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Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 80-81

Technique of intrauterine foetal blood transfusion – A video article


1 Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Transfusion Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Radiotherapy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission07-Jan-2022
Date of Decision26-Feb-2022
Date of Acceptance26-Feb-2022
Date of Web Publication28-Apr-2022

Correspondence Address:
Dr. Latika Chawla
Department of Obstetrics and Gynaecology, Level 6, Academic Block, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_3_22

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How to cite this article:
Chawla L, Rajaram S, Yadav A, Kaur D, Gupta S, Chaturvedi J. Technique of intrauterine foetal blood transfusion – A video article. J Med Evid 2022;3:80-1

How to cite this URL:
Chawla L, Rajaram S, Yadav A, Kaur D, Gupta S, Chaturvedi J. Technique of intrauterine foetal blood transfusion – A video article. J Med Evid [serial online] 2022 [cited 2022 May 21];3:80-1. Available from: http://www.journaljme.org/text.asp?2022/3/1/80/344290



Despite routine antenatal anti-D prophylaxis being introduced worldwide, Rh isoimmunisation in pregnancy is still a worrisome issue in India. Intrauterine blood transfusion (IUT) is an established modality of the management of severe anaemia due to Rh isoimmunisation. This facility, however, is available across only very few centres in India. This article explains and video demonstrates the technique of IUT.


  Indications of Intrauterine Blood Transfusion Top


IUT is done in Rh-isoimmunised pregnancies with severe anaemia (middle cerebral artery peak systolic velocity [MCA PSV] more than 1.5 multiple of median [Figure 1], hydrops and foetal haematocrit <30%).[1]
Figure 1: Foetus with severe anaemia (middle cerebral artery peak systolic velocity >1.5 multiple of median) and hydrops

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  Special Blood Preparation for Intrauterine Blood Transfusion Top


Blood transfused is O-negative, cross-matched with maternal blood. It is doubly centrifuged to obtain a haematocrit of 75%–85%, irradiated to decrease chances of graft-versus-host reaction and leucocyte depleted to reduce cytomegalovirus infection. Blood should be fresh, donated in the last 7 days to prevent decrease in 2–3 diphosphoglycerate levels and thereby allow maximum availability of oxygen to the foetus.[2]


  Procedure Top


Video 1 [Additional file 1] shows how to perform intrauterine fetal blood transfusion. IUT is performed under ultrasound guidance with full aseptic precautions. Intravascular, intrahepatic, and intraperitoneal routes can be used. Prerequisites are shown in [Figure 2].[3] Blood is pre-loaded in 10 cc syringes. A 20G spinal needle is used to gain vascular access [Figure 3]. In patients with posterior placenta, accessing cord insertion may be difficult and thus may require longer needles, or choosing a free loop of umbilical cord may be technically challenging. Use of Doppler can ensure that needle is entering umbilical vein and not the artery. After gaining vascular access, cord blood (pre-IUT) sample is withdrawn and analysed for haematocrit using a capillary microhematocrit . Muscle relaxant vecuronium in dose of 0.1mg/kg estimated fetal weight, may be injected following this to paralyse fetus or it may be given as an intramuscular injection in fetal thigh prior to gaining vascular access. Blood is pushed slowly using a triway connector. During transfusion, blood is visible moving away from the needle tip into the umbilical vein. After transfusing desired volume, a post-IUT blood sample is obtained.
Figure 2: Requirements for intrauterine blood transfusion[3]

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Figure 3: Ultrasound image of spinal needle gaining vascular access

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  Calculating Volume of Blood for Transfusion Top


Mandelbrot formula[4] is used for calculating volume of blood to be transfused:

Volume of blood to be transfused (ml) = ([Final haematocrit − Initial haematocrit]/Transfused blood haematocrit) × fetoplacental volume.

Fetoplacental volume (ml) = 1.046 + foetal weight (g) × 0.14[4]

If a micro-haematocrit/automated haemocytometer is not available, volume of blood is calculated taking initial haematocrit as 30%. Final haematocrit is kept at 50%.[1]

With hydropic foetuses, initial haematocrit is assumed to be 20%. In such cases, volume to be transfused is to be decided keeping in mind not to raise final haematocrit by 4 times of the initial value, because that might result in volume overload and further worsening of cardiac status of the hydropic foetus. A second transfusion is done after 48 h.

MCA PSV is used to decide timing of first transfusion. Sensitivity of Doppler measurements decreases after two transfusions. We transfuse when foetal haematocrit falls below 30%. Further transfusions are decided by assuming a 1% rate of fall in foetal haematocrit per day. IUT should be only up to 35 weeks.

Acknowledgements

We are grateful to the Departments of Transfusion Medicine and Radiotherapy and especially to the Department of Neonatology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moise KJ Jr. Management of rhesus alloimmunization in pregnancy. Obstet Gynecol 2008;112:164-76.  Back to cited text no. 1
    
2.
Fung MK, Grossman MK, Hillyer CD, Westhoff CM. Technical Manual of the American Association of Blood Banks. 18th ed. Bethesda, Maryland: American Association of Blood Banks; 2014.  Back to cited text no. 2
    
3.
Chawla L, Jindal L, Yadav A. Management of rh iso-immunized pregnancy. AOGD Bulletin; 2019;19(4):25-28  Back to cited text no. 3
    
4.
Mandelbrot L, Daffos F, Forestier F, MacAleese J, Descombey D. Assessment of fetal blood volume for computer-assisted management of in utero transfusion. Fetal Ther 1988;3(1-2):60-6.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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