Fetal Middle Cerebral Artery Peak Research Articles

Diagnostic Accuracy of Fetal Middle Cerebral Artery Peak Systolic Velocity in the Detection of Fetal Anaemia Keeping Neonatal Hae Moglobin Estimation at Birth as the Gold Standard

Objective: To assess whether monitoring the peak systolic velocity (PSV) in the middle cerebral artery (MCA) was a useful, non-invasive method for predicting anaemia in fetuses. Study Design: Cross-sectional study Place and Duration of Study: Armed Forces Institute of Radiology, Rawalpindi Pakistan, from Feb and Aug 2022. Methodology: Fifty pregnant women who did not have hydropic babies were included. The peak systolic velocity (PSV) was measured in the middle cerebral artery (MCA). A positive result was determined when the MCA-PSV value exceeded 1.5multiples of the median (MoM). The blood samples obtained from neonates were forwarded to the hospital laboratory to estimate haemoglobin levels shortly after birth. The outcome of the method (MoM) was observed and subsequently compared with neonatal haemoglobin levels. Results: 60% of neonates were anaemic according to middle MCA-PSV while the haematology laboratory reported 74% of neonates as anaemic according to cut-off haemoglobin of less than 13.5gm/dl. Sensitivity, specificity, positive predictive value(PPV), negative predictive value (NPV), and accuracy of the MCA-PSV in detecting the anaemia were 93.75%, 61.1%, 81.08%, 84.62%, and 82%, respectively. Conclusion: MCA-PSV Doppler is deemed valuable as a diagnostic technique for fetal anaemia, albeit secondary to the primary approach of neonatal haemoglobin estimation upon birth.

Suspected twin anemia polycythemia sequence in a dichorionic, diamniotic twin pregnancy: a case report

BackgroundTwin anemia polycythemia sequence is a rare complication in monochorionic twin pregnancy.Case presentationWe describe a case of dichorionic twin pregnancy presenting with suspected twin anemia polycythemia sequence. A 31-year-old White female, on her third pregnancy, had a routine ultrasound scan at 12 weeks gestation, which demonstrated a dichorionic twin pregnancy with one placenta located in the anterior wall and the other in the posterior wall of the uterus. At 21 weeks, a scan demonstrated a 24% growth discordance between the two fetuses with normal Doppler studies and amniotic fluid. At 27 weeks, one twin showed signs of anemia and the other polycythemia; the fetal middle cerebral artery peak systolic velocity was high in the anemic fetus and low in the polycythemic twin (1.8 and 0.5 multiples of the median). An intrauterine blood transfusion was carried out and this increased the fetal hemoglobin concentration in the anemic twin from 3.5 to 12.5 g/dL. At 29 weeks, delivery by cesarean section was carried out because of evidence from middle cerebral artery peak systolic velocity of recurrence of anemia in one twin and worsening polycythemia in the co-twin; at birth the hemoglobin concentrations were 5.6 and 24.9 g/dL, respectively. Histopathological examination confirmed dichorionicity with no communicating vessels between the two placentas.ConclusionsThis is the first case of twin anemia polycythemia sequence in a dichorionic, diamniotic twin pregnancy where intrauterine blood transfusion was used to prolong the pregnancy by almost 2 weeks in a “twin anemia polycythemia sequence-like” setting.

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

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

The rate of decline in fetal hemoglobin following intrauterine blood transfusion in the management of red cell alloimmunization

ObjectiveHemolytic disease of the fetus and newborn is characterized by fetal anemia, secondary to maternal alloantibody-mediated fetal erythrocyte destruction. Despite our reliance on intrauterine blood transfusion (IUT) to maintain severely affected pregnancies, it remains difficult to predict the fetal response to an infusion of donor blood. Our objective was to determine the daily rate of decline in fetal hemoglobin following one, two, and three transfusions. We also evaluated the relationship between the fetal hemoglobin level and the corresponding doppler measurement of the fetal middle cerebral artery peak systolic velocity (MCA-PSV). Study DesignA prospective observational study of all singleton pregnancies treated with intrauterine transfusion for fetal anemia secondary to maternal alloimmunization at the National Maternity Hospital, a tertiary referral centre, was conducted over a 10-year period (2011–2020). Demographic and clinical data was obtained from the electronic patient records. Ethical approval was granted by the Ethics and Research Committee of the National Maternity Hospital. ResultsA total of 90 intrauterine blood transfusions were performed in 41 fetuses affected by maternal alloimmunization, of which 70% (n = 29), 34% (n = 14) and 15% (n = 6) required a 2nd, 3rd, and 4th transfusion, respectively. The mean rate of decline in fetal hemoglobin following the first transfusion was 0.4 g/dl/day (range, 0.12–0.64 g/dl/day). The mean rate of decline was lower after repeat transfusions at 0.27 g/dl/day (range, 0.16–0.45 g/dl/day). The sensitivity of MCA-PSV threshold of 1.5 Multiples of the Median (MoM) to detect moderate-severe anaemia declined with rank of IUT, from 82% after one previous transfusion, to 75% after two or more previous transfusions. No fetal mortality was seen in our series. ConclusionKnowledge of the expected rate of decline in fetal hemoglobin following an IUT aids in the determination of appropriate timing of subsequent transfusions in a fetus affected by red cell alloimmunization. We observed a reducing rate of daily decline in hemoglobin in fetuses requiring successive transfusions. Our findings suggest a reduced accuracy of the MCA-PSV threshold of 1.5 MoM in determining the optimal timing of 2nd, 3rd, and 4th transfusions.

965 Accuracy of middle cerebral artery doppler ultrasound for fetal anemia prior to 24 weeks gestation

Fetal middle cerebral artery (MCA) peak systolic velocity of Doppler ultrasound varies with gestational age, and it is unclear if established reference ranges are applicable to pregnancies less than 24 weeks. We aimed to estimate the positive predictive value and false positive rate of MCA Doppler ultrasound for assessment of fetal anemia at gestational ages less than 24 weeks. A retrospective cohort study was performed in a single healthcare system over a 10-year period. All fetuses at risk of alloimmunization less than 24 weeks gestation who had MCA Doppler ultrasounds were identified. Non-immune causes of fetal anemia were excluded. Peak MCA systolic velocity > 1.5 multiples of the median (MoM) were considered positive and periumbilical blood sampling was considered. Pregnancy and neonatal outcomes were reviewed for all patients. The positive predictive value of MCA Doppler peak systolic velocity for fetal anemia prior to 24 weeks was estimated with 95% confidence intervals based on the binomial exact method. 126 pregnancies at risk for fetal anemia due to maternal alloimmunization had MCA Doppler ultrasound assessments prior to 24 weeks gestation. Of these, eleven had MCA peak systolic velocity > 1.5 MoM. Seven of the eleven were confirmed to have fetal anemia on percutaneous umbilical sampling while four were false positives, corresponding to a positive predictive value of 7/11 (64%, 95% CI 31%, 89%) and a false positive rate of 4/11 (36%, 95% CI 11%, 69%). MCA Doppler assessment performed at less than 24 weeks gestation had a positive predictive value of 64% for identification of fetal anemia, suggesting that 1 in 3 are false positives. This must be taken into account when considering percutaneous umbilical sampling in patients were positive fetal MCA Dopplers before 24 weeks.

Elevated fetal middle cerebral artery peak systolic velocity in diabetes type 1 patient: a case report

Abstract Objectives Doppler measurement of fetal middle cerebral artery peak systolic velocity (MCA-PSV) is used to screen fetuses at risk of developing fetal anemia. This screening tool has demonstrated to be accurate to estimate the likelihood of fetal anemia and it has been used in the management of fetuses at this risk. It is rare to find in the literature cases of increased MCA-PSV in the absence of fetal anemia. We present the case of an elevated MCA-PSV in the absence of common causes of fetal anemia. Case presentation A 30-year-old woman at 21 weeks of gestation was referred to our unit with a left fetal renal agenesis and single umbilical artery diagnosis. The patient had a poorly controlled type 1 Diabetes with a booking HbA1C of 9.1%. At 31 weeks of gestation, MCA-PSV was raised (>1.5 multiples of the median) in the absence of any cause of fetal anemia and discrepancy of ventricular size with normal fetal heart function were seen. In a subsequent scan, thick interventricular septum was seen and hypertrophic cardiomyopathy (HC) was suggested. Follow-up ultrasonography showed a persistent MCA-PSV in a large for gestation age (LGA) fetus with HC. Due to the prenatal diagnosis of persistent elevated MCA-PSV in LGA fetus with diagnoses of HC in a poorly controlled type 1 diabetic patient labor was induced after fetal lung maturation. Biventricular hypertrophic cardiomyopathy was detected after birth. Conclusions HC may be an explanation for increased MCA-PSV without fetal anemia.

Ethical Issues and Management of Fetal Hemolytic Anemia Caused by Anti-Rh17 in a Multipara with Rare –D– Phenotype

Background: The development of allo-anti-Rh17 (anti-Hr0) in a –D– phenotype whose red blood cells (RBCs) lack CcEe antigens is most likely triggered by transfusion, transplantation, or pregnancy. Gene conversion is the predominating factor in generating RHD-CE-D and RHCE-D-CE hybrids like –D–. Methods: We report here immunohematological and obstetrical data from 2 of the 5 pregnancies of a 24-year-old woman presenting with the –D– phenotype with anti-Rh17. Blood group typing, antibody screening, antibody differentiation, direct antiglobulin test (DAT), and antibody titers were performed by routine gel technology and tube testing. Additionally, molecular genetic analysis was performed. Fetal surveillance was done by sonographic evaluation of the fetal middle cerebral artery peak systolic velocity (MCA-PSV). Results: Blood group typing showed O, C-c-D+E-e- and the DAT was negative. DNA sequencing revealed homozygosity for an RHCE-D(3–9)-CE null allele. Anti-Rh17 titers in the fourth pregnancy remained between 1:8 and 1:128, and no signs for a fetal anemia were observed. However, in the fifth pregnancy, the antibody titers increased up to 1:4,096. Signs of moderate fetal anemia were detected and cesarean section was performed at 34 + 6 weeks of gestation. The newborn presented with hemolytic anemia (cord blood hemoglobin [Hb] = 8.5 mg/dL). She received 2 compatible (small) packed RBC concentrates, phototherapy, and intravenous immunoglobulins. Conclusion: Our case shows that the risk for hemolytic complications increases with the number of pregnancies of sensitized women. Only people who also lack CcEe antigens are compatible as donors. The role of such rare donors as lifesavers, their freedom, and voluntariness conflict with the urgent need for compatible blood.

Twin Anemia Polycythemia Sequence: Knowledge and Insights After 15 Years of Research

Abstract Twin anemia polycythemia sequence (TAPS) is a chronic form of unbalanced feto-fetal transfusion through minuscule placental anastomoses in monochorionic twin pregnancies, leading to anemia in the donor twin and polycythemia in the recipient twin. TAPS can occur spontaneously in up to 5% of monochorionic twins or can arise in 2%–16% of cases after incomplete laser surgery for twin-twin transfusion syndrome. TAPS can develop across the entire second and third trimester. Antenatal diagnosis for TAPS is reached via Doppler measurement of the fetal middle cerebral artery peak systolic velocity, showing an increased velocity in the donor, combined with a decreased velocity in the recipient. Treatment options for TAPS include expectant management, preterm delivery, intrauterine blood transfusion with or without a partial exchange transfusion, fetoscopic laser surgery and selective feticide. The best treatment option is unclear and is currently being investigated in an international multicenter randomized trial (the TAPS trial). Spontaneous fetal demise occurs in 5%–11% of TAPS twins, more often in donors (8%–18%) than in recipients (2%–5%). Severe long-term neurodevelopmental impairment is seen in 9% of TAPS twins, with donors having an increased risk for cognitive impairment and hearing problems (15%).

Is fetal middle cerebral artery peak systolic velocity correlated with hemoglobin levels in cases of nonimmune fetal anemia?

Objectives To establish whether a correlation exists between the fetal middle cerebral artery peak systolic velocity (MCA PSV) and fetal hemoglobin levels before intrauterine transfusion (IUT) in cases of severe fetal anemia. Methods This was a single-center, retrospective study of data from 49 fetuses treated with IUT for fetal anemia between 2003 and 2018. Severe fetal anemia was suspected when MCA PSV was or exceeded 1.55 multiples of the median. Results The causes of anemia were largely idiopathic, and the overall survival rate was 57%. MCA PSV and hemoglobin were correlated in all 34 fetuses with alloimmune fetal anemia, whereas the 15 fetuses with nonimmune causes showed no correlation. Of the 15 noncorrelated cases, twin pregnancy was most common, followed by idiopathic causes. All the twin pregnancies involved monochorionic twins. Fetal hydrops, especially ascites, was significantly associated with severe anemia. Conclusions Fetal MCA PSV may not be a reliable independent factor for the diagnosis of severe fetal anemia in nonimmune cases, and the presence of associated hydrops implies that the fetus is more likely to have severe fetal anemia than in a fetus without hydrops.

Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers.

ABSTRACTObjectiveTo investigate the antenatal management and outcome in a large international cohort of monochorionic twin pregnancies with spontaneous or post‐laser twin anemia–polycythemia sequence (TAPS).MethodsThis study analyzed data of monochorionic twin pregnancies diagnosed antenatally with spontaneous or post‐laser TAPS in 17 fetal therapy centers, recorded in the TAPS Registry between 2014 and 2019. Antenatal diagnosis of TAPS was based on fetal middle cerebral artery peak systolic velocity > 1.5 multiples of the median (MoM) in the TAPS donor and < 1.0 MoM in the TAPS recipient. The following antenatal management groups were defined: expectant management, delivery within 7 days after diagnosis, intrauterine transfusion (IUT) (with or without partial exchange transfusion (PET)), laser surgery and selective feticide. Cases were assigned to the management groups based on the first treatment that was received after diagnosis of TAPS. The primary outcomes were perinatal mortality and severe neonatal morbidity. The secondary outcome was diagnosis‐to‐birth interval.ResultsIn total, 370 monochorionic twin pregnancies were diagnosed antenatally with TAPS during the study period and included in the study. Of these, 31% (n = 113) were managed expectantly, 30% (n = 110) with laser surgery, 19% (n = 70) with IUT (± PET), 12% (n = 43) with delivery, 8% (n = 30) with selective feticide and 1% (n = 4) underwent termination of pregnancy. Perinatal mortality occurred in 17% (39/225) of pregnancies in the expectant‐management group, 18% (38/215) in the laser group, 18% (25/140) in the IUT (± PET) group, 10% (9/86) in the delivery group and in 7% (2/30) of the cotwins in the selective‐feticide group. The incidence of severe neonatal morbidity was 49% (41/84) in the delivery group, 46% (56/122) in the IUT (± PET) group, 31% (60/193) in the expectant‐management group, 31% (57/182) in the laser‐surgery group and 25% (7/28) in the selective‐feticide group. Median diagnosis‐to‐birth interval was longest after selective feticide (10.5 (interquartile range (IQR), 4.2–14.9) weeks), followed by laser surgery (9.7 (IQR, 6.6–12.7) weeks), expectant management (7.8 (IQR, 3.8–14.4) weeks), IUT (± PET) (4.0 (IQR, 2.0–6.9) weeks) and delivery (0.3 (IQR, 0.0–0.5) weeks). Treatment choice for TAPS varied greatly within and between the 17 fetal therapy centers.ConclusionsAntenatal treatment for TAPS differs considerably amongst fetal therapy centers. Perinatal mortality and morbidity were high in all management groups. Prolongation of pregnancy was best achieved by expectant management, treatment by laser surgery or selective feticide. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Intrauterine transfusions for maternofetal red‐blood‐cell incompatibility in monochorionic diamniotic twin pregnancy

Maternal alloimmunization to fetal red-blood-cell (RBC) antigens may cause hemolytic disease in the fetus with severe anemia. Intrauterine transfusions (IUTs) in twin pregnancy represent 1.5% of all fetal transfusions for RBC alloimmunization1, 2. Here, we present a case of a monochorionic diamniotic twin pregnancy complicated by severe anti-D maternofetal incompatibility, monitored by fetal middle cerebral artery (MCA) peak systolic velocity (PSV) and treated successfully by repeat IUTs of a single cotwin. The patient was referred to our center at 24 weeks' gestation for suspected fetal anemia. Fetal middle cerebral artery (MCA) peak systolic velocity (PSV) reached 1.64 multiples of the median (MoM) in Twin A and 2.02 MoM in Twin B. Both fetuses presented with ascites. Twin A was transfused with 30 mL of packed RBC. Pretransfusion hemoglobin (Hb) was 3.0 g/dL, with a Kleihauer–Betke test (KBT) result of 100% in fetal blood3, 4. Post-transfusion Hb increased to 8.8 g/dL and KBT decreased to 18%. MCA-PSV decreased from 1.64 to 1.19 MoM in Twin A and from 2.02 to 1.64 MoM in Twin B. Thirty minutes later, as MCA-PSV remained above 1.5 MoM in Twin B, an IUT of 15 mL was administered to Twin B, which enabled Hb level in Twin B to increase from 8.1 to 11.4 g/dL, and KBT in fetal blood decreased from 17% to 10%. The direct antiglobulin test showed a result of 3+ (high intensity) and cord bilirubin was over 70 µmol/L. These findings were suggestive of ongoing hemolytic disease. For subsequent IUTs at 25 + 4, 27 + 3 and 30 + 3 weeks' gestation, only Twin A was transfused. This strategy allowed for the normalization of MCA-PSV in both fetuses (Figure 1, Table 1). Cesarean section was performed at 31 weeks' gestation for non-reassuring fetal-heart tracing. The first delivered male neonate had birth weight of 1330 g, arterial cord blood pH of 7.37, Hb of 11.3 g/dL and bilirubin of 90 µmol/L. The second neonate had birth weight of 1310 g, arterial cord blood pH of 7.43, Hb of 11.5 g/dL and bilirubin of 88 µmol/L. Placental colored dye injection showed several arterioarterial anastomoses. The twins had respiratory distress syndrome which was treated by non-invasive ventilatory support. Severe jaundice worsened despite intensive phototherapy and albumin infusion, requiring exchange transfusion in both neonates. Two transfusions at 15 and 45 days were also needed. The neonates were discharged at 66 days postpartum. In this case, during the first IUT, transplacental intertwin anastomoses were demonstrated by (1) MCA-PSV values in Twin B decreasing after IUT of Twin A, (2) KBT in fetal blood already being reduced in Twin B after IUT of Twin A but before IUT of Twin B, and (3) Hb in Twin B being similar to that observed in Twin A after IUT of Twin A but before IUT of Twin B. To our knowledge, this is the first reported case demonstrating the contribution of MCA-PSV to monitoring monochorionic twin pregnancy complicated by RBC alloimmunization, treated by repeat IUTs of a single cotwin. One case of a monochorionic twin pregnancy in which IUTs performed in turn in each cotwin has been reported, without using MCA-PSV monitoring2. In cases of fetal anemia caused by Rh alloimmunization in monochorionic twin gestations, it appears sufficient to transfuse only one of the fetuses at 2–3 week intervals.

Doppler middle cerebral artery peak systolic velocity measurement as diagnostic tool for fetal anemia after in-utero transfusions in red blood cell alloimmunisation

Background/Aim. Doppler sonography of fetal middle cerebral artery peak systolic velocity (MCA-PSV) can be used to predict fetal anemia and the need for in utero intravascular transfusion (IUIT) in red blood cell (RBC) alloimmunisation pregnancies. The aim of this study was to evaluate whether measurement of MCA-PSV in fetuses that had undergone one to three transfusions is a good diagnostic tool for fetal anemia. Methods. Study included 36 pregnancies treated due to RBC alloimmunisation in our tertiary referral center during the 5-year period (2012?2017). We measured MCA-PSV and hematocrit (Hct) in all patients. In seven pregnancies there was a need to perform sequential IUITs for correction of fetal anemia. In these patients we compared MCA-PSV and Hct values before and after every transfusion. Results. Hct and MCA-PSV correlated negatively before transfusion therapy (p = 0.035) and after the second transfusion (p = 0.046). Contrary, after the first (p = 0.954), before the second (p = 0.738), as well as before (p = 0.092) and after (p = 0,741) the third transfusions there were no significant correlations between Hct and MCAPSV values. Hct values before and after transfusions were positively associated (p = 0.001), but MCA-PSV were not (p = 0.296). According to performed receiver operating characteristic (ROC) analysis the cut-off point of MCA-PSV for investigated patients was 1.22 multiples of its median (MoM). Conclusion. There is a reduction in MCA-PSV accuracy for assessing fetal anemia in previously transfused fetuses. Larger studies are needed to explain the reasons for these findings and potentially set new referral values of MCA-PSV for better diagnostics of fetal anemia.

Performance of fetal middle cerebral artery peak systolic velocity for prediction of anemia in untransfused and transfused fetuses: systematic review and meta-analysis.

To evaluate the performance of fetal middle cerebral artery peak systolic velocity (MCA-PSV) ≥ 1.5 multiples of the median (MoM) for the prediction of moderate-severe anemia, in untransfused and transfused fetuses. A systematic search was performed to identify relevant observational studies reported in the period 2008-2018 that evaluated the performance of MCA-PSV, using a threshold of 1.5 MoM for the prediction of fetal anemia. Diagnosis of fetal anemia by blood sampling was the reference standard. A hierarchical summary receiver-operating characteristics (hSROC) curve was constructed using random-effects modeling. Subgroup and meta-regression analyses, according to the number of previous intrauterine transfusions, were performed. Twelve studies and 696 fetuses were included in the meta-analysis. The area under the hSROC curve (AUC) for moderate-severe anemia was 83%. Pooled sensitivity and specificity (95% CI) were 79% (70-86%) and 73% (62-82%), respectively, and positive and negative likelihood ratios were 2.94 (95% CI, 2.13-4.00) and 0.272 (95% CI, 0.188-0.371). When considering only untransfused fetuses, prediction improved, achieving an AUC of 87%, sensitivity of 86% (95% CI, 75-93%) and specificity of 71% (95% CI, 49-87%). A decline in sensitivity for the prediction of moderate-severe anemia by MCA-PSV ≥1.5 MoM was observed (estimate, -5.5% (95% CI, -10.7 to -0.3%), P = 0.039) as the number of previous transfusions increased. MCA-PSV ≥ 1.5 MoM for the prediction of moderate-severe anemia in untransfused fetuses shows moderate accuracy (86% sensitivity and 71% specificity), which declines with increasing number of intrauterine transfusions. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Management and outcome of pregnancies in women with red cell isoimmunization: a 15-year observational study from a tertiary care university hospital

BackgroundThe aims of this study were to determine the prevalence of the different anti-erythrocytic alloantibodies, to describe pregnancy outcomes according to a low-risk and high-risk classification for fetal anemia and to determine the factors that influence adverse perinatal outcomes.MethodsThis retrospective observational study included women referred to our center following the identification of maternal anti-erythrocytic alloantibodies between 2002 and 2017. Pregnancies were classified as high risk for fetal anemia in cases with clinically significant antibodies, no fetal-maternal compatibility and titers ≥1:16 or any titration in cases of Kell system incompatibility. In high-risk pregnancies, maternal antibody titration and the fetal middle cerebral artery peak systolic velocity (MCA-PSV) were monitored. Low-risk pregnancies underwent routine pregnancy follow-up.ResultsMaternal antibodies were found in 337 pregnancies, and 259 (76.9%) of these antibodies were clinically significant. The most frequent antibodies were anti-D (53%) and anti-K (19%). One hundred forty-three pregnancies were classified as low risk for fetal anemia, 65 (25%) cases were classified as no fetal-maternal incompatibility, 78 had clinically nonsignificant antibodies, 4 (2.8%) resulted in first-trimester pregnancy loss, and 139 (97.2%) resulted in livebirths. Of the 194 high-risk pregnancies, 38 had titers < 1:16 (resulting in 38 livebirths), and 156 had titers ≥1:16 or anti-K antibodies. In the last group, 6 cases miscarried before 18 weeks, 93 had a MCA-PSV < 1.5 multiples of the median (MoM), resulting in 3 perinatal deaths that were unrelated to fetal anemia, one termination and 89 livebirths; and 57 had a MCA-PSV > 1.5 MoM, resulting in 3 intrauterine deaths, 6 terminations and 48 livebirths. Ninety-two intrauterine transfusions were performed in 45 fetuses (87% anti-D). Adverse outcomes were related to a MCA-PSV > 1.5 MoM (p < 0.001), hydrops (p < 0.001) and early gestational age at first transfusion (p = 0.029)ConclusionAnti-D remains the most common antibody in fetuses requiring intrauterine transfusion. A low or high-risk classification for fetal anemia based on the type of antibody, paternal phenotype and fetal antigen allows follow-up of the pregnancy accordingly, with good perinatal outcomes in the low-risk group. In the high-risk group, adverse perinatal outcomes are related to high MCA-PSV, hydrops and early gestational age at first transfusion.

Fetal middle cerebral artery peak systolic velocity as a predictor of fetal anemia in unselected women giving birth at or near term

ObjectiveThis study was performed to evaluate the application of fetal middle cerebral artery peak systolic velocity (MCA-PSV) for prediction of newborn anemia with umbilical cord blood hemoglobin concentration at birth (UCB-Hb) < 10.0 g/dL among infants born at gestational week (GW) ≥ 36 to unselected women. Materials and methodsWe reviewed the medical charts of 699 women giving birth to singleton infants at GW ≥ 36 with available data on MCA-PSV measured at GW ≥ 25 at the discretion of the attending physician. Multiple of the median (MoM) MCA-PSV (MCA-PSV MoM) > 1.5 was defined as a positive MCA-PSV test result. ResultsThe MCA-PSV test was applied 2309 times (313 and 1996 times during second and third trimesters, respectively) in 699 women. The results were positive in 4.4% (102/2309) of tests and at least once in 9.9% (69/699) of women. Anemic infants were born to one (1.4%) and six (1.0%) of 69 and 630 women with and without at least one positive test result, respectively. MoM determined 4, 3, and 2 weeks before birth showed significant weak negative correlations with UCB-Hb at birth (correlation coefficient: 0.298–0.325). ConclusionsAmong unselected women giving birth at or near term, the MCA-PSV test was unsatisfactory for prediction of newborn anemia in this retrospective observational study.

Doppler ultrasonographic assessment of fetal middle cerebral artery peak systolic velocity in gestational diabetes mellitus.

To compare Doppler ultrasonographic measurements of the fetal middle cerebral artery peak systolic velocity (MCA PSV) among women with or without gestational diabetes mellitus (GDM). A cross-sectional study was conducted among pregnant women who presented for prenatal care at a single hospital in Brazil between September 11, 2015, and January 6, 2017. Patients were stratified into a group with GDM and a control group without GDM. One Doppler ultrasonographic assessment was performed per participant. This measurement was made after diagnosis but before the start of treatment among women in the GDM group. Fetal ultrasonographic and biometric variables assessed included MCA PSV, MCA pulsatility index, umbilical artery pulsatility index, the MCA-to-umbilical artery ratio, abdominal circumference, and weight. The study included 238 women: 115 in the GDM group and 123 in the control group. The median MCA PSV was 1.02 in the GDM group and 1.08 in the control group (P=0.036). No statistically significant between-group differences were found for the other fetal ultrasonographic variables or for the fetal biometric variables assessed. None of the maternal or fetal parameters assessed displayed a linear correlation with MCA PSV. Doppler ultrasonographic measurements of MCA PSV were lowered among the fetuses of women diagnosed with GDM.

PLACENTAL CYTOPATHIC DAMAGE FACTOR DUE TO PARVOVIRUS B19 – AS A HALLMARK OF INTRAUTERINE SYMPTOMATHY OF INFECTED FETUS

Aim of the work. The focus of this study was to analyze the frequency of fetal intrauterine symptomatic realization as a result of B19 parvovirus infection of pregnant women during I and II gestation periods, with the combination of determination the levels of alpha-fetoprotein in maternal serum blood and histopathological investigation of placenta in cases of negative effects for infected fetuses. Materials and methods. A total of 478 pregnant women were at risk of infection and screened for parvovirus B19. The study was based on serological, morphological and virological testing of fetuses from mothers with confirmed parvovirus B19 infection. Infection of pregnant women was detected by serological diagnosis of specific antibodies IgM and IgG to parvovirus B19. Intrauterine fetal infection was confirmed by polymerase chain reaction method. Levels of alpha-fetoprotein in meternal venous blood were detected using an immunochemical test method. An antenatal diagnosis of hydrops fetalis was confirmed by ultrasound scanning. Placenta from the 8 infected fetuses was studied histologically with hematoxylin and eosin staining using electron microscope during gestational periods of 12-22 weeks. Statistical analysis of the obtained data was carried out using nonparametric statistics with the definition of Fisher's criterion. Results and discussion. The average gestational period of symptomatic manifestations of intrauterine fetal infection was 19.9±0.5 weeks of gestation. It was established that in 33 of cases were confirmed the intrauterine infection due to parvovirus B19 by using the morphological placenta tissue analysis. The research found that the levels of maternal serum alpha-fetoprotein was significantly higher (in 2.17 times) in group of fetuses who suffered from fetal hydrops and in cases of intrauterine fetal death before detecting the general echographic sings of fetal failure (p˂0.05). It will be very important to compare this indicator with the Doppler ultrasound measurements of the human fetal middle cerebral artery peak systolic velocity (MCA PSV) and blood flow parameters in the fetal ductus venosus and to predict the possibility of poor perinatal outcomes. It was identified a cytopathic effect in placental cells viral origin and detected in cells of the cytotrophoblast, syncytiotrophoblast, endothelial cells, and blood cells. Conclusions. Parvovirus B19 fractions were visualized in 100 % of cases of miscarriages with fetal hydrops and placental edema during 12-22 weeks of gestation, while acute maternal parvovirus infection (with the detection of IgM against to parvovirus B19) was diagnosed by immunoassay only in 62.5 % of cases. Detection of B19 particles in placental tissue from fetuses with non-immune origin hydrops is an auxiliary method in the diagnosis of vertical transmission of parvovirus during pregnancy. It is more preferable to estimate the levels of alpha-fetoprotein in maternal serum blood in case of parvovirus B19 affected pregnancies as raising rates of this marker may be an early prediction hallmark for adverse fetal outcome.

Middle cerebral artery Doppler reference centile charts for the prediction of fetal anemia in a population from India.

To construct reference charts for the fetal middle cerebral artery (MCA) peak systolic velocity (PSV,) and the corresponding cord blood hemoglobin values at 24-40weeks of pregnancy for the identification of fetal anemia. In a cross-sectional study, 300 women with a pregnancy duration of 24-40weeks planned for delivery within 72hours underwent a Doppler study of the MCA and cord blood hemoglobin estimation at delivery. Regression analysis was used to construct reference charts. The validity of the charts was assessed in 40 fetuses from Rhesus-isoimmunized pregnancies. The MCA PSV and hemoglobin values increased with advancing gestational age. Multiples of the median (MOM) were calculated and reference charts were constructed for mild anemia (MCA PSV 1.29 MOM; hemoglobin 0.8 MOM), moderate anemia (MCA PSV 1.50 MOM; hemoglobin 0.6 MOM), and severe anemia (MCA PSV 1.55 MOM; hemoglobin 0.5 MOM). In the validation sample, the hemoglobin value estimated on the basis of the MCA PSV corresponded with the actual hemoglobin range in 90% of the fetuses. The sensitivity was 92% and the specificity was 95%. The constructed charts are suitable for the evaluation of fetal anemia in the regional population.

OP21.02: Assessment of relationship between fetal middle cerebral artery peak systolic velocity and umbilical vein blood gas values in diabetic pregnancies

OP21.02: Assessment of relationship between fetal middle cerebral artery peak systolic velocity and umbilical vein blood gas values in diabetic pregnancies

EP20.04: Diagnostic indices of MCA PSV for fetal severe anemia in MCDA twin pregnancy

To examine the diagnostic indices of fetal middle cerebral artery peak systolic velocity (MCA PSV) above 1.55 multiples of the median(MoM) Doppler velocimetry for the identification of fetal severe anemia in monochorionic diamniotic (MCDA) twin pregnancies. Study population consisted of 178 MCDA twin fetuses who underwent MCA PSV Doppler velocimetry within 7 days of delivery between gestational age (GA) of 24 and 38 weeks at Seoul National University Hospital between 2005 and February 2017. Fetuses with chromosomal abnormalities, major congenital anomalies or intrauterine demise were excluded. We examined the frequency of severe fetal anemia according to the presence of an increased fetal MCA PSV (≥1.55 MoM). Severe anemia was defined in the presence of hemoglobin concentration < 0.55 MoM in umbilical cord blood at the time of delivery. An increased MCA PSV (≥1.55 MoM) was present in 8.4% of study population and severe anemia was present in 2.2%. Diagnostic indices of an increased MCA PSV (≥1.55 MoM) for the identification of severe anemia were as follows: sensitivity 100% (4/4), specificity 93.7% (163/14), positive predictive value (PPV) 26.7% (4/15) and negative predictive value 100% (163/163). However, PPV at GA 30 weeks or more was only 12.5%, while that at GA less than 30 weeks was 42.9%. The sensitivity and specificity of an increased MCA PSV (≥1.55 MoM) for the identification of severe anemia in MCDA twin pregnancies are very high. However, PPV of that is much lower in cases with GA 30 weeks or more than in those with GA less than less than 30 weeks among MCDA twin pregnancies. EP20.04: Table 1. Middle cerebral artery peak systolic velocity (MCA PSV) Doppler velocimetry in the prediction of fetal severe anemia