Intrauterine Transfusion for Rhesus Alloimmunization: A Historical Retrospective Cohort from A Single Reference Center in Brazil.

Objective: This study aimed to describe the historical experience of a single reference center in Brazil with intrauterine transfusion (IUT) for Rhesus (Rh) alloimmunization, evaluating the major complications and the perinatal outcomes of this procedure. Methods: This retrospective cohort study evaluated data from medical records of pregnant women between 20 and 34 weeks of gestation whose fetuses underwent IUT by cordocentesis between January 1991 and June 2021. The same experienced examiner performed all procedures. Univariate and multivariate logistic regression was used to assess the effect of fetal hydrops, duration of IUT, post-transfusion cord bleeding time, and bradycardia on death (fetal or neonatal). Results: We analyzed data from 388 IUTs in 169 fetuses of alloimmunized pregnant women with a mean age of 29.3 ± 5.1 years. Death and fetal hydrops were significantly associated at first IUT (p < 0.001). We had two cases of emergency cesarean section (mean of 0.51% per IUT) and three cases of premature rupture of the ovular membranes (mean of 0.77% per procedure). Thirty-six deaths were recorded, including 14 intrauterine and 22 neonatal. A higher percentage of neonatal deaths was observed in the group with post-transfusion cord bleeding time > 120 s (45.8%). The odds of neonatal death were 17.6 and 12.9 times higher in cases with hydrops and bradycardia than in cases without hydrops and bradycardia, respectively. The odds of death (fetal and neonatal) were 79.9 and 92.3 times higher in cases with hydrops and bradycardia than in cases without hydrops and bradycardia, respectively. Conclusions: The most common complications of IUT for Rh alloimmunization were post-transfusion cord bleeding, fetal bradycardia, premature rupture of ovular membranes, and emergency cesarean section. The IUT complication most associated with death (fetal and neonatal) was bradycardia, and the perinatal outcomes were worse in fetuses with hydrops.

The role of measuring peak systolic velocity of the middle cerebral artery blood flow and anti-K1 titre during pregnancy to detect foetuses with severe anaemia, foetal hydrops, and the requirement of intrauterine transfusion: A systematic review and meta-analysis.

The clinical manifestation of foetal anaemia caused by maternal Kell alloantibodies differs from that caused by non-Kell alloantibodies. Severe anaemia develops in the foetus in the early weeks of gestation; therefore, proper management and early intervention are important. A systematic review and meta-analysis was performed to determine whether the anti-K1 titre can determine the sequelae of Kell alloimmunised pregnancies. Prospective and retrospective cohort studies were used to conduct a systematic review following a comprehensive literature search, in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Studies were screened based on a defined set of inclusion and exclusion criteria. A total of 5143 potential articles were identified. Ten studies were used in the meta-analysis of pregnancy outcomes for a specific anti-K1 titre cut-off. The meta-analysis identified statistical significance for intrauterine transfusion (ARD: 0.351; 95 % CI: 0.593-0.109; p-value = 0.004), hydrops (ARD: 0.808; 95 % CI: 1.145-0.472; p-value <0.001), intrauterine foetal death (ARD: 0.938; 95 % CI:1.344 to -0.533; p-value <0.001) and intrauterine transfusion for Doppler middle cerebral artery >1.5 MoM (ARD: 0.381; 95 % CI:1.079 to -0.317; p-value = 0.285). It was concluded that there is no correlation between anti-K1 titre and Kell sensitised pregnancy outcomes, but monitoring the anti-K1 titre is important to manage the pregnancy and it helps clinicians determine the need for intrauterine transfusions. Doppler middle cerebral artery peak systolic velocity is strongly correlated with foetal anaemia and is an efficient routine method for determining the need for intrauterine transfusions in pregnancies affected by anti-K1.

Parvovirus B19 Infection and Pregnancy: Review of the Current Knowledge.

Parvovirus B19, a member of the Parvoviridae family, is a human pathogenic virus. It can be transmitted by respiratory secretions, hand-to-mouth contact, blood transfusion, or transplacental transmission. Most patients are asymptomatic or present with mild symptoms such as erythema infectiosum, especially in children. In rare cases, moderate-to-severe symptoms may occur, affecting blood cells and other systems, resulting in anemia, thrombocytopenia, and neutropenia. Non-immune pregnant women are at risk for fetal infection by parvovirus B19, with greater complications if transmission occurs in the first or second trimester. Infected fetuses may not show any abnormalities in most cases, but in more severe cases, there may be severe fetal anemia, hydrops, and even pregnancy loss. Maternal diagnosis of intrauterine parvovirus B19 infection includes IgG and IgM antibody testing. For fetal diagnosis, PCR is performed through amniocentesis. In addition to diagnosing the infection, it is important to monitor the peak of systolic velocity of the middle cerebral artery (PVS-MCA) Doppler to assess the presence of fetal anemia. There is no vaccine for parvovirus B19, and fetal management focuses on detecting moderate/severe anemia by fetal PVS-MCA Doppler, which, if diagnosed, should be treated with intrauterine transfusion by cordocentesis. Prevention focuses on reducing exposure in high-risk populations, particularly pregnant women.

Transfusión intrauterina, hidrops fetal no inmune: reporte de un caso / Intrauterine transfusion, non-immune fetal hydrops: case report / Transfusão intrauterina, hidropisia fetal não imune: relato de caso

Introducción: el hidrops fetal es grave, de mal pronóstico y alta morbimortalidad, a pesar de mejoras diagnósticas y terapéuticas desarrolladas en los últimos tiempos. El pronóstico estará determinado por la etiología y posibilidades terapéuticas asociadas a mejores resultados, a la edad gestacional, al diagnóstico y al nacimiento, si bien cabe destacar que no existen suficientes estudios de seguimiento a largo plazo. El diagnóstico ecográfico es confirmatorio, siendo la principal complejidad identificar la etiología y plantear la estrategia terapéutica adecuada. Descripción del caso: presentamos una paciente con diagnóstico de hidrops fetal de tipo no inmune y su abordaje terapéutico. La causa del hidrops correspondió a anemia fetal severa, requiriendo la realización de tres procedimientos con exanguinotransfusión parcial intrauterina mediante cordocentesis. A las 33 semanas, se decidió la finalización del embarazo, con buena evolución neonatal. Conclusión: el hidrops fetal aumenta la morbimortalidad fetal y neonatal, siendo un enorme desafío para el equipo tratante, que requiere de un equipo asistencial interdisciplinario. El conocimiento de esta patología permite realizar un abordaje completo, orientar a la etiología, realizando un diagnóstico oportuno y la selección adecuada del tratamiento. Como en este caso, al identificar la anemia severa como causa del hidrops, es mandatorio definir el manejo para los fetos candidatos a terapia intrauterina.

Introduction: fetal hydrops is a serious condition with a poor prognosis and high morbidity and mortality, despite improvements in diagnostics and therapeutics in recent years. Prognosis is determined by the etiology and therapeutic options associated with better outcomes, gestational age, diagnosis, and birth, although it should be noted that there are not enough long-term follow-up studies. Ultrasound diagnosis is confirmatory, with the main challenge being to identify the etiology and propose the appropriate therapeutic strategy. Description of the case: we present a patient diagnosed with non-immune fetal hydrops and its therapeutic approach. The cause of hydrops was severe fetal anemia, requiring 3 procedures with intrauterine partial exsanguination transfusion through Cordocentesis. At 33 weeks, the decision was made to terminate the pregnancy, with good neonatal outcomes. Conclusions: fetal hydrops increases fetal and neonatal morbidity and mortality, posing a significant challenge for the treating team and requiring an interdisciplinary healthcare team. Understanding this condition allows for a comprehensive approach, guiding the etiology, providing timely diagnosis, and selecting appropriate treatment. As in this case, identifying severe anemia as the cause of hydrops mandates defining the management for fetuses eligible for intrauterine therapy.

Introdução: a hidropisia fetal é grave, com mau prognóstico e elevada morbimortalidade, apesar das melhorias diagnósticas e terapêuticas desenvolvidas nos últimos tempos. O prognóstico será determinado pela etiologia e possibilidades terapêuticas associadas a melhores resultados, idade gestacional, diagnóstico e nascimento, embora se deva salientar que não existem estudos suficientes de seguimento a longo prazo. O diagnóstico ultrassonográfico é confirmatório, sendo a principal complexidade identificar a etiologia e propor a estratégia terapêutica adequada. Descrição do caso: apresentamos uma paciente com diagnóstico de hidropisia fetal não imune e sua abordagem terapêutica. A causa da hidropisia correspondeu a anemia fetal grave, sendo necessária a realização de 3 procedimentos com exsanguineotransfusão intrauterina parcial por meio de cordocentese. Às 33 semanas foi decidida a interrupção da gravidez, com boa evolução neonatal. Conclusão: a hidropisia fetal aumenta a morbimortalidade fetal e neonatal, sendo um enorme desafio para a equipe responsável pelo tratamento, necessitando de uma equipe de atendimento interdisciplinar. O conhecimento desta patologia permite uma abordagem completa, orientação sobre a etiologia, diagnóstico atempado e seleção do tratamento adequado. Assim como neste caso, quando se identifica anemia grave como causa da hidropisia, é obrigatória a definição do manejo para os fetos candidatos à terapia intrauterina.

Prevención de enfermedad hemolítica perinatal severa con inmunoglobulina intravenosa en paciente altamente sensibilizada / Prevention of severe perinatal hemolytic disease with intravenous immunoglobulin in a highly sensitized patient

RESUMEN La enfermedad hemolítica perinatal es infrecuente hoy por la prevención que de ella se hace. Sin embargo, existen casos de madres altamente sensibilizadas que desean tener un hijo, lo que obliga a que ese embarazo deseado sea controlado de manera especial y sometido a procedimientos invasivos no exentos de morbimortalidad fetal. El uso prenatal de inmunoglobulina humana en la madre puede representar una alternativa terapéutica. Se presenta un caso en que su uso impidió el desarrollo de enfermedad intrauterina y favoreció la buena evolución neonatal a pesar de que el pronóstico inicial era muy adverso.

ABSTRACT Perinatal Hemolytic Disease is uncommon today due to its prevention. However, there are cases of highly sensitized mothers who wish to have a child, that forces this desired pregnancy to be controlled in a special way and be subjected to invasive procedures not exempt from fetal morbidity and mortality. Prenatal use of human inmunoglobulin in the mother may represent a therapeutic alternative. We present a case in which its use prevented the development of intrauterine disease and favored a good neonatal evolution despite the fact that the initial prognosis was very adverse.

Transfusión intrauterina: tratamiento de anemia fetal severa en el Centro de Referencia Perinatal Oriente / Intrauterine transfusion: treatment of severe fetal anemia at the Oriente Perinatal Reference Center

RESUMEN INTRODUCCIÓN: La anemia fetal es una importante causa de morbilidad y mortalidad perinatal. En la actualidad la principal herramienta terapéutica es la transfusión fetal intrauterina, permitiendo una mejoría en el pronóstico y sobrevida en fetos con anemia severa. El objetivo de este estudio fue reportar los resultados obtenidos en el Centro de Referencia Perinatal Oriente (CERPO). MÉTODO: Se realizó un análisis descriptivo retrospectivo de los casos de anemia fetal que requirieron transfusión intrauterina en CERPO entre los años 2003-2019. RESULTADOS: Se incluyeron 17 embarazos, con un total de 27 procedimientos. La sobrevida perinatal fue de 82%, con un 18% de mortalidad perinatal. Se reporta una tasa de mortalidad de 3,7% asociado al procedimiento. CONCLUSIÓN: Los resultados observados son similares a lo publicado, con una tasa de complicaciones similar a lo reportado en la literatura internacional y nacional.

SUMMARY INTRODUCTION: Fetal anemia is an important cause of perinatal morbidity and mortality. At present, the main therapeutic tool is intrauterine fetal transfusion, allowing an improvement in the prognosis and survival in fetuses with severe anemia. The objective of this study was to report the results obtained in Centro de Referencia Perinatal Oriente (CERPO). METHOD: A retrospective descriptive analysis of the cases of fetal anemia that required intrauterine transfusion in CERPO between 2003-2019. RESULTS: There were 17 pregnancies included, with a total of 27 procedures. Perinatal survival was 82%, with 18% perinatal mortality; a mortality rate of 3.7% is reported per procedure. CONCLUSION: The observed results agree with previous reports.

Anticuerpos anti-Fya con reacción anamnésica asociada con anti-D en transfusión intrauterina: reporte de un caso / Anti-Fya antibodies with anamnestic reaction associated to anti-D in intrauterine transfusion: A case report

Resumen ANTECEDENTES La enfermedad hemolítica perinatal ocurre después de una transfusión sanguínea, que sensibiliza con antígenos eritrocitarios, hemorragia materno-fetal durante el embarazo o al momento del parto. La incidencia de anticuerpos anti-D ha disminuido de 14 a 0.1% en las madres D-negativas. No existe una inmunoglobulina que evite o disminuya la aloinmunización por otros antígenos eritrocitarios durante el embarazo. La incompatibilidad del grupo sanguíneo Duffy es una causa común de enfermedad hemolítica perinatal. OBJETIVO Exponer el caso de una paciente con hijo con enfermedad hemolítica perinatal por anticuerpos anti-Fya y anti-D tratado con transfusión intrauterina. CASO CLÍNICO Paciente de 22 años, con antecedente de múltiples transfusiones sanguíneas y datos clínicos de síndrome anémico. En la semana 28 del embarazo fue valorada para aplicarle inmunoglobulina anti-D. Luego de aplicarle dos unidades de concentrado eritrocitario Rh negativo se observó incompatibilidad (++) en fase de antiglobulina humana (Coombs), por esto se realizó el escrutinio de anticuerpos irregulares en gel, que resultó positivo en células I y II (+++). Enseguida se inició el protocolo de identificación de anticuerpos irregulares con un panel de 11 células, que reportó aglutinación en las células 1, 2, 3, 5, 6, 7, 8 y 11, sin mostrar especificidad. El estudio de adsorción del anticuerpo anti-D mostró células de antígeno D+ con las que se estableció el diagnóstico de anticuerpos anti-Fya y anti-D. El embarazo finalizó mediante cesárea con el nacimiento de un varón con grupo y Rh O positivo, de 30.1 semanas de gestación (talla de 40 cm y peso de 2000 g) con hidrops fetal. Se le realizaron ciclos de reanimación e ingresó a la unidad de cuidados intensivos neonatales, sin tratamiento farmacológico, y después de una hora de vida extrauterina falleció. La madre se dio de alta del hospital 36 horas después del puerperio, sin complicaciones adicionales. CONCLUSIÓN Los anticuerpos antieritrocitarios anti-Fya, solos o en combinación con otros anticuerpos, provocan enfermedad hemolítica perinatal severa. El laboratorio de inmunohematología tiene participación importante en el diagnóstico, seguimiento y tratamiento de la enfermedad hemolítica perinatal.

Abstract BACKGROUND Hemolytic disease of the fetus and newborn occurs after alloimmunization with red blood cells antigens by blood transfusion, maternal-fetal hemorrhage during pregnancy or at delivery. Currently, the incidence of alloimmunization by anti-D antibody has been reduced from 14% to 0.1% of D-negative mothers, however, there is no immunoglobulin that prevents or decreases alloimmunization by other red blood cells antigens during pregnancy. The incompatibilities of the Duffy blood group are a common cause of hemolytic disease of the fetus and newborn. OBJECTIVE To present the case of a neonate with perinatal hemolytic disease secondary to anti-Fya and anti-D antibodies managed with intrauterine transfusion. CLINICAL CASE A 22-year-old patient with a history of multiple blood transfusions and clinical data of anemic syndrome. In the 28th week of pregnancy it was evaluated for the application of anti-D immunoglobulin. The blood bank was asked for two units of Rh negative erythrocyte concentrate. Incompatibility (++) in the human antiglobulin phase (Coombs) was observed, so the irregular antibody gel was screened, which was positive in cells I and II (+++). An identification protocol for irregular antibodies was initiated with a panel of 11 cells, which reported agglutination in cells 1, 2, 3, 5, 6, 7, 8 and 11, without specificity. The adsorption study of the anti-D antibody showed D + antigen cells. The diagnosis of anti-Fya and anti-D antibodies was established. The pregnant woman was terminated by caesarean section, from which a male with a group was born and Rh O positive, of 30.1 weeks of gestation (size of 40 cm and weight of 2000 g) with fetal hydrops. He underwent resuscitation cycles, entered the neonatal intensive care unit, without pharmacotherapy and died after one hour of extrauterine life. The mother withdrew 36 hours after the puerperium, without additional complications. CONCLUSION The antibodies anti-Fya alone or next to other alloantibodies produce severe hemolytic disease of the fetus and newborn. The laboratory of immunohematology in the blood bank is an essential tool in the diagnosis, monitoring and treatment of hemolytic disease of the fetus and newborn.

Anemia hemolítica fetal rápidamente progresiva en el pretérmino tardío: reporte de caso / Rapidly progressive fetal hemolytic anemia in the late preterm: case report and literature review

Resumen ANTECEDENTES: La isoinmunización Rh es el principal factor de riesgo de anemia fetal. Cuando ésta es moderada o severa la transfusión intrauterina antes de las 34 semanas, y el nacimiento del feto luego de las 37, son las opciones de tratamiento más aceptadas. CASO CLÍNCO: Paciente de 29 años, con 34 semanas de embarazo, con antecedentes de tres gestaciones que terminaron en dos partos y una cesárea e isoinmunización Rh con secuela neurológica por anemia hemolítica. Hallazgo de Coombs indirecto positivo 1/512 y velocidad pico sistólica de la arteria cerebral media de 57 cm/s. Registro cardiotocográfico reactivo y seguimiento ambulatorio semanal. Retornó a Urgencias debido a la percepción de contracciones uterinas esporádicas. El feto se encontró con 140 lpm, peso de 2760 g y cuantificaciones correspondientes a anemia leve. La cordocentesis reportó Hb = 7.7 g/dL; "O" Rh (+). El embarazo terminó mediante cesárea con el nacimiento de una niña de 2702 g, Apgar 9/9, hemoglobina neonatal de 7.9 y 7 g/dL, bilirrubina total de 6.8 y 10.71 mg/dL (a las 4 y 7 horas después del nacimiento). Se efectuó exanguinotransfusión en dos oportunidades por anemia recidivante, fototerapia intensiva durante 5 días, fue dada de alta a los 25 días. CONCLUSIONES: Es importante analizar y cuantificar los riesgos de prolongar el embarazo más allá de las 34 semanas y aplicar transfusión intrauterina versus interrumpirlo y continuar el tratamiento de forma extrauterina; después de las 35 semanas los riesgos de los procedimientos superan los del parto pretérmino.

Abstract BACKGROUND: Rh isoimmunization is the main risk factor for fetal anemia. When this is moderate or severe intrauterine transfusion before 34 weeks, and the birth of the fetus after 37, are the most accepted treatment options. CLINICAL CASE: A 29-year-old patient, 34 weeks pregnant, with a history of three pregnancies that ended in two deliveries and a C-section and Rh isoimmunization with neurological sequelae due to hemolytic anemia. Finding of positive indirect Coombs 1/512 and VPS-ACM = 57 cm/s. Reagent cardiotocographic record and weekly ambulatory follow-up. He returned to the Emergency Department due to the perception of sporadic uterine contractions. The fetus was found with 140 bpm, weight of 2760 g and quantifications corresponding to mild anemia. The cordocentesis reported Hb = 7.7 g/dL; "O" Rh (+). The pregnancy was terminated by caesarean section with the birth of a girl of 2702 g, Apgar 9/9, neonatal hemoglobin of 7.9 and 7 g/dL, total bilirubin = 6.8 and 10.71 mg/dL (at 4 and 7 hours after birth). Exchange transfusion was performed twice due to recurrent anemia, intensive phototherapy for 5 days, and was discharged after 25 days. CONCLUSIONS: It is important to analyze and quantify the risks of prolonging a pregnancy beyond 34 weeks and apply intrauterine transfusion versus interrupting it and continuing the treatment extrauterine; After 35 weeks, the risks of the procedures surpass those of preterm delivery.

Parameters Associated with Adverse Fetal Outcomes in Parvovirus B19 Congenital Infection / Parâmetros associados a desfechos fetais adversos na infecção congênita pelo parvovírus B19

Abstract Objective To investigate the clinical and sonographic parameters associated with adverse fetal outcomes in patients with congenital parvovirus B19 infection managed by intrauterine transfusion. Methods This was a single-center retrospective study conducted from January 2005 to December 2016 that assessed patients with singleton pregnancies with fetal parvovirus infection confirmed by a polymerase chain reaction of the amniotic fluid or fetal blood samples who underwent at least one intrauterine transfusion. The maternal characteristics, sonographic findings and parameters related to intrauterine transfusion were compared between the two groups (recovery/non-recovery), who were categorized based on fetal response after in-utero transfusions. Progression to fetal death or delivery without fetal recovery after the transfusions was considered nonrecovery and categorized as an adverse outcome. Results The final analysis included ten singleton pregnancies: seven of which were categorized into the recovery group and three of which into the non-recovery group. The baseline characteristics were similar between the groups. All fetuses were hydropic at the time of diagnosis. No significant differences related to sonographic or intrauterine transfusion parameters were identified between the groups; however, the nonrecovery group tended to have an increased number of sonographic markers and lower fetal hemoglobin and platelet levels before the transfusion. Conclusion We were unable to firmly establish the clinical or sonographic parameters associated with adverse fetal outcomes in patients with parvovirus infection managed with intrauterine transfusions; however, edema, placental thickening and oligohydramnios may indicate greater fetal compromise and, subsequently, adverse outcomes. However, further studies are necessary, mainly due to the small number of cases analyzed in the present study.

Resumo Objetivo Investigar os parâmetros clínicos e ultrassonográficos associados ao desfecho fetal adverso em pacientes com infecção congênita por parvovírus B19 manejada por meio de transfusão intrauterina. Métodos Trata-se de um estudo retrospectivo de um único centro realizado entre janeiro de 2005 e dezembro de 2016, que avaliou pacientes com gestação única com infecção fetal por parvovírus confirmada por reação em cadeia da polimerase de líquido amniótico ou amostras de sangue fetal submetidas a pelo menos uma transfusão intrauterina. As características maternas, os achados ultrassonográficos e os parâmetros relacionados à transfusão intrauterina foram comparados entre os dois grupos (recuperação/não recuperação), que foram categorizados com base na resposta fetal após transfusão intrauterina. A progressão para morte fetal ou parto sem recuperação fetal após transfusões foi considerada não recuperação, e categorizada como um desfecho adverso. Resultados A análise final incluiu dez gravidezes únicas: sete foram categorizadas no grupo de recuperação, e três, no grupo de não recuperação. As características basais foram semelhantes entre os grupos. Todos os fetos estavam hidrópicos no momento do diagnóstico. Não foram identificadas diferenças significativas entre os grupos em relação aos parâmetros ultrassonográficos ou os das transfusões intrauterinas; Entretanto, o grupo de não recuperação tendeu a ter um número aumentado demarcadores ultrassonográficos e níveis mais baixos de hemoglobina e plaquetas fetais antes da transfusão. Conclusão Não foi possível estabelecer firmemente os parâmetros clínicos ou ultrassonográficos associados ao desfecho fetal adverso em pacientes com infecção por parvovírus manejada por meio de transfusões intrauterinas. Entretanto, edema de pele, espessamento placentário e oligoidrâmnio podem indicar maior comprometimento fetal e, posteriormente, desfechos fetais adversos. No entanto, estudos adicionais são necessários, principalmente devido ao pequeno número de casos analisados neste estudo.

Changes in fetal myocardial performance index following intravascular transfusion: preliminary report.

OBJECTIVE: To investigate the changes in fetal left ventricle myocardial performance index (MPI) following intrauterine intravascular transfusion (IUT). METHODS: Prospective study, including 25 IUT performed in 13 singleton pregnancies with maternal Rh D alloimmune disease. Left ventricle MPI was evaluated prior to transfusion and repeated 24 h after each procedure. Delta MPI was calculated as the difference between post- and pre-transfusion MPI z-scores. Multilevel regression analysis was used to examine the association between delta MPI and gestational age at procedure, fetal middle cerebral artery peak velocity MoM, pre- and post-MPI and hemoglobin z-score values, the volume of blood transfused and feto-placental volume percentage expansion. Adjustments were made for repeated measurements within the same fetus, and across different time points. The significance level was set as 0.05. RESULTS: MPI z-score values increased significantly following transfusion (delta MPI = 1.10 ± 2.47, p=0.036). Delta MPI showed a significant correlation with gestational age at transfusion (r= -0.47, p=0.018), pre-transfusion MPI z-score (r= -0.50, p=0.012) and feto-placental volume percentage expansion (r= -0.41, p=0.044). CONCLUSION: Left ventricle MPI increases significantly after intrauterine blood transfusion and greater changes are associated with procedures at an earlier gestational age, lower pre-transfusion MPI z-scores and smaller feto-placental volume expansion.

Resultado neonatal e infantil de niños con y sin transfusión intrauterina por isoinmunización Rh durante el embarazo / Neonatal outcome of children with and without intrauterine transfusion for Rh isoimmunization during pregnancy

Objetivo: Comparar la morbilidad neonatal y a seis meses de vida de hijos de pacientes con isoinmunización Rh que recibieron al menos una transfusión intrauterina (TIU), con aquellos que no la requirieron. Método: Estudio de caso y control de pacientes con diagnóstico de isoinmunización Rh controladas en la Unidad de Medicina Fetal del Hospital Clínico Universidad de Chile. Se comparó el resultado perinatal y hasta 6 meses de vida de recién nacidos (RN) con TIU (9 casos) y sin TIU (14 casos) entre los años 2004 y 2009. Resultados: Aunque la sobrevida a los 6 meses de los fetos con TIU fue alrededor de un 80 por ciento, solo una muerte puede atribuirse a la severidad de su condición de base. Los RN con TIU nacieron a una menor edad gestacional que los que no requirieron este tratamiento (34,4 +/- 2,2 sem vs. 37,4 +/- 0,6 sem; p=0,003). Al evaluar el manejo neonatal inmediato se observa que el 60 por ciento de los RN isoinmunizados sin TIU requirieron ser hospitalizados y requirieron fototerapia, mientras que todos los RN con antecedente de TIU fueron hospitalizados, recibieron fototerapia y 30 por ciento requirió una exanguineo transfusión. A los 6 meses de vida, 75 por ciento y 20 por ciento de los RN isoinmunizados, con y sin TIU, fueron hospitalizados para una nueva transfusión de GR y/o fototerapia, respectivamente. Conclusión: La isoinmunización Rh es una patología de alto riesgo, pero la terapia intrauterina, en los casos con anemia moderada y severa, permite llegar a edades gestacionales que dan una adecuada sobrevida.

Objective: To compare neonatal and six months of life morbidity of babies affected by Rh isoimmunization during pregnancy that required at least one intrauterine blood transfusion, with babies that did not required that procedure. Methods: Case control study of patients with diagnosis of Rh isoimmunization under control in the Fetal Medicine Unit at the University of Chile Hospital. Perinatal and until 6 months of life outcomes of isoimmunized newborns (NB) with (9 cases) and without intrauterine transfusion (IUT) (14 cases) between years 2004 and 2009 were compared. Results: Although six months of life survival of IUT babies was about 80 percent only one death was related to the severity of isoimmunization. Isoimmunized babies with IUT were delivered at a lower gestational age than those without IUT (34.4 +/- 2.2 vs. 37.4 +/- 0.6 weeks; p=0.003). At the immediate neonatal period only 60 percent of isoimmunized babies without IUT required hospitalization and phototherapy, in contrast to IUT babies where all of them were hospitalized and required phototherapy, and 30 percent required exchange transfusion. Until six months of life, 75 percent and 20 percent of NB with and without IUT required another hospitalization for a new transfusion and/or phototherapy respectively. Conclusion: Rh isoimmunization is a high risk disease, but intrauterine therapy in cases with moderate and severe fetal anemia increases gestational age at delivery with good survival rates.

Transfusión intrauterina en hidrops fetal por Parvovirus B19: a propósito de un caso clínico / Intrauterine transfusion for hydrops fetalis by parvovirus B19 infection: a case report

Hidrops fetal no inmunológico diagnosticado a las 22 semanas de gestación, secundario a infección por Parvovirus B19, tratado exitosamente con cinco transfusiones intrauterinas. Parto vaginal con recién nacido de término sin estigmas de enfermedad. Enfatizamos la importancia de sospechar el diagnóstico, el manejo basado en Vmax de ACM y la capacidad actual de tratamiento exitoso a través de transfusiones intrauterinas.

Non immunologic hydrops fetalis diagnosed at 22 weeks of gestation, secondary to infection by Parvovirus B19, successfully treated with five intrauterine transfusions. Vaginal delivery at 37 weeks without stigmata of disease. We emphasize the importance of suspecting the diagnosis, management based on Vmax of ACM and the current capacity of successful treatment by intrauterine transfusion.

Enfermedad hemolítica perinatal: manejo de la embarazada RhD negativo / Perinatal hemolytic disease: management of RhD immunization in pregnancy

En solo 50 años la enfermedad hemolítica perinatal por isoinmunización anti D pasó de ser una enfermedad sin etiología conocida, incurable y no prevenible, a la situación actual en que por las técnicas de prevención, diagnóstico oportuno y tratamiento especializado tiene baja incidencia y altas expectativas de sobrevida, incluso en los casos más severos. Se describe la historia, las técnicas de prevención, diagnóstico, manejo y tratamiento de la enfermedad.

In just 50 years the perinatal hemolytic disease due to RhD isoimmunization went from being a disease without known etiology, untreatable and not preventable to the current situation in which the prevention techniques, opportune diagnosis and specialized treatment has low its incidence and has an expected high survival even in the more severe cases. This article describes the history, prevention techniques, diagnosis, management and treatment of the disease.

Determining the volume of blood required for the correction of foetal anaemia by intrauterine transfusion during pregnancies of Rh isoimmunised women.

BACKGROUND: Severe anaemic foetuses of Rhesus (Rh) isoimmunised mothers are usually treated by intrauterine transfusion (IUT). It is helpful to determine the volume of blood necessary to raise the concentration of haemoglobin by 1.0 g/dL in response to intrauterine transfusions. METHODS: In this cross-sectional, observational study we evaluated 107 first IUT for the correction of anaemia caused by haemolysis triggered by maternal Rh immunisation. The concentration of foetal haemoglobin was determined in umbilical cord blood before and after the IUT. The variation in foetal concentration of haemoglobin after transfusion was compared between groups of hydropic and non-hydropic foetuses, between groups of foetuses with different degrees of anaemia and with groups of gestational age less than or more than 28 weeks. The t-test for averages and ANOVA were used to compare average differences among the groups. p values less than 0.05 were considered statistically significant. RESULTS: Fifty-five (61.4%) foetuses were found to be anaemic while hydrops was observed in 40 (44%) at the time of the IUT. The volume of red blood cell concentrate infused varied from 5 to 90 mL, with 11.2±1.5 mL being necessary to raise the circulating concentration of haemoglobin by 1.0 g/dL. The foetal response was not influenced significantly by either the degree of foetal anaemia (p=0.56) or the presence of hydrops (p=0.17). The foetuses with a gestational age of 28 weeks or less required a smaller volume of red blood cell concentrate than those with a gestational age of more than 28 weeks (9.3±5.4 mL and 13.4±4.8 mL, respectively; p<0.0001) in order to raise their concentration of circulating haemoglobin by 1.0 g/dL. CONCLUSION: The volume of red blood cell concentrate necessary to correct anaemia in pregnancies complicated by Rh isoimmunisation must be considered carefully, since the response to the infusion of blood is peculiar in extremely premature infants. Hydrops and the degree of anaemia were not determinants of the change in the final concentration of circulating haemoglobin following the blood transfusion.

Papel de la medición de la velocidad sistólica máxima en arteria cerebral media en la isoinmunización rhesus / Fetal middle cerebral artery peak systolic velocity in rh isoimmunization

Objetivo: Evaluación del papel de la velocidad sistólica máxima en arteria cerebral media (VSM-ACM) en casos de isoinmunización Rh. Métodos: 67 casos de isoinmunización Rh, en el Hospital La Paz desde febrero del 2006 hasta agosto del 2009, con título de anticuerpos > 1:32, afectación en embarazo previo y/o casos de isoinmunización anti- Kell, en los que se ha realizado medición de la VSM-ACM. Resultados: La capacidad de detección de anemia moderada-severa en base a la medición de VSM-ACM presenta: sensibilidad 80 por ciento (IC95 por ciento: 59,8-100), especificidad y valor predictivo positivo 100 por ciento, y valor predictivo negativo 85,7 por ciento (IC95 por ciento: 70,7-100). El coeficiente de correlación de Pearson entre la hemoglobina estimada y la real es de 0,71. Conclusión: La medición de VSM-ACM predice casos de anemia moderada y severa que son los clínicamente cruciales por la necesidad de actuación obstétrica activa en forma de transfusión intrauterina o finalización del embarazo.

Objective: To evaluate the fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the management of Rh isoimmunized pregnancies. Methods: 67 pregnancies complicated by Rh isoimmunization, in La Paz Hospital ( Madrid) since 2006 February until 2009 August 2009, with maternal antibody titers > 1:32, affected in previous pregnancies and/or anti-Kell isoimmunization, in which MCA-PSV has been measured. Results: For the detection of moderate-severe fetal anemia, Doppler ultrasonography of the middle cerebral artery had a sensitivity of 80 percent (CI95 percent: 59.8-100), a specificity and positive predictive value of 100 percent, and a negative predictive value of 85.7 percent (CI95 percent: 70.7-100). The Pearson correlation coefficient between estimated hemoglobin and real hemoglobin is 0.71. Conclusion: The measurement of MCA-PSV predicts moderate-severe fetal anemia cases, which are the most important in the clinical management because of the need of active treatment with intrauterine transfusion or induction labor.

Transfusión intrauterina por cordocentesis: efectos adversos inmunohematológicos e impacto en el neonato / Introuterine transfusion by cordocentesis: adverse immunohematological effects and impact on the newborn

Objetivos: Evaluar las complicaciones inmunohematológicas producidas por las madres sensibilizadas que son sometidas a transfusión intrauterina (TIU) y su impacto en el recién nacido (RN). Materiales y métodos: Se realizó un trabajo retrospectivo que incluyó 22 pacientes (ptes) de alto riesgo (20 con anti D, 1 anti C y 1 anti E) a las que se les realizaron tratamiento con TIU, los datos se obtuvieron de la historia clínica de la madre, del RN y fichas inmunohematológicas del servicio de medicina transfusional, a las pacientes se le realizaron controles inmuno - hematológicos en la primera consulta y luego cada 15 días hasta finalizar el embarazo lo que incluyó titulación más dosaje ponderal de anticuerpo, luego cada dos TIU se realizó panel identificador. Resultados: Del total de las ptes; 3 desarrollaron nuevos ac. después del 4° procedimiento, en dos pacientes se sumó un anticuerpo (Ac) y una pte formó 2. Al determinar la causa probable de la formación de dichos Ac se encontró: Un anti C que fue asociado al pasaje de sangre fetal a la madre, un anti Kell a los GR transfundidos, y en los ac anti c y Jka no se pudo dilucidar su origen. El 73% de las ptes elevó los títulos después de las TIU. La relación entre aumento de títulos y n° de TIU fue del 31% posterior a la 1a., el 56% a la 2a., 13% a la 3a. o más. El 69% de las ptes aumentó los títulos una única vez, independientemente del número de punciones y el 31 % ascendió con cada estímulo. En 9 ptes las TIU fueron transplacentarias y todas ellas elevaron los títulos de Ac; en las 13 no transplacentarias solo 7 aumentaron. Del total de RN, 52% tuvo como complicación anemia tadía un 19% recibió exanguíneotransfusión y el resto sin complicación. El dosaje ponderal de Ac se elevó más que los títulos en los casos de mayor afección en RN. Conclusión: Las complicaciones inmunohematológicas por TIU son frecuentes y pueden afectar el futuro obstétrico y transfusional de la madre... (TRUNCADO)

Objectives: Assess the immunohematological complications intrauterine transfusion (lUT) produced in sensitized mothers and its impact on the new born (NB). Materials and methods: A retrospective study was carried out, including 22 high risk patients (20 with anti-­D antibodies, 1 with anti-c antibodies and 1 with anti-E antibodies) which underwent percutaneous umbilical cord blood transfusion (or IUT), the data were obtained from the mothers and the newborns clinical chart as well as immunohematological record cards of the transfusion medicine department. Imunohematological testing including antibody titre and ponderal antibody quantitation was carried out at each patients first ap pointment and thenceforward every two weeks until the end of pregnancy, and cell panel antibody screening after every second IUT. Results: Out of the total of 22 patients; 3 developed new antibodies following the 4th procedure, two patients added one new antibody and one patient formed two antibodies. When determining the probable cause for these antibodies, the following was found: in one case an Anti-C antibody was linked to fetal-to-maternal hemorrhage, an anti-Kell antibody as reponse to antigens from the transfused red cells; and the origin of an anti-c antibody and an anti-Jka could not be explained. Increased antibody titre after IUT was found in 73% of the patients. Increase of titre regarding number of IUTs: 31% following the first procedure, 56% after the second and 13% after 3 or more procedures. Aside from the number of IUTs, in 69% of the cases the titre increased only once, while 31% of the patients suffered increase with each antigenic stimulus. Antibody titre increased in all 9 patients that under­went transplacental IUT; while only 7 of the 13 nontransplacental cases did. Late onset anemia occured in 52% of the newborns, and 19% required exsanguinotransfusion. The rest did not have any complication... (TRUNCADO)