7 May 11 - Helen Savoia
-
Upload
ahmadcaesar -
Category
Documents
-
view
219 -
download
0
Transcript of 7 May 11 - Helen Savoia
-
7/29/2019 7 May 11 - Helen Savoia
1/22
Transfusion in inner space:Transfusion in inner space:Blood products for intrauterineBlood products for intrauterine
transfusiontransfusion
Dr HelenDr Helen SavoiaSavoia
-
7/29/2019 7 May 11 - Helen Savoia
2/22
OverviewOverview
The fetus as transfusion recipientThe fetus as transfusion recipientTechnical aspects of intrauterineTechnical aspects of intrauterinetransfusiontransfusionIndications for intrauterine transfusionIndications for intrauterine transfusionRed cells for fetal transfusionRed cells for fetal transfusion
Platelets for fetal transfusionPlatelets for fetal transfusion
-
7/29/2019 7 May 11 - Helen Savoia
3/22
The fetus as a transfusion recipientThe fetus as a transfusion recipient
No name, no gender, no DOBNo name, no gender, no DOBNo ID bandNo ID band
NoNo prepre --transfusion sampletransfusion sample Designated nameDesignated name -- Maternal Surname, FirstMaternal Surname, FirstName (Name ( FetusFetus ))
Estimated/projected DOBEstimated/projected DOBSeparate identity to mother for transfusionSeparate identity to mother for transfusionSmall sizeSmall size
-
7/29/2019 7 May 11 - Helen Savoia
4/22
The fetus as transfusion recipientThe fetus as transfusion recipient
Complex immunological effects of transfusion,Complex immunological effects of transfusion,poorly definedpoorly defined
Best seen asBest seen as
immunocompromisedimmunocompromised
recipientrecipient
At risk of viral transmission (CMV) At risk of viral transmission (CMV) At risk of At risk of TaGVHDTaGVHD (irradiation)(irradiation)
-
7/29/2019 7 May 11 - Helen Savoia
5/22
Technical aspects of intrauterineTechnical aspects of intrauterinetransfusiontransfusion
IPT feasible from 15IPT feasible from 15 --16 weeks gestation16 weeks gestationIVT feasible from 18IVT feasible from 18 --20 weeks gestation20 weeks gestation
IVT allows FBSIVT allows FBSImmediate correction of fetal anaemiaImmediate correction of fetal anaemiaIVT can reverse fetal hydropsIVT can reverse fetal hydrops
Ultrasound guidedUltrasound guided Fetal paralysis (Fetal paralysis ( pancuroniumpancuronium ))
-
7/29/2019 7 May 11 - Helen Savoia
6/22
20 weeks gestation, EW 250g, EBV 45mls
-
7/29/2019 7 May 11 - Helen Savoia
7/22
The firstThe first IUTsIUTsIntraperitonealIntraperitoneal transfusion 1960stransfusion 1960s
Amniocentesis with injection of contrast Amniocentesis with injection of contrast2424 --48 hours later, fetal gut outlined by contrast48 hours later, fetal gut outlined by contrastXX--RayRay localisationlocalisation of needle into fetal peritoneal cavityof needle into fetal peritoneal cavityRed cells absorbed via thoracic duct into fetalRed cells absorbed via thoracic duct into fetalcirculations over 5circulations over 5 --6 days6 days
Intravascular transfusion 1980sIntravascular transfusion 1980sFetoscopyFetoscopy and intravascular transfusion into umbilicaland intravascular transfusion into umbilicalvesselvessel
-
7/29/2019 7 May 11 - Helen Savoia
8/22
Intrauterine transfusion in 2008Intrauterine transfusion in 2008
Fetal red cell transfusionFetal red cell transfusionHaemolyticHaemolytic disease due to red cell alloimmunisationdisease due to red cell alloimmunisationFetal anaemia due to congenital infection (Parvovirus)Fetal anaemia due to congenital infection (Parvovirus)
FetalFetal anaemia in twin to twin transfusion (donor twin)anaemia in twin to twin transfusion (donor twin)Fetal anaemia due to massive FMHFetal anaemia due to massive FMHFetal haemorrhage (Fetal haemorrhage ( tumourstumours etc)etc)
Fetal platelet transfusionFetal platelet transfusionThrombocytopenia due to platelet antigenThrombocytopenia due to platelet antigenalloimmunisationalloimmunisation
-
7/29/2019 7 May 11 - Helen Savoia
9/22
Complications of IUTComplications of IUT
Cord haematoma with arterial vasospasm andCord haematoma with arterial vasospasm andfetalfetal bradycardiabradycardiaFetalFetal exsanguinationexsanguination
Premature rupture of membranesPremature rupture of membranesInfectionInfection
Augmentation of maternal Augmentation of maternal alloimmunisationalloimmunisation andandnew antibodies due to FMHnew antibodies due to FMHLong term consequences of transfusionLong term consequences of transfusion
-
7/29/2019 7 May 11 - Helen Savoia
10/22
Procedural complicationsProcedural complicationsCohort study 254 fetuses/740Cohort study 254 fetuses/740 IUTsIUTs , 1988, 1988 --20012001(single centre)(single centre)Red cell transfusion for alloimmunisationRed cell transfusion for alloimmunisation225/254 (89%) survival225/254 (89%) survival
19 fetal deaths (7PR), 10 neonatal deaths (5PR)19 fetal deaths (7PR), 10 neonatal deaths (5PR)2 intrauterine infection (2 intrauterine infection ( E.coliE.coli) (both PR)) (both PR)2 PPROM (1 PR)2 PPROM (1 PR)18 emergency deliveries (15 PR)18 emergency deliveries (15 PR)
Total complications 3.1%, 1.6% loss rate perTotal complications 3.1%, 1.6% loss rate per
procedureprocedureVan Kamp et. Al. Am J Obstet Gynecol 2005
-
7/29/2019 7 May 11 - Helen Savoia
11/22
Procedural complicationsProcedural complications
Platelet transfusion in AITPlatelet transfusion in AITIncreased risks of bleeding andIncreased risks of bleeding andbradycardiabradycardiaRecent studies suggest 6%Recent studies suggest 6% fetalfetal loss rateloss rate
-
7/29/2019 7 May 11 - Helen Savoia
12/22
-
7/29/2019 7 May 11 - Helen Savoia
13/22
-
7/29/2019 7 May 11 - Helen Savoia
14/22
-
7/29/2019 7 May 11 - Helen Savoia
15/22
Red Cells for Fetal TransfusionRed Cells for Fetal TransfusionGroup O Rh D negative,Group O Rh D negative, KellKell negative (usually!)negative (usually!)
IATIAT crossmatchcrossmatch compatible with maternalcompatible with maternalplasmaplasmaFree from clinically significant antibodiesFree from clinically significant antibodies< 5 days old< 5 days oldCMV negative, leukocyte depletedCMV negative, leukocyte depleted
Irradiated and used within 24Irradiated and used within 24hours of irradiationhours of irradiation
-
7/29/2019 7 May 11 - Helen Savoia
16/22
BCSH Guidelines 2004BCSH Guidelines 2004In CPD not SAGIn CPD not SAG --MMFree from high titre antiFree from high titre anti -- A and anti A and anti --BBHbSHbS negativenegativeHaematocritHaematocrit 0.70.7 --0.850.85Not transfused straight from 4Not transfused straight from 4 C storageC storage
Transfusion guidelines for neonates and older children BCSH 2004Transfusion guidelines for neonates and older children BCSH 2004
-
7/29/2019 7 May 11 - Helen Savoia
17/22
Local practiceLocal practiceRed cells in additive solutionRed cells in additive solutionHctHct approximately 0.6approximately 0.6Matched for extended maternal antigen typingMatched for extended maternal antigen typing
Anti Anti -- A and Anti A and Anti --B not testedB not testedHbHb S not testedS not testedWarmed to 37Warmed to 37 C prior to transfusion andC prior to transfusion andtransfusion within 4 hourstransfusion within 4 hoursSplit packs to reduce donor exposure withSplit packs to reduce donor exposure withwashing of 2washing of 2 ndnd segment prior to transfusionsegment prior to transfusion
-
7/29/2019 7 May 11 - Helen Savoia
18/22
IssuesIssuesRed cell IUT best seen as a rapid, large volumeRed cell IUT best seen as a rapid, large volumetransfusiontransfusionK+ an issueK+ an issueHaemolysin testing?Haemolysin testing?
Does not seem to be an issue with plasmaDoes not seem to be an issue with plasma --poor RBCpoor RBCtransfusion in the NNUtransfusion in the NNU
Additive solution? Additive solution?No adverse clinical/biochemical effects for neonatalNo adverse clinical/biochemical effects for neonataltoptop --up (Strauss 1996, 2000)up (Strauss 1996, 2000)Effective for cardiac byEffective for cardiac by --pass surgery in infants (pass surgery in infants ( MouMou,,2004)2004)
-
7/29/2019 7 May 11 - Helen Savoia
19/22
Platelets forPlatelets for FetalFetal TransfusionTransfusionGroup OGroup O RhDRhD negative, negative for highnegative, negative for high --titretitreantianti -- A, anti A, anti --B or group specific compatible withB or group specific compatible withmaternal antibodymaternal antibodyHPA compatible with maternal antibodyHPA compatible with maternal antibodyPreferably collected byPreferably collected by apheresisapheresisIrradiatedIrradiatedConcentrated to a platelet count >2000 x 10Concentrated to a platelet count >2000 x 10 9 /L /LTransfused at a rate of 1Transfused at a rate of 1 --5 ml/min5 ml/min
Transfusion guidelines for neonates and older children BCSH 2004Transfusion guidelines for neonates and older children BCSH 2004
-
7/29/2019 7 May 11 - Helen Savoia
20/22
Local PracticeLocal Practice
HPA compatible with maternal antibodyHPA compatible with maternal antibodyStandardStandard apheresisapheresis componentscomponents
CMV negative,CMV negative, leucocyteleucocyte depleteddepletedIrradiatedIrradiatedNot concentratedNot concentrated
-
7/29/2019 7 May 11 - Helen Savoia
21/22
Products forProducts for FetalFetal TransfusionTransfusion
Red cellsRed cellsLarge volume, rapid transfusionLarge volume, rapid transfusion
PlateletsPlateletsBradycardiaBradycardia ? Mediated, ? PAS? Mediated, ? PASHyperconcentrationHyperconcentration ??
-
7/29/2019 7 May 11 - Helen Savoia
22/22
Long term effects of Long term effects of fetalfetaltransfusiontransfusion
Not well studiedNot well studied? Immunological effects? Immunological effects
Expected 80+ years post transfusionExpected 80+ years post transfusionsurvivalsurvival