Eur J Pediatr DOI 10.1007/s00431-015-2573-x
ORIGINAL ARTICLE
Neonatal outcome after fetal anemia managed by intrauterine transfusion C. Garabedian 1 & T. Rakza 1 & D. Thomas 1 & B. Wibaut 2 & P. Vaast 1 & D. Subtil 1,3 & V. Houfflin-Debarge 1,3
Received: 19 April 2015 / Revised: 19 May 2015 / Accepted: 22 May 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract In-utero transfusion is now well under control and improves the survival of foetuses monitored for fetal anemia with a survival rate of more than 80 %. The aim was to evaluate short-term neonatal outcome after fetal severe anemia managed by intrauterine transfusions. We did a retrospective study of all neonates born after management of severe fetal anemia (n=93) between January 1999 and January 2013 in our regional center. The two main causes of anemia were maternal red blood cell alloimmunization (N=81, 87 %) and Parvovirus B19 infection (N=10, 10.8 %). In the alloimmunization group, phototherapy was implemented in 85.2 % of cases with a maximum level of bilirubin of 114.4 ± 60.7 (mg/dl). Communicated by Patrick Van Reempts * C. Garabedian [email protected] T. Rakza [email protected] D. Thomas [email protected] B. Wibaut [email protected] P. Vaast [email protected]
Transfusion and exchange transfusion were, respectively, required in 51.9 % and in 34.6 % of cases. One neonate presented a convulsive episode, and we observed three neonatal deaths. In the parvovirus group, none of the child had anemia at birth and no management was necessary. Conclusion: Contemporary management of Rhesus disease is associated with encouraging neonatal outcomes. In case of Parvovirus infection, no specific management is necessary at. But, in all cases of fetal anemia, children should be followed up with particular attention to neurologic development. What is Known: • In-utero transfusion is now well under control and improves the survival of fetuses monitored for fetal anemia. • Limited studies are available on the effect of IUT on postnatal outcome in infants with a history of fetal anemia. What is New: • Contemporary management of severe Rhesus disease is associated with encouraging neonatal outcomes. • The majority of infants can be managed with phototherapy and a limited number of top-up transfusions and exchange transfusions. In case of Parvovirus infection, the short-term neonatal outcome is excellent.
Keywords Anemia . Hyperbilirubinemia . Intrauterine transfusion . Pediatric outcome . Rhesus hemolytic disease
D. Subtil [email protected] V. Houfflin-Debarge [email protected] 1
Department of Obstetrics, Jeanne de Flandre Hospital, Regional University Hospital Center (CHRU) of Lille, Lille, France
2
Institute of Hematology and Transfusion, Jeanne de Flandre Hospital, CHRU of Lille, Lille, France
3
University of Lille-North of France, Lille, France
Abbreviations CMV Cytomegalovirus ET Exchange transfusion GA Gestational age IUT Intrauterine transfusion MCA PSV MIddle cerebral artery peak systolic velocity MRI Magnetic resonance imaging
Eur J Pediatr
NDI PT Rh
Neurodevelopmental impairment Phototherapy Rhesus
Introduction Main causes of fetal anemia are alloimmune anemia and Parvovirus B19 infection. Since the widespread prevention by anti-RhD immunoglobulin during pregnancy and childbirth, fetal hemolytic anemia by erythrocyte alloimmunization has become rare [3]. The most common immunization is that against RhD antigen with six cases per 1000 live births in the USA and about 750 cases per year births in France (88 % of immunizations) [3, 15]. The discovery of fetal anemia can lead to several therapeutic approaches depending on the etiology, the evolution, and the gestational age: fetal intraperitoneal transfusion at very early gestational age, fetal intravascular transfusion (simple or exchanges consisting in transfusion and withdrawn volumes close to 0 ml) in cases of early gestational age (GA), and fetal extraction when GA is advanced and compatible with moderate prematurity. In-utero transfusion (IUT) is now well under control and improves the survival of fetuses monitored for fetal anemia [19, 21]. However, it carries some risk with a complication rate per procedure of about 3.1 % [21]. In case of fetal anemia due to alloimmunization, prenatal therapies do not ameliorate the hemolytic process and therefore postnatal treatment with phototherapy and/or transfusion or exchange transfusion may still be required. Limited studies are available on the effect of IUT on postnatal outcome in infants with a history of fetal anemia [5, 8, 14, 22]. The aim of our study was to evaluate short-term neonatal outcome after fetal severe anemia managed by intrauterine transfusions.
1.5–1.55 MoM [13]. Technical realization of IUT is the same as previously described [9]. IUT was performed till the 34th week of gestation. Beyond this age, fetal extraction was discussed with the perinatal specialists. Our neonatal management was similar as previously described by De Boer et al. [5]. Briefly, phototherapy (PT) was administered with two devices (Tunnel MIDEPREMA, Tours, France and NATUS NeoBlue, Natus Medical Inc, San Carlos, CA 940070-USA). Exchange transfusion (ET) was performed with double-volume transfusion (160 mL/kg) using irradiated and leukocyte-depleted erythrocytes, and our criteria for ET were bilirubin level at birth >3.5 mg/dl or bilirubin levels above threshold in combination with failure of PT. Indication for red blood cell transfusion was hemoglobin level at birth
ORIGINAL ARTICLE
Neonatal outcome after fetal anemia managed by intrauterine transfusion C. Garabedian 1 & T. Rakza 1 & D. Thomas 1 & B. Wibaut 2 & P. Vaast 1 & D. Subtil 1,3 & V. Houfflin-Debarge 1,3
Received: 19 April 2015 / Revised: 19 May 2015 / Accepted: 22 May 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract In-utero transfusion is now well under control and improves the survival of foetuses monitored for fetal anemia with a survival rate of more than 80 %. The aim was to evaluate short-term neonatal outcome after fetal severe anemia managed by intrauterine transfusions. We did a retrospective study of all neonates born after management of severe fetal anemia (n=93) between January 1999 and January 2013 in our regional center. The two main causes of anemia were maternal red blood cell alloimmunization (N=81, 87 %) and Parvovirus B19 infection (N=10, 10.8 %). In the alloimmunization group, phototherapy was implemented in 85.2 % of cases with a maximum level of bilirubin of 114.4 ± 60.7 (mg/dl). Communicated by Patrick Van Reempts * C. Garabedian [email protected] T. Rakza [email protected] D. Thomas [email protected] B. Wibaut [email protected] P. Vaast [email protected]
Transfusion and exchange transfusion were, respectively, required in 51.9 % and in 34.6 % of cases. One neonate presented a convulsive episode, and we observed three neonatal deaths. In the parvovirus group, none of the child had anemia at birth and no management was necessary. Conclusion: Contemporary management of Rhesus disease is associated with encouraging neonatal outcomes. In case of Parvovirus infection, no specific management is necessary at. But, in all cases of fetal anemia, children should be followed up with particular attention to neurologic development. What is Known: • In-utero transfusion is now well under control and improves the survival of fetuses monitored for fetal anemia. • Limited studies are available on the effect of IUT on postnatal outcome in infants with a history of fetal anemia. What is New: • Contemporary management of severe Rhesus disease is associated with encouraging neonatal outcomes. • The majority of infants can be managed with phototherapy and a limited number of top-up transfusions and exchange transfusions. In case of Parvovirus infection, the short-term neonatal outcome is excellent.
Keywords Anemia . Hyperbilirubinemia . Intrauterine transfusion . Pediatric outcome . Rhesus hemolytic disease
D. Subtil [email protected] V. Houfflin-Debarge [email protected] 1
Department of Obstetrics, Jeanne de Flandre Hospital, Regional University Hospital Center (CHRU) of Lille, Lille, France
2
Institute of Hematology and Transfusion, Jeanne de Flandre Hospital, CHRU of Lille, Lille, France
3
University of Lille-North of France, Lille, France
Abbreviations CMV Cytomegalovirus ET Exchange transfusion GA Gestational age IUT Intrauterine transfusion MCA PSV MIddle cerebral artery peak systolic velocity MRI Magnetic resonance imaging
Eur J Pediatr
NDI PT Rh
Neurodevelopmental impairment Phototherapy Rhesus
Introduction Main causes of fetal anemia are alloimmune anemia and Parvovirus B19 infection. Since the widespread prevention by anti-RhD immunoglobulin during pregnancy and childbirth, fetal hemolytic anemia by erythrocyte alloimmunization has become rare [3]. The most common immunization is that against RhD antigen with six cases per 1000 live births in the USA and about 750 cases per year births in France (88 % of immunizations) [3, 15]. The discovery of fetal anemia can lead to several therapeutic approaches depending on the etiology, the evolution, and the gestational age: fetal intraperitoneal transfusion at very early gestational age, fetal intravascular transfusion (simple or exchanges consisting in transfusion and withdrawn volumes close to 0 ml) in cases of early gestational age (GA), and fetal extraction when GA is advanced and compatible with moderate prematurity. In-utero transfusion (IUT) is now well under control and improves the survival of fetuses monitored for fetal anemia [19, 21]. However, it carries some risk with a complication rate per procedure of about 3.1 % [21]. In case of fetal anemia due to alloimmunization, prenatal therapies do not ameliorate the hemolytic process and therefore postnatal treatment with phototherapy and/or transfusion or exchange transfusion may still be required. Limited studies are available on the effect of IUT on postnatal outcome in infants with a history of fetal anemia [5, 8, 14, 22]. The aim of our study was to evaluate short-term neonatal outcome after fetal severe anemia managed by intrauterine transfusions.
1.5–1.55 MoM [13]. Technical realization of IUT is the same as previously described [9]. IUT was performed till the 34th week of gestation. Beyond this age, fetal extraction was discussed with the perinatal specialists. Our neonatal management was similar as previously described by De Boer et al. [5]. Briefly, phototherapy (PT) was administered with two devices (Tunnel MIDEPREMA, Tours, France and NATUS NeoBlue, Natus Medical Inc, San Carlos, CA 940070-USA). Exchange transfusion (ET) was performed with double-volume transfusion (160 mL/kg) using irradiated and leukocyte-depleted erythrocytes, and our criteria for ET were bilirubin level at birth >3.5 mg/dl or bilirubin levels above threshold in combination with failure of PT. Indication for red blood cell transfusion was hemoglobin level at birth
