Perinatal outcomes of intrauterine transfusion for foetal anaemia due to red blood cell alloimmunisation.

The aim of this study was to evaluate the maternal and neonatal outcomes of patients who underwent intrauterine transfusion (IUT) for foetal anaemia due to red blood cell alloimmunisation and to determine the factors that affected the outcomes. All pregnancies that were treated with IUT due to Rh immunisation between January 2015 and June 2018 in the Kanuni Sultan Süleyman Training and Research Hospital, Department of Obstetrics and Gynaecology, were evaluated retrospectively. IUT due to non-Rh alloimmunisation, parvovirus B19 infection, chronic fetomaternal haemorrhage and foetal anaemia due to homozygous alpha-thalassemia were not included in the study. The perinatal and neonatal outcomes of the patients were retrospectively analysed. The gestational age, ultrasonography findings before and after IUT, laboratory results, complications related to IUT, and data on the newborns were recorded. The cases were divided into two groups, those with complication and those without complications, and their perinatal outcomes were compared. A total of 110 IUTs were performed in 42 foetuses. The survival rate after transfusion was 80.95%. Procedure-related complications were found in 12.7% of cases. There were no significant differences between the demographic and clinical characteristics of the patients with and without complications. The survival rate was lower and perinatal mortality was higher in foetuses with hydrops fetalis. IUT is a safe and effective procedure that can be used in the treatment of foetal anaemia in experienced centres. Survival rates can be increased by referring patients to experienced perinatology centres, by improving the IUT technique, and by reducing technique-related complications.Impact statementWhat is already known on this subject? The predominant use of IUT is to treat foetal anaemia due to red blood cell alloimmunisation. Despite the decrease after anti-D immune globulin prophylaxis, Rh immunisation is still a major cause of foetal anaemia. However, foetal survival rates have increased with the use of IUT.What do the results of this study add? The survival rates were increased after the development of a high-resolution ultrasound. Because foetal monitoring can be performed by ultrasonography, cord accidents and overload findings can be detected during transfusion, which allows for early interventions and increases survival rates.What are the implications of these findings for clinical practice and/or further research? The IUT procedure can be used in the treatment of foetal anaemia in experienced centres. After the technique was improved, the complication rates related to the procedure were decreased and foetal survival rates were increased. Further studies on the use of different IUT techniques will extend our findings.

Prevalence of fetomaternal Rhesus incompatibility at the tertiary care hospital: a cross-sectional study.

Background: Fetomaternal Rhesus incompatibility is a medical condition that affects the pregnant woman [of blood group (A, B, AB, O) and a negative Rhesus] and the foetus (of positive Rhesus). The objective of this study is to determine the prevalence and to present the clinical characteristics of fetomaternal Rhesus incompatibility in a tertiary care hospital. Methods: The authors conducted a retrospective cross-sectional study and 37 participants were recorded during the study period of 4 years. Results: A total of 11 898 pregnant women admitted to the maternity and 37 of them (women with blood groups A, B, AB or O and with a negative Rhesus) participated in our study, including a frequency of 0.31%. Thirty cases of fetomaternal Rhesus incompatibility were recorded in new-borns. 27 (73%) of the women are from the urban region and the age group between 21 and 25 is the most affected with 37.8%. Twenty-two (59.5%) of pregnant women have blood group O (and negative Rhesus) and primiparous women are the most affected with 64.9%. For the discovery of allo-immunization, 43.2% of women discovered it during the second pregnancy and 48.7% women received a single infusion of Anti-D serum during the first pregnancy. Twelve (40%) new-borns developed jaundice as a perinatal prognosis. Conclusion: Fetomaternal Rhesus incompatibility remains a major problem of maternal health because it is likely to lead to the formation of antibodies in women, which by crossing the placental barrier, they destroy red blood cells and thus cause serious complications.

Labour ward negligence.

No amount of symposia and clinical meetings and formal management will make a clinical difference unless obstetric units regularly and ruthlessly self-assess to curb medical negligence. Court case, which represent a small portion of substandard outcomes, not infrequently reveal a serious lack of obstetric judgment as well as paucity of knowledge which are compatible with unsupervised responsibility of labour ward duties. One UK court case ACF 32(2): 09/2019 presents a factual picture of obstetric practice which is difficult to reconcile with modern UK practice. This article limits itself to a number of facts as presented to court by the claimant, and the comments are directed purely at the resulting implications. These facts as stated are seriously worrying in themselves as they reflect practice well below the minimum care to be expected in a modern country and are far from what is recommended by the Royal College of Obstetricians and Gynaecologists and indeed every day standards. The article recommends the shifting of focus from individual to collective or unit responsibility to achieve better care. In any case where gross mismanagement is found, there should be a wider check on practices within the whole obstetric unit.

Management of Rh-isoimmunised Pregnancies : Our Experience.

BACKGROUND: The aim of this study was to assess the role of middle cerebral artery peak systolic velocity (MCA-PSV), as measured by doppler ultrasound, in detecting foetal anaemia in Rh- isoimmunised pregnancies. Intra-uterine foetal blood transfusion was performed in such anaemic foetuses to tide over the crisis of foetal immaturity till considered fit for extra-uterine survival. METHODS: Rh-isoimmunised pregnancies reporting to a tertiary institute from 2003 to 2005, were screened by doppler ultrasound to estimate MCA-PSV to detect foetal anaemia. If the foetus developed MCA-PSV of more than 1.5 multiple of median (MoM) for the gestational age, foetal blood sampling through cordocentesis was performed to confirm foetal anaemia, followed by intrauterine foetal blood transfusion to all anaemic foetuses at the same sitting. Neonatal outcome was evaluated by recording gestational age at the time of delivery, duration of gestational time gained and need for blood transfusion in the neonatal period. RESULTS: A total of thirteen isoimmunised pregnancies were evaluated. Three pregnancies did not require in-utero foetal blood transfusion. Twenty-one intrauterine foetal blood transfusions were performed in the remaining ten patients. Five received blood transfusion in the neonatal period. Intra uterine foetal death occurred in one grossly hydropic foetus and favourable neonatal outcome was recorded in the rest. CONCLUSION: The clinical outcome of these pregnancies justifies the use of doppler studies of MCA-PSV in detecting foetal anaemia and intra uterine foetal blood transfusion is the only hope of prolonging pregnancy and salvaging such foetuses.

Submitting medico-legal intra-partum CTG (I-P CTG) monitoring to the Bolam and Bolitho principles.

The article analyses some of the seeming weaknesses of the Bolam and Bolitho tests as applied to electronic foetal monitoring in labour, in the form of intra-partum CTG monitoring. Homing on to such aspects as confirmation of foetal hypoxia/acidosis, it evaluates the Bolam and Bolitho tests in the context of evidence-based medicine versus traditionally held views, which still hold their own in medical jurisprudence. Case law examples are quoted to illustrate various points. The discussion is of practical relevance both to the individual obstetrician as well as to national budgetary implications, bearing in mind, that, for example, in 2011, 'birth asphyxia' comprised 50% of the UK NHS litigation costs, and in the 2000-2010 decade, the same NHS forked out £3.1 billion for maternity medico-legal claims (the highest of any speciality), mostly involving cerebral palsy and CTG misinterpretation. The article concludes with suggestions to help level the potential extant equivocity between legal principle and medical practice. It also looks at the ruling in Montgomery v Lanarkshire Health Board, UK Supreme Court, and its challenge to Bolam. The implications pose a serious and overdue challenge to a test, born in 1957 and lacking the necessary qualities to serve many 21st century medical quandaries, including the ones raised here.

Foetal scalp blood sampling during labour for pH and lactate measurements.

Second-line methods of foetal monitoring have been developed in an attempt to reduce unnecessary interventions due to continuous cardiotocography (CTG), and to better identify foetuses that are at risk of intrapartum asphyxia. Very few studies directly compared CTG with foetal scalp blood (FBS) and CTG only. Only one randomised controlled trial (RCT) was published in the 1970s and had limited power to assess neonatal outcome. Direct and indirect comparisons conclude that FBS could reduce the number of caesarean deliveries associated with the use of continuous CTG. The main drawbacks of FBS are its invasive and discontinuous nature and the need for a sufficient volume of foetal blood for analysis, especially for pH measurement, resulting in failure rates reaching 10%. FBS for lactate measurement became popular with the design of test-strip devices, requiring <0.5 mL of foetal blood. RCTs showed similar outcomes with the use of FBS for lactates compared with pH in terms of obstetrical interventions and neonatal outcomes. In conclusion, there is some evidence that FBS reduces the need for operative deliveries. However, the evidence is limited with regard to actual standards, and large RCTs, directly comparing CTG only with CTG with FBS, are still needed.