Objective
Methods
Results and Recommendations
Key words
What are the current possible indications for FBS?
Indications | Comment |
---|---|
Current common indications | |
Diagnose and treat fetal severe anemia | Most common indication for FBS |
Diagnose and evaluate therapeutic response in NAIT | |
Evaluate nonimmune fetal hydrops | Only in selected cases |
Historical and less common indications | |
Fetal aneuploidy for karyotyping | Rarely used in current practice; largely replaced by CVS or amniocentesis with FISH, or by NIPT |
Determine fetal blood type and platelet antigen status | Largely replaced by other tests, eg, NIPT, CVS, or amniocentesis, and molecular testing |
Diagnose genetic disorders (eg, hemophilia, thalassemia) | Largely replaced by CVS or amniocentesis for molecular genetic diagnosis |
Measurement of biochemical or other serum markers for fetal disease (eg, fetal infection, thyroid function) | Largely replaced by amniocentesis and PCR (eg, infection); rarely needed (eg, thyroid function) |
Direct intravascular therapy | Reported rarely, most commonly for failed maternal systemic treatment of fetal supraventricular tachycardia |
Others |
What are some historical or less common indications for FBS?
What are the technical aspects of FBS?
Study | No. of procedures | Maternal sedation | Local anesthesia | Ultrasound technique | Puncture site | Confirmation of fetal blood |
---|---|---|---|---|---|---|
Tangshewinsirikul et al, 43 2011 | 2214 | No | Yes | Freehand | PCI or free loop | n/a |
Tongsong et al, 44 2000 | 1320 | No | Yes | Freehand | PCI or free loop | Yes |
Aina-Mumuney et al, 45 2008 | 210 | Yes | Yes | n/a | IHV, PCI, or both | MCV |
Nicolini et al, 46 1990 | 214 | Only 1 y, not last 2 y | n/a | Freehand | IHV | n/a |
Somerset et al, 47 2006 | 221 | n/a | n/a | n/a | IHV, PCI, or intracardiac | n/a |
Sikovanyecz et al, 48 2001 | 268 | n/a | No | Freehand | PCI or free loop | n/a |
Liao et al, 49 2006 | 2010 | n/a | No | Fixed needle guide | 97% free loop, 3% PCI | KHB |
Boulot et al, 50 1990 | 322 | No | Yes | n/a | PCI (majority) or free loop | KHB or MCV |
Johnstone-Ayliffe et al, 18 2012 | 114 | n/a | n/a | Freehand | PCI, IHV, or free loop | n/a |
Technical aspect | Comments |
---|---|
Prophylactic antibiotics | Insufficient evidence to recommend |
Maternal sedation | Used infrequently |
Local anesthesia | Used by some centers |
Skin preparation | Preprocedural antibacterial skin preparation and aseptic technique are recommended |
Needle guidance | Both needle guide instrument and freehand techniques have been reported and are acceptable; direct needle into target (eg, umbilical vein) under continuous ultrasound guidance; avoid umbilical arteries if feasible |
Needle gauge and length | 20- or 22-gauge; gauge and length depend on indication, suspicion of thrombocytopenia, gestational age, maternal body habitus, and distance from skin to target |
Sampling site |
|
Paralytic agent for transfusion | Pancuronium, atracurium, or vecuronium |
Prophylactic antibiotics
Maternal sedation
Local anesthesia
Skin preparation
Needle guidance
Needle gauge and length
Sampling site
Placental penetration
Fetal blood specimen
Use of paralytic agents
Other
Operator experience
What are the procedure-related risks of FBS?
Risk | Comments |
---|---|
Bleeding from puncture site (eg, umbilical cord) | 20-30%; usually self-limited |
Abnormal fetal heart rate | 5-10% bradycardia; majority resolve within 5 min |
Pregnancy loss | 1.3% if no structural anomalies or hydrops and no placental penetration |
Vertical transmission of maternal infection (eg, hepatitis B, hepatitis C, or HIV) | Insufficient information to estimate risk |
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. HIV infected women. Available at: http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed Aug. 7, 2013. Level III.
Recommendations
UpToDate, grading guide. Available at: http://www.uptodate.com/home/grading-guide#GradingRecommendations. Accessed March 10, 2013. Level III.
The quality of evidence for each article was evaluated according to the method outlined by the US Preventative Services Task Force: | |
I | Properly powered and conducted randomized controlled trial (RCT); well-conducted systematic review or metaanalysis of homogeneous RCTs. |
II-1 | Well-designed controlled trial without randomization. |
II-2 | Well-designed cohort or case-control analytic study. |
II-3 | Multiple time series with or without the intervention; dramatic results from uncontrolled experiment. |
III | Opinions of respected authorities, based on clinical experience; descriptive studies or case reports; reports of expert committees. |
Recommendations | Grade of recommendations (Table 6) | |
---|---|---|
1 | When invasive testing is planned for suspected severe fetal anemia or thrombocytopenia, we recommend FBS as procedure of choice, with availability of immediate transfusion if confirmed | 1 C Strong recommendation, low-quality evidence |
2 | We recommend against use of FBS for indications in which other less invasive, and therefore lower risk, alternatives are available | 1 C Strong recommendation, low-quality evidence |
3 | We recommend counseling patients about potential risk of FBS that may include, but may not be limited to: bleeding from puncture site; fetal bradycardia; pregnancy loss; and potential vertical transmission of hepatitis or HIV | Best practice |
4 | We recommend that FBS be performed by experienced operators at centers with expertise in invasive fetal procedures when feasible | Best practice |
UpToDate, grading guide. Available at: http://www.uptodate.com/home/grading-guide#GradingRecommendations. Accessed March 10, 2013. Level III.
Grade of recommendation | Clarity of risk/benefit | Quality of supporting evidence | Implications |
---|---|---|---|
1A Strong recommendation, high-quality evidence | Benefits clearly outweigh risks and burdens, or vice versa | Consistent evidence from well-performed randomized, controlled trials or overwhelming evidence of some other form; further research is unlikely to change our confidence in estimate of benefit and risks | Strong recommendations, can apply to most patients in most circumstances without reservation; clinicians should follow strong recommendation unless clear and compelling rationale for alternative approach is present |
1B Strong recommendation, moderate-quality evidence | Benefits clearly outweigh risks and burdens, or vice versa | Evidence from randomized, controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise), or very strong evidence of some other research design; further research (if performed) is likely to have impact on our confidence in estimate of benefit and risks and may change estimate | Strong recommendation and applies to most patients; clinicians should follow strong recommendation unless clear and compelling rationale for alternative approach is present |
1C Strong recommendation, low-quality evidence | Benefits appear to outweigh risks and burdens, or vice versa | Evidence from observational studies, unsystematic clinical experience, or randomized, controlled trials with serious flaws; any estimate of effect is uncertain | Strong recommendation, and applies to most patients; some of evidence base supporting recommendation is, however, of low quality |
2A Weak recommendation, high-quality evidence | Benefits closely balanced with risks and burdens | Consistent evidence from well-performed randomized, controlled trials or overwhelming evidence of some other form; further research is unlikely to change our confidence in estimate of benefit and risks | Weak recommendation, best action may differ depending on circumstances or patients or societal values |
2B Weak recommendation, moderate-quality evidence | Benefits closely balanced with risks and burdens; some uncertainly in estimates of benefits, risks, and burdens | Evidence from randomized, controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise), or very strong evidence of some other research design; further research (if performed) is likely to have impact on our confidence in estimate of benefits and risks and may change estimate | Weak recommendation, alternative approaches likely to be better for some patients under some circumstances |
2C Weak recommendation, low-quality evidence | Uncertainty in estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens | Evidence from observational studies, unsystematic clinical experience, or randomized, controlled trials with serious flaws; any estimate of effect is uncertain | Very weak recommendation; other alternatives may be equally reasonable |
Best practice | Recommendation in which either: (i) there is enormous amount of indirect evidence that clearly justifies strong recommendation–direct evidence would be challenging, and inefficient use of time and resources, to bring together and carefully summarize; or (ii) recommendation to contrary would be unethical |
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- Fetal blood sampling or follow up and postnatal treatment: a matter of timeAmerican Journal of Obstetrics & GynecologyVol. 210Issue 6
- PreviewIn recent years, indications for fetal blood sampling (FBS) have been reduced thanks to the introduction of advanced technologies that achieve the same or superior diagnostic results earlier and through less invasive procedures, such as fetal cell free DNA analysis, amniocentesis, or chorionic villi sampling. Indeed, FBS could result in serious complications such as bleeding from the umbilical cord access, fetal bradycardia, fetal loss, and maternal complications such as hemorrhage or maternal alloimmunization.
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