Torbjørn Eggebø N

ational Center

for Fetal Medicine

Dept O

b & G

yn Trondheim

- Norw

ay

Organisation of invasive fetal

medicine in N

orway

Deliveries

! 60 000 /year

! O

nly risk groups are offered 1 trimester

examination

" >38 years

! R

outine examination in second trim

ester

Fetal medicine centers

! O

slo (CVS)

! B

ergen (CVS)

! Trondheim

(CVS)

! Stavanger

! Trom

sø (CVS)

KU

B test

! < 5000/year

! 10%

test positive

National center for fetal m

edicine – established 1990

1. N

ational responsibility for invasive procedures w

ith high risk for the fetus (e.g. transfusions) TTS

are referred abroad 2. C

enter of competence for fetal

medicine

NC

FM ! H

igh-risk prenatal invasive procedures like intrauterine transfusions and drainage of fetal effusions are centralized to the N

ational center for fetal medicine (N

SFM)

! The center is also a referral center for fetuses w

ith severe or unclear m

alformations

! A

ll invasive procedures and fetal malform

ations are recorded in a quality registry used for quality assurance and research

! N

CFM

teaches and trains midw

ives and doctors in ultrasound diagnostics

! In cooperation w

ith the Norw

egian University in Technology

(NTN

U), the center develops new

procedures and technologies in fetal m

edicine ! The center is a W

HO

collaborating center for diagnostic ultrasound in obstetrics and gynecology

1988: rhesus negative G

ravida 6, para 3, alive 1 Year

Delivery

Outcom

e o 1973

Vaginal delivery 2840 g, healthy (no anti-D

prophylaxis) o 1975

Vaginal delivery Stillbirth, erythroblastosis

o 1975 C

S N

eonatal death after 1 day o 1983

Miscarriage

o 1985 Ectopic pregnancy

� 1988

CS, 32 w

eeks 5 fetal transfusions; 1600 g

First fetal transfusion in Norw

ay

Etiology of fetal anemia in fetuses treated w

ith blood transfusions at N

CFM

from 1988 to 2007

1988–2007 N

= 101

Rhesus-D

69% Parvovirus

11%

Rhesus-E

2% K

ell 2%

Thalassemia 2%

H

emoglobinopathia 1%

CM

V 1%

Not know

n 12%

Anti-bodies

that may cause

fetal anemia

Anti-D

A

nti-c A

nti-E A

nti Kell

Anti Fy

a (Duffy) rarely (titer > 64)

Trondheim

94%

Anti-D

MC

A

MC

A

AC

A A bas

1995

Anem

ic fetuses ! high peak velocities

MC

A peak velocity in 111 fetuses at risk for anem

ia

16 20

24 28

32 36 w

eeks

MCA-PV (cm/sec)

90

50

40 30

20

10

60 70 80

100

1.50

median

Mari et al., N

Engl J Med 2000

MoM

A

nemia w

ith hydrops Δ A

nemia w

ithout hydrops o N

o anemia

Red cell alloim

munisation

Surveillance today

! O

bstetric history ! A

ntibody levels (titres) ! D

oppler of Arteria cerebri m

edia

! Fetal blood sam

pling and transfusion

MC

A P

V a

nd

EV

F

0

10

20

30

40

50

60

70

80

90

10

0

110

15

20

25

30

35

40

Ge

sta

tion

al a

ge

(we

ek

s)

MCA PV cm/secM

CA

PV

wh

en

EV

F <

25

MC

A P

V w

he

n E

VF

25

-34

MC

A P

V w

he

n E

VF

>3

4

Lin

ea

r (MC

A P

V w

he

n E

VF

<2

5)

Lin

ea

r (MC

A P

V w

he

n E

VF

25

-34

)

Lin

ea

r (MC

A P

V w

he

n E

VF

>3

4)

Correlation of M

CA

PV to EVF Trondheim

2000-2006 n= 66 n= 96 n=159

N=321

Median and 1.5 m

ultiples of the median

of MC

A during pregnancy M

ari et al.

Fetal blood sam

pling

Transfusion

MC

V PV and EVF before and after first transfusion Trondheim

N = 27

EVF before transfusion

EVF after transfusion

MC

V PV before transfusion

MC

V PV after transfusion

Hem

atocrit prior to first transfusion and hydrops

N = 74

hydrops

without

hydrops

Num

ber of fetuses (n=74) treated for red cell alloim

munization per year at N

CFM

Invasive procedures (2008-14)

2008 2009

2010 2011

2012 2013

2014 A

nemia

7 (35) 3 (21)

2 (8) 2 (7)

7 (39) 6 (35)

5 (16)

March 2014

! R

hD - w

omen

! A

ntibodies in first trimester

! Free fetal D

NA

(RH

D) in w

eek 25 ! anti-D

imm

unoglobulin in week 29

(fetus+) ! Testing of child after delivery

2016

! Tw

o experienced doctors will

retire in Decem

ber 2015 ! O

ne of them w

ill still be available for invasive procedures

! Tw

o new doctors trained

Legal terminations

Wom

an decides up to 12+0 A

bortion council from 12-21+6

malform

ations social indications

From w

eek 22 it is not allowed

Exceptions – deadly m

alformations

maternal indications