7 may 11 - helen savoia

7/29/2019 7 May 11 - Helen Savoia

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Transfusion in inner space:Transfusion in inner space:Blood products for intrauterineBlood products for intrauterine

transfusiontransfusion

Dr HelenDr Helen SavoiaSavoia


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OverviewOverview

The fetus as transfusion recipientThe fetus as transfusion recipientTechnical aspects of intrauterineTechnical aspects of intrauterinetransfusiontransfusionIndications for intrauterine transfusionIndications for intrauterine transfusionRed cells for fetal transfusionRed cells for fetal transfusion

Platelets for fetal transfusionPlatelets for fetal transfusion


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The fetus as a transfusion recipientThe fetus as a transfusion recipient

No name, no gender, no DOBNo name, no gender, no DOBNo ID bandNo ID band

NoNo prepre --transfusion sampletransfusion sample Designated nameDesignated name -- Maternal Surname, FirstMaternal Surname, FirstName (Name ( FetusFetus ))

Estimated/projected DOBEstimated/projected DOBSeparate identity to mother for transfusionSeparate identity to mother for transfusionSmall sizeSmall size


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The fetus as transfusion recipientThe fetus as transfusion recipient

Complex immunological effects of transfusion,Complex immunological effects of transfusion,poorly definedpoorly defined

Best seen asBest seen as

immunocompromisedimmunocompromised

recipientrecipient

At risk of viral transmission (CMV) At risk of viral transmission (CMV) At risk of At risk of TaGVHDTaGVHD (irradiation)(irradiation)


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Technical aspects of intrauterineTechnical aspects of intrauterinetransfusiontransfusion

IPT feasible from 15IPT feasible from 15 --16 weeks gestation16 weeks gestationIVT feasible from 18IVT feasible from 18 --20 weeks gestation20 weeks gestation

IVT allows FBSIVT allows FBSImmediate correction of fetal anaemiaImmediate correction of fetal anaemiaIVT can reverse fetal hydropsIVT can reverse fetal hydrops

Ultrasound guidedUltrasound guided Fetal paralysis (Fetal paralysis ( pancuroniumpancuronium ))


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20 weeks gestation, EW 250g, EBV 45mls


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The firstThe first IUTsIUTsIntraperitonealIntraperitoneal transfusion 1960stransfusion 1960s

Amniocentesis with injection of contrast Amniocentesis with injection of contrast2424 --48 hours later, fetal gut outlined by contrast48 hours later, fetal gut outlined by contrastXX--RayRay localisationlocalisation of needle into fetal peritoneal cavityof needle into fetal peritoneal cavityRed cells absorbed via thoracic duct into fetalRed cells absorbed via thoracic duct into fetalcirculations over 5circulations over 5 --6 days6 days

Intravascular transfusion 1980sIntravascular transfusion 1980sFetoscopyFetoscopy and intravascular transfusion into umbilicaland intravascular transfusion into umbilicalvesselvessel


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Intrauterine transfusion in 2008Intrauterine transfusion in 2008

Fetal red cell transfusionFetal red cell transfusionHaemolyticHaemolytic disease due to red cell alloimmunisationdisease due to red cell alloimmunisationFetal anaemia due to congenital infection (Parvovirus)Fetal anaemia due to congenital infection (Parvovirus)

FetalFetal anaemia in twin to twin transfusion (donor twin)anaemia in twin to twin transfusion (donor twin)Fetal anaemia due to massive FMHFetal anaemia due to massive FMHFetal haemorrhage (Fetal haemorrhage ( tumourstumours etc)etc)

Fetal platelet transfusionFetal platelet transfusionThrombocytopenia due to platelet antigenThrombocytopenia due to platelet antigenalloimmunisationalloimmunisation


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Complications of IUTComplications of IUT

Cord haematoma with arterial vasospasm andCord haematoma with arterial vasospasm andfetalfetal bradycardiabradycardiaFetalFetal exsanguinationexsanguination

Premature rupture of membranesPremature rupture of membranesInfectionInfection

Augmentation of maternal Augmentation of maternal alloimmunisationalloimmunisation andandnew antibodies due to FMHnew antibodies due to FMHLong term consequences of transfusionLong term consequences of transfusion


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Procedural complicationsProcedural complicationsCohort study 254 fetuses/740Cohort study 254 fetuses/740 IUTsIUTs , 1988, 1988 --20012001(single centre)(single centre)Red cell transfusion for alloimmunisationRed cell transfusion for alloimmunisation225/254 (89%) survival225/254 (89%) survival

19 fetal deaths (7PR), 10 neonatal deaths (5PR)19 fetal deaths (7PR), 10 neonatal deaths (5PR)2 intrauterine infection (2 intrauterine infection ( E.coliE.coli) (both PR)) (both PR)2 PPROM (1 PR)2 PPROM (1 PR)18 emergency deliveries (15 PR)18 emergency deliveries (15 PR)

Total complications 3.1%, 1.6% loss rate perTotal complications 3.1%, 1.6% loss rate per

procedureprocedureVan Kamp et. Al. Am J Obstet Gynecol 2005


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Procedural complicationsProcedural complications

Platelet transfusion in AITPlatelet transfusion in AITIncreased risks of bleeding andIncreased risks of bleeding andbradycardiabradycardiaRecent studies suggest 6%Recent studies suggest 6% fetalfetal loss rateloss rate


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Red Cells for Fetal TransfusionRed Cells for Fetal TransfusionGroup O Rh D negative,Group O Rh D negative, KellKell negative (usually!)negative (usually!)

IATIAT crossmatchcrossmatch compatible with maternalcompatible with maternalplasmaplasmaFree from clinically significant antibodiesFree from clinically significant antibodies< 5 days old< 5 days oldCMV negative, leukocyte depletedCMV negative, leukocyte depleted

Irradiated and used within 24Irradiated and used within 24hours of irradiationhours of irradiation


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BCSH Guidelines 2004BCSH Guidelines 2004In CPD not SAGIn CPD not SAG --MMFree from high titre antiFree from high titre anti -- A and anti A and anti --BBHbSHbS negativenegativeHaematocritHaematocrit 0.70.7 --0.850.85Not transfused straight from 4Not transfused straight from 4 C storageC storage

Transfusion guidelines for neonates and older children BCSH 2004Transfusion guidelines for neonates and older children BCSH 2004


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Local practiceLocal practiceRed cells in additive solutionRed cells in additive solutionHctHct approximately 0.6approximately 0.6Matched for extended maternal antigen typingMatched for extended maternal antigen typing

Anti Anti -- A and Anti A and Anti --B not testedB not testedHbHb S not testedS not testedWarmed to 37Warmed to 37 C prior to transfusion andC prior to transfusion andtransfusion within 4 hourstransfusion within 4 hoursSplit packs to reduce donor exposure withSplit packs to reduce donor exposure withwashing of 2washing of 2 ndnd segment prior to transfusionsegment prior to transfusion


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IssuesIssuesRed cell IUT best seen as a rapid, large volumeRed cell IUT best seen as a rapid, large volumetransfusiontransfusionK+ an issueK+ an issueHaemolysin testing?Haemolysin testing?

Does not seem to be an issue with plasmaDoes not seem to be an issue with plasma --poor RBCpoor RBCtransfusion in the NNUtransfusion in the NNU

Additive solution? Additive solution?No adverse clinical/biochemical effects for neonatalNo adverse clinical/biochemical effects for neonataltoptop --up (Strauss 1996, 2000)up (Strauss 1996, 2000)Effective for cardiac byEffective for cardiac by --pass surgery in infants (pass surgery in infants ( MouMou,,2004)2004)


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Platelets forPlatelets for FetalFetal TransfusionTransfusionGroup OGroup O RhDRhD negative, negative for highnegative, negative for high --titretitreantianti -- A, anti A, anti --B or group specific compatible withB or group specific compatible withmaternal antibodymaternal antibodyHPA compatible with maternal antibodyHPA compatible with maternal antibodyPreferably collected byPreferably collected by apheresisapheresisIrradiatedIrradiatedConcentrated to a platelet count >2000 x 10Concentrated to a platelet count >2000 x 10 9 /L /LTransfused at a rate of 1Transfused at a rate of 1 --5 ml/min5 ml/min

Transfusion guidelines for neonates and older children BCSH 2004Transfusion guidelines for neonates and older children BCSH 2004


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Local PracticeLocal Practice

HPA compatible with maternal antibodyHPA compatible with maternal antibodyStandardStandard apheresisapheresis componentscomponents

CMV negative,CMV negative, leucocyteleucocyte depleteddepletedIrradiatedIrradiatedNot concentratedNot concentrated


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Products forProducts for FetalFetal TransfusionTransfusion

Red cellsRed cellsLarge volume, rapid transfusionLarge volume, rapid transfusion

PlateletsPlateletsBradycardiaBradycardia ? Mediated, ? PAS? Mediated, ? PASHyperconcentrationHyperconcentration ??


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Long term effects of Long term effects of fetalfetaltransfusiontransfusion

Not well studiedNot well studied? Immunological effects? Immunological effects

Expected 80+ years post transfusionExpected 80+ years post transfusionsurvivalsurvival

7 may 11 - helen savoia

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