H. H. H. Kanhai

Will it ever be possible to balance the risk of intracranial haemorrhage in fetal or neonatal alloimmune thrombocytopenia against the risk of treatment strategies to prevent it

Background and Objectives Intracranial haemorrhage (ICH) of the fetus or newborn is a severe complication of fetal or neonatal alloimmune thrombocytopenia (FNAIT). In order to attain management decisions to prevent ICH, the risk of ICH in successive pregnancies with thrombocytopenia, with or without a history of ICH, must be established.

Maternal Hydrops Syndrome: A Review

The maternal hydrops syndrome (Ballantyne syndrome, mirror syndrome, pseudotoxemia, triple edema) is a preeclampsia-like disease observed in some pregnancies with severe fetal and/or placental hydrops. We describe three pregnancies with severe immunological fetal-placental hydrops resulting in fetal death, in spite of intrauterine transfusions. The mothers suffered severe hydrops syndrome, one of which was complicated by an eclamptic convulsion. All three women had anemia, low hematocrit, and elevated plasma uric acid levels. It is suggested that low hematocrit is an important pathophysiological feature in maternal hydrops syndrome.

Outcome for children treated with fetal intravascular transfusions because of severe blood group antagonism

OBJECTIVE To describe the outcome for 92 fetuses treated between May 1987 and January of 1993 with intrauterine (intravascular) transfusions for severe hemolytic disease in comparison with a high-risk and a healthy control group. STUDY DESIGN Information on the perinatal period was obtained from the patient records. The children regularly attended the outpatient clinic, and a general pediatric examination was performed on each visit. The psychometer development of the child until age 4 1/2 years was assessed according to Gesell. At the age of 5 years, the adaptation part of the Denver Developmental Screening Test and a Dutch-language test were used. A neurologic examination was performed according to Touwen. RESULTS In our study, 77 (83.7%) of 92 fetuses were born alive after intravascular transfusions. The overall survival rate was 79.3%. The follow-up group included 69 infants, with an age range of 6 months to 6 years. Correlation between antenatal and perinatal features showed a significant negative relationship between the number of intrauterine transfusions and the duration of phototherapy (p = 0.002). The probability that neurologic abnormalities would occur was significantly greater when perinatal asphyxia had been present (p < 0.05) and with a lower cord hemoglobin level at birth (p = 0.03). The total number of children with disabilities was 10.1% (7/69). CONCLUSIONS The neurodevelopmental outcome for the group of survivors compared favorably with a group of high-risk, very low birth weight infants (10.1% to 18%), and less favorably with a healthy control group (10.1% to 6%).

The use of ultrasonography and Doppler in the prediction of fetal haemolytic anaemia: a multivariate analysis

Objective To assess the value of ultrasonography and Doppler to predict the severity of fetal haemolytic anaemia.

Twin-to-twin transfusion syndrome after 26 weeks of gestation: is there a role for fetoscopic laser surgery?

Objective  To compare fetoscopic laser surgery with amniodrainage in the treatment of twin‐to‐twin transfusion syndrome (TTTS) diagnosed after 26 weeks of gestation.

Fetal cell detection in maternal blood: A study in 236 samples using erythroblast morphology, DAB and HbF staining, and FISH analysis

A protocol to detect fetal nucleated red blood cells (NRBCs) was tested in 217 pregnant women and in 19 nonpregnant controls. All the pregnant women were sampled after chorionic villus sampling (CVS); 20 were also sampled pre-CVS. NRBC recognition was based upon morphology by using staining of hemoglobin with 3,3-diaminobenzidin (DAB) or by immunocytochemical staining for fetal hemoglobin (HbF). This was combined with FISH analysis for both the X- and Y-chromosomes on the same cells. Progressive refinement of the methods increased the number of cases where NRBCs were detected from 53% (DAB) to 75% and 78% for DAB and HbF staining, respectively, with on average 43 NRBCs (range, 1-220). DAB gave a slightly higher yield than HbF in the lower cell count range (<25). In 6 out of 18 controls, NRBCs were detected with DAB, vs. 1 out of 19 (5%) with HbF. FISH analysis in 41 cases resulted in correct sex prediction in 80% (DAB) and 89% (HbF), respectively. Our data demonstrated an increase of cases with NRBCs (30% to 75%), as well as a rise of the mean number of NRBCs (6 to 29 cells), after CVS. We conclude that DAB staining is a straightforward way to screen for the presence of NRBCs in maternal blood, but is not specific for NRBCs of fetal origin. HbF immunophenotyping is a reliable marker for fetal NRBCs, which detected slightly fewer NRBCs than DAB-staining, but improved sex prediction and significantly reduced false-positive results. CVS at 10-13 weeks of gestation causes a significant increase of NRBCs in maternal blood. These data indicate that further refinement of NRBC detection is needed before application of noninvasive prenatal diagnosis using maternal blood is feasible.

Development of a preparation and staining method for fetal erythroblasts in maternal blood: Simultaneous immunocytochemical staining and FISH analysis†

In order to detect fetal nucleated red blood cells (NRBCs) in maternal blood, a protocol was developed which aimed at producing a reliable staining method for combined immunocytochemical and FISH analysis. The technique had to be suitable for eventual automated screening of slides. Chorionic villi washings, cord blood, and maternal blood samples were used for this study. After a density gradient separation and centrifugal cytology, slides were stained either with 3,3-diaminobenzidin (DAB), a marker for heme, or with antibodies against the gamma-chain of fetal hemoglobin (HbF). FISH analysis for both X- and Y-chromosomes was performed on the same slides. Cytocentrifugation provided a controlled cell density on the slides with good cell morphology. Both the DAB and HbF staining were suitable for manual screening of large numbers of slides. The HbF staining, although supposed to be more specific for fetal NRBCs, appeared to be more sensitive to minor changes in preparation. We were eventually able to combine HbF staining with FISH analysis, and produced a detection efficiency of >85% for both X- and Y-chromosome signals. This preparation protocol simplifies the detection of NRBCs in maternal blood. Immunocytochemical staining and FISH analysis can be performed on the same cell with good image contrast, thus facilitating both manual and automated image analysis. This will facilitate the use of this approach for prenatal diagnosis.

Experience in prenatal testing for Huntington's disease in The Netherlands: procedures, results and guidelines (1987–1997)

We have performed 31 exclusion tests (43 per cent) and 41 direct tests (57 per cent) in 43 couples at risk, in the period 1987 to 1997 in Leiden, The Netherlands. This resulted in termination of 28 pregnancies (39 per cent), with an increased risk. In 28 couples (65 per cent), the woman was at risk. Prenatal testing in consecutive pregnancies (mean number: 3) was performed in 15 couples (35 per cent), with a mean time interval of 15 months. Parents should make an independent choice for (every) pregnancy, although most (86 per cent) did not change their initial choice. It is important that the position of children in the same family, of whom some know their status as a result of prenatal testing, whereas others remain at risk, is taken into consideration in counselling. The relative number of exclusion tests when compared with direct tests has diminished since the mutation was identified. The prenatal exclusion–definitive test (Fig. 1) was rarely used (2/72, 3 per cent). Nowadays, direct mutation testing of the fetus only is simpler and faster and the risk of disclosure of the genetic status of the at‐risk parent is only 25 per cent. This test should therefore be offered as another option and included in the international guidelines. The uptake for prenatal testing is low: for 2 per cent of the at‐risk persons, 11 per cent of the tested carriers and a small group of at‐risk persons wishing not to be tested themselves, prenatal testing seems an acceptable choice regarding reproduction. Copyright

A randomised trial comparing low dose vaginal misoprostol and dinoprostone for labour induction

Objective  To compare vaginal misoprostol with dinoprostone for induction of labour.

Two-colour immunocytochemical staining of gamma (gamma) and epsilon (epsilon) type haemoglobin in fetal red cells

We have developed a two‐colour immunocytochemical staining method for the detection of fetal and embryonic haemoglobin in erythroid cells. The method was applied to study these haemoglobin types in fetal red cells. Specimens from fetal blood (10 weeks), cord blood and fetal liver (14 weeks) as well as chorionic villus samples (10–13 weeks) were stained for γ and ϵ chains using CY3 and FITC labelled antibodies. Morphometric analysis was applied to determine cell size. Samples from organs involved in early embryonic development contained relatively large erythroblasts expressing the ϵ globin chain (megaloblasts); later in gestation the γ chain was co‐expressed by the same cells which ultimately became smaller and contained HbF (α2 γ2 ) only. This phenomenon was confirmed in CVS samples in which all cell types were abundantly present. Since fetal erythroblasts are considered candidate cells for non‐invasive prenatal diagnosis using FISH, we studied the phenotype of erythroblasts circulating in the maternal blood. The majority of erythroblasts in maternal blood appeared to be of the relatively small γ globin‐containing cell type. However, careful screening of the same maternal blood samples also revealed erythroblasts expressing ϵ or ϵ and γ globins simultaneously, although at low frequency. Control specimens from non‐pregnant women did not show nucleated red cells expressing either of the haemoglobin types.