Torbjorn moe eggboe_transfusions_norway

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NNFM Nordic Network of Fetal Medicine

Torbjorn Moe Eggboe, NNFM Nordic Network of Fetal Medicine meeting in Gothenburg 14-16th of April 2015.

Healthcare

TorbjørnEggebø
NationalCenter
forFetalMedicine
DeptOb&Gyn
Trondheim-Norway
Organisationofinvasivefetal
medicineinNorway

Deliveries
! 60000/year
! Onlyriskgroupsareoffered1trimester
examination
" >38years
! Routineexaminationinsecondtrimester

Fetalmedicinecenters
! Oslo(CVS)
! Bergen(CVS)
! Trondheim(CVS)
! Stavanger
! Tromsø(CVS)

Nationalcenterforfetalmedicine–
established1990
1. Nationalresponsibilityforinvasive
procedureswithhighriskforthe
fetus(e.g.transfusions)
TTSarereferredabroad
2.Centerofcompetenceforfetal
medicine

NCFM
! High-riskprenatalinvasiveprocedureslikeintrauterine
transfusionsanddrainageoffetaleffusionsarecentralized
totheNationalcenterforfetalmedicine(NSFM)
! Thecenterisalsoareferralcenterforfetuseswithsevere
orunclearmalformations
! Allinvasiveproceduresandfetalmalformationsare
recordedinaqualityregistryusedforqualityassurance
andresearch
! NCFMteachesandtrainsmidwivesanddoctorsin
ultrasounddiagnostics
! IncooperationwiththeNorwegianUniversityinTechnology
(NTNU),thecenterdevelopsnewproceduresand
technologiesinfetalmedicine
! ThecenterisaWHOcollaboratingcenterfordiagnostic
ultrasoundinobstetricsandgynecology

1988:rhesusnegative
Gravida6,para3,alive1
YearDeliveryOutcome
o 1973Vaginaldelivery2840g,healthy(noanti-D
prophylaxis)
o 1975VaginaldeliveryStillbirth,erythroblastosis
o 1975CSNeonataldeathafter1day
o 1983Miscarriage
o 1985Ectopicpregnancy
 1988CS,32weeks5fetaltransfusions;1600g
FirstfetaltransfusioninNorway

Etiologyoffetalanemiainfetusestreatedwith
bloodtransfusionsatNCFMfrom1988to2007
1988–2007
N=101
Rhesus-D
69%
Parvovirus
11%
Rhesus-E
2%
Kell2%
Thalassemia2%
Hemoglobinopathia1%
CMV1%
Notknown
12%

Anti-bodies
thatmaycause
fetalanemia
Anti-D
Anti-c
Anti-E
AntiKell
AntiFya(Duffy)rarely(titer>64)
Trondheim
94%
Anti-D

MCA
MCA
ACAAbas
1995
Anemicfetuses!highpeakvelocities

MCApeakvelocityin111fetusesatriskforanemia
162024283236weeks
MCA-PV (cm/sec)
90
50
40
30
20
10
60
70
80
100
1.50
median
Marietal.,NEnglJMed2000
MoMAnemiawithhydrops
ΔAnemiawithouthydrops
oNoanemia

Redcellalloimmunisation
Surveillancetoday
! Obstetrichistory
! Antibodylevels(titres)
! DopplerofArteriacerebrimedia
! Fetalbloodsamplingandtransfusion

MCAPVandEVF
0
10
20
30
40
50
60
70
80
90
100
110
152025303540
Gestationalage(weeks) MCA PV cm/sec
MCAPVwhenEVF<25
MCAPVwhenEVF25-34
MCAPVwhenEVF>34
Linear(MCAPVwhenEVF<25)
Linear(MCAPVwhenEVF25-34)
Linear(MCAPVwhenEVF>34)
CorrelationofMCAPVtoEVF
Trondheim2000-2006
n=66
n=96
n=159
N=321

Medianand1.5multiplesofthemedian
ofMCAduringpregnancyMarietal.
Fetalblood
sampling
Transfusion

MCVPVandEVFbeforeandafterfirsttransfusion
Trondheim
N=27
EVFbeforetransfusion
EVFaftertransfusion
MCVPVbeforetransfusion
MCVPVaftertransfusion

Hematocritpriortofirsttransfusionandhydrops
N=74
hydrops
without
hydrops

Numberoffetuses(n=74)treatedfor
redcellalloimmunizationperyearatNCFM

Invasiveprocedures
(2008-14)
2008200920102011201220132014
Anemia7(35)3(21)2(8)2(7)7(39)6(35)5(16)

March2014
! RhD-women
! Antibodiesinfirsttrimester
! FreefetalDNA(RHD)inweek25
! anti-Dimmunoglobulininweek29
(fetus+)
! Testingofchildafterdelivery

2016
! Twoexperienceddoctorswill
retireinDecember2015
! Oneofthemwillstillbeavailable
forinvasiveprocedures
! Twonewdoctorstrained

Legalterminations
Womandecidesupto12+0
Abortioncouncilfrom12-21+6
malformations
socialindications
Fromweek22itisnotallowed
Exceptions–deadlymalformations
maternalindications

'Is everything normal?' 'Is everything fine?' 'Is my baby (fetus) alright?' 'I hope my journey through 9 months will be smooth & safe!' 'My relative's baby delivered prematurely in 8th month.' 'My Friend developed swelling & high Bp in 8th month & her baby did not grow to expected weight.' If you wonder and worry about these questions, please go through this sides and learn the correct answers and help yourselves n choosing the right tests at the right time and prevent, predict early diagnose pregnancy complications & get timely help in case if they develop.

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Torbjorn moe eggboe_transfusions_norway

1. TorbjørnEggebø NationalCenter forFetalMedicine DeptOb&Gyn Trondheim-Norway Organisationofinvasivefetal medicineinNorway

2. Deliveries ! 60000/year ! Onlyriskgroupsareoffered1trimester examination " >38years ! Routineexaminationinsecondtrimester

3. Fetalmedicinecenters ! Oslo(CVS) ! Bergen(CVS) ! Trondheim(CVS) ! Stavanger ! Tromsø(CVS)

4. KUBtest ! <5000/year ! 10%testpositive

5. Nationalcenterforfetalmedicine– established1990 1. Nationalresponsibilityforinvasive procedureswithhighriskforthe fetus(e.g.transfusions) TTSarereferredabroad 2.Centerofcompetenceforfetal medicine

6. NCFM ! High-riskprenatalinvasiveprocedureslikeintrauterine transfusionsanddrainageoffetaleffusionsarecentralized totheNationalcenterforfetalmedicine(NSFM) ! Thecenterisalsoareferralcenterforfetuseswithsevere orunclearmalformations ! Allinvasiveproceduresandfetalmalformationsare recordedinaqualityregistryusedforqualityassurance andresearch ! NCFMteachesandtrainsmidwivesanddoctorsin ultrasounddiagnostics ! IncooperationwiththeNorwegianUniversityinTechnology (NTNU),thecenterdevelopsnewproceduresand technologiesinfetalmedicine ! ThecenterisaWHOcollaboratingcenterfordiagnostic ultrasoundinobstetricsandgynecology

7. 1988:rhesusnegative Gravida6,para3,alive1 YearDeliveryOutcome o 1973Vaginaldelivery2840g,healthy(noanti-D prophylaxis) o 1975VaginaldeliveryStillbirth,erythroblastosis o 1975CSNeonataldeathafter1day o 1983Miscarriage o 1985Ectopicpregnancy  1988CS,32weeks5fetaltransfusions;1600g FirstfetaltransfusioninNorway

8. Etiologyoffetalanemiainfetusestreatedwith bloodtransfusionsatNCFMfrom1988to2007 1988–2007 N=101 Rhesus-D 69% Parvovirus 11% Rhesus-E 2% Kell2% Thalassemia2% Hemoglobinopathia1% CMV1% Notknown 12%

9. Anti-bodies thatmaycause fetalanemia Anti-D Anti-c Anti-E AntiKell AntiFya(Duffy)rarely(titer>64) Trondheim 94% Anti-D

10. MCA MCA ACAAbas 1995 Anemicfetuses!highpeakvelocities

11. MCApeakvelocityin111fetusesatriskforanemia 162024283236weeks MCA-PV (cm/sec) 90 50 40 30 20 10 60 70 80 100 1.50 median Marietal.,NEnglJMed2000 MoMAnemiawithhydrops ΔAnemiawithouthydrops oNoanemia

12. Redcellalloimmunisation Surveillancetoday ! Obstetrichistory ! Antibodylevels(titres) ! DopplerofArteriacerebrimedia ! Fetalbloodsamplingandtransfusion

13. MCAPVandEVF 0 10 20 30 40 50 60 70 80 90 100 110 152025303540 Gestationalage(weeks) MCA PV cm/sec MCAPVwhenEVF<25 MCAPVwhenEVF25-34 MCAPVwhenEVF>34 Linear(MCAPVwhenEVF<25) Linear(MCAPVwhenEVF25-34) Linear(MCAPVwhenEVF>34) CorrelationofMCAPVtoEVF Trondheim2000-2006 n=66 n=96 n=159 N=321

14. Medianand1.5multiplesofthemedian ofMCAduringpregnancyMarietal. Fetalblood sampling Transfusion

15. MCVPVandEVFbeforeandafterfirsttransfusion Trondheim N=27 EVFbeforetransfusion EVFaftertransfusion MCVPVbeforetransfusion MCVPVaftertransfusion

16. Hematocritpriortofirsttransfusionandhydrops N=74 hydrops without hydrops

17. Numberoffetuses(n=74)treatedfor redcellalloimmunizationperyearatNCFM

18. Invasiveprocedures (2008-14) 2008200920102011201220132014 Anemia7(35)3(21)2(8)2(7)7(39)6(35)5(16)

19. March2014 ! RhD-women ! Antibodiesinfirsttrimester ! FreefetalDNA(RHD)inweek25 ! anti-Dimmunoglobulininweek29 (fetus+) ! Testingofchildafterdelivery

20. 2016 ! Twoexperienceddoctorswill retireinDecember2015 ! Oneofthemwillstillbeavailable forinvasiveprocedures ! Twonewdoctorstrained

21. Legalterminations Womandecidesupto12+0 Abortioncouncilfrom12-21+6 malformations socialindications Fromweek22itisnotallowed Exceptions–deadlymalformations maternalindications