a targeted training program.

Early Intravenous Immunoglobulin (IVIG) Therapy and Non Invasive Fetal Monitoring in Rh Alloimmunization (AI) and Pregnancy

High titer (HT), ≥1:32, anti-E, anti-c and anti-D Rh antibodies can cause hemolytic disease of the newborn (HDN). Maternal IVIG therapy may reduce need for intrauterine and exchange transfusions in HDN. Minimal data exists regarding optimal timing of therapy initiation, dose and frequency and fetal outcomes. Late administration of IVIG therapy beyond gestational age of 16 weeks have not been shown to improve fetal outcome. We describe the clinical course of 3 pregnant women with Rh AI. Two women with high titer Rh AI were treated with early IVIG dose of 1 gm/kg/week. A third woman with low titer Rh AI did not receive IVIG. Fetal status was monitored non-invasively with weekly Fetal Doppler ultrasound measurement of peak systolic velocity (PSV) of the middle cerebral artery (MCA). Patient 1 was a 38 year old Caucasian female with high anti- D (> 1:500) and history of HDN; second baby required 3 exchange transfusions and third baby required 3 intrauterine transfusions during pregnancy and 2 exchange transfusions post delivery. IVIG weekly infusion was started on week 11. Amniocentesis done at week 21 showed that baby was Rh(D) positive and the Kleihauer-Bethke test was negative. Serial fetal MCA PSV done weekly till labor induction did not show evidence of significant fetal anemia. The IVIG infusions were completed on 33rd week and the patient delivered healthy baby by cesarean section on the 35th week. The baby did not receive any intra uterine or exchange transfusions.Patient 2 was a 37 year old caucasian woman with anti-c AI. The patient's husband is c antigen positive and she had seroconversion during her third pregnancy which manifested as positive antibody screen in a routine type and screen with her third delivery which was uneventful. She subsequently had a miscarriage of her fourth pregnancy at 9 weeks. Her peak anti –c titer was 1: 128. She received IVIG infusion from week 11 to week 33 with stable anti-c titer of 1: 64. Serial MCA PSV assesments did not reveal significant fetal anemia. She had a normal vaginal delivery on week 34 with a healthy baby not requiring any exchange transfusions. Patient 3 was a 41 year old caucasian woman with low titer anti-E AI (1:8). No IVIG was administered as her titers remained low during her pregnancy course. Her titers were monitored every 2 weeks; peak antibody titer was 1:8. Fetal anemia was ruled out with Serial MCA PSV assesments. She delivered a healthy baby by Ceserean section at 38 weeks, 4 days.Patient 1Patient 2Patient3Gravid statusG4 P2103G5 P3013G8, P4034Blood groupA-A+O+Antibody identificationAnti DAnti cAnti EH/o documented HDNYesNoNoNumber of doses of IVIG2323NAAge of Gestation IVIG started10 weeks11 weeksNACumulative dose of IVIG1580 gms1750 gmsNAPeak antibody titer10481288Serial Fetal Peak MCA velocityNormalNormalNormalIntra uterine/Exchange transfusionsnoneNoneNonePregnancy outcomenormal fetusnormal fetusnormal fetusIVIG adverse effectsHeadache, fatigueNoneN/APatient 1Weeks of gestationAnti D TiterIVIG –Cumulative No. of dosesMCA PSV (cm/s) MoM= Multiples of Median91:512121:10481171:5127201:5121021 (0.83 MoM)211:5121128 (1.04 MoM)221:5121221.3 (0.76 MoM)231:5121328.1 (0.96 MoM)241:5121422 (0.71 MoM)251:5121525 (0.77 MoM)261:5121632 (0.95 MoM)271:5121728 (0.79 MoM)281:5121835 (0.94 MoM)301:5122045 (1.11 MoM)321:5122261 (1.37 MoM)331:5122351.9 (1.1 MoM)Patient 2Weeks of gestationAnti c TiterIVIG – Cumulative number of dosesMCA PSV (cm/s) MoM= Multiples of Median111:1281141:644201:6410221:641122.3 (0.79 MoM)241:641323.7 (0.77 MoM)251:641422.7 (0.70 MoM)261:641530.1 (0.89 MoM)271:641634.3 (0.97 MoM)291:641837.9 (0.98 MoM)301:641933.3 (0.82 MoM)311:642027.9 (0.65 MoM)321:642128 (0.62 MoM)331:642259 (1.26 MoM)341:642335 (0.71 MoM)Patient 3Weeks of gestationAnti E TiterIVIG - Cumulative No. of dosesMCA PSV (cm/s) MoM= Multiples of Median121:80191:80261:80281:8040.6 (1.07 MoM)291:4039.7 (1.02 MoM)321:4042 (0.94 MoM341:4055 (1.12 MoM)Median – 1.29 MoM = No fetal anemia1.29 – 1.5 MoM = Mild anemia>1.5 MoM = Severe anemiaConclusion- Early initiation of weekly IVIg therapy at dose of 1 gm/kg at gestational age of 10 to 11 weeks in high titer (≥ 1:32) maternal Rh AI is well tolerated and can eliminate the need for invasive fetal monitoring, intrauterine transfusion and exchange transfusion.

Middle Cerebral Artery Peak Systolic Velocity

Assessment of the middle cerebral artery (MCA) peak systolic velocity (PSV) can accurately diagnose fetal anemia and has decreased the number of invasive procedures, such as amniocentesis and cordocentesis. The objective of this investigation was to evaluate the intraobserver and interobserver variability as a measure of reproducibility of MCA PSV. The technique of correctly sampling this vessel is described. The study population included 30 appropriate-for-gestational-age fetuses. In each fetus, MCA PSV was determined proximal to the transducer at 3 different locations: 2 mm after its origin from the internal carotid artery, at the midlength between its origin and division, and at its division. The peak systolic velocity was also determined at the contralateral MCA 2 mm after its origin. With each measurement (obtained at 2 different institutions), care was taken to ensure that the ultrasound beam was parallel to the artery for its entire length. The reliability of an angle corrector was also assessed. The intraobserver and interobserver reliabilities were determined from the appropriate version of the intraclass correlation. Gestational age at study entry ranged from 14 to 37.5 weeks (median, 23.6 weeks). The proximal MCA, 2 mm after its origin from the internal carotid artery, had the best intraobserver and interobserver variability in both institutions. (Intraclass correlation ranged from 0.98 to 0.99.) Our data indicate that fetal MCA PSV is optimally measured soon after the MCA's origin from the internal carotid artery. Given the importance of clinical decision making based on this measurement, sonographers and sonologists interested in measuring MCA PSV should test their variability after a suitable period of training.

Prediction of fetal anemia in rhesus disease by measurement of fetal middle cerebral artery peak systolic velocity.

In red blood cell (RBC) isoimmunized pregnancies fetal anemia is associated with a hyperdynamic circulation. The aim of the present study was to examine further the possible value of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the management of affected pregnancies. A reference range of fetal MCA-PSV with gestation was constructed from the study of 813 normal singleton pregnancies at 20-40 weeks' gestation. Fetal MCA-PSV was also measured in 58 fetuses from RBC isoimmunized pregnancies, with maternal hemolytic antibody concentration of >15 IU/mL at 19-38 weeks' gestation and within 10 days of measurement of fetal hemoglobin concentration in blood obtained either by cordocentesis (n = 43) or at delivery (n = 15). In the RBC isoimmunized pregnancies each of the measured MCA-PSV and hemoglobin concentrations was expressed as a delta value (difference in SDs from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA-PSV and delta fetal hemoglobin concentration. In the normal pregnancies there was a significant increase in fetal MCA-PSV with gestation (mean MCA-PSV = 10(0.0223 x GA + 0.963)). In RBC isoimmunized pregnancies the fetal MCA-PSV was increased and there was a significant association between delta MCA-PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA-PSV + 0.093)/-0.356; R(2) = 0.638, P < 0.0001). An MCA-PSV of mean + 1.5 SDs detected 96% of severely anemic fetuses, with a hemoglobin deficit of at least 6 SDs, for a false-positive rate of 14%. Measurement of fetal MCA-PSV is a useful method of assessing fetal anemia. In the clinical management of isoimmunized pregnancies a cut-off in MCA-PSV of mean + 1.5 SDs can identify nearly all severely anemic fetuses with a low false-positive rate.

Fetal middle cerebral artery peak systolic velocity in the investigation of non-immune hydrops.

In some cases of non-immune hydrops there is congenital or acquired fetal anemia. The aim of this study was to investigate the potential value of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the assessment and management of non-immune hydrops due to anemia. Fetal MCA-PSV and fetal hemoglobin concentration, in blood obtained by cordocentesis, were measured in 16 singleton pregnancies referred to our unit for further investigations because of a diagnosis of non-immune hydrops fetalis. In all cases a detailed ultrasound examination demonstrated moderate or severe ascites, with or without skin edema, and pericardial or pleural effusions. Furthermore, there were no obvious malformations to account for the hydrops. In each fetus the measured MCA-PSV and hemoglobin concentration were expressed as delta values (the difference in SD from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA-PSV and delta fetal hemoglobin concentration. In addition, we searched our database to identify the sonographic features and hemoglobin concentration of fetuses with congenital infection. In the 16 cases of non-immune hydrops there were seven with parvovirus B19 infection, one each of alpha-thalassemia and primary cardiomyopathy and seven with no obvious explanation for the hydrops. There was a significant association between delta MCA-PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA-PSV + 0.1437)/-0.4154; R(2) = 0.7202; P < 0.0001). In 10 of the cases the fetal hemoglobin concentration was more than 4 SD below the normal mean for gestation and in all these cases the MCA-PSV was more than 2 SD above the normal mean for gestation. Our computer search identified an additional nine fetuses with parvovirus B19 infection and in all cases the predominant sonographic finding was ascites and the hemoglobin concentration was more than 4 SD below the normal mean. In contrast, only 3/14 fetuses with cytomegalovirus, toxoplasmosis, coxsackie B or Treponema infection had ascites and only 2/14 had a hemoglobin deficit of 4-6 SD. In the management of non-immune hydrops, measurement of fetal MCA-PSV can help identify the subgroup with fetal anemia.

Middle cerebral artery Doppler: the value of a non-invasive test of fetal anaemia in the management of alloimmunised pregnancies

We set out to determine the usefulness of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in predicting fetal anaemia in Rhesus alloimmunised pregnancies before first and subsequent in-utero transfusions. This was a retrospective analysis of fetal MCA-PSV values and haematocrits (Hct) performed in 30 alloimmunised fetuses before their first intrauterine blood transfusion, and before 35 repeat transfusions. A MCA-PSV of greater than 1.5 MoM for gestation would have identified seven of eight severely anaemic fetuses (Hct < 22%) and 3/7 moderately anaemic fetuses (Hct 22–26%). Five fetuses with haematocrits > 26% would have been identified falsely, of which one had a Hct > 35%. Following one intrauterine transfusion the use of this test cut-off was less predictive, detecting 3/4 fetuses with severe anaemia but none of the four fetuses with moderate anaemia. A higher cut-off (1.69 MoM) was as sensitive but more specific in the prediction of severe anaemia. A lower threshold of 1.32 MoM would have identified of 2/4 fetuses with moderate anaemia, but only when utilising a cut-off value of 0.98 MoM could all the severe and moderately anaemic fetuses have been identified.

Accurate prediction of fetal hemoglobin by Doppler ultrasonography

OBJECTIVE: To assess the feasibility of using the middle cerebral artery peak systolic velocity (MCA-PSV) to predict the actual value of fetal hemoglobin in fetuses undergoing a first cordocentesis for detection of anemia caused by maternal red cell alloimmunization. METHODS: Doppler velocimetry of the MCA-PSV was performed in 18 fetuses before an initial cordocentesis. Hemoglobin and MCA-PSV values were expressed as multiples of the median to adjust for the changes that both parameters demonstrate with gestational age. In each fetus we determined: 1) the expected (using a cubic mathematical function describing the correlation between fetal hemoglobin and MCA-PSV) and the observed (determined at the time of the cordocentesis) hemoglobin value; and 2) the percentage differences between the expected and the observed hemoglobin values. RESULTS: Gestational age at the time of the Doppler study ranged from 19 to 31 weeks. On 15 occasions, the fetuses demonstrated anemia. A quadratic relationship was found between the hemoglobin multiples of the median and the percentage differences between the expected and the observed hemoglobin values. As the values of hemoglobin decreased, the percentage difference between expected and observed values significantly decreased ( R 2 = 0.48, P < .05). The cubic model estimated fetal hemoglobin well in severely anemic fetuses and less well when the fetus was not anemic. CONCLUSION: Doppler measurement of the MCA-PSV appears to be a valuable tool for estimating hemoglobin concentration in fetuses at risk for anemia. The correlation between hemoglobin and MCA-PSV becomes more accurate as the severity of anemia increases.