1. Interesting Case Conference: Intrauterine Transfusion
Daniel Long, M.D.
February 22, 2019

2. Case Details 31 year old pregnant female (G4T3003) at 26 wks EGA
The patient’s 3rd child required neonatal transfusion and photherapy for hemolytic of the newborn
2/28/13 (9 wks EGA)
Anti-D titer: 1:16, anti-C titer: 1:2 (OSH)
5/20/13 (20 wks EGA)
Anti-D titer: 1:32, anti-C titer: 1:1 (OSH)
7/4/13 (26 wks EGA)
Anti-D titer: 1:128, anti-C titer: 1:1 (VUMC)
Ultrasound: active fetus, MCA PSV: 1.76 MoM
Fetal monitoring: reassuring

3. Fetal Monitoring: MCA Velocity
Source: Duckler D, et al. Am J Obstet Gynecol. 2003;188:

4. Fetal Monitoring: Amniocentesis
Source: Queenan JT, et al. Am J Obstet Gynecol. 1993;168:

5. Fetal Monitoring
Source: Oepkes D, et al. N Engl J Med. 2006;355:

6. Treatment Algorithm
Source: Moise KJ. Semin Hematol Jul;42(3):

7. Intrauterine Transfusion
Type O Rh negative RBCs
CMV antibody negative
Fresh (enhanced 2-3 DPG level)
In the UK: no more than 5 days old
Irradiated
Leukodepletion
Washed and packed (Hct 75-85%)

8. Intrauterine Transfusion

9. Risks of IUT Perinatal death: 1.6% Emergency cesarean delivery: 2.0%
Infection: 0.3%
Premature rupture of membranes: 0.1%
Inadvertent arterial puncture: 3%
Bradycardia or tachycardia: 5%
57% of cases with perinatal death or emergent delivery
Long-term morbidity
Cerebral palsy: 2.8%, developmental delay: 3.9%, hearing loss: 2.3%
Immunomodulatory effect?
Sources: van Kamp IL, et al. Am J Obstet Gynecol. 2005;192: Moise, KJ, et al. Alloimmune disorders in pregnancy. Anaemia, thrombocytopenia and neutropenia in the fetus and newborn, Hadley, A, Soothill, P (Eds), Cambridge Press, Cambridge, 2002.

10. Iron Overload
Source: Rath MEA. Vox Sang Jun 27.

11. Transfused Volume Goal Hct 40-50% (consistent with the normal fetus)
Giannina G, et al. Fetal Diagn Ther. 1998;13:94-7.
Fetal weight (g) x 0.02 = amount required to increase the fetal Hct by 10%
Mandelbrot L, et al. Fetal Ther. 1988;3(1-2):60-6.
Fetoplacental volume (mL) x goal change in Hct / donor unit Hct
Fetoplacental volume = fetal weight (g) x 0.14

12. 7/5/13 Intrauterine Transfusion
Estimated fetal weight: 940 g (37%ile)
Pre-transfusion fetal Hgb: 4.1 g/dL (Hct 12%)
Amniotic bilirubin scan: OD

13. Fetal Monitoring: Amniocentesis
Source: Queenan JT, et al. Am J Obstet Gynecol. 1993;168:

14. 7/5/13 Intrauterine Transfusion
Estimated fetal weight: 940 g (37%ile)
Pre-transfusion fetal Hgb: 4.1 g/dL (Hct 12%)
Amniotic bilirubin scan: OD
Transfusion requirement (goal Hct 45%)
Giannina estimate: 62 mL / 33% change
Mandlebrot estimate: 55 mL / 33% change
58/60/68 mL of PRBCs were transfused
Post-transfusion fetal Hgb: 7.5 g/dL (Hct 23%)

15. Case Details 7/4, 7/5/13 (26 wks EGA) 7/15, 7/18/13 (28 wks EGA)
Anti-D titer: 1:128 , anti-C titer: 1:1
MCA PSV: 1.76 MoM
IUT: ~60 mL transfused
7/15, 7/18/13 (28 wks EGA)
Anti-D titer: 1:1024, anti-C titer: 1:2
MCA PSV: 1.9 MoM

16. 7/18/13 Intrauterine Transfusion
Estimated fetal weight: 1013 g (56%ile)
Pre-transfusion fetal Hct: 27%
Transfusion requirement (goal Hct 45%)
Giannina estimate: 36 mL / 18% change
Mandlebrot estimate: 32 mL / 18% change
37 mL of PRBCs were transfused
Post-transfusion fetal(?) Hct: 35%

17. Case Details 7/4, 7/5/13 (26 wks EGA) 7/15, 7/18/13 (28 wks EGA)
Anti-D titer: 1:128 , anti-C titer: 1:1
MCA PSV: 1.76 MoM
IUT: ~60 mL transfused
7/15, 7/18/13 (28 wks EGA)
Anti-D titer: 1:1024, anti-C titer: 1:2
MCA PSV: 1.9 MoM
7/23/13 (29 wks EGA)
Non-reassuring fetal status, ↓ movements
C-section performed

18. Case Resolution Baby girl L was delivered at 29.3 wks
APGARS 4/6/6
Initial labs:
Hgb 3.5 g/dL, TBil 5.5 mg/dL, DAT negative
Patient is currently stable on room air
4 additional PRBC transfusions to date
Most recent labs:
Hgb 9.5 g/dL, TBil 5.3 mg/dL, retic 0.3%

19. Efficacy of IVIG?
Sources: Kirplani, A. Gynecol Obstet Invest. 2007;63(3):
Matsuda, H. J Perinatol Apr;31(4):