Placental abruption and neonatal anemia

OBJECTIVE

Placental abruption can cause maternal blood loss and maternal anemia. It is less certain whether abruption can cause fetal blood loss and neonatal anemia.

STUDY DESIGN

Retrospective multi-hospital 24-month analysis of women with placental abruption and their neonates.

RESULTS

Of 55,111 births, 678 (1.2%) had confirmed abruption; 83% of these neonates (564) had one or more hemoglobins recorded in the first day. Four-hundred-seventy (83.3%) had a normal hemoglobin (≥5th% reference interval) while 94 (16.7%) had anemia, relative risk 3.26 (95% CI, 2.66-4.01) vs. >360,000 neonates from previous reference interval reports. The relative risk of severe anemia (<1st% interval) was 4.96 (3.44-7.16). When the obstetrician identified the abruption as "small" or "marginal" the risk of anemia was insignificant.

CONCLUSIONS

Most abruptions do not cause neonatal anemia but approximately 16% do. If an abruption is not documented as small, it is important to surveille the neonate for anemia.

[THE FETAL MIDDLE CEREBRAL ARTERY PEAK SYSTOLIC VELOCITY AS A PEDICTOR OF FETAL ANEMIA IN RH-ALLOIMMUNIZED PREGNANCY]

Rh-isoimmunization is a pathological condition in which the fetal red blood cells of a Rh (+) fetus are destroyed by the isoantibodies of a Rh (-) woman sensitized in a previous event. Despite of the wide spread implementation of anti D-gammaglobolin prophylaxis this is still the most common cause for fetal anemia. Recently, sonographic measurement of the fetal middle cerebral artery peak systolic velocity (MCA-PSV) has been shown to be an accurate non-invasive test to predict low fetal hemoglobin levels. We present a case report of Rh-alloimmunized pregnancy with moderate fetal anemia, followed-up by weekly MCA-PSV measurements.

CASE REPORT

A 37-year-old Rh (-) negative gravida 3, para 1, without anti-D gammaglobolin prophylaxis in her previous pregnancies, presented at 27+0 weeks of gestation (w.g.) for a routine third trimester scan. Subsequent ultrasound measurements of MCA-PSV confirmed a progressive increase of the peak systolic velocities from 40 to 80 cm/sec, as well as a gradual rise in the anti-D titers. The evidence of developing fetal anemia necessitated elective Caesarean section performed at 35 wg. The neonate was admitted in the intensive care unit and required resuscitation, one exchange blood transfusion and several courses of phototherapy. The patient was discharged two weeks post partum.

CONCLUSIONS

There is a strong correlation between the high peak systolic velocities in the middle cerebral artery (MCA-PSV) and the low levels of fetal hemoglobin. The high sensitivity and positive predictive value concerning the development of fetal anemia, as well as its good repeatability, makes this non-invasive test a valuable asset in the management of all pregnancies complicated by severe Rh-alloimmunization.

Risk factors for fetal anaemia in a malarious area of Malawi

The prevalence of infants born with low cord haemoglobin (fetal anaemia) is high in areas where malaria and iron deficiency anaemia in pregnancy are common. The objective of the present study was to determine risk factors for fetal anaemia in an area of high malaria transmission in southern Malawi. A case control study was undertaken with fetal anaemia defined as cord haemoglobin (Hb) < 12.5 g/dl. Between March 1993 and July 1994, pregnant women attending the study hospitals for the first time in that pregnancy were enrolled. Data on socio-economic status, anthropometry, previous obstetric history and current pregnancy were collected. Malaria parasitaemia, Hb levels and iron status were measured in maternal blood at recruitment and delivery and in umbilical venous blood. Fetal anaemia occurred in 23.4% of babies. Mean (SD) cord Hb was 13.6 g/dl (1.83). Factors associated with fetal anaemia were: birth in the rainy season [adjusted odds ratio (AOR) 2.33, 95% CI 1.73-3.14], pre-term delivery (AOR 1.60, 1.03-2.49), infant Hb < 14 g/dl at 24 hours (AOR 2.35, 1.20-4.59), maternal Hb at delivery < 8 g/dl (AOR 1.61, 1.10-2.42) or <11 g/dl (AOR 1.60, 1.10-2.31). A higher prevalence of fetal anaemia occurred with increasing peripheral Plasmodium falciparum parasite density (p=0.03) and geometric mean placental parasite densities were higher in babies with fetal anaemia than in those without (3331 vs 2152 parasites/microl, p=0.07). Interventions should aim to reduce fetal anaemia by improving malaria and anaemia control in pregnancy and by addressing the determinants of pre-term delivery.

[Newborn twins with colour difference]

A 31-year-old woman, pregnant of a monochorionic diamniotic twins had an unremarkable pregnancy. After delivery, the infants showed a colour difference. Blood analysis revealed an anaemia-polycythaemia sequence, caused by arterio-venous anastomoses in the placenta. The diagnosis was 'twin anaemia polycythaemia sequence' an acute and atypical form of twin-to-twin transfusion syndrome.

Fetal anemia of unknown cause--a diagnostic challenge

PURPOSE

To assess the spectrum of underlying diseases in cases of fetal anemia in which the cause was unknown at the time of first and second transfusion or thereafter.

MATERIALS AND METHODS

All patients who underwent intrauterine transfusion were identified in the perinatal databases of two tertiary referral centers for prenatal medicine and treatment between 2002 and June 2010.

RESULTS

82 fetuses received intrauterine transfusion in the study period. A total of 356 transfusions were performed in these patients. The causes of fetal anemia in our cohort were alloimmunization (32), parvovirus infection (23), feto-fetal transfusion syndrome (9), sacrococcygeal teratoma (2) and cytomegalovirus infection (1). In the remaining 15 cases, the cause of fetal anemia was unknown at the time of first and second transfusion, and could only be ascertained in the further course of pregnancy, in the postnatal period or was ultimately left in doubt. In all cases markedly elevated peak systolic velocities in the middle cerebral artery accurately predicted fetal anemia. The final diagnosis in these cases was fetomaternal hemorrhage (4), Blackfan-Diamond anemia (1), diffuse neonatal hemangiomatosis with chorangioma (1), kaposi-like hemangioendothelioma (1), elliptocytosis (1), neonatal hemochromatosis (1), mucopolysaccharidosis type VII (1) and in 5 cases the cause of fetal anemia remained unexplained. The latter 5 cases had an uneventful postnatal course and did not require further transfusions in infancy.

CONCLUSION

In cases of fetal anemia with negative indirect Coombs test and TORCH serology, rare causes of anemia have to be considered. Fetal studies should therefore include reticulocyte count, parameters of hemolysis, peripheral blood smear and fetal liver function tests. Maternal studies should involve a search for fetal red cells using flow cytometry rather than Kleihauer-Betke test.

[The impact of premature rupture of membranes (PROM) on neonatal outcome]

OBJECTIVE

The aim of the following study was to evaluate the impact of premature rupture of membranes (PROM) on neonatal outcome, particularly on the incidence of intrauterine infections (IUI).

MATERIAL AND METHODS

The study included 428 newborns, born after PROM and hospitalized in the Department of Neonatology at Poznan University of Medical Sciences in 2006. The influence of selected variables on the development of IUI and other complications was analyzed.

RESULTS

IUI occurred in 124 newborns (29%). The odds ratio (OR) of IUI incidence increased with decreasing gestational age, birth weight and Apgar score, as well as with increasing duration of the time between PROM and birth, called the latency period. Logistic regression showed that IUI was significantly influenced by the latency period (OR=1.37; 95% CI: 1.10-1.71; p<0.01), gestational age (OR=2.29; 95% CI: 1.59-3.30; p<0.0001) and 5-minute Apgar score (OR=2.50; 95% CI: 1.57-3,98; p<0.001). The incidence of other complications such as prematurity respiratory distress syndrome, respiratory failure, intraventricular hemorrhage, and anemia increased with the duration of the latency period. Compared to uninfected infants, the infected ones were characterized by lower birth weight, lower gestational age, lower Apgar score and poorer laboratory results.

CONCLUSIONS

Among neonates born from pregnancies complicated with PROM, the incidence of IUI is significantly influenced by the latency period, gestational age and 5-minute Apgar score. The incidence of other complications increases with the duration of the latency period. Prematurity is an important contributor to morbidity in this group of neonates.

Clinico-pathologic conference: fetomaternal transfusion

A case is presented of a newborn infant with severe fetomaternal transfusion, which resulted in profound anemia and early demise.

Fetal medicine: Intrauterine fetal demise following laser treatment in twin-to-twin transfusion syndrome

OBJECTIVE

To evaluate the incidence, risk factors and consequences of intrauterine fetal demise (IUFD) of at least one twin in twin-to-twin transfusion syndrome (TTTS) treated by laser.

DESIGN

Retrospective analysis.

SETTING

Experience of a single centre between 1999 and 2004.

POPULATION

A subgroup of 45 cases with fetal demise of one or both twins from a series of 120 cases of TTTS treated by laser.

METHODS

All cases were entered prospectively into a dedicated database and the results were analysed retrospectively.

MAIN OUTCOME MEASURES

Fetal demise prognostic factors, survival, fetal anaemia, brain lesions, neonatal death and intact survival.

RESULTS

IUFD of one twin occurred in 40 of 120 cases (19 donors and 21 recipients). IUFD of both twins occurred in another five cases. From these 40 cases, miscarriage occurred in two and pregnancy termination was requested in another two cases because of antenatal brain lesions. Two neonates died and two presented severe morbidity, survivors were therefore neurologically normal at 6-44 months of life in 89% (32/36) of the cases. Univariate analysis showed that preoperative abnormal umbilical artery Doppler in the donor before laser treatment and in the recipient following laser treatment was associated with their demise. Incomplete coagulation was suspected in cases where anaemia or cerebral lesions developed following the death of the first twin (10).

CONCLUSIONS

IUFD of one or both twins occurred in 45 of 120 (38%) cases of severe TTTS treated by laser. In these, separation of the placental circulations was incomplete in at least 22% (10/45) of the cases. Umbilical artery Doppler abnormalities before laser were found to be risk factors for the donors' demise following the procedure.

Severe Hemolytic Disease of the Newborn Due to Anti-Cw

BACKGROUND

Pregnancies complicated by Rh isoimmunization have decreased significantly since the widespread use of Rh immune globulin. Uncommon red blood cell antigens have therefore become more clinically evident. We report a case of anti-Cw immunization that resulted in severe fetal anemia that required multiple transfusions.

CASE

A 28-year-old multigravida presented to our service at 18 weeks of gestation with her fourth pregnancy. Her pregnancy was complicated by anti-Cw isoimmunization that resulted in severe fetal anemia requiring in utero fetal blood transfusions.

CONCLUSION

While previous reports recommend only postpartum surveillance when Cw isoimmunization is present, we report a case resulting in severe fetal anemia.

Neonatal renal venous thrombosis: clinical outcomes and prevalence of prothrombotic disorders

OBJECTIVE

To determine clinical outcomes and the prevalence of prothrombotic conditions in patients who had neonatal renal venous thrombosis (RVT).

STUDY DESIGN

A retrospective cohort of neonates with RVT who were admitted to 4 pediatric centers from 1980 to 2001 was identified. Information on clinical presentation, laboratory and radiological investigation, and treatment were abstracted. Survivors were evaluated for renal status and prothrombotic conditions.

RESULTS

Forty-three patients with neonatal RVT were identified. RVT was unilateral in 24 patients (56%) and associated with 2thrombi at other sites in 32 patienets (74%). Clinical presentations included renal failure in 24 patients (56%), thrombocytopenia, anemia, or both in 22 patients (51%), and renal mass in 21 patients (49%). Neonatal interventions included anti-coagulants in 28 patients (65%), antihypertensive medications in 9 patients (21%), peritoneal dialysis in 2 patients (5%), and nephrectomy in 2 patients (5%). The median age at follow-up was 3.7 years (range, 0.5-20.2 years). Thirteen patients (34%) had hypertension, and 11 patients (29%) had renal failure. End-stage renal disease developed in 3 patients, and they underwent live-related renal transplants. Twelve of the 28 patients (43%) examined had prothrombotic abnormalities.

CONCLUSION

Neonatal RVT is associated with significant renal morbidity and a high prevalence of prothrombotic abnormalities.

Reduction in red blood cell transfusions among preterm infants: results of a randomized trial with an in-line blood gas and chemistry monitor

BACKGROUND

Critically ill, extremely premature infants develop anemia because of intensive laboratory blood testing and undergo multiple red blood cell (RBC) transfusions in the early weeks of life. To date, researchers have had only limited success in finding ways to reduce transfusions significantly in this patient population.

OBJECTIVE

To reduce RBC transfusions for these infants by using a point-of-care bedside monitor that returns analyzed blood to the patient.

DESIGN, SETTING, AND PATIENTS

This was a prospective, 2-center, randomized, open, controlled, clinical trial with a 1:1 assignment of extremely low birth weight infants (weighing 500-1000 g at birth) to control or monitor groups and analysis with the intention-to-treat approach. Predefined RBC transfusion criteria were applied uniformly in the 2 groups.

INTERVENTIONS

Clinical treatment of study subjects with an in-line, ex vivo, bedside monitor that withdraws blood through an umbilical artery catheter, analyzes blood gases and sodium, potassium, and hematocrit levels, and returns the sample to the patient.

MAIN OUTCOME MEASURES

The total volume and number of RBC transfusions during the first 2 weeks of life and the total volume of blood removed for laboratory testing.

RESULTS

The trial was terminated prematurely when one center's NICU changed its standard method of laboratory testing. In the first 2 weeks of life, there was a nonsignificant 17% lower cumulative RBC transfusion volume in the monitor group (n = 46), compared with the control group (n = 47). However, data from the first week only (the period of greater catheter use) demonstrated a significant 33% lower cumulative RBC transfusion volume in the monitor group. Cumulative phlebotomy loss was approximately 25% less in the monitor group throughout the 2-week study period. There was no difference between groups in neonatal mortality, morbidity, and neurodevelopmental outcome rates at 18 to 24 months. This is the first randomized trial documenting that RBC transfusions administered to neonates can by reduced by decreasing laboratory phlebotomy loss.

CONCLUSIONS

As long as an umbilical artery catheter is available for blood sampling with an in-line blood gas and chemistry monitor, significant reductions in neonatal RBC transfusions can be achieved. The patients most likely to benefit from monitor use are the smallest, most critically ill newborns.

Lower gastrointestinal bleeding in a newborn caused by isolated intestinal vascular malformation

We report a 3-week-old neonate with an intestinal vascular malformation. The usual investigations performed for the examination of lower gastrointestinal bleeding had negative results, but ultrasound revealed bowel loops of abnormal calibre and altered flow in the superior mesenteric artery. Ultrasound should be considered a diagnostic study of primary importance when assessing a neonate with gastrointestinal bleeding.

A comparison of high versus low dose recombinant human erythropoietin versus blood transfusion in the management of anaemia of prematurity in a developing country

The purpose of this study was to evaluate the effectiveness of early treatment with erythropoietin (EPO) in two different treatment regimes (high vs. low dose) in comparison to the conventional treatment of packed red blood cell (PRBC) transfusions in the management of anaemia of prematurity in a country with limited resources. An open controlled trial was conducted on 93 preterm infants (7 days postnatal age, 900-1500 g birthweight). Patients were randomly assigned either to a low dose (250 IU/kg), a high dose (400 IU/kg), or a control group. EPO was administered subcutaneously three times a week and all infants received 6 mg/kg iron orally from study entry to endpoint of therapy. Haematological parameters were measured and compared. The success was defined as an absence of transfusions and a haematocrit that did not fall below 30 per cent during the time period that the infants were in the study. The three groups were statistically comparable at study entry with respect to gestational age, birthweight, Apgar scores, and haematological values. Over the period that the infants were in the study, 75 per cent of the low dose group and 71 per cent of the high dose group met the criteria for success compared with 40 per cent in the control group (p < 0.001). However, there was no significant difference in the number of transfusions when the low and high EPO dose groups (9.5 per cent) were combined and compared with the control group (26.7 per cent) p = 0.0587. It was concluded that in stable infants, 900-1500 g, where phlebotomy losses are minimized and stringent transfusion guidelines are adhered to, EPO does not significantly decrease the number of transfusions. A conservative approach in the management of anaemia of prematurity, is a viable alternative in areas with limited resources.

Profound early-onset neonatal anemia: a case study

B.G. WAS A 38 6/7-WEEK GESTATIONAL age female born to a 29-year-old G2 P0, O+ (antibody negative), rubella immune, RPR nonreactive, GC negative, HepBsAg negative, GBS negative, HIV negative mother. The pregnancy was uncomplicated. The mother had received prenatal care starting in the first trimester. There was no reported history of hydrops fetalis. Thick meconium was noted on artificial rupture of the membranes six hours prior to delivery.

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.

Unusual clinical features of neonatal anemia due to fetomaternal transfusion

Fetomaternal transfusion occurs in about 50 percent pregnancies. However, it can cause severe neonatal anemia at birth. A one-day-old baby girl, small for gestational age, was born to a G1P1 woman without perinatal blood loss or obstetric complication. Pallor and mild tachypnea were noted after birth. Laboratory examination revealed severe anemia, (Hb: 4.8 gm/dl, Hct: 14.7%), reticulocytosis and normoblastemia. Direct coombs' test was negative. Brain echo examination was normal. Maternal peripheral blood smear stained with Kleihauer-Betke technique demonstrated presence of fetal cells. Following packed red blood cells transfusion, the baby's symptoms improved. The unusual clinical features were described and discussed. Kleihauer-Betke test should be performed in unexpected neonatal anemia after birth.