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Objective: This study aimed to investigate the outcomes associated with the administration of maternal intravenous immunoglobulin in high-risk red blood cell-alloimmunized pregnancies., Data Sources: Medline, Embase, and Cochrane Library were systematically searched until June 2023., Study Eligibility Criteria: This review included studies reporting on pregnancies with severe red blood cell alloimmunization, defined as either a previous fetal or neonatal death or the need for intrauterine transfusion before 24 weeks of gestation in the previous pregnancy as a result of hemolytic disease of the fetus and newborn., Methods: Cases were pregnancies that received intravenous immunoglobulin, whereas controls did not. Individual patient data meta-analysis was performed using the Bayesian framework., Results: Individual patient data analysis included 8 studies consisting of 97 cases and 97 controls. Intravenous immunoglobulin was associated with prolonged delta gestational age at the first intrauterine transfusion (gestational age of current pregnancy - gestational age at previous pregnancy) (mean difference, 3.19 weeks; 95% credible interval, 1.28-5.05), prolonged gestational age at the first intrauterine transfusion (mean difference, 1.32 weeks; 95% credible interval, 0.08-2.50), reduced risk of fetal hydrops at the time of first intrauterine transfusion (incidence rate ratio, 0.19; 95% credible interval, 0.07-0.45), reduced risk of fetal demise (incidence rate ratio, 0.23; 95% credible interval, 0.10-0.47), higher chances of live birth at ≥28 weeks (incidence rate ratio, 1.88; 95% credible interval, 1.31-2.69;), higher chances of live birth at ≥32 weeks (incidence rate ratio, 1.93; 95% credible interval, 1.32-2.83), and higher chances of survival at birth (incidence rate ratio, 1.82; 95% credible interval, 1.30-2.61). There was no substantial difference in the number of intrauterine transfusions, hemoglobin level at birth, bilirubin level at birth, or survival at hospital discharge for live births., Conclusion: Intravenous immunoglobulin treatment in pregnancies at risk of severe early hemolytic disease of the fetus and newborn seems to have a clinically relevant beneficial effect on the course and severity of the disease., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In newborns with hemolysis, the direct antiglobulin test (DAT) and indirect antiglobulin test (IAT) play a key role in demonstrating the presence of an immune cause. We aimed to emphasize the importance of IAT in mothers of DAT-positive babies., Methods: DAT was performed with forward blood grouping on cord blood in term babies who were born between September 2020 and September 2022. IAT was performed in the mothers of the babies who were found to have a positive DAT and antibody identification was performed in the mothers who were found to have a positive IAT. Specific antibodies detected and identified were associated with the clinical course., Results: The study included 2769 babies and their mothers. The prevalence of DAT positivity was found to be 3.3% (87 of 2661). In DAT-positive babies, the rate of ABO incompatibility was 45.9%, the rate of RhD incompatibility was 5.7% and the rate of RhD and ABO incompatibility in association was 10.3%. The rate of subgroup incompatibility and other red blood cell antibodies was 18.3%. Phototherapy was applied because of indirect hyperbilirubinemia in 16.6% of the DAT-negative babies and in 51.5% of the DAT-positive babies. The need for phototherapy was significantly higher in DAT-positive infants (p < 0.01). Severe hemolytic disease of the newborn, bilirubin level, duration of phototherapy and use of intravenous immunoglobulin were found to be significantly higher in the babies whose mothers were IAT positive compared with the babies whose mothers were IAT negative (p < 0.01)., Conclusions: IAT should be performed on all pregnant women. When screening with IAT is not performed during pregnancy, performing DAT in the baby plays a key role. We showed that the clinical course was more severe when mothers of DAT-positive babies were IAT positive., Competing Interests: Conflict of interest We declare not to have any conflict of interest as we do not have any financial and personal relationships with other people or organizations that could inappropriately influence this work., (Copyright © 2024 Taiwan Pediatric Association. Published by Elsevier B.V. All rights reserved.)

Background: There is controversy on critical cut-off values of laboratory testing to select pregnancies at increased risk for anti-Kell-mediated hemolytic disease of the fetus and newborn. Without early detection and treatment, anti-Kell-mediated hemolytic disease of the fetus and newborn may result in progressive fetal anemia, fetal hydrops, asphyxia, and perinatal death., Objective: We aimed to determine the value of repeated anti-Kell titer determination and biological activity measurement using the antibody-dependent cellular cytotoxicity test determination in the management of pregnancies at risk for anti-Kell-mediated hemolytic disease of the fetus and newborn., Study Design: This was a retrospective cohort study of pregnancies with anti-Kell and a Kell-positive fetus, identified from January 1999 through April 2015. Laboratory test results and clinical outcome were collected from the Dutch nationwide screening program and the national reference center for fetal therapy in The Netherlands, the Leiden University Medical Center. Diagnostic accuracy was measured (receiver operating characteristic curves, sensitivity, specificity, positive and negative predictive values) for anti-Kell titers and antibody-dependent cellular cytotoxicity test. The relationship between the titer and antibody-dependent cellular cytotoxicity measurements and the 2 foregoing measurements were computed with a Pearson product-moment correlation coefficient., Results: In a 16-year unselected cohort, representing screening results of 3.2 million pregnancies resulting in live births in The Netherlands, we identified 1026 Kell-immunized pregnancies. In all, 93 pregnant women had anti-Kell and a Kell-positive child, without other red cell alloantibodies. In all, 49 children (53%) needed intrauterine or postnatal transfusion therapy. The first anti-Kell titer showed already a high diagnostic accuracy with an area under the curve of 91%. The optimal cut-off point for the titer was 4 (sensitivity 100%; 95% confidence interval, 91-100), specificity 27% (95% confidence interval, 15-43), and positive predictive value 60% (49-71%). The antibody-dependent cellular cytotoxicity test was not informative to select high-risk pregnancies. Linear regression showed no significant change during pregnancy, when antibody titer and antibody-dependent cellular cytotoxicity test results were compared with every 2 foregoing measurements (P < .0001)., Conclusion: Early determination of the anti-Kell titer is sufficient to select pregnancies at increased risk for hemolytic disease of the fetus and newborn with need for transfusion therapy. If the Kell status of the fetus is known to be positive, a titer of ≥4 can be used to target intensive clinical monitoring., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Maternal-fetal red cell antigen incompatibility can lead to alloimmunization, maternal immunoglobulin transplacental transfer, and hemolytic disease of the fetus and newborn (HDFN). The use of routine antenatal anti-D prophylaxis (RAADP) has sharply decreased the incidence of and mortality from HDFN due to RhD allosensitization. The ability to identify pregnancies/fetuses at risk of HDFN has significantly improved due to paternal molecular RHD zygosity testing, and non-invasive fetal molecular diagnostics for detecting putative antigen(s) (notably RhD) in fetuses utilizing cff-DNA in maternal plasma. Fetal RHD genotyping using cff-DNA has become increasingly accurate for fetal RHD detection, prompting some countries to implement targeted RAADP through mass screening programs of RhD-negative pregnant women. Along with middle cerebral artery Doppler ultrasonography for predicting fetal anemia, non-invasive fetal molecular diagnostics have greatly decreased the need for invasive diagnostic procedures in pregnancies at risk for severe HDFN. This review highlights these molecular advancements in HDFN-related prenatal diagnostics., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The direct antiglobulin test (DAT) is the cornerstone of the diagnosis of hemolytic disease of the newborn (HDN). The aim of this study was to review the incidence and causes of positive DAT in cord blood in relation to development of HDN., Methods: We retrospectively reviewed all results of DAT, which is routinely performed in cord blood samples, along with the laboratory and infants' medical records., Results: DAT was positive in 70/2695 (2.59%) cases. In 64/70 (91.43%) cases, DAT positivity was attributed to ABO incompatibility. There were 50/218 (22.93%) DAT (+) cases in the A/O group and 13/97 (13.40%) cases in the B/O group (p = 0.0664). Two DAT (+) cases were attributed to maternal alloimmunization (anti-Fya and anti-JKb, respectively), and one to maternal IgG autoantibodies that developed after methyldopa treatment. Among the 70 DAT (+) cases, 30 (42.86%) cases required phototherapy with no difference between the A/O and B/O groups. The duration of phototherapy in the B/O group was significantly longer than in the A/O group (p = 0.024). There was a trend of correlation of increasing strength of DAT positivity with phototherapy need. No false positive DAT case was detected., Conclusions: Although ABO incompatibility remains the main reason of DAT (+), other causes (e.g., alloimmunization, drugs) should also be explored. The relevant impact of DAT (+) on HDN development should be considered., (Copyright © 2015. Published by Elsevier B.V.)

Rh (Rhesus) proteins (D, CcEe) are expressed in red cells (RBC) in association with other membrane proteins (RhAG, LW, CD47 and GPB). By interacting with the spectrin-based skeleton through protein 4.2 and ankyrin, the Rh complex contributes to the maintenance of the mechanical properties of the erythrocyte membrane. The RH system is one of the most immunogenic and polymorphic human blood group system. Molecular basis of most Rh phenotypes, including the Rh(null) phenotype associated with hemolytic anemia, have been determined. The demonstration that the RHD-positive locus is composed of the RHD and RHCE genes, whereas the RHD gene is deleted in most RhD-negative individuals, allowed fetal RhD genotyping by non-invasive PCR assays for antenatal diagnosis of pregnancy at risk for Rh hemolytic disease of the newborn. In mammals, the Rh protein family includes two non-erythroid members, RhBG and RhCG, mainly expressed in liver and kidney, two organs specialized in ammonia genesis and excretion. Functional analyses in heterologous systems revealed that RhAG, RhBG and RhCG can mediate ammonium (NH(3) and/or NH(4)(+)) transport across the cell membrane and might represent mammalian specific ammonium transporters. Furthermore, recent studies performed in human and murine red blood cells (RBC) indicate that RhAG facilitates CH(3)NH(2)/NH(3) movement across the membrane and represents a potential example of gas channel. The crystallographic structure of the bacterial ammonia channel AmtB and functional studies showing that AmtB conducts NH(3) into reconstituted vesicles is fully consistent with these latter studies. In RBCs, RhAG may transport NH(3) to detoxifying organs like kidney and liver and with non-erythroid tissues orthologs may contribute to regulation of the acid-base balance.

At present, rhesus prophylaxis concerns RhD negative pregnant women, even though 30 to 40% of them are bearing a RhD negative child. Knowing the RhD fetal genotype could change this quite irrational practice of prophylaxis (exposing many more women than needed to blood derived products) without reducing its efficacy. RhD fetal genotype determined on amniotic fluid has an excellent sensitivity. Presence of silent D genes slightly impairs its specificity which remains acceptable. However women have to be informed of possible false positives. Fetal RhD genotyping on maternal blood is more complex. Sensitivity is good from 10 GW and excellent after 15 GW. In case of a first negative result, it is recommended to control fetal RhD on a second sample drawn a few weeks later. Another new perspective for rhesus prophylaxis is the attempt to substitute polyclonal IgG anti-D into human monoclonal IgG anti-D. The main difficulty is to elaborate monoclonal antibodies with a capacity to neutralize RhD positive red blood cells equivalent to those of polyclonal anti-D. A new generation of antibodies is in process and preliminary clinical results are suggesting a possible use of these monoclonal antibodies for future rhesus prophylaxis but long-term follow-up is required to draw further conclusions.

Objective: This study was undertaken to audit ultrasonographic measurements of fetal liver length and middle cerebral artery peak velocity in cases of red blood cell alloimmunization between 1986 and 1999., Study Design: A total of 200 fetuses at risk for anemia because of red blood cell alloimmunization underwent ultrasonographic measurement of the length of the right lobe of the liver, 45 underwent Doppler recording of middle cerebral artery peak velocity, and 119 underwent fetal blood sampling., Results: The overall survival was 188 of 200 (94%). Among 69 fetuses found to have anemia, liver length values in 64 (93%) were at the 95th percentile or greater, and the other 5 were in the upper part of the normal range. The middle cerebral artery peak velocity was > or =95th percentile in 15 of the 19 cases of anemia in which this value was measured (79%). Among those measured within 1 week of birth, all liver lengths were at least in the upper part of the normal range, with most >95th percentile, including 1 case with a cord blood hemoglobin concentration <90 g/L., Conclusions: All fetuses with anemia identified at fetal blood sampling had enlarged livers with 93% at > or =95th percentile. The peak velocity in the middle cerebral artery was abnormal in most fetuses with anemia.

There has been a dramatic reduction in the incidence of neonatal mortality due to fetal hemolytic disease since the introduction of Rhesus prophylaxis. Although routinely used since 1968, the exact mode of action of anti-D IgGs is still not fully understood. Notable advances have taken place in the screening and the management of fetal hemolytic disease. This article describes the antibody detection in the mother, and the fetal management with ultrasound amniocentesis, fetal blood sampling and intrauterine transfusions. Finally, the postnatal management is also considered.

Objective: Current management protocols for pregnancies complicated by red blood cell alloimmunization use the maternal antibody titer to predict the need for invasive testing for detection of fetal anemia. We investigated the use of three maternal serum tests to assess their usefulness in predicting fetal disease: indirect Coombs' titer, Marsh score, and monocyte monolayer assay., Study Design: Forty-seven serum samples from pregnant women with red blood cell antibodies associated with fetal anemia were analyzed at cordocentesis. Fetal blood was analyzed for hematocrit (corrected for gestational age) and antigen status. Fetal anemia was defined as a hematocrit value of < 2 SD from the mean value for gestational age. Fetuses were classified into three groups: Antigen positive with anemia (n = 19), antigen positive without anemia (n = 17), antigen negative (n = 11). Statistical methods included Kruskal-Wallis test, Newman-Keuls test, Spearman's rank correlation, and receiver-operator characteristic curves; p < 0.05 was considered significant., Results: The median monocyte monolayer assay (phagocytosis, adherence, and association) did not differ among the three groups. Both maternal titers and Marsh scores were significantly higher in fetuses with anemia compared with the other two groups of fetuses (256 vs 64 vs 64, p < 0.001, and 86 vs 69 vs 64, p = 0.02, respectively). Both titer and Marsh score exhibited significant correlations with corrected fetal hematocrit (r = -0.70, p < 0.001; r = -0.63, p < 0.001, respectively). Comparison of the overall receiver-operator characteristic curves for titer and Marsh score revealed no statistical difference; however, a Marsh score of 57 was noted to have a superior specificity than a titer of 16 (p = 0.02)., Conclusion: The maternal Marsh score can be performed in conjunction with standard indirect Coombs' titers to enhance the predictability of fetal anemia.

Objective: Our purpose was to describe the clinical utility of a deoxyribonucleic acid amplification method for determining fetal RhD status in alloimmunized pregnancies, Study Design: Six RhD-negative women with alloimmunized pregnancies and heterozygous partners underwent amniocentesis (n = 5) or chorionic villus sampling (n = 1). Fetal RhD type was determined by polymerase chain reaction and results disclosed to the attending physicians., Results: Knowledge of the fetal RhD status avoided further invasive procedures in two pregnancies and facilitated the timing or performance of intrauterine transfusions in the remainder., Conclusions: In alloimmunized pregnancies the ability to RhD-type the fetus in amniotic fluid avoids the risks of fetomaternal hemorrhage and increased sensitization associated with fetal blood sampling or chorionic biopsy. This allows more rational pregnancy management, avoiding invasive procedures in the presence of an RhD-negative fetus, or planning therapeutic interventions or offering termination of pregnancy in the presence of an RhD-positive fetus.

Objective: Diagnosis and treatment of haemolytic disease of the fetus has considerably progressed since the introduction of Liley's diagram. Amniocentesis and cordocentesis have changed diagnostic and therapeutic options. Recently, some authors pleaded for restraint in diagnostic cordocentesis. In this context of relative controversy, we wanted to compare our results with those of the literature., Subjects and Methods: Thirty-nine pregnancies complicated by antigen incompatibilities were referred to our unit. The haemolytic disease was evaluated by the measurement of antibody titers, by spectrophotometry in the amniotic fluid, by measurement of fetal haematocrit in cord blood samples and by ultrasound examination. Sixty-four amniocenteses, 85 cordocenteses and 25 in utero transfusions were performed., Results: Alloimmunization anti-D represented 67% of the cases in our series of 39 pregnancies. Fifteen percent of the fetuses were antigen negative. One neonatal death after chorioamnionitis was observed after cordocentesis, the fetal loss rate related to the procedure was 1.2%, Six fetuses had a haematocrit below 30% at the first sampling; 9 other fetuses developed an anaemia later in pregnancy. Six fetuses underwent in utero transfusion. One of these fetuses had hydrops at the ultrasound before the procedure. Twenty-five in utero transfusions were uncomplicated in spite of the observation of one post-transfusional haematoma of the umbilical cord. The delta OD450 measurement did not predict the severity of fetal anaemia in all cases., Conclusion: In our experience, the fetal haematocrit measurement remains the most reliable method to evaluate the severity of the haemolytic disease.

Objectives: Our purpose was to study deviations in values of amniotic fluid optical density at 450 nm in Rh-immunized pregnancies in the second and third trimesters and to propose a clinical management plan., Study Design: A total of 789 amniotic fluid single and serial values of deviations in optical density at 450 nm were performed on Rh-immunized pregnancies from 14 to 40 weeks' gestation. The relationship of the deviations in amniotic fluid values of optical density at 450 nm to varying degrees of fetal disease were examined., Results: In Rh-negative fetuses (unaffected) amniotic fluid values rise until 22 to 26 weeks before decreasing to term. In fetuses at risk of dying in utero, values are higher and trends rise. A clinical management plan was devised on the basis of the amniotic fluid findings of deviations in optical density at 450 nm., Conclusions: A clinical management scheme consisting of four zones is outlined. Rh-negative fetuses have minimal invasive procedures. Fetuses at risk of death undergo early cordocentesis for evaluation and therapy. Values that fall in between can be separated into two zones on the basis of the degree of risk.

To determine whether elevated fetal mean corpuscular volume is characteristic of a chromosome abnormality or fetal disease, 22 fetuses with chromosome abnormalities, 31 with uteroplacental insufficiency, 50 undergoing their first cordocentesis for hemolytic disease, and 50 control fetuses were identified. Chromosomally abnormal fetuses had a significantly higher mean corpuscular volume than the control fetuses. Among fetuses with chromosome abnormalities, the mean corpuscular volume for trisomic or triploid fetuses was significantly higher than for fetuses with other chromosome abnormalities. An elevated mean corpuscular volume was also associated with uteroplacental insufficiency, intrauterine growth retardation, and hemolytic disease. It correlated significantly with gestational age (p less than 0.002 in all cases) in all groups except trisomy or triploidy. In addition, it correlated with hematocrit in the hemolytic disease group (r = -0.60, p less than 0.0001) and with PO2 in fetuses with intrauterine growth retardation (r = -0.43, p = 0.005) from all causes including uteroplacental insufficiency. Trisomic or triploid fetuses showed no such relationships and therefore appear to have escaped the normal control mechanisms for erythropoiesis. One in 12 fetuses with an elevated mean corpuscular volume had trisomy or triploidy, whereas no fetus with trisomy or triploidy had a normal mean corpuscular volume. Thus an unexpectedly elevated fetal mean corpuscular volume in a patient undergoing cordocentesis for reasons other than evaluation of fetal chromosomes would appear to warrant further karyotypic analysis.

Between January 1985 and November 1990, 128 pregnancies complicated by maternal red blood cell alloimmunization were referred to our Fetal Diagnosis and Treatment Unit. We examined the premise that an evaluation of fetal blood would accurately identify fetuses at risk of requiring antenatal transfusion therapy. Two hundred seventy-two diagnostic cordocenteses were performed. Criteria for the timing of repeat cordocenteses were developed retrospectively on the basis of the fetal hematocrit values, reticulocyte counts, and direct Coombs' test results of the first 84 pregnancies. These criteria were tested and confirmed prospectively on the next 44 pregnancies. On the basis of the first blood sample, four hematologic patterns (and their distributions) were identified in the 98 antigen-positive fetuses. Pattern 1: fetuses at low risk of having significant antenatal anemia (hematocrit less than 30%) (n = 11, 11%). These fetuses had normal hematocrit values and reticulocyte counts coupled with negative or trace-positive direct Coombs' test. No fetus in this group had significant antenatal anemia. Pattern 2: fetuses at intermediate risk of having anemia (n = 29, 31%). Pattern 2 fetuses had normal hematocrit values and either direct Coombs' titers of more than trace less than or equal to 2+ and normal reticulocyte counts or low reticulocyte counts (less than 2.5th percentile for gestation). Twenty-one percent (n = 6) of fetuses in pattern 2 had significant antenatal anemia. Patterns 3 and 4: fetuses at greatest risk of having severe anemia. These fetuses had normal hematocrit values associated with either reticulocyte counts greater than 97.5th percentile for gestation or a direct Coombs' test greater than or equal to 3+ (pattern 3, n = 49, 50%) or both, or a mild anemia (greater than 30% but less than 2.5th percentile for gestation) (pattern 4, n = 9, 10%). Eighty percent (n = 39) of fetuses with pattern 3 and 90% (n = 8) with pattern 4 developed a hematocrit value less than 30%. We conclude that evaluation of fetal hemolytic disease with a fetal blood specimen permits the identification of fetuses at high risk of having antenatal anemia.

A severely Rh-isoimmunized pregnancy is described in which an intrauterine transfusion of blood was given by the intravascular route directly into an umbilical vessel. Fetoscopy was not used, and the procedure was performed percutaneously under direct ultrasound visualization.

Over a 27-month period 17 pregnancies in 16 patients with severe red blood cell isoimmunization were managed with intravascular transfusions performed in utero. Fourteen of these women were Rh negative and sensitized to D or to both D and C, and the remaining two patients were sensitized to the Kell antigen (K). In 12 of the 17 cases (71%) the first intravascular transfusion was performed at 26.5 weeks' gestation or earlier. Thirty-nine of 45 attempted transfusions (87%) were successfully performed. All were done percutaneously under ultrasonic guidance. Two procedures were partial exchanges, while the remainder were straight transfusions. Thirteen of the 17 fetuses (76%) were alive at birth and survived the neonatal period. Four fetuses died in utero at 25 to 26 weeks' gestation, all within 12 hours of an intravascular transfusion. When the 27 procedures attempted during the most recent 9 months of this series were compared with the 18 procedures attempted during the preceding 18 months, no appreciable differences in technical success or fetal outcome were evident. An analysis of this experience is presented, along with modifications in technique that have been implemented. Unresolved issues are discussed.

We previously reported a significant relationship between the hematocrit levels of anemic fetuses and information derived from ultrasonographic and Doppler flow-velocity waveforms. In this study we prospectively tested two formulas for the prediction of hematocrit values, by use of gestational age, presence or absence of hydrops, and Doppler indices. Although one of the two formulas predicted hematocrit values significantly, the only component of the formula that made a significant contribution was fetal hydrops. We conclude that currently available fetal Doppler measurements are unable to be applied in the prospective prediction of hematocrit values in anemic fetuses of isoimmunized pregnancies.

Pulsed Doppler studies of the fetal and maternal circulations were carried out before and after 64 intrauterine transfusions performed on 24 fetuses. A model was derived for the prediction of hematocrit before the first transfusion: Hematocrit = 7.778 - (0.088 x peak velocity in descending aorta) + (0.968 x gestational age [weeks]) - (10.911 if hydrops present) (r = 0.876, p less than 0.0001). An alternative formula, excluding hydrops, was slightly less predictive: Hematocrit = 45.312 - (56.261 x umbilical cord Pourcelot index) - (0.128 x peak velocity in descending aorta) + (1.042 x gestational age) r = 0.822, p less than 0.001). Neither model was accurate in the prediction of hematocrit before second or subsequent transfusions. A third model was derived from second-transfusion data: Hematocrit = 40.524 - (0.045 x peak velocity in descending aorta) - (10.693 x pulsatility index of maternal uterine artery) (r = 0.81, p less than 0.003). However, this model was unable to predict hematocrit before third or later transfusions. No changes in Doppler parameters before and after transfusion were found. We conclude that pulsed Doppler ultrasound may be helpful in the evaluation of isoimmunized pregnancies, in differentiating anemic from normal fetuses. It does not appear to be useful in determining the timing of later transfusions. The lack of change before and after transfusions suggests that these vessels will not provide significant information concerning the effect of rapid volume and hematocrit changes in the fetus.

High-resolution ultrasound has been recently introduced in the management of many conditions in which the fetus is at risk. In the detection of severe erythroblastosis fetalis, sonographic evaluation of fetal anatomic changes is being used in association with amniotic fluid spectral analysis to assess the degree of the hemolytic process. In 1981 it was reported that sonographically detected umbilical vein dilatation, resulting from hepatic congestion, could be used as a sign of impending fetal compromise. We analyzed data obtained from 47 patients in a total of 76 examinations, including sonographic measurement of umbilical vein diameter, associated ultrasound findings, results of amniotic fluid spectral analyses, and neonatal outcome. The collected data, divided in two groups according to the results of amniotic fluid spectral analyses (less than high zone II and greater than or equal to high zone II), showed that the sonographic measurement of umbilical vein diameter does not differ significantly between the two groups (p greater than 0.05). Therefore, the present and relatively large series demonstrates that dimensions of the umbilical vein cannot be used as a reliable predictor of worsening fetal disease.

Ultrasonographic measurements of placental thickness, extrahepatic and intrahepatic umbilical vein diameters, abdominal circumference, head circumference, head/abdominal circumference ratio, and intraperitoneal volume were made in 50 rhesus-isoimmunized pregnancies at 18 to 26 weeks' gestation. The severity of fetal anemia was assessed by fetal blood sampling. Results in the isoimmunized group were compared with a control population of 410 normal pregnancies at 17 to 32 weeks' gestation. In the absence of fetal hydrops, none of the parameters studied could reliably distinguish mild from severe fetal hemolytic disease.

The incidence of Rh isoimmunized twin gestation is extremely low. There are several perinatal risks inherent to twinning. Rhesus isoimmunization further increases hazards of such a compromised gestation. This paper reports three cases of rhesus isoimmunization in twin gestation, discusses the selective problems of such pregnancies, and reviews the pertinent literature.

Fetal blood and amniotic fluid samples were obtained fetoscopically from 59 rhesus-isoimmunized pregnancies at 18 to 25 weeks' gestation. Fetal hemoglobin was measured and amniotic fluid optical density deviation at a wavelength of 450 nm determined. Two sets of normal reference values for optical density at 450 nm and fetal hemoglobin at 16 to 36 and 16 to 25 weeks were established from 475 amniotic fluid and 153 fetal blood samples obtained from pregnancies not complicated by fetal hemolysis. As expected, there was a significant linear correlation between the degree of fetal anemia and the amniotic fluid optical density at 450 nm in rhesus-isoimmunized pregnancies. However, the values of optical density at 450 nm were widely scattered, thereby limiting their ability to predict accurately the severity of disease in these second-trimester pregnancies. In 25 of the patients, the value of optical density at 450 nm was determined at 6 to 16 days before fetoscopy. The severity of fetal anemia could not be predicted by the trend in optical density at 450 nm. These data suggest that the only reliable method to determine the severity of rhesus isoimmunization in the second trimester of pregnancy is the direct measurement of fetal hemoglobin.

The occurrence of Hb H hydrops fetalis is reported for the first time. The mother has zeta-alpha thalassemia 1 (zeta zeta alpha alpha/----) and the father has non-deletion alpha thalassemia [zeta zeta alpha alpha/zeta zeta (alpha alpha)T]. The complete deletion of the zeta alpha cluster on one chromosome was confirmed by quantitation of alpha and zeta gene numbers, the normal alpha and zeta gene patterns arising from the remaining normal chromosome, and the decreased alpha/beta globin chain ratio of 0.57. The non-deletion alpha thalassemia defect could only be identified by the imbalanced alpha/beta globin chain ratio of 0.65 in the presence of normal gene numbers and patterns. The newborn was markedly anemic, unlike those with classical Hb H disease, because the non-deletion alpha thalassemia defect is more severe than alpha thalassemia 2. The decreased zeta genes during fetal life might have additional deleterious effects. In this family, the distinct BamHI restriction fragment length polymorphism in the hypervariable region of the zeta genes may be used for future prenatal diagnosis.

We considered it useful to attempt to diagnose fetal distress or fetal heart failure in hydropic fetuses using external electrodes with a feto-maternal electrocardiographic machine. The pathological tracings that we obtained have been compared with tracings from a normal pregnancy. The authors have not been able to find that there is a significant difference between the electric axes of normal fetuses and pathological fetuses. In fact in both groups we have found as many normal axes with right deviation as with left deviation. In any case we have found that low voltage ventriculograms with a triangular shape have been more common in hydropic fetuses than in the control group. We do not think that this method will be of any use in diagnosing chronic fetal distress of heart failure. All the same we think that we should devote our attention particularly to those patients that have low voltage ventriculograms of triangular shape. We would like to thank Dr Mario Villamichel for his advice and commentary on the manuscript as well as Dr Luis Senties, the Chef de Service of the Department of Isoimmunisation.

Most centers report only moderate success in the intrauterine treatment of severe Rh-isoimmune hemolytic disease. For the hydropic fetus, the prognosis is poor. Innovations in the assessment, treatment, and follow-up of the severely affected fetus have yielded more encouraging results. Among the 24 fetuses receiving a refined management plan, instituted in June, 1980, survival rates were 100% in the nonhydropic fetus and 75% in the hydropic fetus. Improved fetal evaluation by means of extensive real-time ultrasonography allows more exact assessment of stage of disease, safer performance of intrauterine transfusion, and a direct picture of the fetal response to treatment. The intrauterine transfusion procedure differs in many aspects from those used in other centers and is notable mostly because of the absence of traumatic fetal death since the present program began. This improvement and the absence of neonatal death have resulted in 92% survival rate among the fetuses transfused. The success of this integrated team approach suggests revision of the pessimism toward the fetus with severe Rh disease.

A retrospective analysis was made of Rh-sensitized patients delivered of their babies at Duke University Medical Center during a 24 year period. Records of 202 obstetric patients representing 280 sensitized pregnancies from a pool of 39,910 deliveries were analyzed for past obstetric history, blood group information, antibody determinations, amniocentesis data, and details of the pregnancy and delivery. The medical records of the corresponding infants were analyzed for their neonatal course. A severity index (SI) was devised to classify the degree of severity of the erythroblastosis fetalis. A significant correlation between SI and the delta OD450 of amniotic fluid, umbilical cord hematocrit, and bilirubin was noted. The evaluation of amniotic fluid delta OD450 is considered to be the cornerstone of clinical management. Twenty-nine patients had initial Liley zone 1 determinations which decreased to delta OD450 = 0.000; however, only 10 of 29 (34.5%) of the infants were unaffected, and 13 of 29 (44.8%) had mild sensitization, four of 29 (13.8%) had moderate sensitization, and two of 29 (6.9%) had severe sensitization. The previously held concept of "critical titer" as a guide for initiating amniocentesis is challenged, and the recommendation is made that amniocentesis for amniotic fluid determination should be undertaken in any patient with a positive indirect Coombs titer.

A management programme for the control and treatment of Rh0 (D) immunized during pregnancy is presented. A total of 34,650 births were registered during a 4.5 year period and included 63 D positive newborns to D-immunized mothers. The outcome of all infants has been evaluated according to the severity of the haemolytic disease. Exchange transfusion was unnecessary in 43 mild cases (68.3%). Fourteen infants (22.2%) required exchange transfusion, and in 6 severe cases (9.5%) maternal plasma exchange and exchange transfusion was performed. No detrimental effects or deaths occurred among the infants suffering from Rh haemolytic disease. We recommend that the frequency and volume of plasma exchange therapy should be individually adjusted to suit each patient and the effect monitored regularly through maternal anti-D levels using a sensitive quantitative technique.

The mechanism of development of hydrops fetalis in severe isoimmunization has been subject to speculation. We performed pulsed Doppler assessment of cardiac output in 13 severely isoimmunized fetuses before and after intravascular transfusion and compared the results with 37 control fetuses between 20 and 34 weeks' gestation. The cardiac index of the anemic fetuses was significantly greater than that of the control group. A significant (right ventricle, p less than 0.01; left ventricle, p less than 0.02) increase in indexed output was noted from both ventricles and in the combined ventricular output (mean +/- SEM 644 +/- 35.3 ml/kg/min in control fetuses versus 879 +/- 86.0 ml/kg/min in anemic fetuses, p less than 0.006). An increase in cardiac output was also noted when anemic fetuses were compared with gestational age-specific norms. We conclude that severely anemic fetuses of isoimmunized pregnancies tend to have significantly higher cardiac output than do unaffected fetuses and that this high output state may play a part in the development of hydrops fetalis.

The quantitation of bilirubin in amniotic fluid is of paramount importance in prognosticating the severity of Rh isoimmunization. Amniotic fluid contaminated by maternal blood can result in erroneous results when direct spectrophotemetric analysis is performed on such fluid. The technique and results of a one-step chloroform extraction performed on "bloody" amniotic fluid is presented. Results confirm that chloroform extraction yields more accurate clinical information in regard to Rh isoimmunized patients in whom a "bloody tap" is obtained.

A review was made of the data on 42 cases of Rh disease that resulted in the birth of a live infant after 33 weeks' gestation. On 12 occasions, antepartum monitoring of fetal heart rate (FHR) showed a sinusoidal and/or decelerative heart rate pattern. All 12 infants were anemic at birth; only one was born acidotic. One infant died neonatally. Monitoring of FHR identified the severely affected infant more reliably than did the Liley classification. Within the same Liley group, infants with an abnormal heart rate tracing had lower values of hemoglobin at birth than did infants with a normal tracing. The conclusion is that a decelerative heart rate pattern is just as indicative of an infant severely affected with Rh disease as is the sinusoidal pattern. Once the abnormal heart rate pattern is identified, early delivery nearly always results in an infant who survives.

Three cases of pregnancies complicated by feto-maternal anti-Kell iso-immunisation are presented, as well as a review of the literature. The evolution of new techniques for antenatal diagnosis has made it possible to have a new approach to this fetal pathology. Chorionic villus biopsy can be carried out in the first trimester of pregnancy when there has previously been a serious incidence of anti-Kell immunisation with a couple where the husband is heterozygous for the Kell antigen. In the second and third trimesters the surveillance of the patient is essentially dependent on ultrasound examination of the fetus and placenta, which makes it possible to detect hydropic changes, and also depends on blood sampling from the cord which makes it possible to assess by direct measurement the degree of fetal anaemia. Now pulsed Doppler must be added to these classical diagnostic techniques because it allows a gross estimation of fetal haematocrit levels.

In a referral perinatal center a detailed study was made of all the perinatal deaths that occurred during 1 year; they were analyzed according to primary diagnoses on the basis of a classification by R. L. Naeye which included the placenta. This method points to the areas in which special efforts at prevention should be made, and it should become a reliable basis for comparison.

A sensitive test for the detection of the abnormal subunit of unstable hemoglobins is described. The unstable hemoglobin subunit was selectively precipitated by paramercuribenzoic acid treatment of the carboxy hemolysate, and the precipitate was studied by urea polyacrylamide gel electrophoresis for globin composition. The test enabled the detection of an electrophoretically silent, alpha-chain unstable variant comprising only 1% of total hemoglobin. Other applications included the demonstration of Hb Köln in a cord blood, and the detection and purification of very slightly unstable hemoglobin variants.

A pregnancy complicated by severe alloimmunization because of anti-E antibodies was evaluated with fetal movement counts, nonstress tests, and serial ultrasonography-amniocentesis. The successful outcome of this case suggests that such treatment may be an acceptable alternative to intrauterine transfusions for very select cases of severe alloimmunization.

The fetal blood erythroblast and reticulocyte counts were determined in umbilical cord samples obtained at 17 to 36 weeks' gestation from 127 pregnancies complicated by red blood cell isoimmunization. The reticulocyte count increased linearly with fetal anemia, and the erythroblast count increased exponentially. Significant erythroblastosis was observed only when the hemoglobin concentration deficit was greater than 7 gm/dl. Of the 52 fetuses with a hemoglobin concentration deficit greater than 7 gm/dl, 35 had ultrasonographic evidence of hydrops. These data suggest that medullary hematopoiesis is stimulated by mild anemia and that recruitment of extramedullary sites occurs when anemia is severe. Extensive hepatic erythropoiesis may be the cause of fetal hydrops in red blood cell isoimmunization.

The presence or absence of Rho (D) and Kell antigens on fetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling with the use of mixed agglutination and solid phase microimmunofluorescence techniques. Pregnancies in one Kell-sensitized woman and seven severely RH-sensitized women with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in seven of the eight cases studied.

Anti-D quantitation by the AutoAnalyzer technique has been shown to be a helpful aid in assessing the severity of D alloimmunization during pregnancy. In this study, the technique has been used both to detect antibody boosting after amniocentesis and to differentiate active D immunization from the presence of passive antibodies. The AutoAnalyzer technique and the more generally used indirect antiglobulin test titration method showed good agreement at titre levels of 32 or lower. A titre of 32 was found to be a good discriminative level to separate the mildly affected from the more severely affected newborns suffering from Rh haemolytic disease. At higher titre levels, however, the AutoAnalyzer technique was the method of choice for correct clinical assessment of the severity of D alloimmunization.