Intrauterine Transfusion in Ahmedabad: Treating Anaemia Before Birth

A few conditions in the unborn baby can be treated before birth, and fetal anaemia is the most firmly established example. If severe anaemia is left untreated, it strains the baby's heart and can lead to fluid building up in the baby's body (hydrops). Giving the baby blood while it is still in the uterus can correct the anaemia, so that the pregnancy can continue.

An IUT is guided by ultrasound, and it comes at the end of a period of monitoring that begins long before any needle is used. Regular Doppler scans of the circulation in the baby's brain show anaemia at an early stage, so treatment is planned at the right time rather than in a rush.

Fetal reduction, described further down, is the other procedure in this part of my work. The hospital has obstetric, anaesthesia and neonatal cover round the clock.

IUT in Pregnancy: What the Term Means and Why It Is Done

IUT in pregnancy stands for intrauterine transfusion - a transfusion of blood to the baby, not to the mother. It is sometimes confused with IUI (a fertility treatment) or with an intrauterine contraceptive device, but it has nothing to do with either.

The reason for an IUT is anaemia in the baby. A baby with too few red blood cells has to pump harder to deliver oxygen. If the anaemia becomes severe, the heart can start to fail and fluid collects in the baby's body. Replacing the missing red cells takes that strain away and buys time for the baby to mature.

An IUT is never the first step. It comes after the mother's antibody tests, the father's blood group and a series of MCA Doppler scans. Together these must show that the baby is, or is very likely to be, moderately or severely anaemic. Most transfusions are given between 18 and 35 weeks; after that, delivery and treatment of the newborn usually take over. How many transfusions are needed depends on the cause, as the questions further down explain.

Fetal Anaemia Causes: Why a Baby Becomes Anaemic

Fetal anaemia means the baby has too few red blood cells to carry enough oxygen. These are the causes I see.

• Rh disease - if an Rh-negative mother is exposed to Rh-positive blood (for example during an earlier birth, a miscarriage or a procedure), she can make antibodies. In a later pregnancy these antibodies can destroy the red blood cells of an Rh-positive baby.
• Other red cell antibodies - anti-Kell, anti-c and anti-E can cause the same problem. Anti-Kell also holds back the production of red cells, so anaemia can appear even when antibody levels are lower.
• Parvovirus B19 - the "slapped cheek" infection can temporarily stop the baby's bone marrow from making red cells.
• Rarer causes - bleeding from the baby into the mother's circulation (feto-maternal haemorrhage), and inherited alpha-thalassaemia major.

Conditions for Which I Consider Fetal Therapy

• Rh (anti-D) alloimmunisation - the most common reason for IUT in India.
• Other red cell antibodies (anti-Kell, anti-c, anti-E).
• Parvovirus B19 infection with fetal anaemia or hydrops.
• Fetal anaemia from feto-maternal haemorrhage, or from other causes found on Doppler.
• Triplet and higher-order pregnancies, where fetal reduction may be considered.
• Selected complications in monochorionic twins - I assess these and refer onwards for laser treatment when it is needed.

Fetal Anaemia and MCA Doppler: How I Pick Up Anaemia Early

• Your blood group and antibody screen (the indirect Coombs test, ICT) are checked when you book.
• If antibodies are found, I measure the titre every 2–4 weeks.
• An anti-D titre of 1:16 or higher, or a measured level above about 4 IU/mL, usually means Doppler monitoring should begin.
• Testing the father's blood group helps work out whether the baby can be affected at all.
• MCA Doppler is usually done every 1–2 weeks from about 16–18 weeks. A peak systolic velocity above 1.5 MoM for the gestational age predicts moderate or severe anaemia with a high detection rate.
• MCA Doppler has largely replaced repeated amniocentesis for this monitoring.
• Fluid in the baby's chest, abdomen or skin (hydrops) points to severe anaemia that needs urgent treatment.

With regular Doppler monitoring, anaemia can usually be picked up and treated before hydrops develops.

Fetal Anaemia Treatment: Monitoring, Transfusion and Other Options

Intrauterine Transfusion Procedure: How the Blood Is Given

• Watching continuously on ultrasound, I guide a fine needle through your abdomen into the umbilical vein, usually where the cord joins the placenta. Sometimes a vein in the baby's liver is used instead.
• A first sample of the baby's blood gives the haemoglobin within minutes.
• Prepared donor blood is then given slowly. It is group O Rh negative, cross-matched to your blood, screened, irradiated and concentrated.
• A final sample checks the result.
• You stay awake; a local anaesthetic numbs the skin where the needle goes in. The baby may be given a small injection to keep still.
• The procedure usually takes 30–60 minutes. After 24–26 weeks, I do it close to the operating theatre so that an emergency delivery is possible if needed.
• Transfusions are usually repeated every 2–3 weeks until about 34–35 weeks.

IUT Risks and the Steps I Take to Lower Them

The possible risks are bleeding where the needle enters, a temporary slowing of the baby's heart rate, infection, leakage of fluid, preterm labour and loss of the pregnancy. Published series report pregnancy loss in about 1–3% per procedure; the risk is higher before 20 weeks and when the baby already has hydrops.

To lower these risks, I choose the needle site carefully, keep the ultrasound running throughout and use a sterile technique. I give antibiotics where indicated and steroid injections for the baby's lungs from 24 weeks, and I know your antibody status in advance. I discuss every one of these risks with you before you give consent.

After the Transfusion: Recovery, Birth and the Newborn

Once a scan shows the baby is well, you can usually leave on the day of the procedure or the following day. A follow-up MCA Doppler within 1–2 weeks helps me time the next transfusion.

Birth is usually planned at 35–37 weeks, often by induction, with the neonatal team present. Babies with Rh disease may need phototherapy, and some need an exchange transfusion or further blood in the first 2–3 months. This is because the transfused cells gradually fall away while the mother's antibodies are still present. In published follow-up, long-term development has been normal in the large majority of babies treated before severe hydrops set in.

For you, light activity is fine from the next day; avoid heavy lifting for 48 hours and keep an eye on the needle site. I give you a direct number to call if you notice leaking fluid, bleeding, fever or fewer movements. The hospital's staff are there 24×7 if you need to come in. If fetal anaemia is suspected, I arrange the assessment urgently, and the hospital blood bank is informed in advance.

Intrauterine Transfusion in Rh Isoimmunization

Rh isoimmunization (also called alloimmunisation) is the most common reason for an IUT in India. It begins when an Rh-negative mother's blood meets Rh-positive red cells and her immune system makes anti-D antibodies. This can happen at an earlier birth, a miscarriage, an ectopic pregnancy, bleeding or a procedure.

Those antibodies stay for life. In a later pregnancy with an Rh-positive baby they cross the placenta and break down the baby's red cells, so the baby becomes anaemic before birth and jaundiced after it. Once the anti-D titre reaches 1:16 or more, I begin MCA Doppler scans; when the readings rise above 1.5 MoM, a transfusion is considered.

With Rh disease, transfusions are usually repeated every 2–3 weeks, often 3–5 in all, until about 34–35 weeks. Birth is then planned at 35–37 weeks, with the neonatal team ready for phototherapy or an exchange transfusion. Because each pregnancy tends to be affected earlier than the last, monitoring in the next pregnancy starts sooner.

Rh Negative Pregnancy Injection (Anti-D): Prevention and Monitoring

For an Rh-negative mother, treatment starts with prevention, and most Rh disease can be prevented. At booking I check your blood group and the indirect Coombs test (ICT), and the father's blood group tells us whether the baby could be Rh positive at all.

If you are Rh negative and your ICT is negative, anti-D is given at about 28 weeks. It is given again within 72 hours of the birth of an Rh-positive baby. It is also given after any bleeding, miscarriage, ectopic pregnancy, injury to the abdomen or procedure in pregnancy. Anti-D works only before antibodies have formed - it cannot remove antibodies that are already there.

If your ICT is positive, the plan changes from prevention to monitoring. This means titres every 2–4 weeks, and MCA Doppler from about 16–18 weeks when the titre is significant. An IUT is done only if the Doppler shows anaemia. If you have had Rh disease before, I start monitoring early in your next pregnancy, because the disease tends to begin sooner and be more severe.

Fetal Reduction in Triplet and Higher-Order Pregnancies

In triplet and higher-order pregnancies, there is a high risk of very early birth for all the babies. Fetal reduction is usually done at 11–14 weeks, after a detailed scan and NT assessment. It is a sensitive decision that the couple makes after counselling, within the provisions of the MTP Act.

Your Fetal Therapy Pathway, Step by Step

1. Antibody and partner testingto find out whether the baby is at risk.
2. Doppler monitoringMCA scans every 1–2 weeks.
3. Counselling and consentI explain why treatment is advised, how it is done, its risks and the alternatives.
4. The transfusionprepared blood is given through the umbilical vein under continuous ultrasound.
5. Follow-up and birth planthe timing of the next Doppler, and the delivery and newborn care, are planned with the neonatal team.

When to See Me About Antibodies or Fetal Anaemia

• You are Rh negative and your ICT is positive.
• You have anti-Kell, anti-c or other red cell antibodies.
• A previous baby had severe jaundice, needed an exchange transfusion, or had hydrops.
• An MCA Doppler has suggested fetal anaemia.
• You have been exposed to, or infected with, parvovirus (slapped cheek) during pregnancy.
• You are expecting triplets or more.

Rh-Negative Pregnancy: Myths and Facts

Questions Patients Often Ask Me About IUT