First‐trimester treatment of fetal anemia secondary to parvovirus B19 infection

Abstract

Here we report two cases of first-trimester parvovirus B19 CASE REPORTS Case 1A 32-year-old primigravida was referred to our unit after routine ultrasound examination revealed increased fetal nuchal translucency (NT) at 13 + 1 weeks' gestation. A detailed sonographic evaluation demonstrated an NT of 4.4 mm, biventricular myocardial hypertrophy, moderate skin edema, mild ascites and bilateral pleural effusion. The ductus venosus (DV) blood flow was normal (positive awave, pulsatility index for veins (PIV): 1.56) 1 . However, the measurement of the fetal middle cerebral artery peak systolic velocity (MCA-PSV) showed an increased velocity of 37 cm/s, suggestive of fetal anemia (Figure 1). Maternal parvovirus (PV) infection was diagnosed by determining PV-specific immunoglobulin-G (IgG) and IgM as well as PV-B19 DNA by polymerase chain reaction (PCR). Fetal karyotype was normal. Subsequently, fetal therapy by cordocentesis was offered. The placenta was located laterally. Because of the softness of the 25-G spinal needle and an inability to correct the intrauterine position, three attempts were needed to place the needle next to the umbilical cord insertion site. No paralyzing agent was used. The umbilical vein was then punctured in one attempt and 3 mL of packed red cells were transfused. The initial hemoglobin count was 0.8 g/dL. No bradycardia was observed during the procedure, which took about 2 minutes.After 2 days, decline of the MCA-PSV and complete resolution of the fetal hydrops were observed. Ultrasound and Doppler examinations were continued for a period of 10 weeks at 3-week intervals. Measurements of MCA-PSV continued to show velocities in the upper percentile range, but no additional signs of fetal anemia were detected. However, at 24 + 5 weeks' gestation the fetus presented again with severe hydrops fetalis and cardiomegaly. The measurement of MCA-PSV showed an increased velocity of 85 cm/s. Cordocentesis and intrauterine blood transfusion were performed. The initial hemoglobin count was 1.4 g/dL (reticulocytes 13.2%, thrombocytes 22/nL). PCR for PV-B19 DNA was positive in maternal blood as well as in fetal ascites and blood. Two further intrauterine blood transfusions followed (at 25 + 3 and 26 + 2 weeks' gestation) (Table 1) and finally

Early intrauterine transfusion in severe red blood cell alloimmunization

“…The baseline characteristics of these women are summarized in Table 1. Ten women were noted to have had at least one previous stillbirth as a result of alloimmunization at a median gestational age of 24 weeks (range, [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]. Of this cohort, 26 (87%) were associated with anti-D, four (13%) with anti-Kell and 12 had more than one antibody type involved.…”

“…Hydrops rarely appears before 17 weeks of gestation, probably because of the immaturity of the reticuloendothelial system 4 . Therefore, at early gestation, even in the absence of hydrops, an aggressive approach should be used in establishing the diagnosis of fetal anemia based on the MCA-PSV values, which has been shown to be a helpful diagnostic tool, even in the first trimester 28 .…”

Therapeutic management of fetal anemia: review of standard practice and alternative treatment options

“…A review of the literature in a total of 82 studies involving 705 cases of fetal parvovirus infection showed a clear benefi t of active intervention with IUT over conservative management (82 % vs. 55 % survival rates); also, the signs of anemia usually resolve after a single transfusion [84] . Interestingly, successful management of fetal anemia secondary to parvovirus B19 infection with intravascular transfusion at 13 weeks ' gestation has been reported in two fetuses [36] . Each fetus received a 3-mL intravenous transfusion of packed red blood cells into the umbilical vein, using a 25-gauge spinal needle.…”

Increased nuchal translucency in euploid fetuses—what should we be telling the parents?

“…is associated with poor pregnancy outcome (cardiac and other anomalies, perinatal deaths) and should be regarded as an additional risk factor warranting close ultrasound surveillance Oh et al, 2007;Maiz et al, 2008b). Infection screening should not be routinely performed (Sebire et al, 1997), but it may be appropriate when NT enlargement evolves in the second trimester into an increased nuchal fold, generalized edema, or unexplained hydrops or in women with young children who have been recently ill or have been ill themselves (Markenson et al, 2000;Kempe et al, 2007).…”