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Fetaltransfusion

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JointUnited
Kingdom
(UK)BloodTransfusionandTissue
TransplantationServices
ProfessionalAdvisoryCommittee

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10.1:Fetaltransfusion
Themostcommonindicationsforintrauterinetransfusion
(IUT)areredcellsforpreventionandtreatmentoffetal
anaemiaduetohaemolyticdiseaseofthefetusandnewborn
(HDFN)orparvovirusinfectionandplateletsforneonatal
alloimmunethrombocytopenia(NAIT).Thisisahighly
specialisedareaofmedicalpracticerequiringclose
collaborationbetweenexpertsinfetalmedicine,haematology
andbloodtransfusion,andrapidaccesstobloodcounting.
EveninthemostexperthandsIUTcarriesariskoffetaldeath
of13%perprocedureandfetomaternalhaemorrhagemay
causefurthersensitisationandworseningofHDFN.
10.1.1:IntrauterinetransfusionofredcellsforHDFN
MaternalaspectsofthemanagementofHDFNarecoveredin
Chapter9.TheobjectiveofredcellIUTistopreventortreat
lifethreateningfetalanaemia(hydropsfetalis)andallowthe
pregnancytocontinuetoastagewhereaviablebabycanbe
delivered(ideallyatleast36weeksgestation).Highrisk
pregnanciesaremonitoredbyweeklyfetalDopplerultrasound
scanstomeasuremiddlecerebralarterypeaksystolicvelocity,
anindicationoftheseverityoffetalanaemia,andregular
ultrasoundmonitoringoffetalgrowth.Fetalbloodsamplingis
indicatedifsevereanaemiabefore24weeksgestationis
suspected,iftherehasbeenapreviousintrauterinedeath,or
ifthereisarapidincreaseinmaternalredcellalloantibody
levels.
GuidelinesforIUTvarybetweenspecialistunitsbutpublished
indicationsincludeahaematocritof<0.25between18and26
weeksofgestationand<0.3after26weeks.Thetarget
haematocritafterIUTisusuallyaround0.45.Tobalancethe
competingrisksoffetalanaemiaandthehazardsofinvasive
IUTprocedures,thetransfusionprogrammeisstartedaslate
aspossibleandthefrequencyoftransfusionisreducedby
givingthemaximumsafevolumeofaspecialredcell
componentwithahighhaematocrit(Table10.1).Transfusion
volumeiscalculatedbythefetalmedicinespecialistusinga
formulabasedonthehaematocritsofthedonorbloodand
fetus,theestimatedfetoplacentalbloodvolumeandthetarget
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haematocrit.Thecomponentiswarmedto37Cimmediately
beforetransfusion.Wheneverpossible,redcellsforIUTare
requestedwellinadvanceoftheplannedtransfusion,inclose
communicationwiththeBloodServices.Inextreme
emergencies,wheredelayinobtainingspecialIUTblood
wouldbelifethreatening,bloodfromaneonatalexchange
transfusionunitorpaedipackshouldbeused(irradiatediftime
allows)butnotmaternalblood.TheSHOTAnnualReport
2012includedaneonataldeathfromtransfusionassociated
graftversushostdisease(TAGvHD)whennonirradiated
nonleucodepletedmaternalredcellswereusedforanurgent
IUT(http://www.shotuk.org/shotreports/reportsummaryand
supplement2012(http://www.shotuk.org/shotreports/report
summaryandsupplement2012)/).Babieswhohavereceived
IUTshouldbetransfusedwithirradiatedcellularblood
componentsuntil6monthsofpostgestationalage.
Table10.1RedcellcomponentforIUT
Plasmareduced(haematocrit0.70.85)
Incitratephosphatedextrose(CPD)anticoagulant(theoretical
riskoftoxicityfromadditivesolutions)
Leucocytedepleted
Lessthan5daysold(toavoidhyperkalaemia)
Cytomegalovirus(CMV)antibodynegative
Sicklescreennegative
IrradiatedtopreventTAGvHD(shelflife24hours)
UsuallygroupOwithlowtitrehaemolysins(orABOidentical
withthefetus)
RhDandKellnegativeandredcellantigennegativefor
maternalalloantibodies
Indirectantiglobulintest(IAT)crossmatchcompatiblewiththe
mothersplasma

10.1.2:Intrauterinetransfusionofplateletsand
managementofNAIT
TheIUTofplateletsisusedinthetreatmentofseverefetal
thrombocytopeniaduetoplateletalloimmunisation(neonatal
alloimmunethrombocytopeniaNAIT).NAITistheplatelet
equivalentofHDFN.Maternalalloantibodiestoantigenson
fetalplateletscausefetaland/orneonatalthrombocytopenia
withahigh(10%)riskofintracerebralhaemorrhage.Nearlyall
casesarecausedbyantibodiestoHPA1a(8090%of
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cases),HPA5borHPA3a.Themotherisnegativeforthe
implicatedplateletantigenandNAITisdiagnosedby
demonstratingtheplateletalloantibodyinmaternalserum.The
diagnosisismostoftenmadewhenanotherwisehealthy
neonatepresentswithpurpuraandanisolatedsevere
thrombocytopenia.Subsequentatriskpregnanciesshouldbe
managedinafetalmedicinecentreasprenatalmanagement
israpidlyevolving(Petersonetal.,2013
(http://www.ncbi.nlm.nih.gov/pubmed/23384054
(http://www.ncbi.nlm.nih.gov/pubmed/23384054))).
Managementisinfluencedbyanyhistoryofpreviousfetal
lossesandtheirtiming.Fetalbloodsamplingandplatelet
transfusioncarryasignificantriskoflifethreatening
haemorrhage(suitableplateletsshouldalwaysbeimmediately
availablewhenfetalbloodsamplingisperformed).Thereisan
increasingtrendtouseanoninvasiveapproachwithmaternal
intravenousimmunoglobulinandsteroidsandtoavoidfetal
transfusionwherepossible.Hyperconcentratedplateletsfor
IUTarespeciallypreparedbytheBloodServices(seeTable
10.2)andtransfusionshouldbeplannedinadvance.The
transfusionvolumeisdeterminedfromthefetalandplatelet
concentrateplateletcountandestimatedfetoplacental
volume.PlateletsaretransfusedmoreslowlythanIUTred
cellsbecauseofariskoffetalstroke.
Table10.2Plateletsforintrauterinetransfusion
HPAcompatiblewithmaternalalloantibody
Hyperconcentratedtoatleast2000109 /L
Irradiated
CMVnegative

NeonateswithsuspectedorprovenNAITwhoareseverely
thrombocytopenic(<30109/L)shouldbetransfusedwith
HPAcompatibleplatelets.HPA1a/5bnegativeplateletunits
areusuallyavailableofftheshelffromtheBloodServices.
Neonateswithintracranialhaemorrhage(ICH)oraprevious
affectedsiblingwithICHaretransfusedatathresholdof
50109/L.IfHPAcompatibleplateletsarenotavailableina
clinicallyrelevanttimeframe,randomdonorneonatalplatelets
shouldbetransfusedandwillproduceatemporaryplatelet
incrementinmostcases.Spontaneousrecoveryoftheplatelet
countusuallyoccurswithin1to6weeksasmaternallyderived
antibodylevelsfall.Forbabieswithpersistentsevere

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thrombocytopenia,intravenousimmunoglobulinimprovesthe
countinaround75%ofcases,butresponseisoftendelayed
for2448hours.

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