Fetal Anemia: Determinants and Perinatal Outcomes according to the Method of Intrauterine Blood Transfusion.

INTRODUCTION: Fetal anemia from hemolytic disease treated by intrauterine transfusion (IUT) can be performed by intraperitoneal, intracardiac, and intravascular transfusion (IVT). Objective of our study was to compare different transfusion techniques. METHODS: Retrospective review of IUT secondary to red cell alloimmunization was conducted at eight international centers from 2012 to 2020. Severe anemia suspected if middle cerebral artery peaks systolic velocity ≥1.5 multiples of the median. Demographic, delivery, and postnatal variables were analyzed. RESULTS: Total of 344 procedures, 325 IVT and 19 other techniques (non-IVT) included. No difference in demographics, history of stillbirth (20.5 vs. 15.8%, p = 0.7), prior pregnancy IUT (25.6 vs. 31.6%, p = 0.5) or neonatal transfusion (36.1 vs. 43.8%, p = 0.5). At first IUT, non-IVT had higher hydrops (42.1% vs. 20.4%, p = 0.03), lower starting hematocrit (13.3% [±6] vs. 17.7% [±8.2], p = 0.04), and trend toward lower gestational age (24.6 [20.1-27] vs. 26.4 [23.2-29.6] weeks, p = 0.08). No difference in birthweight, neonatal phototherapy, exchange, or simple transfusion was observed. CONCLUSION: This is one of the largest studies comparing techniques to treat fetal anemia. IVT was most performed, other techniques were more likely performed in hydrops, and lower starting hematocrit was seen. Neither technique affected outcomes. This study may suggest that physician's experience may be the strongest contributor of outcomes.

Single fetal demise in monochorionic twins: How to predict cerebral injury in the survivor co-twin?

INTRODUCTION: The aims of the study were to evaluate perinatal outcome in monochorionic (MC) twins complicated with single intrauterine fetal death, spontaneously vs after fetal therapy, and to assess antenatal events that increase the risk of cerebral injury. MATERIAL AND METHODS: Historical cohort study of MC pregnancies with single intrauterine fetal death diagnosed or referred to a tertiary referral hospital (2012-2020). Adverse perinatal outcome included termination of pregnancy, perinatal death, abnormal fetal or neonatal neuroimaging and abnormal neurological development. RESULTS: A total of 68 MC pregnancies with single intrauterine fetal death after 14 weeks of gestation were included. Sixty-five (95.6%) occurred in complicated MC pregnancies (twin to twin transfusion syndrome: 35/68 [51.5%]; discordant malformation: 13/68 [19.1%], selective intrauterine growth restriction: 10/68 [14.7%], twin reversed arterial perfusion sequence: 5/68 [7.3%] and cord entanglement in monoamniotic twins: 2/68 [2.94%]). In 52 cases (76.5%) single intrauterine fetal demise occurred after fetal therapy and in 16 (23.5%) occurred spontaneously. Cerebral damage included 14/68 cases (20.6%): 6/68 cases (8.82%) were prenatal lesions and 8/68 cases (11.8%) were postnatal. Risk of cerebral damage tended to be higher in the spontaneous death group (6/16, 37.5%) compared to the therapy-group (8/52, 15.38%) (p = 0.07). The risk increased with gestational age at intrauterine death (OR 1.21, 95% CI: 1.04-1.41, p = 0.014) and was higher in those surviving co-twins who developed anemia (OR 9.27, 95% CI: 1.50-57.12, p = 0.016). Pregnancies complicated with selective intrauterine growth restriction tended to be at higher risk for neurological damage (OR 2.85, 95% CI: 0.68-11.85, p = 0.15). Preterm birth rate (<37 weeks of pregnancy) was 61.7% (37/60). Seven of eight postnatal cerebral lesions (87.5%) were related to extreme prematurity. Overall perinatal survival rate was 88.3% (57/68) and 7% (4/57) of children had an abnormal neurological outcome. CONCLUSIONS: Risk of cerebral damage in single intrauterine fetal death is especially high when it occurs spontaneously. Gestational age at single intrauterine fetal death, selective intrauterine growth restriction and anemia of the surviving co-twin are the main predictors for prenatal lesions and might be useful in parent counseling. Abnormal postnatal neurological outcome is closely related to extreme prematurity.

Severe fetal anemia after umbilical cord occlusion leading to severe neurological injury in monochorionic twins.

We describe two cases of monochorionic twins with severe anemia in the surviving twin after cord occlusion. The first one was a case of discordant malformation (anencephalia) and the second one was a case of early severe selective intrauterine growth restriction type II in a dichorionic triamniotic triplet pregnancy. In both cases, the cord of the occluded fetus had a marginal insertion. Both of them presented hydrops 2 d after the occlusion, having measurements of the peak systolic velocity (PSV) of the middle cerebral artery (MCA) above 1.5 multiples of the median (MoM). In the first one intrauterine transfusion was performed with pretransfusion measurement of fetal hemoglobin of 3.3 g/dL. An extensive area of destruction of brain tissue at the right parietal-temporal-occipital level was diagnosed at 300 weeks. In the second one, expectant management was decided and a grade 3 intraventricular hemorrhage associated with moderate ventriculomegaly was detected at 22 weeks' gestation. We hypothesize that the surviving fetus after the occlusion can become bloodless and hypovolemic when its blood is poured into the placental and umbilical circulation of the occluded twin through the vascular anastomoses between them. It should not be assumed that cord occlusion removes the risk of transfusional brain injury in surviving-cotwins.

Management of thoracic endometriosis: single institution experience.

OBJECTIVE: Thoracic endometriosis is a relatively rare type of endometriosis and includes catamenial pneumothorax, hemothorax and hemoptysis, and presence of intrathoracic endometriotic nodules. We want to clarify and resume the most appropriate management of this pathology. STUDY DESIGN: We retrospectively reviewed all the cases of thoracic endometriosis diagnosed and followed up in our Unit from 2005 to 2013. This search revealed five women, with a mean age of 34.5 (26-44). Four had previous history of endometriosis or severe dysmenorrhea. One patient complained of chronic shoulder pain with diaphragmatic implants, another one presented catamenial hemoptysis, and three women suffered from catamenial pneumothorax, with right-side preference. RESULTS: Three patients underwent surgery and all of them were treated with GnRH agonists at least during 6 month referring improvement in symptoms. After 1-8 years follow-up, all these patients remain asymptomatic. CONCLUSION: The optimal management of thoracic endometriosis needs further evaluation but the combined approach by hormonal therapy and surgery could be the best option.

Maternal morbidity on 147 triplets: single institution experience.

OBJECTIVES: To evaluate the incidence and characteristics of maternal complications in triple pregnancies. An additional objective was to study the relation between assisted reproductive techniques and maternal complications. MATERIAL AND METHODS: Retrospective study on 147 triplets assisted at the Gynecology and Obstetrics department of La Paz University Hospital between 2000 and 2010. We analyzed the incidence of maternal complications and their relation to assisted reproductive techniques. RESULTS: One triplet was observed every 711 pregnancies. The most frequent maternal complications were spontaneous preterm labor (56%), premature rupture of membranes (28.9%), anemia (24.4%) and preeclampsia (20.4%). Triplets conceived by assisted reproductive techniques were significantly more likely to develop spontaneous preterm labor than spontaneous pregnancies (60% vs. 40%, respectively; p = 0.045). CONCLUSIONS: Triplets have a very high risk of maternal complications such as preeclampsia. Moreover, the presence of spontaneous preterm labor is more frequent in triplets conceived by assisted reproductive techniques than in those spontaneously conceived.