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Interesting Case Conference: Intrauterine Transfusion

Interesting Case Conference: Intrauterine Transfusion. Daniel Long, M.D. December 20, 2019. Case Details. 31 year old pregnant female (G4T3003) at 26 wks EGA The patient’s 3 rd child required neonatal transfusion and photherapy for hemolytic of the newborn 2/28/13 (9 wks EGA)

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Interesting Case Conference: Intrauterine Transfusion

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  1. Interesting Case Conference:Intrauterine Transfusion Daniel Long, M.D. December 20, 2019

  2. Case Details • 31 year old pregnant female (G4T3003) at26 wks EGA • The patient’s 3rd child required neonatal transfusion and photherapy for hemolytic of the newborn • 2/28/13 (9 wks EGA) • Anti-D titer: 1:16, anti-C titer: 1:2 (OSH) • 5/20/13 (20 wks EGA) • Anti-D titer: 1:32, anti-C titer: 1:1 (OSH) • 7/4/13 (26 wks EGA) • Anti-D titer: 1:128, anti-C titer: 1:1 (VUMC) • Ultrasound: active fetus, MCA PSV: 1.76 MoM • Fetal monitoring: reassuring

  3. Fetal Monitoring: MCA Velocity Source: Duckler D, et al. Am J Obstet Gynecol. 2003;188:1310-4.

  4. Fetal Monitoring: Amniocentesis Source: Queenan JT, et al. Am J Obstet Gynecol. 1993;168:1370-6.

  5. Fetal Monitoring Source: Oepkes D, et al. N Engl J Med. 2006;355:156-64.

  6. Treatment Algorithm Source: Moise KJ. Semin Hematol. 2005 Jul;42(3):169-78.

  7. Intrauterine Transfusion • Type O Rh negative RBCs • CMV antibody negative • Fresh (enhanced 2-3 DPG level) • In the UK: no more than 5 days old • Irradiated • Leukodepletion • Washed and packed (Hct 75-85%)

  8. Intrauterine Transfusion

  9. Risks of IUT • Perinatal death: 1.6% • Emergency cesarean delivery: 2.0% • Infection: 0.3% • Premature rupture of membranes: 0.1% • Inadvertent arterial puncture: 3% • Bradycardia or tachycardia: 5% • 57% of cases with perinatal death or emergent delivery • Long-term morbidity • Cerebral palsy: 2.8%, developmental delay: 3.9%, hearing loss: 2.3% • Immunomodulatory effect? Sources: van Kamp IL, et al. Am J Obstet Gynecol. 2005;192:171-7. Moise, KJ, et al. Alloimmune disorders in pregnancy. Anaemia, thrombocytopenia and neutropenia in the fetus and newborn, Hadley, A, Soothill, P (Eds), Cambridge Press, Cambridge, 2002.

  10. Iron Overload Source: Rath MEA. Vox Sang. 2013 Jun 27.

  11. Transfused Volume • Goal Hct 40-50% (consistent with the normal fetus) • Giannina G, et al. Fetal Diagn Ther. 1998;13:94-7. • Fetal weight (g) x 0.02 = amount required to increase the fetal Hct by 10% • Mandelbrot L, et al. Fetal Ther. 1988;3(1-2):60-6. • Fetoplacental volume (mL) x goal change in Hct / donor unit Hct • Fetoplacental volume = 1.046 + fetal weight (g) x 0.14

  12. 7/5/13 Intrauterine Transfusion • Estimated fetal weight: 940 g (37%ile) • Pre-transfusion fetal Hgb: 4.1 g/dL (Hct 12%) • Amniotic bilirubin scan: 0.198 OD

  13. Fetal Monitoring: Amniocentesis Source: Queenan JT, et al. Am J Obstet Gynecol. 1993;168:1370-6.

  14. 7/5/13 Intrauterine Transfusion • Estimated fetal weight: 940 g (37%ile) • Pre-transfusion fetal Hgb: 4.1 g/dL (Hct 12%) • Amniotic bilirubin scan: 0.198 OD • Transfusion requirement (goal Hct 45%) • Giannina estimate: 62 mL / 33% change • Mandlebrot estimate: 55 mL / 33% change • 58/60/68 mL of PRBCs were transfused • Post-transfusion fetal Hgb: 7.5 g/dL (Hct 23%)

  15. Case Details • 7/4, 7/5/13 (26 wks EGA) • Anti-D titer: 1:128 , anti-C titer: 1:1 • MCA PSV: 1.76 MoM • IUT: ~60 mL transfused • 7/15, 7/18/13 (28 wks EGA) • Anti-D titer: 1:1024, anti-C titer: 1:2 • MCA PSV: 1.9 MoM

  16. 7/18/13 Intrauterine Transfusion • Estimated fetal weight: 1013 g (56%ile) • Pre-transfusion fetal Hct: 27% • Transfusion requirement (goal Hct 45%) • Giannina estimate: 36 mL / 18% change • Mandlebrot estimate: 32 mL / 18% change • 37 mL of PRBCs were transfused • Post-transfusion fetal(?) Hct: 35%

  17. Case Details • 7/4, 7/5/13 (26 wks EGA) • Anti-D titer: 1:128 , anti-C titer: 1:1 • MCA PSV: 1.76 MoM • IUT: ~60 mL transfused • 7/15, 7/18/13 (28 wks EGA) • Anti-D titer: 1:1024, anti-C titer: 1:2 • MCA PSV: 1.9 MoM • 7/23/13 (29 wks EGA) • MCA PSV: 1.9 MoM • Non-reassuring fetal status, ↓ movements • C-section performed

  18. Case Resolution • Baby girl L was delivered at 29.3 wks • 1495 g • APGARS 4/6/6 • Initial labs: • Hgb 3.5 g/dL, TBil 5.5 mg/dL, DAT negative • Patient is currently stable on room air • 4 additional PRBC transfusions to date • Most recent labs: • Hgb 9.5 g/dL, TBil 5.3 mg/dL, retic 0.3%

  19. Efficacy of IVIG? Sources: Kirplani, A. Gynecol Obstet Invest. 2007;63(3):176-80. Matsuda, H. J Perinatol. 2011 Apr;31(4):289-92.

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