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PubMed1989

Echogenic venous turbulence is a critical feature of successful intravascular intrauterine transfusion.

Late during the fifth intravascular intrauterine transfusion of a fetus with severe Rh isoimmunization, the loss of visible echogenic turbulence within the umbilical vein during injection preceded the development of unresolving fetal bradycardia. An umbilical cord hematoma was found at the time of emergency cesarean delivery. Although seldom described, echogenic turbulence is an important feature of the successful intravascular intrauterine transfusion, and deserves close surveillance. Disappearance of this visible turbulence suggests loss of proper needle location. Possible sources of needle tip displacement are discussed and preventive measures described.

Adult↗

PubMed1996

Tachycardia as the sole fetal heart rate abnormality after funipuncture.

BACKGROUND: Fetal bradycardia is a common complication of funipuncture. We present a case of fetal exsanguination in which fetal tachycardia was the sole fetal heart rate abnormality. CASE: Funipuncture was performed at 32 weeks' gestation for evaluation of Rh isoimmunization. A persistent fetal tachycardia ensued and, although there was no immediate ultrasound evidence of bleeding, repeat ultrasonography revealed active bleeding at the puncture site. A neonate with an initial hematocrit of 42% was delivered by cesarean. Despite aggressive replacement of blood products, a repeat hematocrit was only 35% and a severe, persistent coagulopathy ensued. The newborn died 18 hours after delivery. Autopsy findings were consistent with neonatal coagulopathy. CONCLUSION: Although fetal bleeding is usually a common, relatively benign complication of funipuncture, streaming may not always be detected on ultrasonographic examination. Our case demonstrates that fetal tachycardia may be the only sign of fetal hemorrhage.

Adult↗

PubMed1990

Umbilical cord haematoma as a complication of intrauterine intravascular blood transfusion.

Between October 1985 and February 1989, 49 ultrasound-guided intravascular fetal blood transfusions were performed in 16 patients (14 with rhesus (Rh) isoimmunization, 2 with non-immunologic hydrops fetalis (NIHF)). As an intra-operative complication, perivascular haematoma of the cord occurred in three patients (7 per cent). In two cases, fetal bradycardia necessitated delivery by Caesarean section at 30 and 32 weeks' gestation, respectively. In the third case, fetal bradycardia developed during transfusion, at 31 weeks' gestation, but normalized within 3 min. The baby was delivered as planned at 36 weeks of gestation, after another transfusion at 34 weeks. Dislodgement of the needle tip into perivascular tissue, caused by sudden fetal or maternal movements, is the reason for this complication. The haematoma develops as a result of delayed recognition and continuous transfusion into Wharton's jelly. Cord haematoma may be diagnosed in time by continuous ultrasound imaging, as illustrated in case 3. To minimize the risk of needle dislodgement during transfusion, sedation of the mother and complete immobilization of the fetus by injecting a short-acting muscle relaxant into the umbilical vessel are recommended.

Adult↗

PubMed1991

The influence of anemia on respiratory gases and acid base parameters of the fetus.

Fetal blood samples were collected by cordocentesis from 82 pregnant women; 12 of whom had severe forms of Rh isoimmunization, while 70 comprised the control group. The mean hematocrit value in the group under investigation was 15.72 +/- 3.62% and indication of severe anemia. The pH value in this group was 7.31 +/- 0.06; pCO2 partial pressure 6.36 +/- 0.64; O2-2.65 +/- 0.89 kPa; bicarbonate 23.84 +/- 3.02 mMol/l: base excess was -2.72 +/- 2.66 mMol/l and saturation 28.66 +/- 15.56%. In the control group the following values were established: pH -7.386 +/- 0.05; partial pressure pCO2-4.980 +/- 0.31 kPa; O2--4.960 +/- 0.90 kPa; bicarbonate 21.560 +/- 0.27 mMol/l; base excess -2.30 +/- 0.90 mMol/l and saturation 67.23 +/- 11.60%. The pH, partial pressure O2 and saturation values were significantly lower, while partial pressure CO2 was significantly higher in the investigated group than in the control group. Bicarbonates and base excess do not change significantly in the presence of anemia. Fetal blood sampling carried out by means of cordocentesis is the most reliable method for assessment of the degree of fetal anemia. The values of acid base parameters and of blood gases are an indication of either respiratory, respiratory-metabolic or metabolic acidosis. The possibilities of prenatal diagnostics, undoubtedly, contribute to a significant reduction of perinatal mortality.

Acid-Base Imbalance↗

PubMed1998

[Diagnosis and therapy of erythrocyte alloimmunization in pregnancy].

INTRODUCTION: By preventive administration of anti-D globulin the number of cases of Rh isoimmunization declines steadily. Severe untreated isoimmunization may lead via foetal hydrops to intrauterine death, sometimes already during the 18th-19th week of gestation. The purpose of prenatal diagnosis in pregnant women with isoimmunization is to assess the danger or affection of the foetus, its prognosis and the mode of monitoring of the foetus. It is necessary to decide in time on intrauterine therapy by transfusion of erythrocyte mass and to assess the optimal time of delivery with regard to the risk of prematurity and foetal erythroblastosis, as well as with regard to intrauterine therapy. The objective of the present work was to test the protocol in the treatment of erythrocytic isoimmunization of the foetus. METHOD: During the period between January 1991 and October 1997 the authors investigated two groups of pregnant women: with a hydropic (n = 5) and non-hydropic (n = 20) foetus at the onset of treatment. In both groups amniocentesis and umbilical puncture were indicated. The authors investigated the number of cordocenteses and the volume of transfused blood per pregnancy, the number of complications and their type, gestation age of the foetuses on delivery, their birth weight, the condition of the neonates after delivery and on discharge to home care. RESULTS: During the mentioned period the authors administered 70 intraumbilical transfusions to 25 foetuses. The transfusion was not repeated more than eight times. The baseline haematocrit of non-hydropic foetuses was 26 (14-34), treatment was started on average during the 28th week (23rd-33rd). Pregnancy in women with a non-hydropic foetus was terminated during the 35th (27th-40th) week, with a mean weight of the foetuses of 2439 g (870-3520). Of 25 treated foetuses 6 were hydropic (24%) at the onset of treatment. The initial haematocrit of hydropic foetuses was 10.7 (4-19.8), treatment was started on average during the 28th (23rd-33rd) week. Pregnancy of women with hydropic foetuses was terminated during the 30th (25th-36th) week, the mean birth weight being 1838 g (660-3500). DISCUSSION: The very favourable therapeutic results in non-hydropic foetuses are in great contrast with the therapeutic results of moribund hydropic foetuses. CONCLUSION: The basic prerequisite of successful treatment by intraumbilical transfusion is to concentrate risk pregnancies in specialized centres with a high standard neonatological team for intensive care of pathological neonates.

Blood Transfusion, Intrauterine↗

PubMed1995

Nonimmune fetal hydrops: diagnosis and obstetrical management.

As the incidence of Rh-isoimmunization has been decreasing with the availability of Rh immune globulin, the proportion of cases of fetal hydrops from nonimmune causes has increased. Evaluation of the fetus with hydrops requires an integrated approach, beginning with targeted ultrasound evaluation and potentially including maternal and fetal blood testing and other invasive testing. Because the list of conditions that may cause hydrops is long and continues to grow, it is often difficult to make a precise diagnosis; however, through a systematic approach, one may frequently narrow the etiology to a category of disorders and determine whether any interventions are available that are likely to be helpful in improving the outlook for the fetus.

Abnormalities, Multiple↗

PubMed1998

[Levels of lymphocyte subpopulations in peripheral fetal blood in Rh(D) erythrocyte isoimmunization in pregnancy].

INTRODUCTION: In the foetus in utero predominates a considerable percentage of immunologically so-called naive lymphocytes of the T and B series. The objective of the presented work was to assess by means of flow cytometry and labelled monoclonal antibodies quantitative changes in cell sub-populations of the foetal immune system before the foetus is altered by severe heamolysis as a result of Rh(D) isoimmunization. METHOD: The authors obtained by intrauterine puncture of the umbilical cord peripheral blood from 10 foetuses with isoimmunization during the 23rd-35th week of gestation, confirmed by the direct Coombs test and with a mean haematocrit value of 30.8% +/- 8.02. These findings were compared with values in the peripheral blood stream in a control group of 35 foetuses during the 18th-39th week of pregnancy with normal intrauterine development (haematocrit 34.2% +/- 5.87). The authors assessed the haemogram and CD signs in the lymphocyte population. RESULTS: In the peripheral bloodstream of foetuses with erythrocyte isoimmunization the authors did not detect, as compared with the control group (p > 0.01), a lower haemoglobin level (10.6 +/- 2.77 g/dl vs. 11.9 +/- 2.03 g/dl) a lower haematocrit (30.8% +/- 8.02 vs. 34.2% +/- 5.87) and fewer leucocytes 5.1 +/- 2.39 x 10(9)/l versus 6.97 +/- 3.29 x 10(9)/l. In foetuses with Rh(D) isoimmunization the authors found a higher percentage of T(CD3+) lymphocytes (79.0% +/- 11.23 vs. 73.7% +/- 12.79, but did not prove an increase of activated T lymphocytes (%DR+ from CD3+) (1.0% +/- 0.52 vs. 1.3 +/- 0.58). The percentage ratio of T helper cells (CD+) was higher than in the control group (61.0% +/- 10.25 vs. 56.1% +/- 12.45). In foetuses with Rh(D) isoimmunization there was no difference in the ratio of CD8 positive cells (24.1% +/- 8.23 vs. 23.6% +/- 7.26). Suppressor T cells (CD8+CD11b+) were fewer (4.1% +/- 1.24 vs. 7.5 +/- 11.23) than in the control group. The number of NK cells in foetuses with Rh(D) isoimmunization was 5.1% +/- 3.26 vs. 6.9% +/- 3.86, in isoimmunized foetuses there is a higher ratio of so-called naive T helper cells Th1 (CD4+ CD45 RA+) 49.3% +/- 12.71 vs. 43.0% +/- 12.88. When assessing naive B1 cells (CD19+CD5+), the authors did not find a difference between the two groups (10.4% +/- 6.20 vs. 9.06% +/- 12.1). The ratio of CD4: CD8 in the group with isoimmunization was higher than in the control group (3.1 +/- 1.39 vs. 2.5 +/- 1.13). CONCLUSION: In isoimmunized foetuses in the initial stages of haemolysis no detactable immune response with significant changes in the lymphocyte sub-populations was found.

Female↗

PubMed1977

Prevention of Rh-hemolytic disease.

The results of Anti (D) immunoglobulin (RhoGAM) therapy in 25 Rh-negative women after delivery of Rh-positive babies are presented. None of the patients studied showed evidence of Rh-isoimmunization while two of 51 unprotected patients subsequently had antibodies detected in their serum. The incidence of Rh-negative patients is low in this environment. Because of the potential risk of isoimmunization, RhoGAM prophylaxis is advocated.

Adult↗

PubMed2001

Determination of RhD zygosity: comparison of a double amplification refractory mutation system approach and a multiplex real-time quantitative PCR approach.

BACKGROUND: Rh isoimmunization and hemolytic disease of the newborn still occur despite the availability of Rh immunoglobulin. For the prenatal investigation of sensitized RhD-negative pregnant women, determination of the zygosity of the RhD-positive father has important implications. The currently available molecular methods for RhD zygosity assessment, in general, are technically demanding and labor-intensive. Therefore, at present, rhesus genotype assessment is most commonly inferred from results of serological tests. The recent elucidation of the genetic structure of the prevalent RHD deletion in Caucasians, as well as the development of real-time PCR, allowed us to explore two new approaches for the molecular determination of RhD zygosity. METHODS: Two methods for RhD zygosity determination were developed. The first was based on the double Amplification Refractory Mutation System (double ARMS). The second was based on multiplex real-time quantitative PCR. For the double ARMS assay, allele-specific primers were designed to directly amplify the most prevalent RHD deletion found in RhD-negative individuals in the Caucasian population. The multiplex real-time quantitative PCR assay, on the other hand, involved coamplification and quantification of RHD-specific sequences in relation to a reference gene, albumin, in a single PCR reaction. A ratio, DeltaCt, based on the threshold cycle, was then determined and reflects the RHD gene dosage. RESULTS: The allele-specific primers of the double ARMS assay reliably amplified the RHD-deleted allele and therefore accurately distinguished homozygous from heterozygous RhD-positive samples. The results were in complete concordance with serological testing. For the multiplex real-time quantitative PCR assay, the DeltaCt values clearly segregated into two distinct populations according to the RHD gene dosage, with mean values of 1.70 (SD, 0.17) and 2.62 (SD, 0.29) for the homozygous and heterozygous samples, respectively (P: <0.001, t-test). The results were in complete concordance with the results of serological testing as well as with the double ARMS assay. CONCLUSION: Double ARMS and real-time quantitative PCR are alternative robust assays for the determination of RhD zygosity.

Albumins↗

PubMed1984

Detection of fetal erythrocytes in maternal blood post partum with the fluorescence-activated cell sorter.

A study was made of the frequency and amount of fetal hemorrhage into maternal blood during labor and delivery as evidenced by the number of fetal cells present in the maternal circulation immediately after spontaneous vaginal delivery. A sensitive, indirect immunofluorescence was used with fluorescence-activated cell sorter analysis of erythrocytes. All of the 16 Rh-negative mothers studied after vaginal delivery of Rh-positive infants had circulating Rh-positive cells. The mean Rh-positive to Rh-negative erythrocyte ratio was 1:14, 100 in maternal blood, which corresponds to a mean fetal hemorrhage of 156 microliters. The test described is sufficiently sensitive to be used for the study of primary Rh isoimmunization and could be clinically applicable for antepartum screening to determine which patients require Rh immune globulin treatment before delivery.

ABO Blood-Group System↗

PubMed1989

[Severe fetal hemolytic disease. Evaluation and successful treatment by means of cordocentesis].

Ultrasonically guided access to the fetal umbilical circulation offers an alternative to the standard management of the severe isoimmunized pregnancy. This technique allows fetal blood sampling, direct hematocrit analysis and intravascular transfusion. A severely Rh isoimmunized pregnancy is described in which five intrauterine transfusions of blood were given directly into the umbilical vein under ultrasound visualization. Technical aspects of the procedure and complications are discussed.

Adult↗

PubMedDate not supplied

Rh negative status and isoimmunization update: a case-based approach to care.

Prior to the 1970s and the advent of Rho (D) immune globulin (RIG) for Rh negative women, hemolytic disease of the newborn led to morbidity, long-term disabilities, and mortality. Antepartum RIG administration has been a standard of practice since 1983. Yet, Rh isoimmunization (sensitization) and its sequelae have not been completely eradicated. Rh-related issues remain clinical challenges facing perinatal and neonatal nurses. Evidence for the administration of RIG prenatally and during the postpartum period is presented including controversies and challenges. Current information about fetal and neonatal care of erythroblastosis fetalis and immune hydrops is also presented.

Adult↗

PubMed1996

RhD genotype determination by single sperm cell analysis.

OBJECTIVE: An Rh-negative woman with preexisting anti-D antibodies may affect some or all subsequent fetuses, depending on the genotype of her Rh-positive partner. Currently, a reliable technique for an absolute determination of RhD genotype is not available. This study was initiated to develop an accurate method for RhD genotyping in men. STUDY DESIGN: RhD genotype was determined by deoxyribonucleic acid amplification of a D-specific sequence in single sperm cell samples. Micromanipulation techniques were used for sampling of single sperm cells, which were further amplified by multiplex nested polymerase chain reaction at the RhD locus. A RhD sequence amplification product was expected in all of the successfully amplified samples from Rh-positive homozygotes, in some of the samples from heterozygotes, and in none of the samples form Rh-negative subjects. RESULTS: RhD genotype was accurately determined in 10 of 10 donors. A total of 132 single sperm cells were analyzed (8 to 17 samples per donor), of which 96 were successfully amplified as assessed by an internal control. As expected, the specific region of the RhD gene was amplified in all, some, and none of the signal-positive sperm samples from Rh-positive homozygotes, heterozygotes, and Rh-negative subjects, respectively, allowing accurate determination of the genotype. CONCLUSION: An accurate diagnosis of the RhD genotype can be attained from single sperm cell analysis by means of polymerase chain reaction and may have major clinical applications in the management of Rh isoimmunization.

Base Sequence↗

PubMed1978

Plasma levels of non-conjugated oestrone in high risk pregnancies.

Plasma levels of non-conjugated oestrone were measured with a radio-immunological method in women with complicated pregnancies during the last trimester. A comparison was performed between values of normal pregnancies from a previous report (3) and those of pathological pregnancies. Women with severe pre-eclampsia were found to have low values and to some extent the oestrone level could predict fetal outcome. In pregnant patients with long-standing diabetes mellitus the plasma levels of oestrone seemed to be higher than those of uncomplicated pregnancy. In women with pregnancies complicated by Rh-isoimmunization, oestrone plasma levels were similar to those found in normal pregnancies.

Antibody Formation↗

PubMed2002

[Neonatal hyperbilirubinemia: evaluation and treatment].

We have analyzed 132 newborns with hyperbilirubinemia (BW < 2500 g, GW > 37 weeks) hospitalized in Neonatal Unit of Paediatric Hospital during 2001. In 78 out of 132 (59.1%) newborns, causal diagnosis were established. Rh isoimmunization caused hyperbilirubinaemia in 2.8% (3/132) cases, ABO isoimmunization in 15.95% (21/32), infections in 9.15% (12/32) and other (polycitaemia, kephalhaematoma, loss of weight > 8%, jaundice related to the brestafeeding) in 31.8% (42/132). Maximal serum bilirubin level was reached between fourth and seventh day of life. In 47/132 newborns (40.9%) non-specific hyperbilirubinaemia were diagnosed. All babies were successfully treated by fototherapy. Blood exchange transfusion was performed in only 2 cases. Rh isoimmunisation was not significant factor in etiology of hyperbilirubinemia because of global prevention of Rh negative mothers. Hyperbilirubinemia of "healthy full-term newborn" was most often seen in 40.9% cases. Diagnostic criteria for hyperbilirubinemia were revised, and fottherapy, as safe, non-invasive method, replaced blood exchange transfusion, as an expansive procedure with low but constant mortality.

Humans↗

PubMedDate not supplied

[Composition of intervillous thrombi from maternal and fetal blood].

In serological studies blood groups of intervillous thrombi of the placenta were identical with maternal blood groups in 88.9%. Identity with fetal blood groups occurred in 11.1%. Utilizing an elution technique in smears prepared from intervillous thrombi, 11.68% of the erythrocytes were of fetal, 88.32% of maternal origin. In conclusion, intervillous thrombi are mainly composed of maternal cells. The existence of small amounts of fetal cells simultaneously, points to the possible etiology: Local damage of the trophoblastic epithelium of the villi is followed by escape of fetal cells into the intervillous space and later aggregation of maternal blood. Finally, the clinical relevance of intervillous thrombosis in maternal Rh-isoimmunization, pregnancy induced hypertension and intrauterine fetal anaemia is discussed.

ABO Blood-Group System↗

PubMed1976

Amniocentesis: indications, technic, and complications.

Common indications for amniocentesis are to assess fetal maturity, to determine the prognosis of Rh isoimmunization, for genetic counseling, and occasionally to diagnose fetal distress or to localize the placenta. The percutaneous transabdominal technic is reviewed, and some of the common complications are discussed.

Amniocentesis↗

PubMed1976

Amniotic fluid analysis in Rh-sensitized pregnancies.

This paper delineates the results of analysis of 234 Rh-sensitized pregnancies. It is now possible to predict the outcome in an Rh-isoimmunized pregnancy based only on the mean amniotic fluid, delta 450. This is an improvement over past methods since it does not depend upon calculation of weeks of pregnancy.

Amniotic Fluid↗