Ultrasound Obstet Gynecol 2004; 23: 432-436 Prediction of ...

Ultrasound Obstet Gynecol 2004; 23: 432-436 Prediction of ...

Loote hemoltiline tbi Aivar Ehrenberg SA TK naistekliinik LHT levimus Anti-D proflaktikaga alustati 1960. aastail 1990. aastail USAs ja Kanadas alloimmunisatsiooni 1,3/1000 snnitust.

DiGuiseppi C. Screening for D (rh) incompatibilityguide to clinical preventive services. In: National Library of Medicine. Health Services/Technology Assessment-Text, 1996: http://text.nlm.nih.gov/cps/www/cps.44.html. Lisaks RhD antigeenile veel 50 hemoltilist tbe phjustavat AG Eesti Meditsiiniline Snniregister 1992-2002

Eesti keskmine: Aastas snnib 40 hemoltilise tvega last 12 last vajavad vahetusverelekannet 7 elupeva jooksul Vastsndinu hemoltiline tbi Kerge vorm 50% Aneemiata Mdukas hperbilirubineemia

Keskmine vorm 25-30% Mdukas aneemia Hdropsita Tugev ikterus, kernikteruse risk Raske vorm 20-25% Sgav aneemia Atsidoos Hdrops in utero

IUT patsiendid Tartus 7 6 5 4 3 2 1

0 1996 1997 1998 1999

2000 2001 2002 2003 2004

Ema RhD-; isa RhD+, emal anti-RhD AKd Sissejuurdunud tegutsemisviis: 1. 2. 3. 4. 5.

AK tiiter (korduvalt) (mnikord IVIG-ravi) Kordotsentees, kui tiiter > 1:16 Korduvad kordotsenteesid kuni 35 r/n IUT(id) kui loote hgb <90 g/l Ema RhD-; isa RhD+, emal anti-RhD AKd

Probleemid: 1. Pole vimalik saada usaldusvrset infot loote seisundi kohta enne 22 r/n 2. Diagnostika on invasiivne, ohtlik keeruline ajuti mittevajalik 3. Mnikord rakendame kallist ravi tarbetult

Probleem 1:RhD+ isa laps vib olla RhD lesanne 1 kuidas teha kindlaks isa sgootsus? lesanne 2 kuidas teha kindlaks loote reesus veel enne, kui kordotsentees vimalik? Farideh Z. Bischoff et al Noninvasive determination of fetal RhD status using

fetal DNA in maternal serum and PCR Journal of the Society for Gynecologic Investigation, Volume 6, Issue 2, 4 March 1999, Pages 64-69 20 sensibiliseeritud RhD rasedat (1536 r/n), kel RhD+ loode RhD-spetsiifiline DNA leiti 14 (70%) juhtudest 11 kontrolli seas ei olnud valepositiivseid tulemusi

Rijnders RJ, et al. Clinical applications of cell-free fetal DNA from maternal plasma. Obstet Gynecol. 2004 Jan;103(1):157-64. 72 analsi (12-19 r/n) Sensitiivsus RhD suhtes 100%, spetsiifilisus 96.6% Kliinilisel rakendamisel (24 p.-i) vlditi invasiivseid

uuringuid 41.7% juhtudest Costa JM et al, Fetal RhD genotyping in maternal serum during the first trimester of pregnancy. Br J Haematol. 2002 Oct;119(1):255-60. 106 analsi RhD rasedatelt

Kik 62 RhD+ lootega juhtu andsid positiivse vastuse Kik 40 RhD lootega juhtu andsid negatiivse vastuse Probleem 2: loote vereproovi vtmine on keeruline ja ohtlik lesanne 1 kuidas hinnata loote Hgb taset, kui kordotsentees ei ole veel tehniliselt vimalik? lesanne 2 kuidas hinnata loote Hgb taset mitteinvasiivsete vtetega?

Esther Sikkel et al. Amniotic fluid OD 450 values accurately predict severe fetal anemia in D-alloimmunization Obstetrics & Gynecology, Volume 100, Issue 1, July 2002, Pages 51-57 79 rasedust, hdropsita Raske aneemia piir 5SD

Amniotsentees kuni 4 peva enne loote I vereproovi Enne 27 n Sensitiivsus (%) 95 CI 74-100

Prast 27 n 98 89-100 Sikkel 2002 Probleem 2: loote vereproovi vtmine on keeruline ja ohtlik

lesanne 1 kuidas hinnata loote hgb taset, kui CC ei ole tehniliselt vimalik? lesanne 2 kuidas hinnata loote hgb taset mitteinvasiivsete vtetega? T. G. Divakaran, et al. Noninvasive Techniques to Detect Fetal Anemia Due to Red Blood Cell Alloimmunization: A Systematic Review

Obstet Gynecol 2001;98:509 17. 1248 viidet Selale ji 8 primaarset uuringut (362 rasedust) Kokkuvte: uuringud on metodoloogiliselt puudulikud, ei vimalda standardset lhenemist. Praktiliseks rakendamiseks ei saa soovitusi anda

Laura Detti et al. Longitudinal assessment of the middle cerebral artery peak systolic velocity in healthy fetuses and in fetuses at risk for anemia American Journal of Obstetrics and Gynecology, Volume 187, Issue 4, October 2002, Pages 937-939 19 aneemilist loodet, 15 normaalset kontrolli

Detti 2003 . Deren, L. nderoglu The value of middle cerebral artery systolic velocity for initial and subsequent management in fetal anemia Eur J Ob Gyn Rep Biol, 2002 52 hdropsita loodet

MCA-PSV 1.35 MoM ennustas rasket aneemiat 100%liselt Valepositiivseid tulemusi 18% Referentskverad 813 normaalse raseduse phjal 58 loodet sensibiliseeritud rasedustest, AK kontsentratsioon emal >15 IU/mL MCA-PSV lvivrtus 1.5 SD eristas 96% raskelt aneemilistest loodetest (Hgb defitsiit min 6 SD)

Valepositiivseid tulemusi 14% () MDUKAS ANEEMIA (loote hgb > 6SD alla keskmise) () RASKE ANEEMIA (loote hgb < 6SD alla keskmise) (o) LOOTE HDROPS Sheier 2004 () LOOTE HDROPS Sheier 2004

63 93 117 117 112; Rh-

125 Probleem 3: verelekanne pole ohutu Ema ja loote infektsioon Loote ekssangvinatsioon Enneaegne snnitus Fetomaternaalne hemorraagia letransfusioon, sdamepuudulikkus

Nabavdi hematoom lesanne kuidas prssida immuunkonflikti? Rh-konflikti supressioon Intravenoosne immunoglobuliin (IVIG) 1 g/kg ndalas ema AK tiiter langeb

katab trofoblasti retseptorid, millest sltub AK transport katab retseptorid loote prnas, vltides ertrotstide lagundamist Voto LS, et al. High-dose gammaglobulin (IVIG) followed by intrauterine transfusions (IUTs): a new alternative for the treatment of severe fetal hemolytic disease. J Perinat Med. 1997;25(1):85-8.

30 patsienti said IVIG enne 21 rasedusndalat ja IUT prast 20 n 39 patsienti said IUT alates 20-25 n. IVIG rhmas vhem hdropsi, rasket aneemiat ja loote surmajuhte Anti-D tiitrid ja hematokrit I IUT-l oluliselt ei erinenud

Kokkuvtteks OLEVIK Anti-D proflaktika!!! LHITULEVIK Loote RhD mramine ema verest Mitteinvasiivne Rh-konflikti seire KAUGEM TULEVIK

Immuunreaktsiooni mjutamine RhD- tdrukute vaktsineerimine???

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