Hb Dartmouth [alpha66(E15)Leu-->Pro (alpha2) (CTG-->CCG)]: a novel alpha2-globin gene mutation associated with severe neonatal anemia when inherited in trans with Southeast Asian alpha-thalassemia-1

We report a novel mutation at alpha66(E15)Leu-->Pro (alpha2) (CTG-->CCG), that we have named Hb Dartmouth for the medical center at which the patients were cared for, in monozygotic twins who also inherited the Southeast Asian alpha-thalassemia-1 deletion. The mother, of Khmer ancestry, is heterozygous for alpha-thalassemia-1. The father, who is of Scottish-Irish ancestry, is a silent carrier of the codon 66 mutation. The twins had severe neonatal anemia requiring transfusion.

[Fetomaternal macrotransfusion after attempted external version]

BACKGROUND

External cephalic version is an alternative to both vaginal breech delivery and to caesarean section. The objective of this study was to summarize potential complications of external cephalic version. Which means are available for early detection and treatment of these complications?

CASE REPORT

A 28-year-old 1/0 with breech presentation was considered for external cephalic version at the 38th week of gestation. As three version attempts failed, the patient was discharged after normal fetal heart tone (FHT) registration and normal ultrasonographic findings on the next day. Caesarean section was planned six days later. On the day of admission, FHT registration revealed a decreased beat-to-beat variability and a sinusoidal baseline. Doppler-flow indices of the A. umbilicalis and A. cerebri media were normal, although middle cerebral artery peak systolic velocity was increased. Rapid caesarean section was performed, and an anemic baby (hemoglobin 3.4 g/dl) was born. After transfusion of 100 ml red blood cells, further development of the newborn was normal.

DISCUSSION AND CONCLUSION

Fetomaternal macrotransfusion may be a rare complication of external cephalic version, occurring even several days after the mechanical manipulation. FHT registrations and ultrasonographic doppler flow measurements performed periodically unit birth are necessary to detect such complications early. The Kleihauer-Betke test is the method of choice to diagnose fetomaternal macrotransfusion.

Anemia of prematurity

Physiologic anemia is a common and normal finding in newborn infants. In preterm infants, anemia of prematurity is the result of this normal physiologic process compounded by the morbidity of prematurity. Premature infants reach their nadir hematocrit sooner and at a lower level than term. This article reviews the physiology of stem cell differentiation and the structure and function of the red blood cell, as well as examining red blood cell indices. It also addresses the etiology, symptomatology, diagnostic workups and treatment/prevention modalities of anemia of prematurity. Treatment for and prevention of anemia of prematurity remain controversial, and specific criteria are lacking.

Chloroquine prophylaxis, iron/folic-acid supplementation or case management of malaria attacks in primigravidae in western Uganda: effects on congenital malaria and infant haemoglobin concentrations

A randomized, double-blind, placebo-controlled trial, which compared the effects of three interventions (weekly chloroquine prophylaxis, daily iron and weekly folic-acid supplementation, and case management of malaria) on congenital malaria, maternal haemoglobin (Hb) and foetal outcome, was conducted among primigravidae resident in Hoima district, Uganda. Among 473 babies examined at birth or within 7 days of birth, 198 (42%) were parasitaemic, the level of parasitaemia in an infant being strongly correlated with those of placental (P< 0.01) and maternal, peripheral parasitaemia (P < 0.01). However, 33 (17%) of the parasitaemic babies were born to mothers who had placental but not peripheral parasitaemia, 22 (11%) to mothers who had peripheral but not placental parasitaemia, and 12 (6%) to mothers with neither peripheral nor placental parasitaemia. Overall, 163 babies were each examined for malarial parasites at birth and 1 month later. Of the 76 (47%) found to have parasitaemia at birth, 37 (23%) appeared aparasitaemic at the 1-month follow-up but 28 (17%) were still parasitaemic at that time. Among the babies born to the mothers who only received case management of malaria during pregnancy, parasitaemia at birth was associated with infant anaemia at birth (i.e. < 140 g Hb/litre; P = 0.03). Infants found to be parasitaemic at the 1-month follow-up had lower mean concentrations of Hb at that time than their aparasitaemic counterparts (P= 0.03). Parasitaemia at birth was not significantly associated with low birthweight, in any of three intervention groups. The intervention given to the mother had no significant effect on the parasitaemia of her baby, either at birth or at the age of 1 month. Congenital malaria per se may have little influence on birthweight but may have an impact on infant anaemia. In conclusion, congenital parasitaemia was not associated with birthweight, but was related to anaemia at birth in infants born to women who had only received active case management during their pregnancies.

Twin-twin transfusion syndrome: a five year review

OBJECTIVE

To determine the incidence, complications, management, and outcome in infants with twin-twin transfusion syndrome (TTTS) over a period of five years.

METHODS

TTTS was diagnosed in monochorionic twins if one was pale and the other plethoric with a haemoglobin difference > or =5 g/100 ml and/or birthweight differences > or =15%.

RESULTS

Eighteen (6.2%) of the 292 twin pairs had TTTS. Eight pairs (44%) had the acute type and the rest (56%) had the chronic type of TTTS. The mean (SEM) intrapair haemoglobin difference in the acute type was 4.8 (2.1) g/100 ml which gave a discordance of 7.1 (4.6)%, whereas that in the chronic type was 6.9 (2.9) g/100 ml and 24.4 (6.1)% respectively. Infants with the acute type had a significantly higher incidence of vaginal delivery (p<0.03), hypotension (p<0.025), and respiratory distress (p<0.01) compared with those with the chronic type. There was no significant difference in the incidence of anaemia, polycythaemia, asphyxia, hypoglycaemia, and hyperbilirubinaemia. Two recipients died in utero as the result of chronic TTTS, while their survivors developed spastic cerebral palsy. There were no neonatal deaths.

CONCLUSIONS

TTTS, although uncommon, may have an adverse neurodevelopmental outcome especially if one twin dies in utero. Prompt recognition and management of the haemodynamic and haematological problems of infants with the acute types of TTTS will result in optimal neurodevelopmental outcome.

The outcome of pregnancy in Kell alloimmunisation

OBJECTIVE

To assess management and outcome of pregnancies with anti-Kell in the West Midlands in the UK over 13 years.

DESIGN

A retrospective review of casenotes.

SETTING

A regional referral clinic for red cell alloimmune disease and fetal medicine unit at a university hospital.

POPULATION

Sixty-five pregnancies were identified in 52 Kell-sensitised women with Kell positive partners from the records of the Birmingham Blood Transfusion Centre.

METHODS

Information from the casenotes was entered on a database and comparisons were made using the SPSS for Windows statistics package.

MAIN OUTCOME MEASURES

Mode of sensitisation, degree of fetal or neonatal anaemia, need for transfusion, gestation at delivery, birthweight and pregnancy outcome.

RESULTS

Alloimmunisation was transfusion-related in 29 pregnancies and pregnancy-induced in 33. The cause could not be identified in three cases. There were 22 proven Kell positive fetuses, of which 18 were affected, in which alloimmunisation was pregnancy-related in 12 cases and transfusion-related in five. Antibody titres and amniotic fluid OD450 were not helpful in management. Severe or very severe disease occurred in 50% of the affected pregnancies (9/18). There was no difference in pregnancy outcome between transfusion or pregnancy induced sensitisation.

CONCLUSIONS

Anti-Kell alloimmunisation is an uncommon cause of serious anaemia in a significant proportion of affected pregnancies. There appears to be no difference between that caused by pregnancy or transfusion. Estimation of fetal haemoglobin concentration by cordocentesis is recommended, as antibody titres and amniocentesis are not helpful.

Management of severe neonatal anemia due to fetomaternal transfusion

Three cases of severe neonatal anemia due to fetomaternal transfusion are reported. The key features that lead to early diagnosis were the maternal history, fetal monitoring, the clinical and laboratory findings of anemia, and a negative Coombs test. Diagnosis was confirmed by a rapid Kleihauer-Betke test. A partial exchange transfusion was performed in two of the three neonates with rapid clinical and hematological improvement. As two patients showed signs of heart decompensation, a partial exchange transfusion was performed with good success. In patients presenting with severe subacute or chronic anemia and heart failure, a partial exchange transfusion may be preferable to that of simple transfusion associated with diuretics.

Fetal complication after external cephalic version at term: case report and literature review

We report a case of fetal distress following external cephalic version at term, which resulted in delivery by emergency cesarean section of an anemic, acidemic infant. The characteristics of the fetal heart rate tracing, the clinical findings, and a positive Kleihauer-Betke test after delivery suggest that fetomaternal hemorrhage or placental abruption was the most likely cause of the fetal distress. We review the incidence of the reported fetal complications after external version.

[Common anemias in neonatology]

We describe the four most common groups of neonatal anemia and their treatments, with particular emphasis on erythropoietin therapy. The hemolytic anemias include the ABO incompatibility (much more frequent, nowadays, than the Rh incompatibility, which has nearly disappeared following the use of anti-D immunoglobulin in postpartum Rh-negative mothers), hereditary spherocytosis and G-6-PD deficiency. Among hypoplastic anemias, that caused by Parvovirus B19 predominates, by far, over Diamond-Blackfan anemia, alpha-thalassemia and the rare sideroblastic anemias. "Hemorrhagic" anemias occur during twin-to-twin transfusions, or during feto-maternal transfusions. Finally, the multifactorial anemia of prematurity develops principally as a result of the rapid expansion of the blood volume in this group of patients. Erythropoietin therapy, often at doses much higher than those used in the adult, should be seriously considered in most cases of non-hypoplastic neonatal anemias, to minimise maximally the use of transfusions.

Fetomaternal haemorrhage and prenatal intracranial bleeding: two more causes of blueberry muffin baby

Blueberry muffin lesions are associated with prenatal infections, severe and chronic anemia and neoplastic infiltrative diseases. In the first two instances they represent postnatal re-expression of cutaneous haematopoiesis, in the latter they are cutaneous localizations of a neoplastic disease. Chronic prenatal anaemia leading to blueberry muffin lesions in the neonate has been reported in association with severe haemolytic anaemia such as congenital spherocytosis, Rhesus haemolytic disease and ABO incompatibility, or in anaemia caused by twin-to-twin transfusion. We present two more causes of prenatal anaemia leading to blueberry muffin lesions: chronic fetomaternal haemorrhage and severe intracranial bleeding.

CONCLUSION

In any blueberry muffin baby with profound anaemia, chronic fetomaternal haemorrhage and severe internal bleeding should be included in the differential diagnosis. Skin biopsy must be performed to rule out neoplastic infiltrative diseases.

[Fetomaternal hemorrhage: a series of 9 cases]

AIM

This study was designed to stress the importance of early diagnosis of fetomaternal hemorrhage (FMH) in attempt to prevent the subsequent adverse outcome on the fetus and the newborn.

PATIENTS AND METHODS

Nine newborns were admitted because of neonatal anemia to our neonatal unit from October 1989 through September 1995. The diagnosis of FMH was made by the sigma diagnostic fetal hemoglobin that is the Kleihauer test in our hematologic laboratory. Other causes of neonatal anemia have been ruled out.

RESULTS

Seven out of the nine cases have expressed early signs of fetal distress in term of abnormal fetal monitoring and/or thick meconium associated with decreased fetal movements. At birth, a wide clinical spectrum depending on the amount of the hemorrhage was seen, ranging from mild anemia with no symptoms (four cases), hypovolemic shock (one case), respiratory distress syndrome (two cases) and maladjustment to extra-uterine life (one case). There was one death at 48 hours after birth; one infant survived with severe encephalopathy.

CONCLUSION

These results indicate that it is mandatory to carry out a Kleihauer test whenever a high suspicious index of FMH is faced or an unexplained neonatal anemia is found.

Anemia in newborn

Various blood indices vary in a newborn as compared to older child or adult. It depends on the gestational age, day of life, maternal factors, mode of delivery and site of blood collection. Hemoglobin, HCT & MCV tend to be higher in newborns. They further increase in first 2 days of life. Reticulocytosis and presence of nucleated red cells are normally seen in first week of life. Neonatal anemia is a common problem in NICU. It is usually caused by either hemorrhage or hemolysis and rarely due to decreased production. Hemorrhage can be ante or intra or post natal and it could be external or internal. It could be acute or chronic. Management of acute severe hemorrhage includes packed cell transfusion. Hemolysis is usually due to isoimmune hemolysis, G6PD deficiency or rarely due to the hemoglobinopathy like alpha-thalassemia or due to spherocytosis. Usually patients will have indirect hyperbilirubinemia which needs phototherapy or exchange transfusion. Rarely congenital pure red cell aplasia can present at birth with physical anomalies and anemia. Treatment of neonatal anemia depends on the arteriology.

[The risk factors for early anemia in premature infants]

The following items were the main risk factors for development of early anemia of prematurity (EAP): profound prematurity, prenatal hypotrophy, multiple pregnancy, gestosis, anemia of pregnancy, cardiovascular disorders in the mother. Hence, prevention of failing to bear, timely detection and treatment of anemia of pregnancy, of gestosis, health promotion in women of child-bearing age are all considered essential measures to be instituted in EAP prophylaxis.

[Successively improved prognosis in erythrocyte immunization]

Prognosis in cases of erythrocyte immunisation has improved continuously over the past decades. Morbidity and mortality have been reduced by improvements in management, including screening programmes, non-invasive ultrasound evaluation and invasive procedures. The article provides an outline of the latest developments in the management of erythrocyte immunisation, and several controversial issues are discussed, such as antibody screening, strategies for the reduction of antibody titres, and the organisation of care.

Transfusion practices in infants receiving assisted ventilation

Controversies about medical practices usually arise from lack of definitive scientific studies. In the presence of continuing controversy about the appropriate hemoglobin level for ventilated (or nonventilated) infants, we can attempt to derive as much useful information as possible. In this article, the authors focus on four subjects: the physiologic role of red cells, the clinical effects of anemia and the proposed clinical benefit of red cell transfusions in preterm infants, the risks associated with transfusions, and the use of recombinant erythropoietin as an alternative to transfusion therapy.

Serum erythropoietin concentrations fail to increase after significant phlebotomy losses in ill preterm infants

OBJECTIVE/STUDY DESIGN: After blood loss, production of erythropoietin in adults increases, which accelerates erythropoiesis and restores the erythroid mass. It is unclear whether preterm infants with large phlebotomy losses have a similar response. We therefore measured serum erythropoietin concentrations in 11 ill preterm infants (1057 +/- 167 gm) as their phlebotomy losses accumulated.

RESULTS

Before the first transfusion, erythropoietin concentrations were 68.9 +/- 36.2 mU/ml (range 0 to 205 mU/ml) at 5 ml/kg blood out, 17.4 +/- 8.9 mU/ml at 10 ml/kg, and 4.8 +/- 2.6 mU/ml at 15 ml/kg. Erythropoietin concentrations did not increase in any patients despite increasing phlebotomy losses.

CONCLUSION

Serum erythropoietin concentrations in ill preterm infants do not increase in the face of significant blood loss. Although the mechanistic explanation for this failure is unclear, it likely contributes to the transfusion requirements of this population.

Massive thymic hemorrhage in a neonate: an entity revisited

The authors describe a case of early neonatal death of a full-term infant who had respiratory distress and anemia after fetal distress during labor. Postmortem examination disclosed mediastinal compression by a large fresh hemorrhage into the left lobe of the thymus. Massive thymic hemorrhage is an extremely rare but sometimes lethal occurrence; it may represent a manifestation of early-onset hemorrhagic disease of the newborn.

The role of haemopoietic growth factors in the pathogenesis of the early anaemia of premature infants

The anaemia of prematurity has been attributed to an insufficient erythropoietin (Epo) level. However, haemopoiesis is known to be regulated by a cohort of growth factors including interleukin-3 (IL-3), IL-6, stem cell factor (SCF), granulocyte monocyte-colony stimulating factor (GM-CSF) and insulin-like growth factors-I and -II (IGF-1, IGF-II). Circulating levels of these growth factors were measured in cord blood at the following gestational ages: 25-28 weeks, 29-32 weeks, 33-36 weeks and > 37 weeks. This study indicates that low concentrations of IGFs as well as a low Epo level in early gestational ages may play a role in anaemia of prematurity.

Management of neonatal Rh disease

Dramatic improvements have been made in the management of Rh disease. Anti-D immune globulin has reduced the incidence of Rh sensitization. Intrauterine transfusions have become routine to treat fetal anemia. Once an affected infant is born, several recent improvements in neonatal care have aided in the treatment of hyperbilirubinemia. These include improved phototherapy, such as fiberoptic delivery systems, and intravenous immunoglobulin. Experience with heme oxygenase inhibitors is accumulating, and they may prove efficacious in Rh disease. Double-volume (and perhaps single-volume) exchange transfusion remains an effective method to control hyperbilirubinemia when other therapies fail. Erythropoietin may have a role in treating late, hyporegenerative anemia. Finally, better ways to assess the risk of brain injury in patients with hyperbilirubinemia may become available. Cooperation between the obstetric and neonatal teams to treat Rh-sensitized mothers and their babies is essential.

Hemolytic anemia in the newborn

Evaluation of hemolytic anemia in the newborn may be complicated owing to the physiologic changes that occur during this time; however, the newborn period is a time when congenital red cell abnormalities may first present and when maternal factors need to be considered. In this article, an approach to the diagnosis of hemolytic disease in the newborn is reviewed. The unique properties of the neonatal red cell, the normal red cell changes present in the neonate, the potential congenital defects and maternal factors that may influence the associated clinical and laboratory findings consistent with the diagnosis of hemolytic anemia, and a brief review of the red cell disorders associated with hemolytic anemia in the newborn are discussed.

Diffuse neonatal haemangiomatosis with intra-uterine haemorrhage and hydrops fetalis: a case report

A case of diffuse neonatal haemangiomatosis involving the skin, liver, lungs, adrenals, gums, diaphragm, skull, and testes is reported. Intra-uterine onset of bleeding led to bloody amniotic fluid, severe anaemia, congestive heart failure, and hydrops fetalis. Intractable coagulopathy and renal failure resulted in persistent bleeding, anuria, metabolic acidosis, and hyperkalaemia, leading to a fatal outcome.

Erythropoietin production by macrophages from preterm infants: implications regarding the cause of the anemia of prematurity

In the human fetus, liver macrophages appear to be the primary source of erythropoietin (Epo). Epo production shifts from the liver to peritubular cells in the kidney sometime during the 3rd trimester. Some preterm infants experience a hyporegenerative anemia that appears to be caused by inadequate Epo production. It is not clear whether this anemia is due to deficient Epo production by liver macrophages or renal peritubular cells. To assess this situation, we measured Epo mRNA and protein in macrophages obtained from cord blood of preterm and term infants and from peripheral blood of adults. Macrophages from preterm infants generated Epo mRNA and protein as effectively as those from term infants and adults. It appears that the anemia of prematurity is not due to defective Epo production by macrophages.