Intrauterine management of fetal parvovirus B19 infection.
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OBJECTIVES: The aim of our study was to determine the outcome of pregnancies after intrauterine management of fetal parvovirus B19 infection. DESIGN: Retrospective study. SUBJECTS: A total of 37 cases of maternofetal parvovirus B19 infection, 35 of which were associated with hydrops fetalis, were referred to our tertiary level center between 1989 and 1996. With regard to fetal hydrops, no apparent cause other than parvovirus B19 infection was found in any patient. METHODS: In all patients, cordocentesis was performed to assess the degree of fetal anemia. When anemia was present, cordocentesis was followed by intrauterine transfusion with packed red cells into the umbilical vein. Further management depended on the degree of fetal anemia and gestational age and included follow-up fetal blood sampling/transfusion as well as ultrasound examinations as deemed appropriate. RESULTS: Packed red cell transfusion was performed in 30 patients with significant fetal anemia (Z-score 1.6-7.8 below the mean for gestational age). The fetal hemoglobin values ranged from 2.1 to 9.6 g/dl. Serum levels of platelets in the transfusion group were 9-228 x 10(9)/l with Z-scores in the range of < 1 to 3.8 below the mean. During treatment and follow-up, there were five intrauterine deaths (13.5%), one neonatal death (2.7%) and 31 live births (83.8%). CONCLUSIONS: Fetal parvovirus infection can lead to marked anemia and hydrops formation. Cordocentesis allows precise assessment of fetal anemia which can then be corrected by intravenous transfusion. Under this regimen, the outcome proved favorable in the majority of fetuses, even those that were severely anemic. (+info)
Cardiac changes in fetuses secondary to immune hemolytic anemia and their relation to hemoglobin and catecholamine concentrations in fetal blood.
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OBJECTIVES: Immune hemolytic anemia in the fetus may cause cardiac decompensation and intrauterine death. Postnatally, norepinephrine (noradrenaline) is released in chronic heart failure, and may lead to myocardial hypertrophy. The aim of this study was to determine fetal cardiac changes associated with immune hemolytic anemia by means of echocardiography, and to relate them to fetal hemoglobin and norepinephrine levels. DESIGN: Thirty anemic fetuses underwent a total of 76 umbilical venous transfusions. Before the procedure, fetal echocardiography was performed, and end-diastolic myocardial wall thicknesses and ventricular dimensions together with Doppler flow patterns at the atrioventricular and semilunar valves were measured. Fetal hemoglobin, epinephrine and norepinephrine concentrations were determined before the transfusion. Statistical analysis of this prospective study comprised descriptive statistics including linear regression and correlation analyses. Two samples of measurements were compared by the Mann-Whitney U test. RESULTS: The mean hemoglobin concentration before the first transfusion was 6.9 g% at a mean gestational age of 26.8 weeks. Norepinephrine values were elevated in comparison to a reference range, and were higher than epinephrine values. The most striking echocardiographic finding was myocardial hypertrophy of all ventricular walls. Mean blood flow velocities were increased; at the left ventricle, they were negatively related to the hemoglobin concentrations, and positively to the norepinephrine values. CONCLUSIONS: Fetal myocardial hypertrophy in anemia may be the result of an augmented cardiac workload, indicated by the increased left ventricular mean velocities. This reaction reflects the redistribution of blood flow that may depend on hemoglobin and norepinephrine concentrations. (+info)
Perinatal management of fetal hemolytic disease due to Rh incompatibility combined with fetal alloimmune thrombocytopenia due to HPA-5b incompatibility.
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We report out experience in the perinatal management of a complex case of fetal hemolytic disease primarily due to Rhesus incompatibility combined with fetal alloimmune thrombocytopenia. The lowest fetal hemoglobin and platelet levels were 2.6 g/dl and 13,000/microliter, respectively. Intrauterine treatment consisted of six transfusions of packed red cells into the umbilical vein and one transfusion of platelets. The neonate required four transfusions of packed red cells to correct her hyporegenerative erythropoiesis. Postnatal management also included one platelet transfusion, intravenous immunoglobulins and erythropoietin. Although some degree of fetal thrombocytopenia may invariably be found in fetal red cell incompatibility, other rare causes need to be excluded. (+info)
Pathophysiology and treatment of fetal anemia due to placental chorioangioma.
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Placental chorioangiomas occur in 1% of pregnancies. Large chorioangiomas may cause serious complications such as fetal anemia, hydrops and fetal death. In this case report, a pregnancy complicated by a large placental chorioangioma is described. Severe fetal anemia without the occurrence of hydrops fetalis was suspected using ultrasound and Doppler examinations. Successful intrauterine blood transfusion was performed, with an unusually large amount of blood needed to obtain an adequate rise in fetal hematocrit. Two weeks later, at 32 weeks, the infant was born in good condition. In pregnancies with large chorioangiomas, we advise regular ultrasound and Doppler examinations, with the aim of detecting fetal anemia before hydrops develops. When anemia is suspected, fetal blood sampling is indicated and intrauterine transfusion therapy may be beneficial to preserve fetal health until maturity is reached. (+info)
Survival of donor cells 25 years after intrauterine transfusion.
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Persistence of donor leukocytes in the circulation of recipients of intrauterine transfusion (IUT) has been observed up to 5 years after birth. The aim of this study was to determine whether transfusions with nonirradiated, nonleukocyte-depleted donor blood during the fetal period resulted in long-term immunomodulation of the recipient. Twenty-four surviving IUT recipients between 1966 and 1976 were tested for autoimmune disease and autoantibodies at follow-up. Ten had sex-mismatched donors and were therefore informative for chimerism studies using fluorescence in situ hybridization (FISH). Seven female recipients could be tested for chimerism using a Y- chromosome-specific polymerase chain reaction (PCR) because they received at least 1 IUT from a male donor. Nine recipients could be studied for cytotoxic T-lymphocyte precursor (CTLp) and helper T-lymphocyte precursor (HTLp) frequencies because the original donors were available for testing. All surviving IUT recipients were in good health at the time of the examination, and routine laboratory testing revealed no abnormalities. None of the IUT recipients were chimeric as determined by FISH analysis, but Y-chromosome-specific sequences were detected by PCR in 6 of the 7 women. However, the CTLp and HTLp frequencies of the IUT recipients against the donors were comparable to those of the controls. The current study provides evidence that IUT can result in the persistence of donor cells in the recipient for a period longer than 20 years but that it is not associated with immunotolerance or with signs of chronic antigenic stimulation. (Blood. 2000;95:2709-2714) (+info)
Dual natriuretic peptide response to volume load in the fetal circulation.
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OBJECTIVE: To measure atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) in control fetuses and fetuses with Rhesus isoimmunisation before and after intravascular transfusion. The current study was designed to investigate the response of ANP and BNP to cardiac short-term and long-term volume load in the human fetus. METHODS: Fetal blood samples were collected from 18 human fetuses (nine controls, nine anemic fetuses with Rhesus isoimmunisation before and after intravascular transfusion). Fetal ANP and BNP concentrations were measured and compared to maternal plasma levels. RESULTS: Both ANP and BNP were significantly higher in fetal blood compared to the mothers. Fetuses with Rhesus isoimmunisation, characterized by long-term cardiac overload, showed significantly elevated ANP but not BNP concentration compared to the fetal controls (ANP: 80.8+/-16.6 vs. 31.6+/-7.7 pg/ml, P<0.05). However, short-term volume load due to intravascular transfusion leads to a significant increase in the fetal BNP- but not ANP-plasma level (BNP: 112.9+/-14.1 vs. 64.8+/-6.6 pg/ml, P<0.05). CONCLUSION: ANP and BNP respond differently to cardiac short- and long-term volume load in the fetal circulation. Therefore, the data suggest that in the fetus, similar to adults, ANP and BNP constitute a dual natriuretic peptide system responsive to changes in cardiac filling pressure. (+info)
Hydrops fetalis-associated congenital dyserythropoietic anemia treated with intrauterine transfusions and bone marrow transplantation.
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Hydrops fetalis is rarely caused by congenital dyserythropoietic anemia (CDA). We report a patient with hydrops fetalis as a result of severe anemia. This patient needed intrauterine transfusions from 21 weeks of gestation until birth. The hematologic study showed an atypical CDA (hydrops fetalis-associated CDA) characterized by features resembling CDA type II, but negative acidified serum lysis test (HEMPAS negative). The patient was regularly transfused for a year, after which an allogeneic bone marrow transplantation (BMT) from an HLA-identical sibling was successfully carried out. His actual hemoglobin is 127 g/L, and he has not received transfusions for more than a year. In conclusion, intrauterine transfusions and BMT could cure an otherwise lethal atypical CDA. (+info)
Management of single fetal death in twin-to-twin transfusion syndrome: a role for fetal blood sampling.
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OBJECTIVE: Intrauterine death of one twin in monochorionic pregnancies is associated with an increased mortality and morbidity of the cotwin. This is likely to occur as a consequence of acute hemodynamic changes due to feto-fetal hemorrhage at the time of death of the cotwin. We assessed the role of fetal blood sampling and intrauterine transfusion to rescue the survivor. MATERIALS AND METHODS: We managed 12 cases of single intrauterine death at between 17 and 26 weeks' gestation in monochorionic twins complicated by twin-to-twin transfusion syndrome (TTTS). All these cases had been treated either by laser therapy or by serial amniodrainage. When the demise of one twin occurred, ultrasound-guided fetal blood sampling was performed in the surviving twin using a 20-gauge needle within 24 h of death. Intrauterine transfusion was performed at the same time in cases where the survivor was anemic. All survivors were assessed in the neonatal period and at 1 year of age. RESULTS: Six of the 12 surviving fetuses were found to be anemic and underwent intrauterine transfusion. All fetuses survived the procedure. Four of these fetuses had normal neurological development at 1 year of age. Periventricular leukomalacia developed in one case and the patient underwent termination of pregnancy at 34 weeks. In one case delivery occurred at 34 weeks' gestation and the baby developed periventricular leukomalacia at 1 month of age. In all six non-anemic fetuses pediatric examination was normal at birth and at 1 year of age. CONCLUSION: Intrauterine death of one monochorionic twin in TTTS puts the survivor at high risk of intrauterine death or of developing ischemic/hypoxic lesions. Our results suggest that fetal blood sampling is a useful diagnostic tool to identify those fetuses that are not anemic and hence unlikely to be at risk of developing a cerebral lesion. (+info)