Intrauterine blood transfusion in immune hydrops fetalis , corrects middle cerebral artery Doppler velocimetry very quickly

Th e aim of our study was to evaluate the middle cerebral artery velocimetry before and after intrauterine blood transfusion in immune hydrops fetalis. Th e current study was conducted in a tertiary research hospital, from February  to January . Nineteen intrauterine blood transfusions performed during the study period. Th e factors recorded were age of the mothers, gestational weeks, pre-transfusion fetal hematocrit and post-transfusion fetal hematocrit, and also middle cerebral artery peak systolic velocimetry (MCA-PSV) was detected and recorded before and after intrauterine transfusion. A control group of twenty two cases for normal MCA doppler velocimetry was also included to the study. During the study, a total of eleven rhesus isoimmunized pregnancies underwent intrauterine blood transfusions at our perinatal diagnose unit. Before transfusion seventeen severe and two moderate anemias were detected and mean MoM of MCA-PSV was .±. MoM. Post transfusion mean MoM of MCA-PSV in the patient group and control group were .±. MoM and .±. MoM, respectively. Th e mean MCA-PSV values were higher in RI fetuses than post transfusion and control group. In current study, we found that MCA-PSV is a valuable parameter in detecting fetal anemia requiring intrauterine transfusion and mean MCA-PSV values is higher than . MoM in fetuses with anemia. And also decrease in MCA-PSV just after transfusion in anemic fetuses showed the quick response of the fetus to correction of anemia. ©  Association of Basic Medical Sciences of FBIH. All rights reserved


INTRODUCTION
Rhesus isoimmunization (RI) is a frequent cause of fetal anemia caused by the transport of maternal antibodies from the placenta and subsequently destroys fetal red blood cells.In the United States the ratio of fetuses under risk of anemia due to RI has a ratio of  per . live births and of these fetuses only  percent will require intrauterine blood transfusion because of severe anemia [-].The detection of anemia in RI fetuses is the most important point in the treatment of immune hydrops fetalis.Invasive techniques such as amniocentesis (AC) and cordocentesis (CC) used to identify the fetuses with severe anemia [-].Mari et al. [] reported that MCA-PSV value, detected by Doppler ultrasonography, increases in fetuses with anemia.In a prospective multicenter trial Zimmermann et al. [] studied the MCA-PSV in fetus-es with anemia to find the need of invasive procedures and found that  of  fetuses avoided from AC or CC.In current study, we aimed to evaluate the pre-transfusion and just after transfusion MCA-PSV values of RI fetuses with anemia and compare with healthy fetuses.

Subjects
Th is prospective case control study was performed at perinatal diagnose unit of Dicle University, School of Medicine from February  to January .Th is is a tertiary and reference hospital in the southeast region of Turkey.Most of the patients referred from the outside health centers.The health services are mostly free of charge and supported by the government.The study was approved by the Ethics Committee of the instuition, and written informed consent was received by all of the patients.

Procedures
A total nineteen intrauterine blood transfusion to eleven pregnancies with RI fetuses were included to this study.In fi ve patient one, in four patients two and in two patients three

Statistical analysis
Mean and standard deviation (SD) were calculated for continuous variables.Chi-Square and Independent Sample t test were used to evaluate associations between the categorical and continuous variables.Two-sided p values were considered statistically signifi cant at p<..Statistical analyses were carried out by using the statistical packages for SPSS . for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS
Th e demographic and clinical characteristics of the cases are shown in  In control group, mean MCA-PSV were .±.MoM, there was statistically significant difference between  [] also found similar findings to the literature and reported that MCA-PSV values were higher in fetuses with anemia than in normal fetuses.Similar to these studies, we found that MCA-PSV levels were higher in anemic RI fetuses when compared with the normal fetuses.
Previously the gold standards in detecting the anemia in RI fetuses were AC and CC.AC has been used for last  years and CC  years.Both of these procedures are invasive and related with risks for fetus.Mari et al. [] found that   of fetuses underwent CC were either non-anemic or mildly anemic.Th erefore, they recommended avoiding or delaying this procedure.Detti et al. [] performed a study to determine the need of the transfusion of the RI fetuses and studied on sixty four fetuses that had one previous transfusion.With traditional criteria, they found that forty-six fetuses () were not or mildly anemic;  fetuses () were moderately anemic, and  fetuses () were severely anemic.Middle cerebral artery peak systolic velocity for the prediction of severe, moderate, and mild anemia at a sensitivity of  showed false-positive rates of , , and , respectively.As a re-sult they reported that in fetuses previously transfused once, timing of the second transfusion can be determined noninvasively by Doppler ultrasonography on the basis of an increase in the peak velocity of systolic blood fl ow in the middle cerebral artery.We also found that MCA-PSV is a valuable parameter in detecting the fetal anemia requiring intrauterine transfusion and mean MCA-PSV values in higher than . MoM in fetuses with anemia.Also the decrease in MCA-PSV just after the transfusion in anemic fetuses showed the quick response of the fetus to correction of anemia.

CONCLUSION
Middle cerebral artery-PSV values seem to be an effective method in detecting the need of transfusion of the RI fetuses.It also helps to determine to predict the timing of the following transfusions.Another important finding is by the correction of the fetal anemia, the MCA-PSV values quickly straighten out to normal ranges.

DECLARATION OF INTEREST
We declare no confl ict of interest.
Th ere were no signifi cant diff erences in maternal and gestational age and gestational weeks between groups (p> .) Th e fetal hemoglobin levels of the fetuses before the transfusions were shown in Figure .Of these nineteen transfusions, seventeen fetuses had severe and two fetuses had moderate anemia.In RI fetuses, mean pre-transfusion MCA-PSV values were .±.MoM, seventeen of these fetuses had a MoM of MCA-PSV greater than . MoM and two lower than . MoM.These two fetuses had previous transfusion before the evaluation.Just after the transfusion the mean MoM of MCA-PSV values were .±.MoM and all were lower than . MoM.There was a statistically signifi cant decrease between the groups before and after the transfusions (p<.)(Figure).


Bosn J Basic Med Sci 2012; 12 (1): 38-40 AHMET YALINKAYA ET AL.: INTRAUTERINE BLOOD TRANSFUSION IN IMMUNE HYDROPS FETALIS, CORRECTS MIDDLE CEREBRAL ARTERY DOPPLER VELOCIMETRY VERY QUICKLY transfusions at diff erent gestational ages were determined.The factors recorded were age of the mothers, gestational weeks, pre-transfusion fetal hematocrit and post-transfusion fetal hematocrit, and middle cerebral artery Doppler velocimetry.The patient group had Rh-negative blood group, positive indirect coombs test, and a obstetric history of fetal anemia requiring intrauterine transfusion and/or intrauterine or postpartum fetal demise due to fetal anemia.All pregnancies were accurately dated by the last menstrual period and /or by fi rst-trimester ultrasonographic investigation.Th e MCA-PSV was detected by using Doppler ultrasonography pre transfusion and post transfusion (just after procedure, approximately in fi ve minute).All of the transfusions were performed by experienced perinatologist with ultrasound (Volusun  PRO D ultrasound device).Fetal hydrops was defined as the presence of generalized skin thickening of greater than  mm and at least two of the following conditions: ascites, pleural eff usion, pericardial eff usion or placental enlargement.The transfusions were performed by CC.Th e amount of blood transfused to the fetuses was calculated according to the formula advised byMandelbrot et al. [].Th e severity of fetal anemia was determined according to the reference values reported previously[].

Table  .
Th e mean age and gestational age of the pregnant women in patient and control group were .±. years old (range,  to  years) and .±. years old (range,  to  years), and .±.weeks (rage, . to . weeks) and .±.weeks (range,  to . weeks), respectively.

TABLE 1 .
The clinical and demographic characteristics of the pregnant women control group and pre-tranfusion MCA-PSV MoM (p<.),whereascontrol group measurements were similar with post-transfusion MCA-PSV MoM (p=.).PSV in anemic fetuses due to the decreased viscosity of the blood, increased cardiac output, vasodilatation and brain sparing eff ects[,].Zimmermann et al.[] reported a positive correlation of   between fetal anemia and MCA-PSV.In current study, we conducted a prospective case control study to evaluate the MCA-PSV values of RI fetuses before and just after the intra uterine blood transfusions.Eleven RI fetuses underwent a total of nineteen transfusions during the study period.The MCA-PSV values were determined before and just after the transfusions.Before transfusion seventeen severe and two moderate anemias were detected and mean MoM of MCA-PSV was .±.MoM.The pre-transfusion seventeen MCA-PSV values were higher, and the other two were lower than . MoM according to the same gestational age.Post transfusion mean MoM of MCA-PSV in the patient group and control group were .±.MoM and .±.MoM, respectively and both were under . MoM.The mean MCA-PSV values were higher in RI fetuses than post transfusion and control group.