Intrauterine fetal transfusion of red cells
- Kenneth J Moise Jr, MD
Kenneth J Moise Jr, MD
- Professor of Obstetrics, Gynecology and Reproductive Sciences
- Professor of Pediatric Surgery
- University of Texas School of Medicine at Houston
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Steven Kleinman, MD
Steven Kleinman, MD
- Section Editor — Transfusion Medicine
- Clinical Professor of Pathology
- University of British Columbia, Vancouver
The infusion of red blood cells into the fetus is one of the most successful in utero therapeutic procedures. Although never studied in randomized trials, observational studies have clearly demonstrated that intrauterine transfusion (IUT) of the severely anemic fetus improves survival. Universal use of prophylactic Rh(D) immune globulin has reduced the need for IUT dramatically; however, the procedure continues to be an essential modality for treatment of severe fetal anemia from a variety of causes, such as non-Rh(D) alloimmunization, parvovirus B19 infection, chronic fetomaternal hemorrhage, and homozygous alpha-thalassemia.
We consider pregnancies with severe fetal anemia at 18 to 35 weeks of gestation optimal candidates for IUT. We obtain fetal blood via percutaneous umbilical blood sampling for hematocrit/hemoglobin determination when the fetal middle cerebral artery peak systolic velocity is greater than 1.50 multiples of the median and perform the first IUT if fetal hemoglobin is two standard deviations below the mean value for gestational age (table 1). Intervention at this moderately reduced hemoglobin level results in a better fetal outcome than waiting until development of severe anemia (hemoglobin level more than 7 g/dL below the normal mean for gestational age ) or hydrops (actual hemoglobin level <5 g/dL) . A hematocrit less than 30 percent can also be used as the threshold for fetal transfusion .
The procedure is generally limited to pregnancies between 18 and 35 weeks of gestation because before 18 weeks the small size of the relevant anatomic structures causes technical challenges and after 35 weeks IUT is considered riskier than delivery followed by postnatal transfusion therapy .
For the rare patient with very early (≤18 weeks) severe alloimmunization, plasma exchange and administration of intravenous immunoglobulin G may maintain the fetal hematocrit above life-threatening levels long enough to achieve a gestational age when IUT is technically feasible. A variety of therapeutic regimens have been described in case reports and small cases series .
Anonymous donor units — Red blood cells (RBCs) used for IUT should undergo the same testing that occurs for any red cell donor unit. The units are cross-matched with maternal blood to reduce the risk of sensitization to new red cell antigens. (See "Blood donor screening: Laboratory testing".)
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- PATIENT SELECTION
- BLOOD PREPARATION
- Anonymous donor units
- Maternal donor units
- - Maternal siblings as donors
- Maternal preparation
- Choosing a fetal access site
- - Umbilical vein
- Umbilical cord at placental insertion site
- Intrahepatic umbilical vein
- - Peritoneal cavity
- - Combined approach
- Calculating transfusion volume
- - Intravascular transfusion
- - Intraperitoneal transfusion
- Scheduling the second and subsequent transfusions
- When to stop IUTs
- Timing delivery
- Special populations
- - Multiple gestations
- Intravascular transfusion
- Intraperitoneal transfusion
- Neonatal transfusion
- Neurologic outcome
- - Hemolytic disease of the fetus/newborn
- - Parvovirus
- SUMMARY AND RECOMMENDATIONS