Acute villous inflammation in the placenta following intrauterine transfusion

Abstract

SYNOPSIS Infection is well recognized as a complication of intrauterine transfusion. The majority of cases are fortunately mild and consist merely of chorio-amnionitis. The present case, of severe type, resulted from contamination of the donor blood with Acinetobacter calcoaceticus. Spread of infection from foetus to mother has been carefully studied and an entirely new type of lesion in the placenta described. This takes the form of acute villous inflammation with resultant micro-abscess formation beneath the trophoblast layer and eventual rupture into the intervillous space. Attempts at localization are poor.Though intrauterine transfusion is widely used in the treatment of babies severely affected by erythroblastosis foetalis due to maternal Rhesus isoimmunization, it is not a procedure which is entirely free from risk. According to Queenan (1969) one out of every three patients is liable to go into premature labour and 10% develop infection. Fortunately the latter is generally mild in nature but occasionally it can be severe. This was true of the present case, where we were able not only to identify the source of infection in the baby but also to relate it to unusual changes in the placenta and so determine the natural spread of the disease through the foeto-placental unit to the mother. Case HistoryThe patient had already lost three babies due to Rhesus isoimmunization and in the present pregnancy it was decided to carry out intrauterine transfusion at 28 weeks because amniocentesis readings had shown the bilirubin peak to be rising steeply. Antibiotic coverage in the form of cephaloridine 1 g bd intramuscularly was commenced on the morning of transfusion and at 3 pm on the same day 75 ml of group 0, Rhesus-negative, washed packed cells was introduced into the foetal abdomen without undue difficulty. The foetal heart rate remained satisfactory and the patient was returned to the antenatal ward for observation. On the following morning the foetal heart could not be heard. By evening the patient complained of feeling cold and shivery; her temperature had risen to 40 3°C and Received for publication 12 July 1972. she began to vomit. This persisted, necessitating the administration of intravenous fluids. Eventually tenderness developed over the uterus and as the diagnosis was suggestive of intrauterine infection it was decided to deliver her vaginally as soon as possible. Blood cultures were taken and syntocinon given together with gentamycin tid and cephaloridine four hourly, all administered intravenously. Labour ensued and six hours later the patient had a spontaneous breech delivery of a macerated male child. It was noted that the liquor was not foul smelling. Blood loss amounted to 180 ml. The patient's temperature fell to near normal levels but later signs of general peritonitis began to appear, and on surgical advice a laparotomy was performed. It is not proposed to discuss here the patient's further course and treatment, but in brief it can be said that despite complications and a protracted puerperi...