Severe in-utero anemia, how to manage at birth

[abeluchin]

Hi,

I recently heard of a case of an infant born at term from an apparently uncomplicated pregnancy. Mother of the infant with h/o sickle cell trait. Mother visited the OB doctor at 40 weeks due to painful contractions. Questionable decreased fetal movements was recollected on further questioning, but no clear on initial presentation. Mother was admitted to L&D due to active labor. A stat c-section was performed after 4hrs of labor due to a category III fetal heart tracing (with absence of variality). A severely depressed infant was born through meconium-stained amniotic fluid. ET intubation was performed, but no mec was seen below the glottis. PPV was initiated due to persistent apnea and neonatologist was called. Infant was immediately intubated and transported to the NICU while been bagged at 25/5, 100% FiO2. Upon admission to the NICU, a stat ABG was performed that showed severe metabolic acidosis (7.0/73/25/-20) and severe anemia with a HCT of 19. O2 sats in the low to mid 50's. HR always above 100. Infant was placed on HFOV and umbilical lines placed. A NS bolus of 10ml/kg was given (3.3kg weight) and PRBC was requested stat. Infant oxygenation failed to improve, with O2 sats now at 0. A trial of CMV was attempted with some improvement in O2sats. F/U ABG with worseing metabolic acidosis (ph 6.5,BE -30), but PCO2 in the low 40's. CRX with clear lungs and normal CTS. Infant in shock, received 2 additional boluses of NS at 10ml/kg, and finally PRBC at 1 HOL, with IV transfusions over 10 minutes each. Infant was started on dopamine, dobutamine, epi for persistent hypotension with shock. ECHO with poor bi-ventricular dysfunction and PPHN, normal otherwise. iNO started. Infant did not show improvement in oxygenation, and after several rounds of chest compressions for severe bradycardia, withdrawal of care was suggested and infant died at 4 HOL.

Questions:

1. Have you managed this infant differently?

2. The primary cause of the shock and hypoxemic respiratory failure was speculated to be the severe chronic anemia(given aneia with large amount of PRBC and evidence of hemolysis on peripheral smear), but we have all see infant with worse anemia that are way more stable on initial presentation

3. Have you chose to exchange transfusion instead of direct PRBC transfusion, despite the poor initial presentation with severe anemia, with anemic shock and severe hypoxemic respiratory failure?

4. In your personal practice, what patient with chronic in-utero anemia do you transfuse vs. exhange transfusion at birth?

Thanks for any comments

[Alex]

Dear member! Hi!

Some later we observed a case with sever feto-maternal transfusion. Baby had mass 2900g, term of gestation. The RBC 0.59, Hb 23 g/l was in delivery room. pH 6.79, BE -20. No pulse of peripheral artery or umbilical artery was. The algorithm of therapy was like youth. O negative ErM 30 ml was done immediately after birth (total volume 95 ml). Totally NS before NICU was about 100 ml. We could correct shock, but miltiorgan disfunction was in progress for a 2 days. The leading syndrome of miltiorgan disfunction was respiratory distress. We do not have NO. A trying surfactant use was unsuccessful. The baby died in 2,6 days.

It was a third case of severe intrauterine hemorrhage.

We had get two babies before. The bleeding was acute with Hb about 37 and 42 g/l. A babies survive without problems. The therapy was same.

Edited May 24, 2011 by Alex
grammatic mistake

[Stefan Johansson]

1. A challenging case indeed, and I think the staff did everything they could for this poor baby.

2. I think the problems of this baby was not only long-standing anemia/heart failure, but also antepartal hypoxia which contributed greatly to the problems described, including myocardial "stunning" and PPHN.

3. Since it was probably a long-standing anemia, I would personally advocate partial exchange transfusion instead of regular transf.

4. I think that our fetal specialist look for early signs of heart failure and transfuse as soon as such signs appear. What they exactly look for and assess, I don't know unfortunately.

[abeluchin]

Thanks to all for your responses. It was indeed a very difficult case. I am as a young neonatologist trying to get the best experience from these difficult cases, and give the best possible care to the next baby in a similar situation

Thanks again for your comments