What is the role of intrauterine peritoneal transfusion (IPT) to the treatment of hemolytic disease of the newborn (HDN)?

Updated: Dec 28, 2017
  • Author: Sameer Wagle, MBBS, MD; Chief Editor: Muhammad Aslam, MD  more...
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Answer

During the period when intrauterine peritoneal transfusion was the only means of treatment, newborns were routinely delivered at 32 weeks' gestation. This approach resulted in a high incidence of hyaline membrane disease and exchange transfusions. With the advent of intravascular transfusion (IVT) in utero, the general approach to the severely affected fetus is to perform IVT as required until 35 weeks' gestation, with delivery planned at term. Establishment of lung maturity is difficult in these fetuses because of contamination of amniotic fluid with residual blood during transfusion; however, if delivery is planned prior to 34 weeks' gestation, maternal steroid administration to enhance fetal lung maturity is indicated.

In addition, excess amniotic fluid bilirubin levels cause false elevation on the fluorescence depolarization TDx fetal lung maturity test, version II (TDX-FLMII); therefore, other tests to determine fetal lung maturity should be used, such as infrared spectroscopy, lamellar body count, phosphatidylglycerol quantitation or lecithin/sphingomyelin (L/S) ratio.

Liley first described intraperitoneal transfusion (IPT) in 1963. A Tuohy needle is introduced into the fetal peritoneal cavity under ultrasonographic guidance. An epidural catheter is threaded through the needle. A radiopaque medium is injected into the fetal peritoneum. The proper placement is confirmed by delineation outside of bowel or under the diaphragm or by diffusion in fetal ascites. Packed red blood cells (RBCs) at a hemotcrit (Hct) of 75-80% that are CMV-negative, less than 4-days-old, group O, Rh-negative, Kell-negative, leukoreduced, irradiated with 25 Gy to prevent graft versus host disease, and cross-matched with maternal serum are injected in 10-mL aliquots to a volume calculated by the following formula: [1]

IPT volume = (gestation in weeks - 20) × 10 mL

Residual hemoglobin (Hb) in the fetus is estimated to allow for proper spacing of IPT and selection of gestation of delivery by the following formula:

Hb g/dL = 0.85/125 × a/b × 120 - c/120

In the formula, a is the amount of donor RBC Hb transfused, b is the estimated fetal body weight, and c is the interval in days from the time of transfusion to the time of donor Hb estimation.

IPT is repeated when the fetal Hb is estimated to have dropped to 10 g/dL. Usually, a second IPT is performed 10 days after the first transfusion in order to raise the Hb above 10 g/dL. Then another transfusion is performed every 4 weeks until the time of planned delivery at 34-35 weeks' gestation. Fetal diaphragmatic movements are necessary in order for absorption of RBC to occur. This approach is of no value for a moribund nonbreathing fetus. Maternal complications include infection and transplacental hemorrhage, whereas fetal complications are overtransfusion, exsanguination, cardiac tamponade, infection, preterm labor, and graft versus host disease. Survival rates after IPT approached approximately 75% with the help of ultrasonography.


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