Treatment of fetal anemia in Rh isoimmunized pregnancies with intrauterine fetal blood transfusion

Deptt. Of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, 110029 India
Journal of Obstetrics and Gynecology of India 04/2010; 60(2):135-140. DOI: 10.1007/s13224-010-0019-y


IntroductionDespite the availability of prophylactic rhesus immune globulin, hemolytic disease of the newborn and fetal death (hydrops
fetalis) due to rhesus alloimmunization, is still a major contributor to perinatal morbidity and mortality in India. Pregnancy
outcome after fetal therapy with ultrasound guided intrauterine transfusion (IUT) for fetal anemia was studied.

MethodsA prospective cohort study of 99 Rh isoimmunized pregnancies, Indirect Coomb’s test Positive (ICT > 1:16) was conducted from
July 2002 to June 2007. Intensive fetal monitoring by sériai ultrasound and middle cerebral artery peak systolic velocity
using Color Doppler was performed to detect fetal anemia. When necessary, invasive testing with cordocentesis for Hb, PCV
was per-formed if pregnancy was less than 32–34 weeks gestation. If PCV was <30, or there was fetal hydrops, Ultrasound guided
intrauterine transfusion was carried out by the intravascular (IVT) or the intraperitoneal (IPT) routes. Primary outcome variables
were fetal survival in relation to gestational age and procedure related factors.

ResultOf 99 pregnancies, 43 cases (25 — hydropic, 18-nonhydropic fetuses) required 135 intrauterine blood transfusions. The rest
56 pregnancies were managed conservatively and did not need IUT. IUTs were performed when indicated starting from 16 weeks
(IPT) and 21 weeks (IVT) of gestation by the intraperitoneal / intravascular routes respectively. Pre-transfusion Hb ranged
from 3g% to 8g%. The amount of blood transfused varied from 10 ml to > 110 ml depending on the period of gestation and degree
of fetal anemia. The number of transfusions per pregnancy was 1–7, at intervals of 1–4 weeks, till delivery at 28 to 36 weeks
of gestation. Survival of hydropic babies (88%) was almost similar to those without hydrops (83.3%) Prognosis was slightly
better in Rh isoimmunized pregnancies not requiring IUT (94%) compared to fetuses receiving transfusions (85.6%)

ConclusionIntrauterine fetal blood transfusion was found to be the only life saving therapy, and very effective in the management of
preterm Rh isoimmunized pregnancies. Results are comparable with the best centers in the world, hence early referral to specialized
centers with expertise of specialized intensive fetal monitoring for early diagnosis of fetal anemia, and of intrauterine
fetal blood transfusion are important for optimal perinatal outcome.

Key wordsRh isoimmunsation-Intrauterine transfusion-fetus

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    ABSTRACT: BACKGROUND: Fetal umbilical cord blood sampling is now being performed worldwide, using an ultrasound guided technique, for prenatal diagnosis in pregnancies at high risk for several congenital and genetic defects in the fetus. Awareness of feasibility of the procedure and indications for the same should be known to every obstetrician. AIMS AND OBJECTIVES: To study the indications for Fetal Cord Blood Sampling in high risk pregnancy patients in the last 20 years at a tertiary referral center in India. MATERIALS AND METHODS: Women referred to the Fetal Medicine Clinic for fetal blood sampling from January 1990 to November 2009, were assessed. An informed consent was taken. Under continuous ultrasound guidance, a 22 gauge long spinal needle was inserted through the maternal abdomen and uterine wall into the umbilical cord, and about 2-4 ml of blood, depending on the indication was aspirated by syringe. The various indications for fetal blood sampling in 1342 women were analyzed. RESULTS: Cord blood sampling was performed for the following indications: Hb in Rh Isoimmunized pregnancies-553 cases, Chromosomal analysis-427 cases, non-immune hydrops/pleural effusion/ascites-cases 88, Congenital Infections-131 cases, Intrauterine Growth Restriction-51 cases, Thalassemia-53 cases, Hemophilia-36 cases, and for Thyroid function test for fetal goiter in 3 cases, in total 1,342 women. CONCLUSION: There were several absolute indications for fetal cord blood sampling in high risk pregnant women, to provide state-of-the-art information on the health of the fetus. Awareness of the procedure and indications for the same should be known to every obstetrician as it is technically feasible, expertise is available in India; so that women who require the procedure may be referred in time.
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