Fertility NEWS LETTER

Ideal fertility : ICSI / IVF & Genetic Center India

Dear Colleges
Hello

A very warm good morning of cold days of my city.
I wish you all a very happy and prosperous New Year 2010

In this newsletter I am putting three topics, two of which are my OPD cases. The other one on Rh is from my colleague Dr.Sarika.

Hepatitis B is one of the dreaded infections and if it occurs in pregnancy it is matter of concern as there is reduction of immunity and any hepatitis with jaundice is dangerous. There are at least five different types of viral hepatitis: A, B, C, D and E. all hepatitis viruses except B are RNA viruses. Hepatitis A is not transmitted critically to the fetus. Hepatitis B and C nay be transmitted vertically to the fetus and are the main concern to the obstetrician. Hepatitis D is a defective RNA virus that requires concomitant infection with hepatitis B. Hepatitis E has similar characteristic to hepatitis A but is more serious condition predominant in countries with poor sanitary conditions.

Main advantage of obtaining fetal blood instead amniotic fluid for the diagnosis of chromosome abnormalities is that ti is possible to obtain a high quality karyotype in 48-72 hours (rapid karyotype) rather than in 10-14 days for amniotic cell culture.

Different approach to Rh non sensitized and sensitized pregnancy is given in flow-charts way.

With warm regards
Dr. D’Pankar Banerji

1. Lady with Australia antigen +ve carrying a 2 month pregnancy

26 yrs lady named Anita comes to my clinic with a report of HBsAg +ve with pregnancy of two months for checkup. Her question was will it transmit to my baby ? will my baby also infected with Hepatitis B when it takes birth? She has report of Hepatitis e antigen also, which is negative. Somebody has done a viral load also in her serum ( I don’t know why?… any comments by any of this newsletter reader is welcome)
There are few facts about Hepatitis B I wish to write

• The diagnosis of acute HBV infection is made by the presence of HbsAg early in the course of the disease ,followed by the appearance of antibodies against the core and the e, and the surface antigens.
• Presence HbsAg more than 6 months in serum makes a person carrier
• 90 % of acute infection resolve spontaneously and rest 5-9% become chronic carrier. 1% may die of fulminent hepatitis.
• Seven of 10 chronic carrier have chronic persistent hepatitis(CPH) and other 3 have chromic active hepatitis(CAH). CPH disease does not pregresss and liverenzumes are normal. CAH may develop cirrhosis,hepatic failure and primary hepatocellular carcinoma .
• HbeAg is a marker of infectivity and viral replication.
• Transplacental infection of the fetus is rare and viral DNA is rearely found in the amniotic fluid and cord blood .
• Neonatal infections are the result of contact with infected maternal blood and vaginal secretions during parturition or acquired during breast feeding.
• Neonate should be administered HBV immune globulin(0.5 ml i/m) followed by first dose of hepatitis B vaccine (0.5ml i/m) with in 12 hours of birth and then 1 and 6 months later.( active and passive immunization)
• 85 to 95 %  neonatal transmission is prevented.
• HBV vaccination can be done during pregnancy in seronegative women.
• Use of cesarean operarion for delivery to prevent neonatal infection is controversial.
• No teratogenic association with maternal HBV infection.
• Most infants born to carrier mother are HbsAg negative at birth,but seroconvert in first 3 months ( if not treated) ,suggesting acquiring the virus at birth.

Hence this lady should be asked to continue the pregnancy , her household and sexual contact should be offered passive immunization ,HBIG ( if seronegative). Liver function should be assessed . Repeating the HbsAg and Liver function late in pregnancy will not be required.
Compared with other transmissible viruses, such as the human immunodeficiency virus (HIV)HBV is fairly stable virus and remains infectious on household surfaces that may then contact mucous membranes ,such as tooth brushes ,baby bottles,razors and eating utensils. Thus nonsexual house hold contact has been established as a route of HBV transmission.

2. We did a cordocentesis at our center

Indication : Gravid woman presenting with 19 weeks pregnancy with Polyhydramnios and multiple cord cysts and with lower limb skeletal anomaly.

The left lower limb : club foot and very short leg. Cordocentesis  was tried to rule out chromosomal abnormalities.

Method : patient in supine position , the abdominal sonography done to see the cord attachment at the placental end and the path of the needle is decided. Then the area of interest is painted and draped . Abdominal transducer is covered with sterile glove. Needle guide is attached to the abdominal transducer. We used a 18 gauge ovum pickup needle . The purpose of using this needle is , a heparinized tube can be attached and a helper can do the suction to collect the blood.

Patient was sedated with 2 ml i.v. midazolam one hour prior to the procedure. With that the movement of fetus is reduced to some extent.

The track of the needle is fixed through the base of cord and then needle is pushed through the guide and reached towards the umbilical vein and with a slight jab needle is pushed.

Assistant is asked to aspirate the 2 ml blood.There was immediate bradycardia but it recovered .

Blood is transferred to lab and put for lymphocyte culture. Chromosomes are harvested and were found to be of normal karyotype ( no chromosomal anomalies seen after geimsa banding)