Outcome predictors for maternal red blood cell alloimmunisation with anti-K and anti-D managed with intrauterine blood transfusion

Red blood cell (RBC) alloimmunisation with anti-D and anti-K comprise the majority of cases of fetal haemolytic disease requiring intrauterine red cell transfusion (IUT). Few studies have investigated which haematological parameters can predict adverse fetal or neonatal outcomes. The aim of the present study was to identify predictors of adverse outcome, including preterm birth, intrauterine fetal demise (IUFD), neonatal death (NND) and/or neonatal transfusion. We reviewed the records of all pregnancies alloimmunised with anti-K and anti-D, requiring IUT over 27 years at a quaternary fetal centre. We reviewed data for 128 pregnancies in 116 women undergoing 425 IUTs. The median gestational age (GA) at first IUT was significantly earlier for anti-K than for anti-D (24·3 vs. 28·7 weeks, P = 0·004). Women with anti-K required more IUTs than women with anti-D (3·84 vs. 3·12 mean IUTs, P = 0·036) and the fetal haemoglobin (Hb) at first IUT was significantly lower (51.0 vs. 70.5 g/l, P = 0·001). The mean estimated daily decrease in Hb did not differ between the two groups. A greater number of IUTs and a slower daily decrease in Hb (g/l/day) between first and second IUTs were predictive of a longer period in utero. Earlier GA at first IUT and a shorter interval from the first IUT until delivery predicted IUFD/NND. Earlier GA and lower Hb at first IUT significantly predicted need for phototherapy and/or blood product use in the neonate. In the anti-K group, a greater number of IUTs was required in women with a higher titre. Furthermore, the higher the titre, the earlier the GA at which an IUT was required in both groups. The rate of fall in fetal Hb between IUTs decreased, as the number of transfusions increased. Our present study identified pregnancies at considerable risk of an unfavourable outcome with anti-D and anti-K RBC alloimmunisation. Identifying such patients can guide pregnancy management, facilitates patient counselling, and can optimise resource use. Prospective studies can also incorporate these characteristics, in addition to laboratory markers, to further identify and improve the outcomes of these pregnancies

Fetoscopic laser therapy for twin-twin transfusion syndrome: beyond current gestational age limits.

Both "early" (< 16 weeks' gestation) and "late" (> 26 weeks' gestation) presentations of twin-twin transfusion syndrome (TTTS) are rare and challenging complications of monochorionic/diamniotic twin pregnancies. Growing evidence suggests that fetoscopic laser therapy for both "early" and "late" TTTS is feasible, safe, and yields similar outcomes to cases treated between 16 and 26 weeks' gestation. We suggest reevaluation of conventional gestational age guidelines for laser therapy for TTTS

Heparin therapy for complications of placental dysfunction: A systematic review of the literature

ObjectiveTo assess the benefits and harms of antenatal antithrombotic therapy for women at risk of adverse pregnancy outcomes associated with placental dysfunction.Search strategyPUBMED and the Cochrane Controlled Trials Register (CENTRAL) were searched. Reference lists of retrieved studies were searched by hand. No date or language restrictions were placed. Date of last search February 2008.Selection criteriaRandomized controlled trials comparing antenatal antithrombotic therapy (alone or combined with other agents) with placebo or no treatment were considered. Cohort studies with an appropriate control group were also considered. Studies were evaluated independently for appropriateness for inclusion and methodological quality without consideration of their results. Our search strategy identified five case series, two cohort studies with a control group, and one randomized controlled trial. All of the case series and one of the cohort studies were excluded.Data collection and analysisThe methodological quality of the included studies was poor. There was considerable variation in methodology and the interventions. It was not appropriate to combine results in meta-analysis.Main resultsFrom the randomized trial, heparin was not associated with a reduction in preterm birth less than 37 weeks gestation (Heparin 5/68 versus Control 7/39; relative risk (RR) 0.41; 95% confidence intervals (CIs) 0.14-1.20), or birth weight below 10th centile (Heparin 4/68 versus Control 6/39; RR 0.38; 95% CI 0.11-1.27).ConclusionThere is insufficient information to recommend the use of heparin during pregnancy for women at risk of complications due to placental dysfunction. Further information from randomized trials is required.Jodie M. Dodd, Kiran Sahi, Anne Mcleod, Rory C. Windrim & John P.C. Kingdo

Fetal middle cerebral artery Doppler to time second and subsequent transfusions in fetal red cell alloimmunisation: A randomised trial

Category D: Oral Presentations: Fetal MedicineDodd, J; Andersen, C; Dickinson, J, Kilby, M; Windrim, R; Ryan,

Highly realistic simulator for teaching and training fetoscopic laser surgery in twin-to-twin transfusion syndrome

Developmen

Screening for Placental Insufficiency in High-risk Pregnancies: Is Earlier Better?

ObjectiveTo compare a profile of placental function between the first and second trimesters in pregnancies at high risk of adverse perinatal outcomes attributable to placental insufficiency.Study designProspective cohort study in 61 singleton pregnancies. Uterine artery Doppler and placental morphology (shape and texture) were determined at 11-13(+6) weeks and at 18-23(+6) weeks. First trimester (pregnancy-associated placental protein-A [PAPP-A]) and second trimester (total hCG and alpha fetoprotein [AFP]) serum biochemistry were determined. The two screening periods were compared for the prediction of a range of severe adverse perinatal outcomes (intrauterine growth restriction [IUGR], abruption, severe pre-eclampsia/HELLP syndrome, deliveryResultsAdverse perinatal outcomes occurred in 14 (23%) women; 3 (4.9%) losses20 weeks, 4 (6.6%) IUGR, 7 (11.5%) severe pre-eclampsia/HELLP syndrome, and 10 (16.4%) deliveries or = 1 abnormal second trimester tests [+LR: 5.9, 95% CI: 1.6-24; -LR: 0.68, 95% CI: 0.59-0.89; p=0.005] or > or = 2 abnormal second trimester tests [+LR: 3.6, 95% CI: 1.3-7.7; -LR: 0.58, 95% CI: 0.27-0.94; p=0.035]. No combination of first trimester tests significantly predicted severe adverse perinatal outcomes. A study sample size of 822 women with similar high-risk characteristics would be needed in order to refute the conclusion that present methods of first trimester screening are not inferior to second trimester screening for severe placental insufficiency (p=0.05, power 80%, z-test).ConclusionsIn clinically high-risk pregnancies, prediction of adverse perinatal outcomes using placental function testing is more effective in the second compared with the first trimester.S.L. Costa, L. Proctor, J.M. Dodd, M. Toal, N. Okun, J.-A. Johnson, R. Windrim and J.C.P. Kingdo

Is anemia an independent risk factor for postpartum depression in women who have a cesarean section? - A prospective observational study

Abstract Background The symptoms of anemia and depression are very similar suggesting that there may be an association between the two entities. The aim of this study is to assess whether postpartum anemia (PPA) is an independent risk factor for de novo postpartum depression (PPD)in women undergoing elective cesarean section. Methods Women after an uncomplicated term cesarean section were recruited and their hemoglobin and iron status were measured on day 3–5 post section and again at 6 weeks. Postpartum depression was screened using the Edinburgh Postnatal Depression Scale (EPDS) and functional capacity was assessed with the RAND 12-item Health survey. Results One hundred and three women completed the study. The incidence of probable postpartum depression (PPD) as defined by EPDS score ≥ 10 was 17% at 6 weeks. There was no difference in hemoglobin or iron status in women who had PPD compared to those without (OR-0.69; 95% CI-0.15-2.49). Similarly, there was no significant association between low hemoglobin and maternal functional status (OR -1.03; 95% CI-0.34 - 2.94). Conclusions Neither anemia or low iron stores were found to be an independent risk factors for postpartum depression or decreased postpartum functional capacity in women who undergo an elective cesarean section