Is intrauterine exchange transfusion a safe procedure for management of fetal anaemia?

OBJECTIVE: To study modalities and complications of intrauterine exchange transfusion (IUET) for the management of severe fetal anaemia. STUDY DESIGN: Retrospective study of all IUET procedures performed between January 1999 and January 2012 at a regional centre. Characteristics of each procedure were studied to identify risk factors for complications. Survival rates according to the different aetiologies of anaemia were evaluated. RESULTS: In total, 225 IUET procedures were performed in 96 fetuses. Major indications were feto-maternal erythrocyte alloimmunization (n=80/96, 83.3%) and parvovirus B19 infection (n=13/96, 13.5%). Twenty-six percent of the fetuses (25/96) had hydrops fetalis before the first IUET. Intrauterine fetal death occurred after 2.7% (6/225) of procedures, premature rupture of the membranes occurred after 0.9% (2/225) of procedures, and emergency caesarean section was required after 3.6% (8/225) of procedures. Fetal bradycardia [odds ratio (OR) 37, 95% confidence interval (CI) 8.3-170; p<0.01] and gestational age up to 32 weeks (OR 3.67; 95% CI, 1.07-12.58; p=0.038] were significantly associated with complications after IUET. Complications occurred in 17.7% of pregnancies (17/96) and 7.5% of IUET procedures (17/225). The overall survival rate in the study cohort was 87.5% (84/96): 90% (72/80) in the alloimmunization group and 76.9% (10/13) in the parvovirus-infected group (NS). CONCLUSION: IUET has a higher complication rate than simple intrauterine transfusion, and should be performed by well-trained specialists.

Red cell storage: does duration matter?

The report by Solomon et al in this issue of Blood is a welcome addition to understanding the clinical impact of prolonged red cell storage.

Mortality increases after massive exchange transfusion with older stored blood in canines with experimental pneumonia.

Two-year-old purpose-bred beagles (n = 24) infected with Staphylococcus aureus pneumonia were randomized in a blinded fashion for exchange transfusion with either 7- or 42-day-old canine universal donor blood (80 mL/kg in 4 divided doses). Older blood increased mortality (P = .0005), the arterial alveolar oxygen gradient (24-48 hours after infection; P ≤ .01), systemic and pulmonary pressures during transfusion (4-16 hours) and pulmonary pressures for ~ 10 hours afterward (all P ≤ .02). Further, older blood caused more severe lung damage, evidenced by increased necrosis, hemorrhage, and thrombosis (P = .03) noted at the infection site postmortem. Plasma cell­free hemoglobin and nitric oxide (NO) consumption capability were elevated and haptoglobin levels were decreased with older blood during and for 32 hours after transfusion (all P ≤ .03). The low haptoglobin (r = 0.61; P = .003) and high NO consumption levels at 24 hours (r = −0.76; P < .0001) were associated with poor survival. Plasma nontransferrin-bound and labile iron were significantly elevated only during transfusion (both P = .03) and not associated with survival (P = NS). These data from canines indicate that older blood after transfusion has a propensity to hemolyze in vivo, releases vasoconstrictive cell-free hemoglobin over days, worsens pulmonary hypertension, gas exchange, and ischemic vascular damage in the infected lung, and thereby increases the risk of death from transfusion.

Exchange transfusion and its morbidity in ten-year period at King Chulalongkorn Hospital.

The objectives of this study were to consider the rate of exchange transfusion (ET) in the newborns at King Chulalongkorn Hospital, Bangkok, from 1994 to 2003, and to evaluate its morbidity and mortality. One hundred and sixty five neonates underwent 183 episodes of ET: In-housed fullterm had ET performed at a younger age than the readmitted/referred infants (72.2 +/- 30.9 vs 150.2 +/- 90.7 hours, p < 0.001), and the in-housed preterm neonates (85.4 +/- 36.7 hours, p < 0. 05). They also had lower mean TsB than those of the readmitted/referred infants when ET was initiated (21.8 +/- 2.1 vs.26. 0 +/- 5.1 mg/dL, p < 0.001). Preterm needed phototherapy after ET longer than fullterm neonates (5.3 +/- 3.2 vs 3.3 +/- 1.7 days, p < 0.001). ABO incompatibility (21.3%), G6PD deficiency (13.4%), both conditions (6.7%), and others (22.2%) were identified as causes of hyperbilirubinemia. Unknown causes accounted for 36.4%. There was no mortality in the present study. Overall rate of morbidity was 15.3% of which 67 percent was infection associated conditions. Preterm suffered additional complications of anemia, apnea and cardiac arrest. Sick infants (31.3%) were more likely to develop complications than healthy ones (6.8%). In the healthy group, preterm were more likely to develop morbidity than fullterm neonates (p = 0.0016), while no significant difference was identified between them in the sick group (p = 0.8). ET causes high morbidity, therefore, it should be initiated only when the benefit of preventing kernicterus outweighs the complications associated with the procedure.

Adverse events associated with exchange transfusion in healthy and ill newborns.

OBJECTIVE: To determine the incidence of adverse events attributable to exchange transfusion during the past 15 years and compare the incidence of severe complications between healthy and ill infants. DESIGN: Medical records for the past 15 years from two teaching hospitals with neonatal intensive care units were reviewed. Those newborns who underwent exchange transfusions were classified as healthy or ill. Adverse events were analyzed to determine whether they were attributable to the procedure. RESULTS: Of the 106 patients who underwent exchange transfusion, 81 were healthy and had no medical problems other than jaundice. The remaining 25 patients were classified as ill and had medical problems ranging from mild to severe. At least 2 (2%) of the 106 patients died of complications probably attributable to exchange transfusion. None of the 81 healthy infants died, but 1 had severe necrotizing enterocolitis requiring surgery. Of the 25 ill infants, at least 3 (12%) experienced severe complications (including 2 deaths) probably attributable to exchange transfusion. Serious complications from the most common adverse events, hypocalcemia and thrombocytopenia, were limited to the group of infants already ill with other medical problems. CONCLUSIONS: Because of the significantly greater rate of severe complications in ill infants, exchange transfusion should be delayed until the risk of bilirubin encephalopathy is as high as the risks of severe complications from the procedure itself (12%). These results do not support recommendations to use lower exchange levels in ill infants compared with healthy infants.

Exchange transfusion with fresh heparinized blood is a safe procedure. Experiences from 1 069 newborns.

1 069 newborns were subjected to exchange transfusion with fresh heparinized blood in the years 1968, 1971, 1974, 1977 and 1981. There were 258 infants with Rh disease, 328 with hyperbilirubinemia with ABO incompatibility, 436 with hyperbilirubinemia without ABO incompatibility and 47 infants without hyperbilirubinemia or evidence of hemolytic disease. The total annual number of infants decreased gradually from 279 in 1968 to 130 in 1981. A total of 48 infants of the 1 069 newborns died during neonatal period but the death was possibly related to exchange transfusion in four of them. There were serious complications in 14 infants during and in only five infants after the procedure. Morbidity related to exchange transfusion was the highest among newborns with serious basic disease. Using the presented bilirubin nomograms and fresh heparinized blood we have not found that the hazards of exchange transfusion would have overgone the risks of hyperbilirubinemia.

Neonatal death in babies with rhesus isoimmunization.

In the 27 years, 1951--1977, 4315 babies weighing over 1 kg were born alive in Newcastle suffering from haemolytic disease of the newborn due to Rhesus isoimmunization; 197 (4.5 per cent) died within four weeks of delivery. Many babies with severe anaemia (cord Hb less than or equal to 8 g/dl) died of cerebral and/or pulmonary haemorrhage as a result of coagulation failure; others with hydrops had a chance of recovery with intensive care as long as there was no associated pulmonary hypoplasia. Hyaline membrane disease was no more common in babies with haemolytic disease than in other preterm babies of comparable birthweight, but incorrect assessment of gestational age prior to the induction of labour increased the risk of death from hyaline membrane disease. The introduction of closed chest cardiac massage virtually eliminated the risk of sudden unexpected death during exchange transfusion but there was still a 1.5 per cent chance of sudden circulatory collapse during exchange transfusion. Affected babies of less than 36 weeks gestation with respiratory problems face a substantial risk of kernicterus when the indirect serum bilirubin level exceeds 270 mumol/l (15 mg/100 ml). The establishment of a single referral centre for Rhesus isoimmunization reduced neonatal mortality in the area to half the national average in the early 1950's and this superiority was maintained throughout the next decade.

A simple method for blood exchange in mice.

Ease of transfusion and high long-term survival rate were obtained when whole blood was administered via the corpus cavernosum of the penis and removed from the orbital sinus of male C57Bl mice. When 2 volumes of blood are replaced approximately 14% of pre-transfusion red cells remain after hematocrit corrections are made. The post-transfusion hematocrit levels dropped 19%, probably the result of leakage, which is difficult to avoid.

The mortality of exchange transfusions.

A prospective study of the effect and mortality of exchange transfusion was carried out in the Kandang Kerbau Hospital, Singapore. Altogether 140 exchange transfusions were performed on 122 infants. The exchanges were done for hyperbilirubinaemia due to "idiopathic" jaundice, ABO haemolytic disease, and glucose-6-phosphate dehydrogenase deficiency. Eight infants deteriorated during the exchange, in three of whom the procedure had to be terminated prematurely. Two deaths occurred two days after the exchange--the procedure being partly responsible in one case; necrotizing enterocolitis was present in addition to the kernicterus. Exchange transfusion is not without hazards, and should be performed carefully with close monitoring of the clinical status of the infant during and immediately after the procedure.