Volume 162 Number 4
renin to the protease inhibitors and lipoproteins? Clin Sci Mol Med 1978;SS(suppI4):12SS-8S. IS. Ramsay DJ, Reid lA, Keil LC, Ganong WF. Evidence that the effects of isoproterenol on water intake and vasopressin secretion are mediated by angiotensin. Endocrinology 1978;103:S4-9. 16. Wolff F, Carstens V, Behrenbeck D, Bolte A, Fisher JH.
Renin-angiotensin system during ritodrine treatment
The effect of fenoterol and betamethasone on pulmonary circulation-results of intensive monitoring of pregnant women, using cardiac catheter, for prevention of pulmonaryedema. In: J ung H, Lamberti G, eds. Betamimetic drugs in obstetrics and perinatology. Stuttgart: Georg Thieme Verlag, 1982:132-6.
Intrauterine transfusion-Intraperitoneal versus intravascular approach: A case-control comparison C. R. Harman, MD,. J. M. Bowman, MD,b F. A. Manning, MD: and S. M. Menticoglou, MD"
Winnipeg, Manitoba, Canada Intravascular fetal transfusion has gained widespread acceptance and has supplanted the use of intraperitoneal fetal transfusion in management of severe alloimmune disease in many centers. This study compares the two methods with regard to multiple objective end points of performance, therapy, and outcome in a highly matched case-control fashion. The intravascular approach is better on almost every level. More surviving infants who are in better condition at a mature gestation and whose mothers have fewer complications and sequelae are the result. Whereas intraperitoneal transfusion should not be abandoned altogether, it is a second-line procedure used only in very limited circumstances. Intravascular fetal transfusion offers realistic prognosis for intact survival at virtually any extreme of alloimmune disease. (AM J OSSTET GVNECOL 1990;162:1053-9.)
Key words: Intraperitoneal fetal transfusion, intravascular fetal transfusion, alloimmunization Having a choice of procedures for intrauterine treatment is a recent option in the management of severe fetal alloimmune disease. Whereas intraperitoneal fetal transfusion has been used for 25 years, I. 2 the new alternative, intravascular fetal transfusion, has been available for only a few years in most centers. 3 . 4 The widespread adoption of the new procedure suggests it has demonstrable advantages, but the data supporting that conclusion are few. Whereas hard data may be lacking, intravascular fetal transfusion has an intrinsic appeal. By definition, intravascular fetal transfusion includes fetal vascular access and all the hematologic, acid-base-respiratory, and biochemical data that that entails. This permits management by detailed fetal evaluation, rather than according to the indirect amniotic fluid and ultrasonographic inferences that guided treatment before fetal From the Division of Maternal awl Fetal Medicine, Department of Obstetrics, Gynecology awl Reproductive Sciences, University of Manitoba: awl Rh Laboratory, Women's Hospital.' Received for publication June 27, 1989 .. revised December 15, 1989.. accepted December 29, 1989. Reprint requests: C. R. Harman, MD, WR-120 Women's Hospital, 735 Notre Dame Ave., Winnipeg, Canada MB R3E OL8. 611119141
blood sampling was available. Second, the procedure is technically more pleasing-a small needle is guided with high resolution into a small, precisely defined target with virtual certainty as to proper placement. Intraperitoneal fetal transfusion, on the other hand, has much more force involved in directing a larger needle into a general area (the fetal peritoneal cavity) with some uncertainty as to proper placement. Third, some differences in results for the most severely affected fetuses are clear: at the dire extreme of disease (moribund hydrops fetalis), intraperitoneal fetal transfusion is likely futile, whereas intravascular fetal transfusion offers hope. 5 Because fetal breathing movements essential for absorption of the transfusion mass after intraperitoneal fetal transfusion are absent in the moribund fetus, intraperitoneal transfusion probably cannot work. 6 Therefore, several aspects of the newer intravascular procedure suggest advantages over the intraperitoneal procedure. This study was designed to address the comparison between intraperitoneal fetal transfusion and intravascular fetal transfusion in fetuses that require intrauterine therapy for severe alloimmune disease. At our institution, early experience with intravascular fetal transfusion in severely ill fetuses has been such that a 1053
1054 Harman et al.
April 1990 Am J Obstet Gynecol
Table I. Ultrasonographic classification of alloimmune disease Ultrasonographic appearance Class 1
2
3 4
+ + + +
+ + +
+ +
Anasarca
Abnormal BPS
renin to the protease inhibitors and lipoproteins? Clin Sci Mol Med 1978;SS(suppI4):12SS-8S. IS. Ramsay DJ, Reid lA, Keil LC, Ganong WF. Evidence that the effects of isoproterenol on water intake and vasopressin secretion are mediated by angiotensin. Endocrinology 1978;103:S4-9. 16. Wolff F, Carstens V, Behrenbeck D, Bolte A, Fisher JH.
Renin-angiotensin system during ritodrine treatment
The effect of fenoterol and betamethasone on pulmonary circulation-results of intensive monitoring of pregnant women, using cardiac catheter, for prevention of pulmonaryedema. In: J ung H, Lamberti G, eds. Betamimetic drugs in obstetrics and perinatology. Stuttgart: Georg Thieme Verlag, 1982:132-6.
Intrauterine transfusion-Intraperitoneal versus intravascular approach: A case-control comparison C. R. Harman, MD,. J. M. Bowman, MD,b F. A. Manning, MD: and S. M. Menticoglou, MD"
Winnipeg, Manitoba, Canada Intravascular fetal transfusion has gained widespread acceptance and has supplanted the use of intraperitoneal fetal transfusion in management of severe alloimmune disease in many centers. This study compares the two methods with regard to multiple objective end points of performance, therapy, and outcome in a highly matched case-control fashion. The intravascular approach is better on almost every level. More surviving infants who are in better condition at a mature gestation and whose mothers have fewer complications and sequelae are the result. Whereas intraperitoneal transfusion should not be abandoned altogether, it is a second-line procedure used only in very limited circumstances. Intravascular fetal transfusion offers realistic prognosis for intact survival at virtually any extreme of alloimmune disease. (AM J OSSTET GVNECOL 1990;162:1053-9.)
Key words: Intraperitoneal fetal transfusion, intravascular fetal transfusion, alloimmunization Having a choice of procedures for intrauterine treatment is a recent option in the management of severe fetal alloimmune disease. Whereas intraperitoneal fetal transfusion has been used for 25 years, I. 2 the new alternative, intravascular fetal transfusion, has been available for only a few years in most centers. 3 . 4 The widespread adoption of the new procedure suggests it has demonstrable advantages, but the data supporting that conclusion are few. Whereas hard data may be lacking, intravascular fetal transfusion has an intrinsic appeal. By definition, intravascular fetal transfusion includes fetal vascular access and all the hematologic, acid-base-respiratory, and biochemical data that that entails. This permits management by detailed fetal evaluation, rather than according to the indirect amniotic fluid and ultrasonographic inferences that guided treatment before fetal From the Division of Maternal awl Fetal Medicine, Department of Obstetrics, Gynecology awl Reproductive Sciences, University of Manitoba: awl Rh Laboratory, Women's Hospital.' Received for publication June 27, 1989 .. revised December 15, 1989.. accepted December 29, 1989. Reprint requests: C. R. Harman, MD, WR-120 Women's Hospital, 735 Notre Dame Ave., Winnipeg, Canada MB R3E OL8. 611119141
blood sampling was available. Second, the procedure is technically more pleasing-a small needle is guided with high resolution into a small, precisely defined target with virtual certainty as to proper placement. Intraperitoneal fetal transfusion, on the other hand, has much more force involved in directing a larger needle into a general area (the fetal peritoneal cavity) with some uncertainty as to proper placement. Third, some differences in results for the most severely affected fetuses are clear: at the dire extreme of disease (moribund hydrops fetalis), intraperitoneal fetal transfusion is likely futile, whereas intravascular fetal transfusion offers hope. 5 Because fetal breathing movements essential for absorption of the transfusion mass after intraperitoneal fetal transfusion are absent in the moribund fetus, intraperitoneal transfusion probably cannot work. 6 Therefore, several aspects of the newer intravascular procedure suggest advantages over the intraperitoneal procedure. This study was designed to address the comparison between intraperitoneal fetal transfusion and intravascular fetal transfusion in fetuses that require intrauterine therapy for severe alloimmune disease. At our institution, early experience with intravascular fetal transfusion in severely ill fetuses has been such that a 1053
1054 Harman et al.
April 1990 Am J Obstet Gynecol
Table I. Ultrasonographic classification of alloimmune disease Ultrasonographic appearance Class 1
2
3 4
+ + + +
+ + +
+ +
Anasarca
Abnormal BPS
