Outcome predictors for maternal red blood cell alloimmunisation with anti-K and anti-D managed with intrauterine blood transfusion.

Red blood cell (RBC) alloimmunisation with anti-D and anti-K comprise the majority of cases of fetal haemolytic disease requiring intrauterine red cell transfusion (IUT). Few studies have investigated which haematological parameters can predict adverse fetal or neonatal outcomes. The aim of the present study was to identify predictors of adverse outcome, including preterm birth, intrauterine fetal demise (IUFD), neonatal death (NND) and/or neonatal transfusion. We reviewed the records of all pregnancies alloimmunised with anti-K and anti-D, requiring IUT over 27 years at a quaternary fetal centre. We reviewed data for 128 pregnancies in 116 women undergoing 425 IUTs. The median gestational age (GA) at first IUT was significantly earlier for anti-K than for anti-D (24·3 vs. 28·7 weeks, P = 0·004). Women with anti-K required more IUTs than women with anti-D (3·84 vs. 3·12 mean IUTs, P = 0·036) and the fetal haemoglobin (Hb) at first IUT was significantly lower (51.0 vs. 70.5 g/l, P = 0·001). The mean estimated daily decrease in Hb did not differ between the two groups. A greater number of IUTs and a slower daily decrease in Hb (g/l/day) between first and second IUTs were predictive of a longer period in utero. Earlier GA at first IUT and a shorter interval from the first IUT until delivery predicted IUFD/NND. Earlier GA and lower Hb at first IUT significantly predicted need for phototherapy and/or blood product use in the neonate. In the anti-K group, a greater number of IUTs was required in women with a higher titre. Furthermore, the higher the titre, the earlier the GA at which an IUT was required in both groups. The rate of fall in fetal Hb between IUTs decreased, as the number of transfusions increased. Our present study identified pregnancies at considerable risk of an unfavourable outcome with anti-D and anti-K RBC alloimmunisation. Identifying such patients can guide pregnancy management, facilitates patient counselling, and can optimise resource use. Prospective studies can also incorporate these characteristics, in addition to laboratory markers, to further identify and improve the outcomes of these pregnancies.

Effect of intravenous immunoglobulins to postpone the gestational age of first intrauterine transfusion in very severe red blood cell alloimmunization: A case-control study.

BACKGROUND: Early intrauterine transfusion (IUT) is associated with a higher risk of fetal loss. Our objective was to evaluate the efficiciency of intravenous immunoglobulins (IVIG) to postpone the gestational age at first IUT beyond 20 weeks of gestation (WG) compared to the previous pregnancy in case of very severe red blood cell (RBC) alloimmunization. STUDY DESIGN AND METHODS: Very severe RBC alloimmunization was defined by a high titer of antibodies and a previous pregnancy complicated by a first IUT before 24 WG and/or perinatal death directly related to alloimmunization. We performed a single-center case-control study. Cases and controls were patients respectively treated with weekly IVIG infusions started before 13 WG, and without. RESULTS: Twenty cases and 21 controls were included. Gestational age (GA) at first IUT was postponed after 20 WG in 18/20 (90 %) of patients treated with IVIG and in 15/21 (71 %) in the control group (p = 0.24). Compared to the previous pregnancy, the GA at first IUT was postponed by a median of 22 [+11; +49] days in the IVIG group and occurred in average 2 days earlier [-17 ; +12] in the non-treated group (p = 0.02). There was no difference between number of IUT and need for exchange-transfusion. IVIG treatment was associated with a significant decrease of antibodies' quantitation. CONCLUSION: In our series, IVIG tends to differ first IUT beyond 20 WG and have a significant effect in postponing the gestational age of the first IUT in patients with very severe RBC alloimmunization.

Hyperferritinaemia following intrauterine transfusions for Rh isoimmunisation.

Intrauterine transfusion is one of the mainstays of treatment in isoimmunised pregnancies guided by the changes in middle cerebral artery Doppler of the fetus. The common postnatal complications associated with Rh isoimmunisation are high unconjugated bilirubin requiring blood exchange transfusions, cholestasis due to bile inspissation, thrombocytopenia and anaemia. Hyperferritinaemia is an uncommon adverse effect observed in Rh isoimmunised pregnancies. In this case report, we describe the clinical course of a Rh isoimmunised neonate with hyperferritinaemia and transfusion acquired cytomegalovirus disease which resolved. Iron chelation therapy was not necessary.

Fetal middle cerebral artery Doppler to time intrauterine transfusion in red-cell alloimmunization: a randomized trial.

OBJECTIVES: To evaluate whether Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) for timing subsequent intrauterine transfusions (IUTs) in fetuses that had undergone one IUT for anemia secondary to red-cell alloimmunization is non-inferior to timing based on expected decrease in fetal hematocrit (Hct) or fetal hemoglobin level, without compromising infant hemoglobin at birth. METHODS: This was an international, pragmatic multicenter randomized controlled trial. Women with a pregnancy complicated by fetal anemia secondary to red-cell alloimmunization (due to any antibody alone or in combination), as indicated by the need to undergo a single IUT, were eligible for inclusion. Women were randomized to the determination of timing of further transfusion(s) by Doppler measurement of MCA-PSV (MCA-PSV Group), with a serial upward trend of values >1.5 multiples of the median considered indicative of the need for another IUT, or timing of transfusion by a decrease in fetal Hct (fetal Hct Group), with subsequent IUTs timed according to an estimated fall in fetal Hct of 1% per day or fetal hemoglobin of 0.3 g/dL per day, to maintain fetal hemoglobin level between 7 and 10 g/dL. The primary outcome was infant hemoglobin level measured at birth. RESULTS: A total of 71 women were randomized, 36 to the MCA-PSV Group and 35 to the fetal Hct Group. Median gestational age at randomization was 30.3 weeks, the majority of women were Caucasian and non-smokers, 9.9% of women had Kell alloimmunization, and 14% of fetuses were hydropic at their first IUT. No statistically significant differences between the two treatment groups were observed with regard to mean hemoglobin levels at birth (MCA-PSV Group, 10.36 ± 3.82 g/dL vs fetal Hct Group, 12.03 ± 3.14 g/dL; adjusted mean difference -1.56 g/dL (95% CI, -3.24 to 0.13 g/dL); P = 0.070), or the number of IUTs performed after randomization (MCA-PSV Group, 1.75 ± 1.79 vs fetal Hct Group 1.80 ± 1.32; adjusted relative risk 0.88 (95% CI, 0.61-1.26); P = 0.474). There was no statistically significant difference between the two groups with respect to the risk of adverse infant outcomes related to alloimmunization or procedure-related complications. CONCLUSION: Both Doppler measurement of MCA-PSV and estimation of the decrease in fetal Hct or hemoglobin can be used to determine the timing of second and subsequent IUTs in fetuses with red-cell alloimmunization. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

A Doppler velocimetry evaluation of intestinal blood flow characteristics in neonates receiving intravenous immunoglobulin therapy: a prospective observational study.

OBJECTIVES: To evaluate intestinal blood flow changes after intravenous immunoglobulin (IVIg) infusion among neonates with Rh isoimmunization and alloimmune thrombocytopenia. METHODS: This prospective observational study was conducted in level III NICU from July 2011 through August 2012. Thirty three consecutive instances (30 neonates) of IVIg treatment (1 g/kg) were studied. Celiac (CA) and superior mesenteric artery (SMA) doppler evaluations were performed immediately prior (baseline), immediately after and 12 to18 h following IVIg infusion. Peak systolic velocity, end diastolic velocity, time-averaged mean velocity, pulsatility index, resistive index and systolic/diastolic ratio were measured. The doppler indices measured immediately after and 12 to 18 h after IVIg infusion were compared with the baseline values. RESULTS: The mean gestation and birth weight of the cohort were 36 ± 2 wk and 2597 ± 563 g respectively. Doppler flow variables measured immediately after and 12 to 18 h after IVIg were comparable to baseline values, in both the arteries. However, systolic/diastolic ratio in SMA immediately post-IVIg was lower than baseline, [median (IQR): 5 (3, 9) vs. 7 (4, 14), respectively; p=0.02]. None of the study infants developed feed intolerance or necrotizing enterocolitis (NEC). CONCLUSIONS: There was no significant change in the celiac and SMA blood flows following IVIg therapy in neonates with Rh isoimmunization and alloimmune thrombocytopenia.

Fluid shift from intravascular compartment during fetal red blood cell transfusion.

OBJECTIVES: Intrauterine transfusion imposes a considerable burden on the fetal circulation by increasing volume and pressure, and a fluid shift from the fetal circulation occurs even during the procedure. The aim of this study was to quantify the intraprocedural fluid shift and to investigate the effect of procedural and fetal characteristics on this fluid shift. METHODS: In 95 alloimmunized pregnancies, we calculated fluid shift at the first intrauterine transfusion by determining initial and final blood volumes. We evaluated the association of the fluid shift with the speed and volume of the transfusion, the severity of anemia and the presence of hydrops. RESULTS: Of the included fetuses, 11 were mildly hydropic and four were severely hydropic. A mean fluid shift of 36% of the transfused volume was found. Fluid shift related positively to transfused volume (P < 0.001). The percentage fluid shift of transfused volume was inversely related to the speed of transfusion (mL/kg/min) (P < 0.041) and was not related to the severity of anemia (P = 0.55) or to hydrops (P = 0.66). It was found that younger fetuses had been unintentionally subject to high volumes and speeds of transfusion relative to their size. CONCLUSIONS: Around one-third of the transfused volume is lost from the intravascular compartment during the procedure of intrauterine transfusion. There is a large variation between fetuses, partly explained by the volume and speed of the transfusion. Neither severity of anemia nor hydrops plays a clear-cut role, and thus other factors may explain the variation in fluid shift. The probability that hematocrit will still increase after transfusion, as a result of a continuing fluid shift, should be considered in transfusion policy. Advice is given on gestational age-adjusted speed of transfusion.

Aportación del Doppler de la arteria cerebral media y del genotipado RHD fetal en el manejo de la isoinmunización / Contribution of middle cerebral artery Doppler and fetal RHD genotype in the management of alloimmunization

Objetivo. Evaluar la aplicación clínica de los métodos no invasivos en el manejo de la isoinmunización, durante el período de 2006-2010. Sujetos y métodos. Se estudiaron 70 gestaciones con riesgo de anemia fetal en las que se realizó el estudio Doppler de la velocidad sistólica de la arteria cerebral media (VS-ACM). Se comparó la eficacia de la VS-ACM después de una, 2 o 3 transfusiones intrauterinas. El genotipado fetal RHD en sangre materna se realizó en las gestaciones seguidas en nuestro centro. Resultados. Se practicó cordocentesis en 22 de gestaciones y en 20 se practicó transfusión intrauterina. Las tasas de detección y de falsos positivos de la VS-ACM en la predicción de anemia fetal moderada o severa fueron del 89 y el 15% en gestaciones sin transfusión previa, del 100 y el 41% en los casos con una transfusión previa y del 40 y el 24% cuando se practicaron más de una transfusión. Conclusiones. La VS-ACM mantiene una sensibilidad alta en una transfusión previa aunque su especificidad disminuye (AU)

Objective. To assess the clinical application of non-invasive methods in the management of alloimmunization from 2006 to 2010. Subjects and methods. Seventy pregnancies with risk of fetal anemia were studied by fetal middle cerebral artery peak systolic velocity (MCA-PSV). The efficacy of MCA-PSV was compared between the first, second and third transfusions. Prenatal testing of fetal RHD blood group using maternal blood was performed in pregnancies followed-up in our center. Results. Fetal blood sampling was performed in 22 pregnancies; of these, fetal transfusion was carried out in 20. Detection rates and the false-positive rate of MCA-PSV in the prediction of severe or moderate fetal anemia were 89% and 15% in pregnancies with no previous transfusions, 100% and 41% in patients with one previous transfusion, and 40% and 24% when more than one transfusion was performed. Conclusion. MCA-PSV has high sensitivity when there is one previous fetal transfusion but its specificity is lower (AU)

Childhood cardiac function after severe maternal red cell isoimmunization.

OBJECTIVE: To estimate the long-term effects of anemia on the fetal heart by echocardiography of children who received intrauterine blood transfusions for red cell isoimmunization. METHODS: Surviving children who received intrauterine transfusions during the period from 1992 to 2003 were identified. Children matched for age and sex were chosen for the control group to create a 1:1 case-control study design. A clinical interview, physical examination, and echocardiography assessment (corrected for body surface area) were performed. RESULTS: Twenty-five children were recruited for the case group and matched to 25 healthy children for the control group. Children in the case group had received a median of four intrauterine transfusion procedures (range 1-7), with a median gestation at initial intrauterine transfusion of 28 weeks (range 22-34 weeks). Hydrops was present in 32%. Median initial hemoglobin was 76 g/L (range 25-133 g/L). Median gestation at delivery was 36 weeks (range 29-38 weeks). The median age of children in the case group was 10.1 years (range 3.6-15.8 years) and of those in the control group was 10.5 years (range 3.8-16.4 years; P=.122). There was no difference in body surface area, baseline heart rate, systolic blood pressure, or diastolic blood pressure between children in the case group and those in the control group. Echocardiography demonstrated three main differences: children in the case group had 9% less left atrial area (95% confidence interval [CI] 2-16% less; P=.02), 10% less ventricular mass (95% CI 1-19% less; P=.039), and an average 11 ms less mitral valve atrial duration (95% CI 3-19 ms less; P=.009) than did those in the control group. These results did not alter when adjusted for isoimmunization severity. CONCLUSION: Fetal anemia secondary to red cell isoimmunization is associated with a reduction in left ventricular mass and left atrial area in childhood, although resting ventricular function is maintained. We speculate this may be secondary to the prenatal effects of anemia on cardiomyocyte proliferation and differentiation. LEVEL OF EVIDENCE: III.

Isolated early onset anemia after rh isoimmunization: a unique presentation in 3 neonates.

SUMMARY: Rh isoimmunization manifesting as isolated early onset neonatal anemia has not been reported. We describe the presentation of 3 infants who manifested with isolated early severe anemia. All the infants presented early (3 to 7 d of age) with severe pallor. None had clinically significant jaundice. Evidence for hemolysis was present in all and their direct antiglobulin test was positive. To reduce the hemolysis, immunoglobulin was administered after which their hemoglobin improved. This report highlights the possibility of early onset anemia without significant jaundice as the sole manifestation of Rh isoimmunization and the possible beneficial role of immunoglobulin in them.

The role of calprotectin in obstetrics and gynecology.

The purpose of this article is to create the first complete review concerning the role of calprotectin, a calcium- and zinc-binding protein of the S100/calgranulins family, in obstetrics and gynecology. A Medline search was conducted between 6 and 8 June 2009 using the term calprotectin and its synonyms combined with the following ones: calprotectin, obstetrics and gynecology, breast cancer, ovarian cancer, endometrial cancer, cervical cancer, menstrual cycle, pregnancy, fetal implantation, labor, intra-amniotic inflammation, preeclampsia, HELLP syndrome, Rh(-) incompatibility. We found 46 studies which referred to obstetrics and gynecology. We excluded 11 studies which referred to obstetrics and gynecology but did not include enough information about calprotectin, and another two which referred to calprotectin but were not related to subjects of obstetrics and gynecology. Thus, we ended up with 33 studies which contained sufficient information to extract data for this review. All the articles were written in English. It was found that calprotectin is associated with many physiologic and pathologic processes in obstetrics and gynecology, such as: breast cancer, ovarian cancer, endometrial cancer, cervical cancer, cervical and vaginal physiology, menstrual cycle, pregnancy and labor. The role of calprotectin in these conditions is significant. In conclusion, the role of calprotectin seems to be important in several issues of obstetrics and gynecology. For example, calprotectin could be used as a diagnostic, prognostic or metastatic marker in several types of cancer, as a marker of inflammation and as a pharmaceutical target in many conditions. Further studies must be conducted to elucidate this role.

Papel de la medición de la velocidad sistólica máxima en arteria cerebral media en la isoinmunización rhesus / Fetal middle cerebral artery peak systolic velocity in rh isoimmunization

Objetivo: Evaluación del papel de la velocidad sistólica máxima en arteria cerebral media (VSM-ACM) en casos de isoinmunización Rh. Métodos: 67 casos de isoinmunización Rh, en el Hospital La Paz desde febrero del 2006 hasta agosto del 2009, con título de anticuerpos > 1:32, afectación en embarazo previo y/o casos de isoinmunización anti- Kell, en los que se ha realizado medición de la VSM-ACM. Resultados: La capacidad de detección de anemia moderada-severa en base a la medición de VSM-ACM presenta: sensibilidad 80 por ciento (IC95 por ciento: 59,8-100), especificidad y valor predictivo positivo 100 por ciento, y valor predictivo negativo 85,7 por ciento (IC95 por ciento: 70,7-100). El coeficiente de correlación de Pearson entre la hemoglobina estimada y la real es de 0,71. Conclusión: La medición de VSM-ACM predice casos de anemia moderada y severa que son los clínicamente cruciales por la necesidad de actuación obstétrica activa en forma de transfusión intrauterina o finalización del embarazo.

Objective: To evaluate the fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the management of Rh isoimmunized pregnancies. Methods: 67 pregnancies complicated by Rh isoimmunization, in La Paz Hospital ( Madrid) since 2006 February until 2009 August 2009, with maternal antibody titers > 1:32, affected in previous pregnancies and/or anti-Kell isoimmunization, in which MCA-PSV has been measured. Results: For the detection of moderate-severe fetal anemia, Doppler ultrasonography of the middle cerebral artery had a sensitivity of 80 percent (CI95 percent: 59.8-100), a specificity and positive predictive value of 100 percent, and a negative predictive value of 85.7 percent (CI95 percent: 70.7-100). The Pearson correlation coefficient between estimated hemoglobin and real hemoglobin is 0.71. Conclusion: The measurement of MCA-PSV predicts moderate-severe fetal anemia cases, which are the most important in the clinical management because of the need of active treatment with intrauterine transfusion or induction labor.

Severe hemolytic disease of the newborn from anti-e.

Maternal antibody-mediated fetal red blood cell destruction secondary to non-D Rhesus (Rh) antibodies is a significant cause of hemolytic disease of the newborn (HDN). Here, we report a rare case of severe HDN associated with maternal antibody to Rh e. In addition to severe anemia, the infant developed thrombocytopenia, conjugated hyperbilirubinemia and cholelithiasis. Resolution of the infant's cholelithiasis occurred following treatment with ursodeoxycholic acid.

Intraperitoneal transfusion in severe, early-onset Rh isoimmunization.

OBJECTIVE: To describe the management of five women with severe, early-onset Rh isoimmunization with a series of intraperitoneal transfusions. METHODS: Intraperitoneal transfusions were started at 15 to 16 weeks of pregnancy, with small volumes of blood given weekly until the umbilical cord could be successfully entered and further transfusions given intravascularly. RESULTS: The initial range of anti-D immune globulin levels was 24-244 international units, and all women had severe Rh isoimmunization complicating previous pregnancies. No fetus was severely anemic at the first intravascular transfusion (lowest hemoglobin 8.9 g/dL), and there were no fetal losses. Middle cerebral artery peak systolic velocity responded to treatment with intraperitoneal transfusions, suggesting that even at 15 to 16 weeks of gestation it correlates with fetal hemoglobin. CONCLUSION: This series shows that intraperitoneal transfusions can be used to successfully treat severe, early-onset Rhesus disease.

[Assess flow velocity in the ductus venosus and inferior vena cava in fetuses in isoimmunized pregnancies]. / Fluxo no ducto venoso e na veia cava inferior dos fetos em gestações isoimunizadas.

OBJECTIVE: Ductus venosus and inferior vena cava flow velocity was assessed in fetuses in isoimmunized pregnancies. METHODS: Examination of 61 fetuses aged 27 to 35 weeks from Rh-erythrocyte antigen isoimmunized women was carried out from June 1999 to June 2004. All fetuses were submitted to the examination of ductus venosus and inferior vena cava flow velocity. Blood samples were collected to determine hemoglobin values and hemoglobin concentration deficits. Accordingly, fetuses were grouped as follows: non-anemic; mildly anemic; moderately anemic and severely anemic fetuses. Comparison of the variation of average flow velocity in the inferior vena cava and ductus venosus across the four groups was carried out using the chi-square test. RESULTS: Inferior vena cava flow velocity was found to be altered in 3.8% of non-anemic fetuses; in 3.1% of the mildly anemic, in 40.0% of those moderately anemic; and in 76.0% of the severely anemic ones. Alteration in ductus venosus flow velocity, in turn, was identified in 7.7% of non-anemic fetuses; 3.1% of mildly anemic; 32.5% of moderately anemic and 68.0% of those severely anemic. Results were statistically significant with p < 0.001. CONCLUSION: The study shows that alteration of flow velocity in the inferior vena cava and ductus venosus increased with the severity of anemia.

Fluxo no ducto venoso e na veia cava inferior dos fetos em gestações isoimunizadas / Assess flow velocity in the ductus venosus and inferior vena cava in fetuses in isoimmunized pregnancies

OBJETIVO: Avaliar a velocidade de fluxo na veia cava inferior e no ducto venoso em fetos, nas gestações isoimunizadas. MÉTODOS: De junho de 1999 a junho de 2004, foram avaliados 61 fetos, entre 27 e 35 semanas, de gestantes portadoras de isoimunização por antígenos eritrocitários. Em todos os fetos foram avaliadas as velocidades de fluxo na veia cava inferior e no ducto venoso. Obteve-se amostra de sangue fetal para determinação dos valores da hemoglobina e calculou-se o déficit da concentração de hemoglobina. Esses fetos foram divididos em quatro grupos, de acordo com o déficit da concentração de hemoglobina: fetos não anêmicos, anêmicos leves, anêmicos moderados e anêmicos graves. Utilizou-se o teste Qui-quadrado para comparar os quatro grupos de fetos quanto à proporção da alteração da velocidade média de fluxo na veia cava inferior e no ducto venoso. RESULTADOS: A velocidade de fluxo na veia cava inferior estava alterada em 3,8 por cento dos fetos não anêmicos, em 3,1 por cento dos fetos com anemia leve, em 40 por cento dos anêmicos moderados e em 76 por cento dos fetos com anemia grave. Já a velocidade de fluxo no ducto venoso estava alterada em 7,7 por cento dos fetos não anêmicos, em 3,1 por cento dos fetos com anemia leve, em 32,5 por cento dos anêmicos moderados e em 68 por cento dos fetos com anemia grave. O valor p foi inferior a 0,001. CONCLUSÃO: Verificou-se aumento da freqüência de alteração da velocidade de fluxo na veia cava inferior e no ducto venoso à medida que a anemia se agravava.

OBJECTIVE: Ductus venosus and inferior vena cava flow velocity was assessed in fetuses in isoimmunized pregnancies. METHODS: Examination of 61 fetuses aged 27 to 35 weeks from Rh-erythrocyte antigen isoimmunized women was carried out from June 1999 to June 2004. All fetuses were submitted to the examination of ductus venosus and inferior vena cava flow velocity. Blood samples were collected to determine hemoglobin values and hemoglobin concentration deficits. Accordingly, fetuses were grouped as follows: non-anemic; mildly anemic; moderately anemic and severely anemic fetuses. Comparison of the variation of average flow velocity in the inferior vena cava and ductus venosus across the four groups was carried out using the chi-square test. RESULTS: Inferior vena cava flow velocity was found to be altered in 3.8 percent of non-anemic fetuses; in 3.1 percent of the mildly anemic, in 40.0 percent of those moderately anemic; and in 76.0 percent of the severely anemic ones. Alteration in ductus venosus flow velocity, in turn, was identified in 7.7 percent of non-anemic fetuses; 3.1 percent of mildly anemic; 32.5 percent of moderately anemic and 68.0 percent of those severely anemic. Results were statistically significant with p < 0.001. CONCLUSION: The study shows that alteration of flow velocity in the inferior vena cava and ductus venosus increased with the severity of anemia.

[Indexes of a functional condition of a liver with hemolytic disease of the newborn stipulated incompatibility between the mother and fetus].

The hemolytic disease of the newborn, originating as a result of sensitization of the mother to the Rh-antigen of erythrocytes of the fetus (Rh-HDN) is one of the most important causes of the loss of a fetus and newborn. One of the pathogenetic mechanisms of Rh-HDN is the hyperbilirubinemia at the expense of the toxiferous fraction of a bilirubin negatively influencing many organs of the child, including the liver. The purpose of the work was the complex study of indexes of a functional condition of a liver newborn with a various degree of gravity Rh-HDN and definition of effectiveness of the conducted therapy. The direct association between severity of illness and indexes of pigmental, excretion and detoxication of the function of the liver in newborns with Rh-HDN has been found. There were found significant relations of ALT/AP, AST/AP, GT/AP, albumin and globulin factors with the degree of cholestasis and toxic damage of the liver. The lack of normalization of indexes of the peptide uptake and the excretion function of the liver on the background of treatment indicate to the necessity of further monitoring of functional condition of the liver and realization of the correction of therapy after discharge of children from the hospital, especially with the serious form of Rh- HDN.

Prediction of severe fetal anemia in red blood cell alloimmunization after previous intrauterine transfusions.

OBJECTIVE: This study was undertaken to determine the detection of fetal anemia and false-positive rates by fetal middle cerebral artery peak systolic velocity (MCA-PSV) and the estimated daily decrease of hemoglobin (Hb) in red blood cell alloimmunized pregnancies that had previous fetal transfusions. STUDY DESIGN: We examined the relation between MCA-PSV measured before cordocentesis, and fetal Hb at the time of the second (n = 42) and third (n = 31) intrauterine blood transfusions. In addition, the daily Hb drop between the transfusions was calculated. RESULTS: The MCA-PSV provided significant prediction of severe anemia (Hb deficit > or = 6 g/dL) for the second but not for the third transfusion. Detection of 95% of severely anemic fetuses was achieved with a false-positive rate of 37% for the second transfusion and 90% for the third, compared with 14% in our previous study for the first transfusion. In patients who had received 2 previous transfusions, the only significant predictor of fetal anemia was the estimation of the Hb from the measured posttransfusion Hb after the second transfusion and the assumption that the rate of decrease in fetal Hb is 0.3 g/dL per day. CONCLUSION: Prediction of severe fetal anemia after one transfusion is less accurate than in nontransfused fetuses. The MCA-PSV is not useful in predicting severe anemia in fetuses that already had 2 previous transfusions.