Prediction of fetal anemia by different thresholds of MCA-PSV and Delta-OD in first and second intrauterine transfusions.
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Our aim was to compare different thresholds of middle cerebral artery peak systolic velocity (MCA-PSV) and amniotic fluid delta optical density (Delta-OD) with fetal hemoglobin (Hb) during first and second intrauterine transfusions (IUT).We determined serial MCA-PSV and Delta-OD in 27 red blood cell alloimmunized fetuses who needed IUT. Before the second IUT, MCA-PSV was measured. The sensitivity and specificity of MCA-PSV and Delta-OD were calculated and compared with fetal hemoglobin levels.From 27 fetuses, first time IUT MCA-PSV with a normal median value (MOM) cutoff of > 1.29 detected 60% of the moderate and 100% of the severe anemia cases. MCA-PSV of MOM > 1.5 detected none of the moderate and 93% of severe anemia cases. Delta-OD detected 50% of moderate anemic and 80% of severe anemic cases. At the second IUT, 91% of severe anemia cases were confirmed by MCA-PSV with MOM > 1.5 whereas MCA-PSV with MOM > 1.29 confirmed all cases. One case of moderate anemia was de-tected by MCA-PSV of MOM > 1.29 and none were detected by MCA-PSV with MOM > 1.5.Different thresholds of MCA-PSV have higher sensitivity and specificity for detecting moderate and severe fetal anemia compared with Delta-OD. It also has a high sensitivity at the second IUT.Cite
To assess the feasibility of using the middle cerebral artery peak systolic velocity (MCA-PSV) to predict the actual value of fetal hemoglobin in fetuses undergoing a first cordocentesis for detection of anemia caused by maternal red cell alloimmunization.Doppler velocimetry of the MCA-PSV was performed in 18 fetuses before an initial cordocentesis. Hemoglobin and MCA-PSV values were expressed as multiples of the median to adjust for the changes that both parameters demonstrate with gestational age. In each fetus we determined: 1) the expected (using a cubic mathematical function describing the correlation between fetal hemoglobin and MCA-PSV) and the observed (determined at the time of the cordocentesis) hemoglobin value; and 2) the percentage differences between the expected and the observed hemoglobin values.Gestational age at the time of the Doppler study ranged from 19 to 31 weeks. On 15 occasions, the fetuses demonstrated anemia. A quadratic relationship was found between the hemoglobin multiples of the median and the percentage differences between the expected and the observed hemoglobin values. As the values of hemoglobin decreased, the percentage difference between expected and observed values significantly decreased (R(2) = 0.48, P <.05). The cubic model estimated fetal hemoglobin well in severely anemic fetuses and less well when the fetus was not anemic.Doppler measurement of the MCA-PSV appears to be a valuable tool for estimating hemoglobin concentration in fetuses at risk for anemia. The correlation between hemoglobin and MCA-PSV becomes more accurate as the severity of anemia increases.
Hemoglobin F
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The major hemoglobin (Hb) during fetal life is fetal Hb (Hb F). It is mostly replaced by adult Hbs before birth and during the first year of life. In adults, where Hb F comprises <2.0% of the total Hb, it is not homogenously distributed among the red blood cells (RBCs) but is concentrated in a few RBCs, termed F-cells. Interestingly, for reasons that are unclear, Hb F increases in the maternal circulation during pregnancy. This increased Hb F could have two potential origins that are not mutually exclusive: A) maternal origin, due to inducing environment of Hb F in the maternal erythroid precursors; B) fetal origin, due to fetal cells crossing the placenta and entering the maternal circulation. The question we present herein is whether the observed increased Hb F in the maternal circulation during pregnancy is, at least partially, derived from the fetal origin. Peripheral blood was obtained from normal neonates (1-3 days old), adult men and pregnant and non pregnant women. The RBCs were stained for Hb F and carbonic anhydrase (CA) using a fetal cell count kit and analyzed by flow cytometry. Fetal and adult F-cells were distinguished by their expression of Hb F and CA. Fetal F-cells were Hb F++/CA-, while adult F-cells were Hb F+/CA+. Comparing pregnant and non pregnant women samples (n = 10), we found six samples of pregnant women with 0.2-1.7% fetal cells, but none in the non pregnant group. These results support the possibility that at least part of the increase in Hb F during pregnancy is due to fetal cells entering the maternal circulation.
Fetal circulation
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To establish whether a correlation exists between the fetal middle cerebral artery peak systolic velocity (MCA PSV) and fetal hemoglobin levels before intrauterine transfusion (IUT) in cases of severe fetal anemia.This was a single-center, retrospective study of data from 49 fetuses treated with IUT for fetal anemia between 2003 and 2018. Severe fetal anemia was suspected when MCA PSV was or exceeded 1.55 multiples of the median.The causes of anemia were largely idiopathic, and the overall survival rate was 57%. MCA PSV and hemoglobin were correlated in all 34 fetuses with alloimmune fetal anemia, whereas the 15 fetuses with nonimmune causes showed no correlation. Of the 15 noncorrelated cases, twin pregnancy was most common, followed by idiopathic causes. All the twin pregnancies involved monochorionic twins. Fetal hydrops, especially ascites, was significantly associated with severe anemia.Fetal MCA PSV may not be a reliable independent factor for the diagnosis of severe fetal anemia in nonimmune cases, and the presence of associated hydrops implies that the fetus is more likely to have severe fetal anemia than in a fetus without hydrops.
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Abstract Objective In red blood cell (RBC) isoimmunized pregnancies fetal anemia is associated with a hyperdynamic circulation. The aim of the present study was to examine further the possible value of fetal middle cerebral artery peak systolic velocity (MCA‐PSV) in the management of affected pregnancies. Methods A reference range of fetal MCA‐PSV with gestation was constructed from the study of 813 normal singleton pregnancies at 20–40 weeks' gestation. Fetal MCA‐PSV was also measured in 58 fetuses from RBC isoimmunized pregnancies, with maternal hemolytic antibody concentration of >15 IU/mL at 19–38 weeks' gestation and within 10 days of measurement of fetal hemoglobin concentration in blood obtained either by cordocentesis ( n = 43) or at delivery ( n = 15). In the RBC isoimmunized pregnancies each of the measured MCA‐PSV and hemoglobin concentrations was expressed as a delta value (difference in SDs from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA‐PSV and delta fetal hemoglobin concentration. Results In the normal pregnancies there was a significant increase in fetal MCA‐PSV with gestation (mean MCA‐PSV = 10 0.0223 × GA + 0.963 ). In RBC isoimmunized pregnancies the fetal MCA‐PSV was increased and there was a significant association between delta MCA‐PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA‐PSV + 0.093)/−0.356; R 2 = 0.638, P < 0.0001). An MCA‐PSV of mean + 1.5 SDs detected 96% of severely anemic fetuses, with a hemoglobin deficit of at least 6 SDs, for a false‐positive rate of 14%. Conclusion Measurement of fetal MCA‐PSV is a useful method of assessing fetal anemia. In the clinical management of isoimmunized pregnancies a cut‐off in MCA‐PSV of mean + 1.5 SDs can identify nearly all severely anemic fetuses with a low false‐positive rate. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.
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To establish relation between fetal MCA’s PSV in 3rd trimester and fetal anemia as non-invasive method. The study was done retrospectively, including 40 pregnant women who had raised PSV of MCA (Multiple of Median(MoM) >1.5) blood flow in third trimester and was correlated with the new born’s Hemoglobin and Blood indices (MCV and MCH). Forty fetuses who had MCA’s PSV more than 1.5 MoM(coming out to be around 66.50 ± 12.35 cm/seconds), after delivery, blood samples of these 40 neonate were taken, of which 37 were anemic based on hemoglobin and blood indices using reference range from study done by kumar et al8. Sensitivity was 92.5% and specificity around 88 %. Doppler spectral analysis of PSV of MCA is very reliable for predicting fetal anemia. MoM of PSV of Fetal MCA correlates very well with MoM of Neonatal Hemoglobin . Thus, fetal MCA’s PSV is very potential to replace invasive method for diagnosis of fetal anemia.
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Chorioangiomas are benign vascular tumors of the placenta. Complications occur when their size exceeds 5 cm.We report the use of peak systolic velocity in the middle cerebral artery, fetal hemoglobin levels in maternal circulation, and maternal serum alpha-fetoprotein levels in the diagnosis and management of fetal anemia in a patient with a large placental chorioangioma.Fetal hemoglobin levels in maternal circulation and abrupt elevations of middle cerebral artery peak velocity may be useful in detecting fetal anemia.
Fetal circulation
Umbilical artery
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To assess the value of peak systolic velocity in the middle cerebral artery (MCA) in prediction of fetal anemia as a non invasive method in non hydropic fetuses. The study included 30 pregnant women with non hydropic fetuses and with known red cell antibodies. Full ultrasound examination was done and peak velocity of systolic cerebral blood flow in MCA was measured. If severe anemia was suspected, fetal blood sampling by cordocentesis was performed. Thirty fetuses were examined, 22 were anemic and eight had a hemoglobin value within a normal range. The mean MCA peak systolic velocity for fetus with the normal hemoglobin (Hb) was 48.98 ± 13.94 while that for the anemic fetus was 64.79 ± 11.97 and P = 0.004. Sensitivity of increased peak velocity of systolic blood flow in MCA for prediction of fetal anemia was 90.5% and specificity was 78.6%. Doppler of peak velocity of systolic blood flow in MCA can be reliable in predicting anemia so delaying invasive methods until treatment (blood transfusion) is expected to be necessary.
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This paper presents a possibility of non-invasive diagnosis of fetal anemia based on the Doppler assessing of peak systolic velocity (PSV) in the fetal middle cerebral artery. The results of Doppler measurements were compared with fetal peripheral blood count estimated after cordocentesis.Doppler measurements of blood flow velocity in the fetal middle cerebral artery were performed in years 2000 and 2001 in 22 pregnancies complicated by maternal blood group alloimmunisation. Gestation age varied from 27 to 36 weeks, the mean gestation age was 32 weeks. Depending on hemoglobin concentration in the fetal blood sample the severity of anemia was divided into three groups: severe anemia (Hb = < 7 g%), middle (Hb = = 8-10 g%) and light (Hb = = 10-12 g%). The fourth group consisted of fetuses without anemia (Hb > 12 g%). The results were statistically analyzed to estimate correlation between the Doppler blood flow indexes (PI, RI, SD and PSV) in the middle cerebral artery and the peripheral blood count (Hb, Ht, erythrocyte count) of fetal blood received by cordocentesis. Using T-Student-test the differences of average maximal blood flow velocities and mean Doppler indexes in the group of fetuses with severe anemia (Hb < 7 g%) and fetuses without anemia (Hb > 12 g%) were compared.Highest (negative) correlation was found between the peak systolic velocity and the fetal hemoglobin concentration. The correlation index was -0, 85, which means the higher the peak systolic velocity the lower the hemoglobin concentration. The difference between the mean peak systolic velocity in the group of fetuses with severe anemia and the group without anemia was statistically significant (p < 0.001). However, there was no statistical significant difference in the mean peak systolic velocity between the group with middle anemia (Hb = 10-12 g%) and the group without anemia (Hb > 12 g%).Doppler ultrasonography with the measurement of peak systolic velocity in the middle cerebral artery is a good method in evaluating of fetal peripheral blood count. Non-invasive peak systolic velocity measurements in the middle cerebral artery allow to assess the fetal hemoglobin concentration and also to reduce the count of diagnostic cordocentesis.
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