Intrauterine Exchange Transfusion Research Articles

Does an intrauterine exchange transfusion improve the fetal prognosis in parvovirus infection cases?

Almost 20% of parvovirus B19 foetal infections require intrauterine transfusions. In addition, myocardial dysfunction has been observed in severe parvovirus B19 infections. One objective of an intrauterine exchange transfusion (IUET) is to avoid an overload during the transfusion. Our aim was to study the obstetrical and neonatal outcomes in cases of IUETs performed for foetal parvovirus infections and to compare our survival rate to those studies in which simple in utero transfusions were chosen. This was a retrospective monocentre study of all patients followed up for parvovirus B19 infections in which IUETs were performed. An IUET was indicated when foetal hydrops was observed and/or when severe foetal anaemia was diagnosed though an elevation in the middle cerebral artery peak systolic velocity. The characteristics of each pregnancy and the neonatal outcomes were studied until hospital discharge. Thirty-five IUETs were performed in 26 foetuses. The median gestational age of the first IUET was 22.6 weeks. Only one foetal bradycardia incidence was recorded during the procedure. Three medical pregnancy terminations were observed in our series, secondary to severe cerebral anomalies confirmed in the magnetic resonance imaging. Five in utero deaths occurred, in which 2 of the foetuses underwent multiple IUETs. All the neonates had normal haemoglobin levels at birth, and none were transferred to the neonatal intensive care unit. The overall survival rate was 70%. IUETs exhibit a survival rate similar to that of simple intrauterine transfusions in foetal parvovirus infection cases.

Is intrauterine exchange transfusion a safe procedure for management of fetal anaemia?

ObjectiveTo study modalities and complications of intrauterine exchange transfusion (IUET) for the management of severe fetal anaemia. Study designRetrospective study of all IUET procedures performed between January 1999 and January 2012 at a regional centre. Characteristics of each procedure were studied to identify risk factors for complications. Survival rates according to the different aetiologies of anaemia were evaluated. ResultsIn total, 225 IUET procedures were performed in 96 fetuses. Major indications were feto-maternal erythrocyte alloimmunization (n=80/96, 83.3%) and parvovirus B19 infection (n=13/96, 13.5%). Twenty-six percent of the fetuses (25/96) had hydrops fetalis before the first IUET. Intrauterine fetal death occurred after 2.7% (6/225) of procedures, premature rupture of the membranes occurred after 0.9% (2/225) of procedures, and emergency caesarean section was required after 3.6% (8/225) of procedures. Fetal bradycardia [odds ratio (OR) 37, 95% confidence interval (CI) 8.3–170; p<0.01] and gestational age up to 32 weeks (OR 3.67; 95% CI, 1.07–12.58; p=0.038] were significantly associated with complications after IUET. Complications occurred in 17.7% of pregnancies (17/96) and 7.5% of IUET procedures (17/225). The overall survival rate in the study cohort was 87.5% (84/96): 90% (72/80) in the alloimmunization group and 76.9% (10/13) in the parvovirus-infected group (NS). ConclusionIUET has a higher complication rate than simple intrauterine transfusion, and should be performed by well-trained specialists.

213: Is intrauterine exchange transfusion a safe procedure for management of severe fetal anemia?

213: Is intrauterine exchange transfusion a safe procedure for management of severe fetal anemia?

In Utero Diagnosis and Management of a Fetus With Homozygous α-Thalassemia in the Second Trimester

Alpha thalassemia with the absence of 4 α-globin genes leads to fetal hydrops and fetal death from anemia. Historically considered a lethal condition, optimal in utero management of homozygous α-thalassemia is unclear. A fetus of Filipino descent at 26 weeks gestation presented with ultrasound evidence of anemia. Cordocentesis confirmed anemia and homozygous α-thalassemia (--/--). Intrauterine transfusion corrected anemia but fetal growth restriction and oligohydramnios persisted. Intrauterine exchange transfusion improved hemoglobin parameters, fetal growth, and oligohydramnios. The late preterm infant was delivered with classic limb reduction defects. Hemoglobin Bart's is nonfunctional for oxygen transport, and intrauterine exchange transfusion may be effective first-line therapy and further investigation is warranted.

Serial blood donations for intrauterine transfusions of severe hemolytic disease of the newborn with the use of recombinant erythropoietin in a pregnant woman alloimmunized with anti‐Ku

The management of a pregnant woman with the rare Ko phenotype and anti-Ku is a special challenge, because matched blood is extremely rare and the possibility of severe hemolytic disease of the newborn is high. A 30-year-old woman with rare Ko (Knull) phenotype presented at 18 weeks of gestation with positive indirect agglutination test results. She had anti-Ku due to previous blood transfusion, one pregnancy, and two abortions. During this pregnancy, anti-Ku titers ranged from 1024 to 4096. At the 26th week of gestation ultrasound showed a hydropic fetus and urgent intrauterine exchange transfusion was performed with the maternal red blood cells (RBCs). Recombinant human erythropoietin (rHu-EPO) and intravenous (IV) iron were administered to the mother to ensure an adequate supply of matched RBCs for intrauterine transfusions and possible perinatal hemorrhage. Intrauterine transfusions were repeated every 1 to 3 weeks. By 35 weeks 2 days of gestation, the mother had donated 4 units of blood, and four intrauterine transfusions had been performed. Cesarean section was then decided and a healthy male newborn was born. He was treated with phototherapy but without exchange transfusions. By the 15th day of life rHu-EPO was administrated to the newborn because of anemia. The maternal RBCs completely disappeared from the child's blood by Day 100. As shown in this case, treatment with rHu-EPO and IV Fe has effectively increased the mother's capacity to donate RBCs for autologous use and intrauterine transfusions, with no adverse effects to the mother or the child.

HAEMOLYTIC DISEASE OF THE FETUS AND NEWBORN (HDFN) – CASE REPORT

Background. Hemolytic disease of the fetus and newborn (HDFN) develops because of the passage of maternal erythrocyte alloantibodies through the placenta. These antibodies cause a reduction of the erythrocyte life span in the fetus and newborn. This severe form of the disease is most commonly caused by anti-D antibodies. Besides those, the hemolytic disease can also be caused by anti-K, anti-c, anti-E, anti-A, anti-B and some other antibodies. Methods and material. A case of a pregnant woman who has been pregnant four times is presented. During the first pregnancy, she developed anti-D erythrocyte antibodies, and after the third pregnancy also additional anti-C antibodies. During the first pregnancy, hemolytic disease of fetus led to the intrauterine death of the fetus. The second child died one day after birth. The third and fourth fetuses required several intrauterine exchange transfusions due to high titers and great hemolytic activity of anti-D antibodies. In both newborns, exchange transfusions had to be performed after birth, and both received additional transfusions of concentrated erythrocytes because of anemia. Conclusions. HDFN is a severe disorder that can be successfully prevented with appropriate legalized measures.

Intrauterine therapy for homozygous α-thalassemia

Alpha-thalassemia is one of the most common genetic disorders in the world and is becoming more common in the United States with the increase in immigration of susceptible populations. This disease has been stated previously to be incompatible with extrauterine life. A Filipino woman with a prior loss due to hemoglobin Bart's underwent prenatal diagnosis that confirmed recurrence in the index pregnancy. Intravascular intrauterine exchange transfusions maintained appropriate fetal growth. A cesarean delivery yielded a 2190-g male infant with minor malformations. The postnatal course was characterized by mild respiratory insufficiency. Postnatal chronic transfusion therapy is underway pending consideration for bone marrow transplantation. Antenatal diagnosis and therapy of homozygous alpha-thalassemia can prevent the prenatal consequences of hydrops and fetal death. New technologies such as stem cell transplantation may help to avert both prenatal and postnatal consequences.

Fetal surgery in the 1990s.

In the recent past, the first opportunity to visualize fetal structure and function occurred at birth. Two major contributions in the 1960s inaugurated the era of the fetus as a patient: (1) Prenatal diagnosis became possible using amniocentesis as a technique to evaluate fetal health by cytogenetic 1 and biochemical 2,3 analysis. (2) Prenatal treatment became possible using fetal transfusion to control rhesus factor erythroblastosis fetalis. 4 Intrauterine exchange transfusions through an abdomen and uterine incision were attempted and abandoned due to unacceptably high maternal morbidity associated with open procedures. 5 The development of less invasive techniques for percutaneous placement of catheters or needles for intraperitoneal transfusion permitted in utero exchange transfusion. 6 In the 1970s, the introduction of fetal ultrasonography allowed for accurate visualization of the structure and function of the fetus. 7 As skill and technology advanced, the list of fetal anomalies able to be diagnosed by

Intra-uterine exchange transfusion under ultrasound guidance

Thirty intra-uterine exchange transfusions (LUE.T.) under ultrasound guidance were performed on 15 pregnancies in 14 severely Rh-sensitized women. Our technique and a new method of catheterization of the umbilical cord are described. I.U.E.T. were commenced at 19–34 gestational weeks and repeated up to 5 times at 15 to 60 days intervals. The lowest pretransfusion fetal hemoglobin was 3 g/l at 25 weeks. All the hydrops (4 cases) reversed a few days after the first procedure. The survival rate is 50% for hydropic fetuses and 66.6% for all cases. This technique avoids fetal hypervolemia and also too repetitive procedures by quick renewal of red cells. Catheterization offers a simple and safe access to the umbilical vein even with important fetal movements.

Two hundred intrauterine exchange transfusions in severe blood incompatibilities

Two hundred intrauterine exchange transfusions were performed under local anesthesia in 107 cases of blood incompatibilities (60 fetuses with severe anemia and 47 with hydrops). Under sonographic guidance, depending on fetal and placental position, an optimal puncturing site was selected along the umbilical vein: placental insertion, fetal insertion, or fetal intraabdominal segment. Tests were immediately performed to confirm fetal origin of blood obtained and estimate hemoglobin level. Blood used for exchange transfusion was compatible with maternal blood and had a hematocrit value of 75%. Exchange transfusion was continued until a hemoglobin level of 16 gm/dl was reached. This procedure was first associated with intraperitoneal transfusions and was subsequently used independently once a month to maintain an adequate hemoglobin level. In 4 fetuses with hydrops, antenatal regression of this sign was observed in 33 cases (70.2%). Overall outcome of 107 fetuses after exchanges was 84 living neonates (78.5%), 15 deaths in utero, and eight neonatal deaths. The survival rate was 91.6% for fetuses without hydrops and 61.7% for those with hydrops. The advantage of exchange transfusion appears to be rapid and efficient correction of anemia with elimination of incompatible fetal red blood cells.

Fetal umbilical cord catheterization under ultrasound guidance.

Since 1984 we have performed 30 intrauterine exchange transfusions (IUET) under ultrasound guidance. In 4 pregnancies with anterior placenta, we performed 9 umbilical cord catheterizations in 11 IUET: the first with material for epidural analgesia and the others with a central venous catheter. The latest one was performed at 34 weeks, the earliest at 27 weeks and repeated up to 4 times. Every catheterization did not last more than 5 min and we did not find any infection, hematoma or placental or cord injury. All 4 pregnancies were delivered at 34-36 weeks and the babies are alive and healthy (the oldest is 4 years old). This technique, when possible, is a good alternative to long procedures with risk of fetal movements, and limits the risk of hematoma.

Improved Care for Rh-Isoimmunized Patients in Saudi Arabia

ABSTRACT Although the number of patients with Rh isoimmunization in pregnancy has been decreasing in recent years, this category of patients contributes significantly to the perinatal mortality in ...

Midtrimester intrauterine exchange transfusion of the fetus

Thirty-seven fetuses, 15 to 23 weeks' gestation, were subjected to intrauterine exchange transfusion under direct vision with a fetoscope prior to therapeutic abortion. A maximum of 30 ml of blood was exchanged, so that as much as 95% of the blood in the fetoplacental circulation was of donor origin. The technique clearly has potential value in the management of severe rhesus-hemolytic disease of newborn infants.

Conjugated hyperbilirubinemia in infants with erythroblastosis fetalis.

In an attempt to identify the incidence of conjugated hyperbilirubinemia in infants with erythroblastosis fetalis the records of 67 infants were reviewed. Twenty-two infants were found to have direct bilirubin concentrations greater than 1.0 mg./dl. Among 11 infants who underwent intrauterine exchange transfusion, nine (82%) had conjugated hyperbilirubinemia. Of the remaining 56 infants without the procedure, only 13 (23%) showed evidence of this complication. To predict infants at risk of developing conjugated hyperbilirubinemia, the ratio of hematocrit and total bilirubin concentration in cord blood (H/B ratio) was examined.

EARLY PREDICTION OF CONJUGATED HYPERBILIRUBINEMIA IN INFANTS WITH ERYTHROBLASTOSIS FETALIS

In an attempt to identify those infants at risk of developing conjugated hyperbillrnbinemia (CH), the ratio of hematocrit to total bilirubin concentration in cord blood at birth (H/B ratio) hat been examined in 67 infants with erythroblastosis fetalis. 22 developed CH and 45 made an uneventful recovery. Between these groups, there were no differences in birthweight, gestational age, peak total bilirubin level, and the number of extrauterine exchange transfusions. Statistically significant differences (P<.05) were demonstrated in cord total bilirubin concentration, delivery by cesarian section, time of peak bilirubin, intrauterine exchange transfusions and respiratory problems. Of the 22 who developed CH, 73% had an H/B ratio of 5 or less. Although the mean H/B ratio of each group was not significantly different, 67% of those with an H/B ratio of 5 or less developed CH while only 22% with a ratio of 6 or more developed this complication (P<.01). Of those with an H/B ratio of 20 or less, 92% required extrauterine exchange transfusion while of those with a ratio of 21 or more only 18% required subsequent exchange. The H/B ratio identifies those infants at highest risk of developing CH and requiring exchange transfusion. It permits the physician to introduce preventive measures early in the course of treatment or to study different modes of therapy in a high risk group.

The unborn patient.

Gregg and Hutchinson (p 1059) tell of 15 infants who would probably have died as fetuses save for intrauterine exchange transfusion and who, at an average age of 2 years, have normal physical and mental development. Their report confirms the hopes that have led mothers and physicians to accept risks, discomforts, and complications in order that the techniques of intrauterine exchange transfusion might be developed and refined. The report will also be a stimulus for the many who have watched such studies with reservations to undertake treatment of the unborn child with isoimmune hemolytic disease. Most important, however, the report will compel us to enlarge our concepts of the patient-doctor contract, the contract that exists whenever there is a sick patient and a doctor who will provide care. The qualities of choice, knowledge, and direct interaction that are crucial to the doctor-patient relationship are not basic to the patient-doctor contract.

Intrauterine exchange transfusion: A new technique : S. H. Ascensio, J. G. Figueroa-Longo, and I. A. Pelegrina. Obstet. Gynec. 32:350–355, (September) 1968

Intrauterine exchange transfusion: A new technique : S. H. Ascensio, J. G. Figueroa-Longo, and I. A. Pelegrina. Obstet. Gynec. 32:350–355, (September) 1968

The effect of fetal exchange transfusions with adult blood upon fetal oxygenation.

Extract: Intrauterine exchange transfusions were conducted in fetal sheep using adult sheep as donors. Indwelling catheters in the fetus permitted sampling of blood for 8 to 36 days following the transfusion. In the first days after the procedure there was a decreased oxygen affinity of umbilical blood, an increase of about 5 mm Hg in umbilical venous O2 tension, and a decrease of about 30% in O2 saturation. In the following weeks there was a gradual return of O2 affinity, PO2, and oxygen saturation to normal. In all of the experiments there was a good correlation between the O2 affinity of umbilical blood and the percentage of adult cells present. This correlation indicated that adult cells retained a normal O2 dissociation curve even after weeks of exposure to the new environment. Despite an increased umbilical venous PO2, the fetal reticulocyte count increased significantly after transfusion, but the oxygen capacity of umbilical blood remained within normal limits.Speculation: These studies suggest that the correction of fetal anemia in erythroblastosis fetalis by the use of fetal blood instead of adult blood would produce a greater increase in the amount of hemoglobin capable of carrying oxygen at the low oxygen tensions characteristic of the fetal circulation.

Intrauterine exchange transfusion

Intrauterine exchange transfusion

Prenatal Treatment of Erythroblastosis

I was most interested in the papers published from the International Conference of Intrauterine Fetal Surgery held in Stowe, Vermont, November 9-1l, 1964 (Pediatrics 35: 813, 1965). The current interest in this subject induced me to request publication of the following commentary: I think that intrauterine exchange transfusion, as performed by Karlis Adamsons, Jr., et at., where the femoral artery was cannulated in order that the arterial pressure should permit the withdrawal of blood, seems to be an unnecessary risk since, until birth, the mother is perfectly able to withdraw the excess of fetal bilirubin.