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Volume 166 Number I, Part 2

Tm TO TrlN TRANSFUSION. J. Castanerf'C, Cetrulo, M. D'Uton; Dept. 01 MFH, St. Hargaret's Hospital lor 'olen/Tufts Univ. School 01 Medicine, Boston, Hl

Eighteen cases of twin to twin transfusion sydrole (TTS) were revieved to elucidate if gestational age at presentation or ob­stetrical unagelent affected perinatal outcOIt. All cases let 2 or lore criteria: II like sex tvins with .onochorionic placentas (18 pts.), 2) we igbt differences )20\ (J3 of 18), J) polyhydrmios/ oligohydrunios (17 pts.), I) 'stuck tvin' (7 pts.), 5) hydrops fetalis (3 pts.), or 6) difference in heloglobin )5 gl. (6 pts.) Obstetrical unage.ent consisted of conservative observation in 12 cases, deco.pression nniocentesis in 4 cases and Indolethacin therapy in 2 others. Eight cases presented before 25 veeks and 10 cases after 26 veeks. The perinatal IOrtality (PMH) rate vas 12.5\ for those vith conservative lanagelent, 25\ for the aaniocentesis group and 75\ for those heated with Indo.ethacin. In the alnio' centesis group reversal of hydrops vas visualized in 1 case. All the pel inatal deaths were confined to the group vho presented before 25 veeks gestation. The PH" rate vas 21.2\ for the total group, 50\ for those presenting <25 weeks and zero if presentation vas alter 26 veeks. Three patients vith one [UFO continued their pregnancy for another I, 10, and 14 weeks respectively. One case developed lUCR, licrocepbaly, IUlticystic encephalo.alacia. The other 2 pregnancies proceeded to 34 and 35 weeks respectively with uneventful outco.es. [n conclusion, ve observed that TTS presenting before 25 veeks gestation delonstrates poor outcOIt irrespective of unage.ent vhi Ie those presenting after 26 veeks has a zero PI" rate. Because of the high PH" associated vith IndOiethacin ve discourage its use. Deco.pression nniocentesis needs further study to elucidate its role in lanagelent of TTS.

RENAL FUNCT(ON AFTER IN-UTERO INTERVENTION FOR FETAL OBSTRUCTIVE UROPATHY. Meljssa Frjes,X Mary Norton,X James Goldberg. Michael Harrison,x Roy Filly,X Peter Callen.x Ruth Goldstein,x Mitchell Golbusx. Univ. CA, San Francisco

In-utero vesicoamniotic shunting and vesicostomy by open fetal surgery have been used to relieve fetal urinary outflow obstruction, theoretically preventing pulmonary hypoplasia and preserving renal function. Past studies have suggested that hypotonic fetal urine (Na.s;l OOmeqldl; CI .s;90meqldl; osmolality .s.210mOsm/l) predicted fetal survival with normal renal function. Twenty-four cases of fetal intervention (16 shunts; 8 open surgeries) were performed from 1981-1991, with shunts producing 7 survivors, 4 neonatal demises (NND), and 5 TAB's; and surgery leading to 3 survivors, 4 NND, 1 TAB. Five of the 7 shunt survivors had hypotonic urine electrolytes and ultrasonically-normal kidneys; values were hypertonic on 1 survivor and not studied on the other. All 7 had variable renal dysfunction at birth, with Cr 1.1-9.0 mg/dl and BUN 18-56 mg/dl. Renal transplant is planned for 3 pts. Of shunt non­survivors (9 pts), only 2 had hypotonic urine. In the fetal surgery survivors, 1 had hypotoniC urine and one had borderline hypertonic values (osm=221); both these pts. have normal renal function. The other survivor had hypertonic urine (osm=255) and has had renal transplant. Of the non-survivors, electrolytes were not studied in 2 pts. and were hypotonic or borderline hypertonic (osm=215) in the remaining 3. NND were from complications of prematurity. Hypotonic urine may predict survival but not good long term renal function for fetuses treated by intervention. A randomized trial of intervention vs non-intervention and early delivery appears indicated.

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SPO Abstracts 357

FETAL HEMOGLOBIN QUANTITATIONS USING THE HEMOCUE® SYSTEM ARE FAST AND ACCURATE. S.M. Berry. M. Dombrowski, W.B. Blessed,'J.A. Bichalski,' T.B. Jones, D.B. Cotton. Dept. of Ob/Gyn, Hutzel Hosp./WSU, Detroit. MI

Rapid and accurate quantitations of fetal hemoglobin (hgb) levels during cordocentesis (PUBS) are critical in making the decision to perform an intrauterine transfusion, and in deciding how much blood to transfuse. Hemocue (weight = 700g) provides Hgb levels in 45 seconds. Accuracy of the Hemocue system has not been adequately validated for prenatally obtained fetal blood. We compared fetal Hgb' 5 from the Hemocue versus those from the Coulter S-Plus IV on 44 fetal specimens obtained via PUBS. Gestational age (GA) = 26.7 ± 5.7 wks (range = 18 to 37).

18

H .. E 14 M '.' 0 .' C 10

U E 6 r=.94

2 2 6 10 14 18

COULTER S-PLUS IV The Hemocue values ranged from 3.3 to 16.4 gm/dl. GA and extremes in Hgb levels were not significantly correlated to Hemocue values by stepwise regression. Conclusions: 1) The Hemocue system is fast and accurate for fetal Hgb quantitations throughout gestation, despite varying Hgb FI Hgb A, ratios. 2) The accuracy of the Hemocue system is not significantly affected by extremes in fetal Hgb levels.

FETAL PLATELET COUNTS IN RED CELL ALLOIMMUNIZATlIJIj CORRELATE WITH THE SEVERITY OF THE DISEASE. George R. Saade. M.O.X. Kemeth J. Moise, Jr., M.D., Michael A. BeLfort, M.O.X, Diane

Hesketh, RoN"x, Robert J. Carpenter, Jr., M.D.; Dept. of Ob/Gyn; Baylor College of Medicine; Houston, Tx.

Thrombocytopenia has been noted in hydropic neonates with HDN and its presence could cCMTpl ieate intrauterine vascular transfusions (IVT). Purpose: To determine whether any subgroup

of fetuses with red cell alloilTlTllllization have lower platelet counts CPlt). Material and Methods: The records of 53 patients undergoing IVT for red cell alloirmunization were reviewed. The pre-transfusion fetal Plt was coq>ared between hydropic and non-hydropic fetuses and with the fetal bil irubin, hct, and retic count at the initial JUT" In addition, the het was adjusted for gestational age by calculating the nunber of standard deviations (#SO) below the mean for that age. The student t test and the Pearson R coefficent were used to analyze the data. Results: 29 fetuses were hydropic; 24 non-hydropic. Hydropic fetuses had a significantly lower Plt

count than non-hydropic fetuses (195.8 :!: 96.0 vs 250.0 :!: 78.6

103/nm3 ; p = .02), with 31% and 17% of hydropic fetuses having plt counts less than 150,000 and 100,000/nm3 respectively. Plt

counts correlated positively with the hct (r = .65; p <.01) and negatively with the retic count (r = .65; p <.01), and the

hct #SO below the mean (r = .65; p <.01), but did not correlate

with bilirubin (r = .07; p = NS). Conclusions: Hydropic and

severely anemic fetuses are at risk for thrombocytopenia. We suggest that increased erythropoeisis drives the hematopoietic stem cell away from platelet production.