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Intrauterine Fetal Transfusion in Cases with Immune Hydrops Fetalis: When and How Effective It Is?

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Intrauterine Fetal Transfusion in Cases with Immune Hydrops Fetalis: When and How Effective It Is? A L J O A T U N R I N R A E L P Original Article P L E R A Perinatal Journal 2018;26(2):97–101 I N N R A U T A L J O Intrauterine fetal transfusion in cases with immune hydrops fetalis: when and how effective it is? Emre Ekmekci1, Emine Demirel2 1Perinatology Clinic, fianl›urfa Training and Research Hospital, fianl›urfa, Turkey 2Perinatology Clinic, ‹zmir Ege Maternity and Gynecology Training and Research Hospital, ‹zmir, Turkey Abstract Özet: ‹mmün hidrops fetalis olgular›nda intrauterin fetal transfüzyon: Ne zaman ve ne kadar etkili? Objective: We aimed to assess perinatal and neonatal outcomes in Amaç: ‹mmün fetal hidrops nedenli intrauterin fetal transfüzyon cases who underwent intrauterine fetal transfusion due to immune uygulanan olgularda perinatal ve neonatal sonuçlar› de¤erlendir- fetal hydrops, and to determine the factors associated with mek ve ifllem sonras› intrauterin fetal kay›pla iliflkili faktörleri sap- intrauterine fetal loss. tamay› amaçlad›k. Methods: The cases who underwent intrauterine fetal transfusion due Yöntem: Retrospektif olarak fianl›urfa E¤itim ve Araflt›rma Has- to the diagnosis of immune fetal hydrops within 13 months at tanesi’nde, 13 ay süre içerisinde immün fetal hidrops tan›s› ile in- fianl›urfa Training and Research Hospital were retrospectively includ- trauterin fetal transfüzyon yap›lan olgular çal›flmaya dahil edildi. ed in the study. The cases were classified according to the severity of Olgular hidrops bulgular›n›n fliddetine göre s›n›fland›r›ld›. ‹ntrau- hydrops findings. The cases with intrauterine fetal loss after intrauter- terin fetal transfüzyon sonras› intrauterin fetal kay›p olan olgular; ine fetal transfusion were examined in terms of hydrops severity, total canl› devam eden olgulara k›yasla hidrops fliddeti, toplam transfüz- transfusion number, the week of gestation when transfusion was initi- yon say›s›, transfüzyona bafllan›lan gebelik haftas› ve di¤er iliflkili ated and other potential associated factors compared to the cases with olabilecek faktörler aç›s›ndan incelendi. ‹flleme ba¤l› di¤er komp- live fetuses. Other procedure-related complications were evaluated. likasyonlar de¤erlendirildi. Results: A total of 11 cases with immune fetal hydrops were found, Bulgular: Toplam 11 immün fetal hidrops olgusu saptanm›fl olup, and 8 cases underwent 19 intrauterine fetal transfusion procedures. 8 olguya toplam 19 intrauterin fetal transfüzyon ifllemi yap›lm›flt›. Four of 8 cases had intrauterine fetal loss after the procedure, and 4 Sekiz olgudan 4 tanesinde ifllem sonras› intrauterin fetal kay›p ger- cases gave live birth. The week of gestation that hydrops developed çekleflmifl olup 4 olguda canl› do¤um olmufltu. ‹ntrauterin fetal ka- was determined as the primary factor associated with intrauterine y›p ile iliflkili primer faktör hidropsun geliflti¤i gebelik haftas› ola- fetal loss. After the procedure, it was seen that one case had sponta- rak saptand›. ‹fllem sonras› bir olguda 31. gebelik haftas›nda spon- neous preterm labor at 31 weeks of gestation. tan preterm do¤um gerçekleflmifl oldu¤u görüldü. Conclusion: While the primary factor for the success of intrauter- Sonuç: ‹mmün nedenli fetal hidrops olgular›nda intrauterin fetal ine fetal transfusion in cases with immune-related fetal hydrops is the transfüzyonun baflar›l› olmas›ndaki iliflkili temel faktör fetal ane- severity of fetal anemia, the success rate of fetal transfusion decreas- minin fliddeti olmakla birlikte, aneminin erken bafllad›¤› fetal hid- es in fetal hydrops cases with early-onset anemia. The first intrauter- rops olgular›nda fetal transfüzyonun baflar›s› düflmektedir. ‹lk in- ine fetal transfusion being successful is a significant prognostic factor trauterin fetal transfüzyonun baflar›l› olmas› canl› do¤uma ulafla- in order to achieve live birth. bilme aç›s›ndan en önemli prognostik faktördür. Keywords: Fetal therapy, intrauterine transfusion, hydrops fetal- Anahtar sözcükler: Fetal terapi, intrauterin transfüzyon, hidrops is, erythrocyte alloimmunization. fetalis, eritrosit alloimmünizasyonu. Correspondence: Emre Ekmekci, MD. Perinatology Clinic, fianl›urfa Training and Research Available online at: Hospital, fianl›urfa, Turkey. e-mail: [email protected] www.perinataljournal.com/20180262008 doi:10.2399/prn.18.0262008 Received: July 07, 2018; Accepted: August 10, 2018 QR (Quick Response) Code: Please cite this article as: Ekmekci E, Demirel E. Intrauterine fetal transfusion in cases with immune hydrops fetalis: when and how effective it is? Perinatal Journal 2018;26(2):97–101. ©2018 Perinatal Medicine Foundation Ekmekci E, Demirel E Introduction under risk and to initiate first transfusion when fetal hemoglobin is below two standard deviations. The primary indication for intrauterine fetal transfusion is the erythrocyte alloimmunization-induced fetal ane- Intrauterine fetal transfusion is the standard man- mia. It is also carried out due to rarer reasons such as agement method in the treatment of fetal hemolytic Parvovirus B19 infection, fetomaternal hemorrhage, disease, and it may be required to repeat many times twin-to-twin transfusion syndrome, and fetal/placental during the pregnancy. Preterm labor, early rupture of tumors.[1] With the addition of Rhesus D (RhD) screen- membrane, chorioamnionitis, emergency cesarean sec- ing and immunoprophylaxis into the routine practice tion, and fetal and neonatal deaths are among the and being used more frequently, perinatal Rhesus major complications associated with the procedure. hemolytic disease decreased prominently. Yet, it is still a Procedure-related fetal loss risk is 1–3%, and compli- [6,7] significant problem due to the reasons such as insuffi- cation risk per procedure is 9%. cient practice, unidentified fetomaternal hemorrhage and timing delays. Also, with the decrease of RhD-asso- Methods ciated alloimmunization, fetal erythrocyte alloimmu- This retrospective study was conducted at the nization associated with non-RhD antigens comes into [2] Perinatology Clinic of fianl›urfa Training and Research prominence. Hospital, and the cases with fetal hydrops developed due Hydrops fetalis is defined as the abnormal fluid accu- to erythrocyte alloimmunization between June 2017 and mulation in fetal soft tissues and serous cavities. Non- July 2018 were included in the study group. As a tertiary immune hydrops fetalis defines the group not associated center in the southeastern region of Turkey, our clinic is with erythrocyte alloimmunization, and it may develop a busy center which accepts patients referred from near- due to multiple fetal anatomic and functional reasons, by cities and carries out 35,000–40,000 deliveries annu- and genetic and metabolic disorders. Fluid accumulation ally. The approval of ethics committee was not obtained in serous cavities is defined as fetal acid, fetal pericardial since the retrospective method of the study and patient effusion and fetal pleural effusion. Skin edema is also a management did not make any change, and the [3] definitive finding which develops late in hydrops cases. approvals for the use of patient data were taken when The most important matter in the approach towards the collecting the informed consents. The approval for using cases with hydrops fetalis is to define whether there is a medical data in scientific studies was obtained from the condition that can be treated by intrauterine procedure hospital management. Fetal hydrops was defined accord- or not. The most important part of treatable cases is the ing to the ultrasonographic findings. The presence of at cases with fetal anemia-induced hydrops. Transfusing least two findings among the following findings was erythrocytes into fetus is the most successful practice defined as hydrops: Fetal acid, fetal pericardial effusion, among intrauterine procedures. As shown in many fetal pleural effusion and fetal skin edema. observational studies, intrauterine fetal transfusion The severity of the hydrops was defined according to prominently increases the survival rate in severe anemic the ultrasonographic fetal findings. When free fluid fetuses. More successful results are obtained with the accumulation was observed in only two cavities, it was transfusions performed at an early stage before anemia defined as mild hydrops; with or without subcutaneous reaches to a severe level. Therefore, transfusion can be edema, fluid accumulation in more than two cavities was planned in risky patients when hemoglobin level defined as severe hydrops. For the definition of erythro- [4] decreases below 30%. cyte alloimmunization as the etiology of hydrops, the Since the time when fetal anemia was first reported presence of increased velocity in MCA and maternal to be identifiable as non-invasive in 2000, middle cere- indirect Coombs test positivity were sought. Direct bral artery peak systolic velocity (MCA-PSV) Doppler Coombs test was performed on fetal cord blood sample measurement has been used in the follow-up of the collected before the additional first fetal transfusion, and fetuses under risk.[5] The preferred method today is to alloimmunization was confirmed with the positive test collect cord blood sample when MCA-PSV is 1.50 result. Fetal karyotypes were examined on cord blood MOM and higher in the follow-up of the patient group sample of all fetuses included in the study, and the aneu- 98 Perinatal Journal Intrauterine fetal transfusion in cases with immune hydrops fetalis ploidies were ruled out. All transfusions were carried out cy was terminated due to spontaneous preterm labor at 31 as intravascular
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