Double/Triple Intrauterine Blood Transfusion in Rh-isoimmunized Anemic Fetuses in Multiple Pregnancies with Favorable Outcome

Vandana Bansal¹ · Meera Jayaprakash¹ · Akshay Gangurde¹

Dr Vandana Bansal (MD, DGO, DNB, MNAMS, FRCOG (UK), FICOG, FNB (High Risk Pregnancy and Perinatology)) Addl. Professor, Department of Obstetrics and Gynaecology and Fetal Medicine; Dr Meera Jayaprakash (MS (Obstetrics and Gynecology), FCPS) Fellow Fetal Medicine; Dr Akshay Gangurde, (MS (Obstetrics and Gynecology)), Senior Resident, Nowrosjee Wadia Maternity Hospital, Seth G. S. Medical College, Parel, Mumbai, Maharashtra, India.

Vandana Bansal drvandana_bansal@yahoo.co.in

Meera Jayaprakash meera.jps@gmail.com

Akshay Gangurde akshaygangurde42@gmail.com

1 Department of Obstetrics and Gynecology and Fetal Medicine, Nowrosjee Wadia Maternity Hospital and Seth G. S. Medical College, Parel, Mumbai, Maharashtra, India

Background Multiple pregnancies have increased with the use of assisted reproduction, and we expect more women reporting with Rh isoimmunization among multiple gestation in near future. Intrauterine transfusion in singleton itself is technically difficult and requires a lot of skill and precision. Performing double/triple transfusion in twins/triplets is expected to be more demanding.

Aim To create awareness on the technical difficulties encountered in intrauterine transfusion in twins and triplets.

Methodology We report a case series of four Rh-isoimmunized twins/triplets in 5 years who presented with severe anemia requiring intrauterine transfusion.

Results Each of the four sets of cases had their own intricacies that needed to be pondered before tackling them as not much was available in the literature. In Case 1, the first twin intrauterine transfusion in our 20-year-long experience, the difficulty in the approach to the first twin due to a posteriorly placed placenta has been highlighted. Case 2 was rare due to the concomitant presence of atypical antibodies in the mother in addition to Rh-D isoimmunization that made it difficult to cross match any donor blood for intrauterine transfusion. The third case was exclusive due to its monochorionic–diamniotic nature of the twins where the impact of inter-twin anastomosis on the transfusion was to be taken into consideration. Fourth case was a triplet gestation where the difficulty of which cord to be assigned to which fetus, the crowded space for intervention, as well as the risk of prolonged operative time and associated risk of preterm/premature rupture of membranes were our concern. Conclusion Intrauterine transfusion (IUT) in twins/triplets is challenging. Difficulties encountered during IUT in multifetal gestation are due to different or uncertain chorionicity, intraplacental anastomosis between vessels, different degree of anemia in twins, difficult to ascertain cord–fetus relationship and difficulty to reach placental insertion site due to crowding by multiple fetal parts.

Keywords : Fetal anemia · Intrauterine transfusion · Rh isoimmunization · Twin transfusion · Twin intrauterine transfusion

Rhesus isoimmunization causes significant perinatal morbidity and mortality in the form of in utero anemia, hydrops, fetal demise and postnatal hyperbilirubinemia and cardiac failure. Intrauterine blood transfusion is the only proven lifesaving therapy for Rh-isoimmunized pregnancy with fetal anemia. Isoimmunization of sufficient severity requiring intrauterine transfusions in multifetal gestation is unusual and is expected to be a challenging task. There are very few cases in the literature describing intrauterine fetal blood transfusion in twins and triplets.

It is a retrospective analysis of four cases, in past 5 years of Rh-isoimmunized multifetal pregnancy (3 twin pair and one set of triplets) with fetal anemia resulting in successful outcomes after intrauterine blood transfusion. All these women were referred to our institute, following the identification of maternal anti-erythrocytic alloantibodies between 2016 and 2021. Each case was unique and had its own complexities to manage.

Giannina G, Moise KJ Jr, Dorman K. A simple method to estimate volume for fetal intravascular transfusion. Fetal Diagn Ther. 1998;13:94–7.
Manning FA, Bowman JM, Lange IR, et al. Intrauterine transfusion in an Rh immunized twin pregnancy: a case report of successful outcome and review of literature. Obstet Gynecol. 1985;65:2S.
Mari G, Deter RL, Carpenter RL, et al. Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization. Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses. N Engl J Med. 2000;342:9–14.
Oepkes D, Seaward PG, Vandenbussche FP, et al. Doppler ultrasonography versus amniocentesis to predict fetal anemia. N Engl J Med. 2006;355:156–64.
Mari G. Middle cerebral artery peak systolic velocity for the diagnosis of fetal anemia: the untold story (Level III). Ultrasound Obstet Gynecol. 2005;25:323–30.
Mari G, Norton ME, Stone J, et al. Society for Maternal-Fetal Medicine (SMFM); Clinical Guideline #8: the fetus at risk for anemia diagnosis and management. Am J Obst Gynecol. 2015;212:697–709.
Nicolaides KH, Thilaganathan B, Rodeck CH, et al. Erythroblastosis and reticulocytosis in anemic fetuses. Am J Obstet Gynecol. 1988;159:1063–5.
Chitty LS, Finning K, Wade A, et al. Diagnostic accuracy of routine antenatal determination of fetal RHD status across gestation: population based cohort study (Level II-2). BMJ. 2014;349:g5243.
Schonewille H, Klumper FJ, Watering LM, et al. High additional maternal red cell alloimmunization after Rhesus- and K-matched intrauterine intravascular transfusions for hemolytic disease of the fetus (Level II-2). Am J Obstet Gynecol. 2007;196(2):143.e1-6.
Abassi N, Johnson JA, Ryan G. Fetal anemia. Ultrasound Obstet Gynecol. 2017;50:145–53.
Jacques L, Poissonnier MH, Coutanceau MJ, et al. Management and outcome of Fetomaternal alloimmunization in twin pregnancies. Fetal Diagn Ther. 1999;14:26–30.
Lindenburg IT, Smits-Wintjens VE, Klink JM, et al. Long-term neurodevelopmental outcome after intrauterine transfusion for hemolytic disease of the fetus/newborn: the LOTUS study. Am J Obstet Gynecol. 2012;206(141):e1-8.
Lindenburg IT, Van Kamp IL, Oepkes D. Intrauterine blood transfusion: current indications and associated risks. Fetal Diagn Ther. 2014;36:263–71.
Radunovic N, Lockwood CJ, Alvarez M, et al. The severely anemic and hydropic isoimmune fetus: changes in fetal hematocrit associated with intrauterine death. Obstet Gynecol. 1992;79:390–3.
Van Kamp IL, Klumper FJ, Bakkum RS, et al. The severity of immune fetal hydrops is predictive of fetal outcome after intrauterine treatment. Am J Obstet Gynecol. 2001;185:668–73.
Scheier M, Hernandez-Andrade E, Fonseca EB, et al. Prediction of severe fetal anemia in red blood cell alloimmunization after previous intrauterine transfusions. Am J Obstet Gynecol. 2006;195:1550–6.
Zwiers C, Scheffer-Rath EAM, Lopriore E, et al. Immunoglobulin for alloimmune hemolytic disease in neonates. Cochrane Database Syst Rev. 2018;3:1–64.