Deaths from rhesus haemolytic disease in England and Wales in 1978: accuracy of records and assessment of anti-D prophylaxis

Plasmapheresis in Rh Hemolytic Disease: The Danger of Amniocentesis

We have treated 25 women with poor obstetric histories and high levels of anti-Rh antibodies by plasmapheresis during pregnancy. One baby was Rs negative, but 13 of the remaining 24 babies survived. Most of the foetal deaths were associated with a rapid rise in antibody level uncontrollable by plasmapheresis and which followed either amniocentesis or intra-uterine transfusion. Plasmapheresis throughout pregnancy with early delivery and avoidance of amniocentesis is recommended.

Intra-uterine exchange transfusion under ultrasound guidance

Thirty intra-uterine exchange transfusions (I.U.E.T.) under ultrasound guidance were performed on 15 pregnancies in 14 severely Rh-sensitized women. Our technique and a new method of catheterization of the umbilical cord are described. I.U.E.T. were commenced at 19-34 gestational weeks and repeated up to 5 times at 15 to 60 days intervals. The lowest pretransfusion fetal hemoglobin was 3 milligrams at 25 weeks. All the hydrops (4 cases) reversed a few days after the first procedure. The survival rate is 50% for hydropic fetuses and 66.6% for all cases. This technique avoids fetal hypervolemia and also too repetitive procedures by quick renewal of red cells. Catheterization offers a simple and safe access to the umbilical vein even with important fetal movements.

Deaths from rhesus haemolytic disease in England and Wales in 1982 and 1983

Examination of death certificates and the clinical notes of the patients concerned showed that the number of deaths from rhesus (D) haemolytic disease in England and Wales was 44 and 34 during 1982 and 1983, respectively, a substantial decrease from the figure of 106 for 1977. Of the 78 women whose infants died in 1982 and 1983, 49 had not received anti-Rh immunoglobulin after previous pregnancies with Rh positive infants; most of these deaths would presumably have been prevented had postnatal anti-Rh immunoglobulin been given. In 13 women anti-D was detected during, or immediately after, a first pregnancy, and in 15 women rhesus immunisation developed despite administration of anti-Rh immunoglobulin postnatally. One or two apparent failures of treatment may have been due to underdosage, but it must be concluded that about one third of the deaths in 1982 and 1983 could have been prevented only by giving anti-Rh immunoglobulin antenatally as well as postnatally.

Hemolytic disease of the newborn due to rare alloantibodies

In the period January 1975 to December 1981, serum samples from 9,525 pregnant women were examined for irregular red cell antibodies. Red cell antibodies were found in 719 cases (7.5%); anti-D antibodies were present in 532 cases (5.5% of the whole series), rare antibodies (other than anti-D) in 187 cases (2%). Seven pregnant women with rare red cell antibodies were followed at our Institute up to delivery. The clinical management, which was based on the diagnostic and therapeutic procedures of hemolytic disease of newborn due to anti-D antibodies, is reported in detail. The findings underline the importance of careful screening for irregular red cell antibodies in all pregnant women, both Rh-negative and Rh-positive, and confirm the validity of Rh clinical management also for moderate or severe immunizations due to rare red cell antibodies.

Fetal blood group studies during mid-trimester pregnancy and the management of severe isoimmunization

Fetal blood samples collected at 14-22 weeks' gestation by fetoscopy have been analysed for 25 different red cell antigens and anti-A antibodies. The results obtained demonstrate that the technique can be used to determine fetal blood groups during mid-pregnancy and also to provide the opportunity to study the physiological and pathological developments of blood groups and their antibodies and to manage more rationally those pregnancies threatened by erythroblastosis fetalis.

Midtrimester intrauterine exchange transfusion of the fetus

Thirty-seven fetuses, 15 to 23 weeks' gestation, were subjected to intrauterine exchange transfusion under direct vision with a fetoscope prior to therapeutic abortion. A maximum of 30 ml of blood was exchanged, so that as much as 95% of the blood in the fetoplacental circulation was of donor origin. The technique clearly has potential value in the management of severe rhesus-hemolytic disease of newborn infants.

Direct intravascular fetal blood transfusion by fetoscopy in severe Rhesus isoimmunisation

Two fetuses with severe anaemia due to rhesus incompatibility each received two early blood transfusions (between 23 and 25 weeks) by fetoscopy. The blood was given directly into an umbilical vessel, either at the umbilicus or at the placental cord insertion. Fetal blood samples were taken before and after transfusion to assess the haematological status of the fetus. One grossly hydropic fetus survived.