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PubMed1987

Fetal blood flow measurements in severe rhesus isoimmunization. A case report.

Maternal isoimmunization can result in fetal anemia. Current management of isoimmunized pregnancies involves amniocentesis and spectrophotometry. Pulsed Doppler ultrasound can provide fetal blood flow determinations from the fetal umbilical vein. A pregnancy complicated by severe rhesus isoimmunization was studied with Doppler ultrasound. Increased fetal umbilical blood flow was associated with increased fetal hemolysis. Umbilical vein blood flow decreased after intrauterine transfusion. Doppler ultrasound assessment of fetal blood flow is a useful noninvasive adjunct in isoimmunized pregnancies.

Adult↗
PubMed1995

Neonatal hepatitis and excessive hepatic iron deposition following intrauterine blood transfusion.

The management of hemolytic disease has undergone a number of significant changes over the past few decades. Intrauterine transfusion therapy, particularly intravascular transfusions, have significantly reduced the morbidity and mortality associated with isoimmunization. This therapy results not only in the transfusion of blood, but also in the transfusion of iron. The long-term consequences of iron loading in the fetus are unknown. We report a case of a newborn with Rh hemolytic disease who was treated with in utero transfusions and subsequently developed liver disease consistent with iron overload.

Adult↗
PubMed2002

Isoimmunization is unlikely to be the cause of hemolysis in ABO-incompatible but direct antiglobulin test-negative neonates.

OBJECTIVE: It is stated that the direct antiglobulin (Coombs') test (DAT) may be negative in ABO hemolytic disease of the newborn. Thus, significant jaundice in neonates who are A-B incompatible with their mothers but DAT test negative is often attributed to isoimmunization and another diagnosis is not sought. We wished to determine the rate of bilirubin production, as an objective measure of hemolysis, in 2 groups of DAT-negative neonates--ABO-compatible and ABO-incompatible--and in DAT-positive ABO-incompatible neonates. METHODS: In consecutive, term, healthy newborns who were admitted to the general care nursery, we measured the level in parts per million (ppm) of end-tidal breath carbon monoxide (CO), corrected for inspired CO (ETCOc), an index of the rate of bilirubin production. We compared the levels in DAT-negative ABO-incompatible neonates with those in ABO-compatible neonates and with the levels in DAT-positive ABO-incompatible neonates. Statistical analysis was performed using 2-sample t and chi(2) tests. RESULTS: There was no significant difference between the mean 12-hour ETCOc levels in DAT-negative ABO-incompatible neonates (n = 60, 2.2 +/- 0.6 ppm) versus DAT-negative ABO-compatible neonates (n = 171, 2.1 +/- 0.6 ppm), although there was a difference between the mean levels in DAT-positive ABO-incompatible neonates (n = 14, 3.4 +/- 1.8 ppm) and the DAT-negative groups. Four DAT-negative ABO-incompatible neonates had elevated ETCOc levels; in 2, we diagnosed a specific hematologic abnormality, namely, glucose-6-phosphate dehydrogenase deficiency in 1 and elliptocytosis in the other. CONCLUSION: In DAT-negative newborns with significant jaundice or increased bilirubin production, even if ABO-incompatible, a cause other than isoimmunization should be sought.

Bilirubin↗
PubMed1987

Percutaneous umbilical transfusion in severe rhesus isoimmunization: resolution of fetal hydrops.

The rhesus-sensitized fetus with the worst prognosis is one with early onset of hydropic changes. Percutaneous umbilical blood sampling now enables access to the fetal circulation and thereby allows more precise evaluation of fetal anemia and direct intravascular transfusion. A variation of this technique was used in three pregnancies complicated by fetal pericardial effusion, scalp edema, and abdominal ascites before 26 weeks' gestation. Twelve ultrasound-guided percutaneous transfusions of 30 to 85 ml packed red blood cells were administered into the umbilical cord at its placental insertion. In each fetus the hydropic changes completely resolved and pregnancy outcome was successful. Neither adjunctive therapy with digoxin or Lasix nor exchange transfusions were used. Percutaneous umbilical transfusions appear to have the potential to improve the prognosis for the severely isoimmunized fetus.

Adult↗
PubMed1985

Ultrasound-guided fetal blood transfusion for severe rhesus isoimmunization.

Four fetuses with severe rhesus isoimmunization were transfused with packed red blood cells directly into the umbilical vein. The outcome was successful in three. In one infant, this ultrasound-guided technique resulted in resolution of severe fetal hydrops at 27 weeks, allowing delivery of a healthy nonhydropic infant at 33 weeks, and in the other three infants in prolongation of the pregnancy. The last four transfusions were performed after fetal neuromuscular blockade with curare. The procedure would appear to be associated with a low risk of complication and to provide an excellent chance of a successful outcome of a fetus with severe rhesus isoimmunization even when fetal hydrops is present.

Blood Transfusion, Intrauterine↗
PubMed1987

Immunologic disease and fetal death.

Both maternal isoimmunization and maternal autoimmune disease are associated with fetal death. For isoimmunization the immunologic nature of fetal death (hydrops fetalis) is beyond question, but many of the details are poorly understood. It would be extremely helpful to know what immunologic factors are responsible for the wide variation in the degree of fetal hemolysis. This information would surely lead to improved management of isoimmunized pregnancies and create new and more successful therapies for fetuses at risk for hemolysis. The immunology of autoimmune-associated fetal death is, for the most part, an enigma. For the fetal deaths associated with SLE and the antiphospholipid antibodies, demise appears to be a consequence of uteroplacental vascular damage. But the observable pathology is nonspecific, and the evidence for a direct immunologic mechanism is sparse. The similarity between the uteroplacental vascular lesions found with these autoimmune conditions and those seen in preeclampsia demands more intensive investigation. For the fetal deaths caused by complete congenital heart block associated with maternal autoantibodies, the evidence for a direct immunologic mechanism is now being established. As with isoimmunization, a more complete understanding of autoimmune-associated fetal death will open new avenues of management and therapy.

Autoantibodies↗
PubMed1985

The unreliability of amniotic fluid bilirubin measurements in isoimmunized pregnancies in sickle cell disease patients.

Amniotic fluid spectrophotometric analysis for bilirubin (delta optical density [delta OD450], at 450 nm) is used to assess the severity of fetal involvement in isoimmunized pregnancies. Two patients presented with sickle cell anemia and hyperbilirubinemia who also were isoimmunized. The first patient had anti-kell and anti-e antibodies, whereas the second patient had anti-Lewisa and anti-Coltonb antibodies. Delta OD450 was elevated in both patients. The difficulty in interpretation of high delta OD450 in the presence of maternal hyperbilirubinemia is stressed. Sickle cell diseased patients are particularly prone to present with this problem. These patients always have hyperbilirubinemia and a relatively high incidence of irregular antibodies because of the numerous blood transfusions they receive. The management of these two patients is presented with suggestions for the use of alternative modalities of monitoring isoimmunized pregnancies in patients with hyperbilirubinemia.

Adult↗
PubMed1996

The nonreactive nonstress test: predictive value for neonatal anemia in the isoimmunized pregnancy.

OBJECTIVE: To assess the value of the fetal nonstress test (NST) in predicting neonatal transfusion in pregnancies complicated by red cell isoimmunization. METHODS: We retrospectively reviewed the records of all patients evaluated for isoimmunization in pregnancy for the period January 1992 to December 1994. In addition to prenatal care, serial ultrasonography, and invasive testing when indicated, patients had NSTs two times per week. Nonstress tests were interpreted as either reactive or nonreactive using standard criteria. Results of the last NST before delivery were analyzed. Neonatal outcome data were obtained prospectively and by chart review. RESULTS: Sixty patients with isoimmunization were identified during the study period. Fifty-one patients (85%) had reactive NSTs until delivery, and nine (15%) had nonreactive NSTs that prompted delivery. Twelve of 51 (23.5%) patients with reactive NSTs and seven of nine (77.8%) patients with nonreactive NSTs required neonatal transfusion (P = .003, odds ratio 11.4 [95% confidence interval (CI) 1.7-120.2]). The mean (standard error of the mean; range) hematocrit (%) at birth was 38.9 (3.0; 21.3-52.0) in patients with reactive NSTs and 28.3 (3.8; 14.5-45.0) in those with nonreactive NSTs (P < .05). A nonreactive NST had a 77.8% positive predictive value (95% CI 49.0-100) in identifying the need for neonatal transfusion. CONCLUSION: These findings indicate that a nonreactive NST is predictive of subsequent neonatal transfusion in patients with isoimmunization. The antepartum fetal NST is a useful adjunct in the management of isoimmunized pregnancies.

Adult↗
PubMed1985

Isoimmune neonatal thrombocytopenia: a case report and review.

Isoimmune neonatal thrombocytopenia is an unusual problem with significant morbidity and mortality. Though it is often self-limited, it is potentially fatal due to hemorrhage. Specific therapy with compatible platelets is indicated. In previously unrecognized cases, platelet antigen and antibody studies delay therapy unacceptably. Therefore, maternal platelets are used, which also aid in establishing a therapeutic diagnosis. A case of isoimmune neonatal thrombocytopenia is reported, and the etiology, clinical and laboratory implications, and methods of management are discussed.

Adult↗
PubMed2004

A retrospective review of isoimmunized pregnancies managed by middle cerebral artery peak systolic velocity.

OBJECTIVE: The purpose of this study was to determine the clinical outcome of isoimmunized pregnancies managed primarily by middle cerebral artery peak systolic velocity. STUDY DESIGN: A retrospective chart review was conducted of isoimmunized pregnancies that underwent ultrasound examinations from January 1, 2001, through May 1, 2003. Ultrasound reports, laboratory tests, and maternal and neonatal charts were reviewed. RESULTS: Women with a clinically significant red blood cell antibody and titer value were included. The study population consisted of 39 women (40 pregnancies, 42 fetuses). Patients with a middle cerebral artery peak systolic velocity of > or =1.5 MoM were offered amniocentesis. Seven pregnancies had an abnormal middle cerebral artery peak systolic velocity. Three of these infants had significant anemia. Six of the 7 pregnancies required an exchange transfusion. None of the 33 pregnancies (35 neonates) with normal middle cerebral artery peak systolic velocity measurements resulted in a neonate with significant anemia or severe hyperbilirubinemia. CONCLUSION: The clinical outcome of these pregnancies supports the use of middle cerebral artery peak systolic velocity measurements in the management of isoimmunized pregnancies.

Adult↗
PubMed1997

Ultrasonographic fetal cardiac measurement in isoimmunized pregnancies.

OBJECTIVE: To investigate the predictive value of the ultrasonographically measured fetal biventricular outer dimension (BVOD) in diastole in detecting neonatal anemia in pregnancies complicated by isoimmunization. STUDY DESIGN: The records of all patients evaluated for isoimmunization in pregnancy from January 1992 to December 1994 were reviewed retrospectively. The fetal BVOD had been measured with real-time-directed M-mode fetal echocardiography. The BVOD measurement was plotted on a nomogram (with reference to biparietal diameter) and a percentile value determined graphically from the nomogram. Neonatal outcome was obtained prospectively and by chart review. RESULTS: Sixty-three singleton fetuses from the study period who met entry criteria were identified. Anti-D sensitization represented 66% of cases of isoimmunization. Twenty (32%) fetuses required subsequent neonatal transfusion, and 43 (68%) did not. Seventeen fetuses (27%) had BVOD measurements greater than the 95th percentile, and 10 (59%) required subsequent transfusion. Infants in this group also had significantly lower hematocrits at birth (37.7 +/- 13.0% vs. 46.6 +/- 9.0%) and prolonged neonatal intensive care unit stay (10.7 +/- 10.0 vs. 4.7 +/- 3.6 days), respectively, when compared to patients with a BVOD measurement less than the 95th percentile. A BVOD 95th percentile threshold had a sensitivity, specificity and positive predictive value of 50%, 84% and 59%, respectively, in predicting the need for neonatal transfusion. CONCLUSION: In patients with isoimmunization, a BVOD measurement in the 95th percentile or greater was associated with a relatively high likelihood of neonatal anemia and transfusion. Although the measurement is not sufficiently sensitive to be used as a single parameter in predicting neonatal compromise in these patients, it can be a useful, noninvasive adjunct to the management of isoimmunized pregnancies.

Anemia, Neonatal↗