Academic literature on the topic 'Blood transfusion intrauterine'

ABSTRACT Fetal anemia is a recognizable and treatable condition. It requires identification of the etiology to plan a comprehensive treatment strategy. Fetal blood transfusions help tide over crisis and avert fetal cardiovascular decompensation or deterioration due to the anemia. Based on the cause and the fetal condition, the timing and requirement for transfusion are determined. At present, noninvasive monitoring with fetal middle cerebral arterial Doppler peak systolic velocity is the standard for monitoring and diagnosis of fetal anemia. How to cite this article Indersen A. Fetal Intrauterine Transfusion. World J Anemia 2017;1(1):27-29.

Aim. To assess the adaptive capacity of newborns who have had intrauterine blood transfusions.Materials and methods. The study included 40 newborns who underwent intrauterine intravascular blood transfusion due to hemolytic disease of the fetus RH-factor.Results. The percentage of antenatal fetal losses in hemolytic disease is significantly reduced. Intravascular blood transfusion allowed the fetus to prolong the pregnancy for at least 32 weeks. Survival of newborns with hemolytic disease has significantly increased. Conducting intrauterine blood transfusions leads to a decrease in the frequency and multiplicity of postpartum blood transfusions.Conclusion. With timely delivery and adequate use of high-tech methods of treatment, both intrauterine and postnatal, it is possible in 88% of cases to preserve the life of the newborn with satisfactory rates of physical and neuropsychological development.

Abstract Background: Intrauterine blood transfusion is an important treatment of foetal anaemia. Although the standard access to the foetal vasculature for transfusion is the umbilical vein, the intracardiac route is used when foetal or placental positions make other accesses technically challenging. Intrauterine, intracardiac blood transfusion is associated with complications including haemopericardium, damage to cardiac tissues and foetal bradycardia. Highlights of the present report: We report a case of monochorionic twins with twin anaemia-polycythaemia sequence (TAPS). Intracardiac, intrauterine blood transfusion of the donor twin was complicated by haemopericardium and sustained bradycardia which necessitated delivery by emergency caesarean section. Postnatally, the bradycardia was sustained and was diagnosed electrocardiographically as heart block, which spontaneously reversed on the second day after birth. The management of heart block in the neonatal period is discussed. Conclusion: Foetal intracardiac intrauterine blood transfusion can be associated with transient congenital heart block (CHB).

Objective To investigate the clinical and sonographic parameters associated with adverse fetal outcomes in patients with congenital parvovirus B19 infection managed by intrauterine transfusion. Methods This was a single-center retrospective study conducted from January 2005 to December 2016 that assessed patients with singleton pregnancies with fetal parvovirus infection confirmed by a polymerase chain reaction of the amniotic fluid or fetal blood samples who underwent at least one intrauterine transfusion. The maternal characteristics, sonographic findings and parameters related to intrauterine transfusion were compared between the two groups (recovery/non-recovery), who were categorized based on fetal response after in-utero transfusions. Progression to fetal death or delivery without fetal recovery after the transfusions was considered non-recovery and categorized as an adverse outcome. Results The final analysis included ten singleton pregnancies: seven of which were categorized into the recovery group and three of which into the non-recovery group. The baseline characteristics were similar between the groups. All fetuses were hydropic at the time of diagnosis. No significant differences related to sonographic or intrauterine transfusion parameters were identified between the groups; however, the non-recovery group tended to have an increased number of sonographic markers and lower fetal hemoglobin and platelet levels before the transfusion. Conclusion We were unable to firmly establish the clinical or sonographic parameters associated with adverse fetal outcomes in patients with parvovirus infection managed with intrauterine transfusions; however, edema, placental thickening and oligohydramnios may indicate greater fetal compromise and, subsequently, adverse outcomes. However, further studies are necessary, mainly due to the small number of cases analyzed in the present study.

During ultrasonography examinationfetuses infected by parvovirus B19, we have established 36/129 (27.9%) cases of non-immune hydrops in the different periods of pregnancy.The hyperdynamic type of blood flow in fetal middle cerebral arterial was observed in fetuses at the second trimester. Measurement of fetal middle cerebral arteria peak systolic velocity was started at 18 weeks of gestationonce a week in pregnant women who were infected by parvovirus B19. During our study were found 17 cases of severe fetal anemia which manifested after 18 weeks of gestation.Intrauterine transfusions were performed for 11 pregnant women with parvovirus induced fetal hydrops whose gestation age were between 22.4 -25.7 (average 24.0±0.2). After cordocentesis11 cases of severe fetal anemia were confirmed.In the last 6 cases fetuses were diagnosed terminal condition due to women`s refusal of intrauterine transfusion or untimely admission to the hospital. Taking to account the results of study, the efficacy of treatment non-immune hydrops infected by parvovirus B19 with severe fetal anemia and outcomes were evaluated and analyzed. Successful treatment of parvovirus-induced fetal non-immune hydrops in the second trimester of pregnancy has been found in 72.7% cases (OR=95%) after intrauterine transfusion compared to 100% lethal rate in fetuses with non-immune hydrops and severe anemia who were not treated. Criteria for effectiveness of intrauterine transfusion are in time diagnosis of severe fetal anemia in infected fetus with non-immune hydrops, determine the optimal gestation age for intrauterine transfusion, indicators of viremia in umbilical cord blood, the compensatory capacity of the fetus based on Doppler metric indicator of middle cerebral arterial peak systolic velocity and changes blood flow in ductus venous of the fetus. It helps to reduce perinatal loss. Keywords: parvovirus infection, non-immune hydrops fetalis, intrauterine transfusion.

OBJETIVO: O objetivo deste estudo foi avaliar fatores clínicos, laboratoriais, dopplervelocimétricos e hematimétricos preditivos da velocidade de hemólise entre a primeira e a segunda transfusões intrauterinas em gestantes aloimunizadas. MÉTODOS: Este estudo retrospectivo compreendeu gestações únicas, com fetos não hidrópicos, submetidos à primeira e à segunda transfusões intrauterinas pela técnica intravascular direta simples, acompanhadas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Foram coletados os seguintes dados das gestantes: idade materna, antecedente obstétrico, antecedente obstétrico relacionado à aloimunização (classificado em grave, moderado, leve e nenhum), tipos e títulos dos anticorpos antieritrocitários e dados da transfusão intrauterina (TIU) (idade gestacional da TIU, valores da concentração da hemoglobina antes e depois da primeira e antes da segunda TIU, medida da velocidade sistólica máxima da artéria cerebral média antes da primeira e da segunda TIUs, volume de sangue infundido, concentração de hemoglobina do sangue transfundido, intervalo de tempo entre as transfusões e o tipo de punção uterina transplacentária ou não). Foram calculados a razão entre a quantidade de hemoglobina endógena em relação à quantidade total de hemoglobina após a primeira transfusão, a expansão de volume e taxa de hemólise. RESULTADOS: Quarenta e uma gestantes foram incluídas e apresentaram na primeira TIU, idade gestacional média de 26,1 ± 4,6 semanas, média de volume de sangue infundido de 44,4 ± 23,5 ml e média de expansão de volume de 51,3 ± 14,5%. A média do intervalo entre as transfusões foi de 15,7±6,5 dias. A média da taxa de hemólise foi de -0,40 ± 0,25 g/dl/d entre a primeira e a segunda transfusões e não houve diferença estatisticamente significante da taxa de hemólise nos distintos grupos de antecedente obstétrico relacionado à aloimunização (p = 0,21). Não houve diferença significante entre a média da hemólise e o tipo de punção intrauterina (p = 0,387). A análise multivariada anterógrada demonstrou correlação significativa da taxa de hemólise com a concentração de hemoglobina depois da 1ª TIU (r = 0,60, p<0,001), o intervalo de tempo entre as transfusões (r = 0,64, p<0,001) e a Vmáx ACM antes da segunda TIU (r = 0,56, p<0,001). A equação encontrada que melhor representa a taxa de hemólise foi: 0,31517 + 0,03463 x Intervalo 0,314038 x Vmáx ACM pré 2 0,068719 x Hb DP pós 1 (r2 = 0,58). CONCLUSÃO: A taxa de hemólise fetal entre a primeira e a segunda transfusões intrauterinas em gestantes aloimunizadas pode ser predita pela combinação da concentração de hemoglobina após a primeira TIU, do intervalo de tempo entre as transfusões e medida da Vmáx ACM antes da segunda TIU
OBJECTIVE: To evaluate clinical and laboratory factors, dopplervelocimetric and hematimetric values in the prediction of fetal hemolysis between first and second intrauterine transfusion in alloimmunized pregnant women. METHODS: This retrospective study involved singleton pregnancies with non hydropic fetus, that underwent to first and second intrauterine transfusions (IUT) by simple direct intravascular technique, accompanied at Hospital das Clínicas da Faculdade de Medicina de São Paulo. The following data were collected: maternal age, obstetric history, previus history of alloimmunization (classified in severe, moderate, mild and none), antibodies type and titre and data from the IUT (gestational age, hemoglobin levels before and after first IUT and before second IUT, middle cerebral artery peak systolic velocity before first and second IUT, transfused blood volume, transfused blood hemoglobin concentration, time interval between transfusions and type of intrauterine puncture). The ratio between amount of endogenous hemoglobin and total amount of hemoglobin after IUT, volume expansion and hemolysis rate were calculated. RESULTS: Forty-one pregnant women were included and presented at first IUT, mean gestational age of 26.1 ± 4.6 weeks, mean of transfused blood volume of 44.4 ± 23.5ml and mean expansion volume of 51.3 ± 14.5%. The mean interval between the transfusions was 15.7±6.5 days. The mean hemolysis rate was 0.40 ± 0.25 g/dl/d between the first and second transfusions and there was not significant difference between the distinct groups of previous history of alloimmunization (p = 0.21). There was not significant difference between mean hemolysis rate and the type of intrauterine punction (p = 0.387). Stepwise multiple regression analysis demonstrated that hemolysis correlated significantly with hemoglobin levels after the first transfusion (r = 0.60, p<0,001), the interval of time between transfusions (r = 0.64, p<0,001) and middle cerebral artery peak systolic velocity before the second transfusion (r = 0.56, p<0.001). The best-fit equation for hemolysis rate was: 0.31517 + 0.03463 x Interval 0.314038 x MCA PSV pre 2 0.068719 x Hb zeta pos1 (r2 = 0.58). CONCLUSION: Fetal hemolysis rate between first and second transfusions in alloimmune disease can be predicted by a combination of hemoglobin levels after the first transfusion, interval between both procedures and middle cerebral artery peak systolic velocity before the second transfusion

OBJETIVOS: Avaliar a correlação entre títulos de anticorpos anti-D em gestantes com antecedente de doença hemolítica perinatal (DHPN) e desfecho gestacional adverso. MÉTODOS: Coorte retrospectiva (2006-14) envolvendo gestantes Rh negativo, com antecedente de DHPN moderada ou grave, acompanhadas na Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Critérios de inclusão: gestação única com idade gestacional inferior a 32 semanas e ausência de derrames cavitários ou hidropisia fetal durante a 1a avaliação ultrassonográfica; e desfecho perinatal conhecido. Necessidade de transfusão intrauterina (TIU), ou ocorrência de óbito fetal (OF) foram considerados os desfechos de interesse. Análise por curva ROC foi utilizada para examinar a correlação entre os títulos de anticorpos e os desfechos; valores de sensibilidade, especificidade, preditivos positivo (VPP) e negativo (VPN), acurácia e razões de verossimilhança positiva (RVP) e negativa (RPN) foram calculados para diferentes níveis de corte. RESULTADOS: O estudo envolveu 58 gestações com antecedente moderado (n=18, 31%) ou grave (n=40, 69%) de DHPN. Um total de 29 (50,0%) gestações apresentaram desfecho adverso, sendo que TIU foi realizada em 28 (48,3%, 28/58) casos e OF ocorreu em 7 (12,1%, 7/58). A frequência de desfechos adversos foi diferente entre gestantes com título inicial baixo (< 16: 1/10, 10,0%), moderado (entre 16 e 64: 8/22, 26,9%) e alto ( >= 128: 20/26, 76,9%, p < 0,001). O comportamento dos títulos (declínio, estabilidade ou aumento) não se correlacionou com a necessidade de TIU ou OF (p=0,48). A curva ROC dos títulos iniciais de anticorpos apresentou área sob a curva de 0,78 (intervalo de confiança 95%, IC 95%: 0,66 - 0,90) para predição de desfechos gestacionais adversos, sendo 128 o melhor nível de corte, com sensibilidade de 69,0%, especificidade de 79,3%, VPP de 76,9%, VPN de 71,9%, acurácia de 74,0%, RVP de 3,33 (IC95%: 1,68-7,23) e RVN de 0,39 (IC95%: 0,21 - 0,66). CONCLUSÃO: Gestações com antecedente moderado ou grave de DHPN com títulos de anticorpos anti-D iniciais >= 128 apresentam aumento da chance de ocorrência de desfechos gestacionais adversos (TIU ou OF) de 3,33 vezes em relação àquelas com títulos iniciais baixos. Portanto, a titulação inicial de anti-D auxilia na triagem das gestações com maior chance de anemia fetal moderada ou grave, exigindo vigilância com avaliações mais frequentes do pico de velocidade sistólica da artéria cerebral média
OBJECTIVE: To evaluate the correlation between anti-D antibody titers in pregnant women with a previous history of hemolytic disease and adverse pregnancy outcome. METHODS: Retrospective cohort (2006-14) involving Rh negative pregnant women with a previous history of moderate or severe hemolytic disease, seen at the Department of Obstetrics and Gynecology, Hospital das Clinicas, São Paulo University Medical School. Inclusion criteria: singleton pregnancies, without fetal effusions or hydrops, first evaluated before 32 weeks of gestation, and known perinatal outcome. Primary outcomes were: need for intrauterine transfusion (IUT) and/or stillbirth (SB). ROC curve analysis was used to examine the correlation between antibody titers and adverse pregnancy outcome. Sensitivity, specificity, positive predictive (PPV) and negative (NPV) values, accuracy and positive (PLR) and negative (NLR) likelihood ratios were calculated for different cut-offs. RESULTS: The study included 58 singleton pregnancies with a history of moderate (n=18, 31.0%) or severe (n=40, 69.0%) hemolytic disease in a previous pregnancy. Adverse outcome occurred in 29 (50.0%) pregnancies: IUT was performed in 28 (48.3%, 28/58) cases and SB occurred in 7 (12.1%, 7 / 58). The frequency of adverse outcomes was significantly different (p < 0.001) according to initial antibody titers: low ( < 16), 1/10 (10.0%); moderate (between 16 and 64), 8/22 (26.9%); and high ( >= 128), 20/26 (76.9%). ROC curve analysis showed an area under the curve of 0.78 (95% confidence interval, 95% CI: 0.66 to 0.90) for the prediction of adverse pregnancy outcomes. Initial antiD > 128 was considered the best cut-off level, with sensitivity of 69.0%, specificity of 79.3%, PPV of 76.9%, NPV of 71.9%, accuracy of 74.0%, PLR of 3.33 (95% CI: 1.68 to 7.23) and NLR 0.39 (95% CI: 0.21 to 0.66). Antibody levels trend throughout pregnancy (decrease, stability or increase) was not correlated with adverse outcome (p = 0.48). CONCLUSION: Pregnancies with a previous history of moderate to severe hemolytic disease, and initial anti-D antibody titers >= 128, present increased chance (3.33 times) of need for intrauterine transfusion and/or stillbirth compared to those with low initial titers. Therefore, initial anti-D titers improve the screening of pregnancies at higher risk of moderate/severe fetal anemia and will require more frequent monitoring of fetal middle cerebral artery peak systolic velocity

A hemólise decorrente da doença aloimune desencadeia mecanismos adaptativos hematológicos e hemodinâmicos fetais, com intuito de garantir o suprimento adequado de oxigênio para todos os tecidos e órgãos. Na anemia grave, a sobrecarga imposta ao coração fetal, devido ao fluxo hiperdinâmico, tem sido considerada responsável pela insuficiencia cardiaca, e posterior desenvolvimento de hidropisia fetal. No entanto, a literatura médica ainda apresenta controvérsias acerca da integridade da função cardiaca nesta doença. O índice de performance miocárdico (IPM) é uma ferramenta propedêutica não invasiva, derivada do Doppler pulsátil, que permite avaliar a função cardíaca global (sistólica e diastólica). Objetivo: Estudar a função cardíaca fetal, na doença aloimune, utilizando o índice de performance miocárdica. Métodos: Foram seguidos, prospectivamente, fetos únicos, de gestantes sensibilizadas pelo antígeno eritrocitário D, sem malformações estruturais, na Clinica Obstétrica, Hospital das Clinicas da Faculdade de Medicina de São Paulo. A cada avaliação ultrassonográfica, o IPM foi investigado por meio de Doppler pulsátil, com janela de 2-4mm, filtro>190Hz e velocidade de varredura que permitisse observar de 3 a 4 ciclos cardíacos simultâneos no ecrã. O IPM corresponde à soma dos tempos isovolumétricos (contração e relaxamento) dividido pelo tempo de ejeção do ciclo cardíaco. O IPM do ventrículo equerdo (IPM VE) foi realizado em ciclo único, sendo possível obter seus componentes: tempo de contração isovolumétrico (TCI), tempo de relaxamento isovolumétrico (TRI) e tempo de ejeção (TE). O IPM do ventrículo direito (IPM VD) foi obtido em dois tempos. Os valores obtidos de IPM VE, seus componentes foram convertidos em escore zeta para a idade gestacional. Frente à suspeita de anemia fetal, realizou-se cordocentese com determinação dos níveis de hemoglobina fetal antes e após a transfusão intra-uterina. Os respectivos valores foram convertidos em escore-zeta (Hb zeta). Na análise estatística, foram incluidas avaliações do IPM realizadas com menos de 72 horas antes, e até 24 horas após cada transfusão. Para cada transfusão foi calculada a variação no IPM (delta IPM = IPM antes - IPM após). O nível de significância estatísca adotado foi de 0,05. Análises por regressão linear simples e logística foram utilizadas para examinar a associação entre os valores de IPM e delta IPM e as seguintes variáveis: idade gestacional no procedimento, múltiplos da mediana (MoM) da Vmax ACM, Hb zeta pré e após TIU, volume de sangue transfundido e porcentagem da expansão do volume feto-placentário (EVFP). Resultados: Foram incluidas 14 gestações submetidas a 31 procedimentos de cordocentese para transfusão intra-uterina. A idade gestacional média na 1ª transfusão foi de 28,2 ± 4,1 semanas Em 6 procedimentos, a avaliação do IPM pós transfusional foi incompleta, e esses dados não foram incluídos na análise. Quanto à análise dos dados obtidos nas cordocenteses, observou-se correlação significativa entre os valores de escore zeta de IPM VE (r= 0,59, p <0,001), TRI (r= 0,45, p =0,01) e o TE (r= 0,42, p=0,2) e o escore zeta da hemoglobina fetal. Não foi observada correlação significativa com o escore zeta do TCI (r= 0,35, p=0,054) e do IPM VD (r=0,12, p= 0,53). Quando comparados aos valores observados antes das transfuões intra-uterinas, observou-se aumento significativo do escore zeta de IPM VE após os procedimentos (Delta MPI = 1,10 ± 2,47, p = 0,036). Não foi observada correlação entre os valores de escore zeta de IPM antes e após TIU. Delta MPI do VE se correlacionou inversamente, e de forma significativa, com a idade gestacional no procedimento (r= 0,47, p=0,018), escore zeta IPM VE pré-TIU (r= 0,50, p=0,012) e EVFP (r= 0,41, p=0,044). Conclusões: O desempenho miocárdico do ventriculo esquerdo fetal permanece preservado frente a anemia, e nos casos de anemia moderada e grave encontra-se ainda mais eficiente. Após a realização da transfusão intrauterina, observou-se aumento significativo do índice de performance miocárdica, e este aumento esteve relacionado com idade gestacional no procedimento, valores de IPM pré-transfusionais e a expansão do volume feto-placentário
Fetal anemia is associated with several adaptative mechanisms in order to maintain adequate tissue oxygenation. Circulatory changes play a key role in such circumstances. In severe anemia, the overload imposed on the fetal heart, due to the hyperdynamic flow, has been considered to be responsible for cardiac failure and finally hydrops fetalis. However, cardiac failure in this pathology remains controversy. Myocardial performance index (MPI) is a novel technique, Doppler derived and non-invasive that allows assesses global cardiac function (systolic and diatolic). Objective: Evaluate global cardiac function in alloimune disease through myocardial performance index. Methods: This prospective study was carried out at a tertiary referral center for fetal medicine (Clínica Obstetrica do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo). Women with singleton pregnancies and Rh D alloimmune disease were invited to take part in the study and gave informed consent. Fetal examinations did not show structural abnormalities. At every ultrasonography evaluation, MPI was examined with Doppler sample gate set between 2-4mm, wall motion filter >190Hz and high sweep-speed to allow simultaneous identification of 3-4 cardiac cycles on the screen. MPI is the sum of isovolumetric times (contraction and relaxation) divided by ejection time. Left ventricle MPI (LV MPI) was obtained in a single cycle and the MPI components were obtained: isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT) and ejection time (ET). Right ventricle MPI (RV MPI) was obtained in two cycles. The values obtained for LV MPI and its components were converted in zeta score for gestacional age. Cordocentesis was perfomed if fetal anemia was suspicion and fetal hemoglobin levels were determined: before and after intrauterine transfusion. Hemoglobin values were converted into the zeta score (Hb zeta). Statistical analysis included MPI evaluations performed within less than 72 hours before and until 24 hours after every transfusion. Variation in the MPI was calculated for every transfusion (delta MPI = MPI before - MPI after). Significance level was set at 0,05. Linear and regression analyses were made in order to examine association between MPI values and delta MPI gestational age at procedure, fetal ACM multiples of median (MoM), Hb zeta before and after the IUT, volume of blood transfused and percentage of the feto-placental expansion volume (FPEV). Results: 14 pregnancies were included. Overall 31 cordocentesis for intrauterine transfusion were performed at mean gestational age of 28,2 ± 4,1 weeks. In 6 procedures, post transfusion MPI evaluation was incomplete and these data were not included in the analysis. Zeta-score values LV MPI (r= 0,59, p < 0,001), IRT (r= 0,45, p =0,01) and ET (r= 0,42, p=0,02) correlated significantly with fetal hemoglobin zeta score. Left ventricle ICT zeta-score (r= 0,35, p=0,054) and RV MPI (r=0,12, p= 0,53). did not show significant correlation. After intrauterine transfusion, LV MPI z-score ]increases and it was statistical significant (Delta MPI = 1,10 ± 2,47, p = 0,036). No correlation was observed between MPI zeta score values before and after the IUT. Delta LV MPI had inverse and significant correlation with pregnancy age in the proceedings (r= 0,47, p=0,018), LV MPI zeta score before IUT (r= 0,50, p=0,012) and FPEV (r= 0,41, p=0,044). Conclusions: Left ventricle myocardial performance not only remains preserved but is actually enhanced in cases of moderate/severe fetal anemia. After intrauterine transfusion procedure, left ventricle myocardial performance index increases significantly and greater changes are associated with procedures at earlier gestational age, lower pre transfusion MPI z-scores and smaller feto-placental volume expansion

Parvovirus B19 is a common infection in humans that occurs worldwide. Parvovirus B19 is transmitted through exposure to respiratory droplets, blood, and blood products, and through mother-to-child transmission (MTCT) in utero. Intrauterine parvovirus B19 infection is a rare occurrence during pregnancy but can result in significant morbidity and mortality for the fetus, including severe fetal anemia and nonimmune fetal hydrops (NIFH). Intrauterine transfusion can be successful in treating fetal anemia. Neurodevelopmental impairment has been reported in infants with congenital infection who have received intrauterine transfusion (IUT). Future research on the development of antiviral agents for the treatment of parvovirus B19 infection in pregnant women is needed, along with the development of a parvovirus B19 vaccine. Longitudinal studies to evaluate neurodevelopmental outcome of infants with a history of congenital parvovirus B19 infection are needed in order to facilitate the optimal evaluation and management of these infants.

This chapter contains details of methods used for screening and diagnosis of fetal anomalies using antenatal blood tests, ultrasound scanning, chorionic villous sampling, amniocentesis, and fetal blood sampling. There are sections on pre-existing maternal diseases presenting risks to the fetus including maternal diabetes, systemic lupus erythematosus, thrombocytopenia, and neuromuscular disease, as well as those specific to pregnancy—pre-eclampsia, HELLP syndrome, and eclampsia. Intrauterine growth restriction and monitoring is covered in detail. The increased fetal risks of multiple birth due to twin-to-twin transfusion syndrome and other pregnancy complications are described, with detail on oligohydramnios, polyhydramnios, antepartum haemorrhage, preterm prelabour rupture of membranes, cord prolapse, preterm labour, and breech presentation. Intrapartum fetal assessment using electronic fetal monitoring and fetal blood sampling to diagnose fetal distress is covered to enable health professionals involved in care of the newborn to understand events which may have resulted in a baby born in poor condition.

Recent data shows that 30 million low-birth-weight (LBW) infants are born annually worldwide (23.8% of all births). Although the global prevalence of such births is gradually decreasing, rates are still as high as 30% in many developing countries (World Health Organization 2008). Low birth weight is due to intrauterine growth restriction (IUGR), rather than or in addition to prematurity, in approximately one-third of these cases. This staggering number of affected children underscores the importance of understanding the short- and long-term cognitive and behavioral complications of IUGR. Intrauterine growth restriction conveys short- and long-term neurodevelopmental risks and thus requires costly long-term investment of medical, cognitive emotional, educational, and economical resources. Nevertheless, if treated aggressively, IUGR more often than not bears a fairly optimistic outlook, once the infant overcomes the initial life-threatening issues (Geva et al. 2006a). Intrauterine growth restriction is frequently detected in a pregnancy with a less-than-expected third trimester weight gain (100–200 g [3.5–7 oz] per week) or as an incidental finding on ultrasound examination when fetal measurements are less than expected for gestational age (GA; Geva et al. 2005). An estimated fetal weight under the 10th percentile, as determined by serial ultrasound examination, strongly correlates with growth restriction (Bernstein and Gabbe 1996; McCormick 1985). The etiologies of IUGR are typically thought of according to three interdependent categories: fetal factors, placental factors, and maternal factors (Kay 2008). Fetal factors include chromosomal events, such as trisomy 18 and 13 and sex chromosome abnormalities, which account for 5%–15% of all IUGR cases. Further exploration of genetic factors is currently under way, with mixed results (Kotzot et al. 2001). Other fetal factors linked to IUGR include congenital anomalies, mostly cardiovascular malformations, gastroschisis and omphalocele; infection, often related to rubella, cytomegalovirus, and toxoplasmosis (see Chapter 25); and multiple gestations, in which uteroplacental blood flow variations and/or twin–twin transfusion develops (Miller et al. 2008). Fetal villus circulation abnormalities are placental factors related to IUGR (Roberts and Post 2008).

Blood- borne viruses (BBVs) are viral infections transmitted by blood or body fluid. In practice, any viral infection that achieves a high viral load in blood or body fluid can be transmitted through exposure to infected biological materials. In western countries, the most significant BBVs are human immunodeficiency viruses (HIV1 and HIV2), hepatitis B virus (HBV) and hepatitis C virus (HCV). Other viruses that can be transmitted by blood and body fluid include human T cell lymphotropic viruses (HTLV1 and HTLV2), cytomegalovirus, West Nile virus and viruses responsible for viral haemorrhagic fever such as Ebola virus, Lassa virus, and Crimean-Congo haemorrhagic fever virus. BBVs are transmitted via exposure to blood and body fluid. Some examples of routes of transmission include: ● Sharing needles in people who inject drugs (PWID); ● Medical re-use of contaminated instruments (common in resource poor settings); ● Sharps injuries in healthcare setting, including in laboratories (less commonly through mucosal exposure); ● Transfusion of blood contaminated with BBVs (failure to screen blood donors); ● Transplantation of organs from BBV-infected donors; ● Sexual exposure to BBV-infected body fluid; and ● Exposure to maternal BBV infection: intrauterine, perinatally, or postnatally. If exposure to a BBV is via a needle stick injury in a healthcare setting, immediate first aid needs to be carried out by gently encouraging bleeding and washing the exposed area with soap and water. Prompt reporting of the incident is required so that an assessment can be done as soon as possible to determine if post-exposure prophylaxis (PEP) is required. The decision may be aided by urgent assessment of source patient infection status. The British Medical Association has issued guidance for testing adults who lack the capacity to consent. In the case of a sexual exposure to a BBV, immediate consultation to a genito-urinary medicine (GUM) clinic is warranted. The risk of transmission of BBVs associated with exposure depends on the nature of the exposure and the body fluid involved. The following factors are important in needle stick injuries: ● Deep percutaneous injury. ● Freshly used sharps. ● Visible blood on sharps.

Intracranial haemorrhage is the most serious complication of alloimmune neonatal thrombocytopenia (ANT). It has generally been assumed that this occurs during delivery, but evidence is accumulating that intracranial haemorrhage may have already occurred in utero. Management of the pregnancy at risk is therefore more exacting, and it has been suggested that intrauterine platelet transfusions may be of benefit (Daffos et al, Lancet, Li, 632. 1984). We have used this approach in two pregnancies in PlA1 negative mothers with PlA1 positive fetuses affected by ANT. Both were second pregnancies, the first in each case having produced a brain damaged infant due to CNS haemorrhage. First patient (CW): Ultrasound scans of the fetal head at 10,22,28 and 32 weeks were all normal. She was admitted at 35 weeks for fetal sampling and platelet transfusion. Ultrasonography showed dilated ventricles and a left anterior cerebral haematoma. The fetal platelet count was 12 × 109/1,rising after transfusion of PlA1negative platelets to 139 x 109/1. The baby was delivered by Caesarean section and the cord blood platelet count was 126 × 109/1.Subsequent clinical assessment by CT scanning and NMR indicated both recent (1-2 weeks) and older (>4weeks) cerebral haemorrhages (de Vries et al, in press). Second patient (CR): Platelet transfusions were started earlier in this pregnancy. At 26 weeks the fetal platelet count was 32 × 109/1, rising to 160 × 109/1 after platelet transfusion. This was repeated at 27 wk (25 to 280 × 109/1), 29 weeks (5 to 320 × 109/1) and regularly until birth. Before the third platelet transfusion, the mother received intravenous IgG 0.4 g/Kg/d for 5 days, which had no effect on the fetal platelet count. These cases illustrate the potential value of ultrasound-guided intravascular, umbilical cord transfusions of compatible platelets in raising the fetal platelet count in ANT, but emphasise the short duration of this effect (<1 week). As the procedure is so labour intensive, further studies are needed to identify the high risk pregnancies, to determine the optimal time for intervention and to assess the success of this approach.

We previously determined platelet antigens and glycoproteins in the human fetus after 19 weeks of intrauterine life (Blood 68, 488-92,1986). These results obtained in fetuses with normal platelets allowed us to do the first attempt of antenatal diagnosis in Glanzmann thrombasthenia. The fetal propositus was tested with monoclonal (AP2, AP3) or polyclonalantibodies (IgGL) directed against GPIIbllla or platelets antigen (PLA1, Leka). The foetus was found to be heterozygous for GT and similar results were foundafter his birth.Grey platelet syndrome is a rare congenital platelet defect caracterized by an alpha granule deficiency and is transmitted on the dominant feature. To be able to detect this abnormality before birth we have measured the platelet content of alpha granules.The amount of Beta thromboglobulin (gTG) at 18 weeks of intrauterine life was32±4.3 mg/109 platelets in normal platelets (adults 60 mg/10^ platelets). The foetus of the mother with grey platelet syndrome was sampled at 19 weeks when the mother was under platelet transfusion and the platelets were studied by electron microscopy and for their BTG content. The platelet morphologyshowed the presence of alpha granules and the $TG content was in the range of the control fetuses (42mg/109 platelets). The baby was born after artificial delivery under platelet transfusion. These results showed that the antenatal diagnosis of thrombopathies is feasible and can permit a therapy to avoid dramatic haemorrhage during pregnancy or delivery.