Fetomaternal Transfusion
Blood Transfusion
Rh Isoimmunization
Blood Transfusion, Intrauterine
Prenatal diagnosis of acute massive fetomaternal hemorrhage. (1/54)
We present here 2 cases of acute and 2 cases of chronic massive fetomaternal hemorrhage. A sinusoidal fetal heart rate pattern may indicate chronic fetomaternal hemorrhage, but, when increased variability is observed in fetal monitoring, maternal hemoglobin F should be measured to exclude acute fetomaternal hemorrhage. (+info)An unusual concurrence of graft versus host disease caused by engraftment of maternal lymphocytes with DiGeorge anomaly. (2/54)
We describe a girl with DiGeorge anomaly and normal cytogenetic and molecular studies, whose clinical course was complicated by graft versus host disease caused by intrauterine materno-fetal transfusion, and several immunohematological alterations including a monoclonal gammapathy of undetermined significance (first IgG, which subsequently changed to IgM). The main clinical features and pathological findings are discussed. (+info)Massive transplacental hemorrhage: clinical manifestations in the newborn. (3/54)
Thirteen newborn infants had transplacental hemorrhage in excess of 30 ml. Fetal blood in the maternal circulation was demonstrated in all cases by the acid elution technique. Anemia was noted in five babies either at birth or within the first 24 hours of life. One baby was stillborn, the death possibly being related to fetal hemorrhage. The other seven babies were clinically normal in spite of massive transplacental hemorrhage. The hemoglobin values and reticulocyte counts were normal at birth and the first 5 days of life. The data on this group of babies suggest that the clinical manifestations of transplacental hemorrhage are related not only to the size of the hemorrhage but also to the time at which the hemorrhage occurs. (+info)Microchimerism in a female patient with systemic lupus erythematosus. (4/54)
Systemic lupus erythematosus (SLE) is a serious multisystem disease that has a striking propensity to affect women. The cause of SLE remains elusive. Fetomaternal cell trafficking, or the passage of fetal cells into the maternal circulation, is now a well-established phenomenon. In addition, fetal cells have been implicated in the development of preeclampsia and in the pathogenesis of scleroderma. We undertook this study to determine whether fetomaternal cell trafficking might also be involved in pathogenic processes in SLE. Fluorescence in situ hybridization analysis was performed using X and Y chromosome-specific probes on affected and unaffected tissue obtained at autopsy from a woman who had previously given birth to 2 males and who had died of complications of SLE. The goal of the analysis was to detect the presence of male cells of putative fetal origin. Male cells were found in every histologically abnormal tissue type that was examined, but were not found in histologically normal tissue. These data suggest that fetal cells may be associated with SLE. It is unclear whether their presence may be related to disease causation, an effect of disease progression, or unrelated to disease pathology. However, this case study is an important step toward understanding the potential relationship between fetomaternal cell trafficking and SLE pathology. (+info)Fetal and embryonic hemoglobins in erythroblasts from fetal blood and fetal cells enriched from maternal blood in fetal anemia. (5/54)
BACKGROUND AND OBJECTIVES: To determine whether there is a delay or reversal in switch mechanisms from embryonic (e and z) to fetal (g) hemoglobins accompanying the erythroblastosis of anemic fetuses and whether an increased erythroblast count in fetal blood is associated with an increase in feto-maternal cell trafficking. DESIGN AND METHODS: Fetal and maternal blood samples were obtained from 10 cases with rhesus isoimmunization and 2 cases with maternal Parvo-B19 virus at 19-33 weeks' gestation. Blood samples were also taken as controls from 61 fetuses and 86 mothers. Fetal erythroblasts were isolated by triple density gradient centrifugation and magnetic cell sorting with CD71 antibody. Fluorescent antibodies were used to immuno-stain for zeta (z), epsilon (e) and gamma (g) hemoglobin chains. In the maternal samples, fluorescence in situ hybridization (FISH) for X and Y chromosomes was also carried out to confirm the presence and proportion of the enriched fetal cells from maternal blood. RESULTS: In both fetal and maternal blood the percentage of erythroblasts positive for g-globin chain was significantly higher in the anemic fetuses compared to the controls (fetal blood, p<0.001, R=0.91; maternal blood, p<0.001, R=0.56), but there was no significant difference in expression of the e and z-chains. The percentage of cells with Y-signals was also higher in the maternal samples of anemic fetuses compared to normal controls (p<0.001, R=0.56). INTERPRETATION AND CONCLUSIONS: These findings suggest that the erythroblastosis of anemic fetuses is not accompanied by a delay or a reversal in switch from embryonic to fetal hemoglobin chains. Severe fetal anemia is associated with an increase in feto-maternal cell trafficking. (+info)Possible contribution of microchimerism to the pathogenesis of Sjogren's syndrome. (6/54)
OBJECTIVES: Microchimerism of foetal cells occurs during most pregnancies. Two autoimmune diseases, systemic sclerosis (SSc) and Sjogren's syndrome (SS), have many clinical and pathological similarities to chronic graft-vs-host disease (GVHD). These findings suggest that anti-maternal graft-vs-host reaction by foetal cells may be involved in the pathogenesis of the diseases. To explore this hypothesis, we examined foetal DNA in peripheral blood of 59 women and in salivary glands from 28 women. METHODS: DNA extracted from peripheral blood and the affected minor salivary glands was analysed for the Y-chromosome-specific gene using a nested polymerase chain reaction (PCR) test. In the minor salivary gland specimens, the Y-chromosome-positive foetal cells were identified by in situ hybridization with a Y-chromosome-specific DNA probe. RESULTS: In peripheral blood, there was no significant difference between controls and patients with SSc or SS. In salivary glands, foetal DNA was detected in 11 of 20 women with SS but in only one of eight normal controls using PCR test. Additionally, foetal cells were clearly detected in three out of eight women with SS by the use of in situ hybridization. CONCLUSIONS: The identification of foetal cells in salivary glands suggests that anti-maternal GVHD may be involved in the development of SS. (+info)Fetal-maternal hemorrhage detection in Ontario. (7/54)
The results from fetal-maternal hemorrhage (FMH) detection and quantitation external quality assessment surveys conducted in Ontario indicate that the rosette test had a sensitivity and specificity for an FMH of more than 10 mL of 1.0 and 0.75, respectively, compared with 0.96 and 0.92, respectively, for acid elution. With FMH quantitation, the percentage error of the mean from the target FMH was 20% or more in 7 of 8 surveys, and coefficients of variation ranged from 39.5% to 71.8%. Inadequate Rho(D) immune globulin prophylaxis could have occurred in 19.4% of the challenges with an FMH of more than 10 mL. The rosette and acid elution techniques are both effective for the detection or exclusion of FMH, but acid elution lacks adequate accuracy and precision for reliable FMH quantitation. Furthermore, a strategy of prescribing an extra 1,500-IU Rho(D) immune globulin dose, in addition to the dose required to treat the volume of fetal blood detected, is an effective strategy to overcome the limitations of FMH quantitation by acid elution. (+info)Cellular microchimerism as a lifelong physiologic status in parous women: an immunologic basis for its amplification in patients with systemic sclerosis. (8/54)
OBJECTIVE: To quantitatively measure male DNA in blood from women with systemic sclerosis (SSc) and from controls and to evaluate in vitro the modulation of the microchimeric cell population size following immunologic stimuli that were expected to trigger antigen-specific T cells. METHODS: A real-time polymerase chain reaction for a Y chromosome sequence was used to measure male DNA in blood from women with SSc and from controls who gave birth to sons. The in vitro change in the microchimeric cell population size was measured following immunologic stimuli, which were expected to trigger antigen-specific T cells. RESULTS: Cellular microchimerism was found in SSc patients and controls, but the absolute amount of male DNA was higher in the patients, and the in vitro addition to blood mononuclear cells of an anti-CD28 costimulatory signal acted as a powerful amplification of microchimeric cells in 3 patients with SSc but not in controls. CONCLUSION: Cellular microchimerism is a physiologic phenomenon in parous women. In SSc patients, cellular microchimerism is accounted for by a higher number of cells that have the characteristics of T lymphocytes specific to maternal allogeneic antigens. (+info)Fetomaternal transfusion, also known as fetal-maternal hemorrhage, is a medical condition where there is a transfer of fetal blood cells into the maternal circulation. This can occur during pregnancy, childbirth, or in the postpartum period due to various reasons such as placental abnormalities, trauma, or invasive procedures like amniocentesis. In some cases, it may lead to complications for both the fetus and the mother, including fetal anemia, hydrops fetalis, and maternal alloimmunization.
A blood transfusion is a medical procedure in which blood or its components are transferred from one individual (donor) to another (recipient) through a vein. The donated blood can be fresh whole blood, packed red blood cells, platelets, plasma, or cryoprecipitate, depending on the recipient's needs. Blood transfusions are performed to replace lost blood due to severe bleeding, treat anemia, support patients undergoing major surgeries, or manage various medical conditions such as hemophilia, thalassemia, and leukemia. The donated blood must be carefully cross-matched with the recipient's blood type to minimize the risk of transfusion reactions.
Rh isoimmunization is a condition that occurs when an Rh-negative individual (usually a woman) develops an immune response to the Rh-positive blood of another individual (usually a fetus during pregnancy or a transfused blood). The Rh-negative person's immune system recognizes the Rh-positive blood as foreign and produces antibodies against it. This sensitization can lead to hemolytic disease of the newborn if the mother becomes pregnant with another Rh-positive fetus, as the maternal antibodies can cross the placenta and attack the fetal red blood cells, potentially causing anemia, jaundice, or more severe complications.
The first exposure to Rh-positive blood typically does not cause a significant reaction because the mother's immune system has not yet produced enough antibodies. However, subsequent exposures can lead to increasingly severe reactions due to the presence of pre-existing antibodies. Preventive measures such as administering Rh immunoglobulin (RhIg) to Rh-negative women during pregnancy and after delivery help prevent sensitization and reduce the risk of hemolytic disease of the newborn.
Intrauterine blood transfusion (IUT) is a medical procedure in which blood is transfused into the fetal circulation through the umbilical vein while the fetus is still in the uterus. This procedure is typically performed to treat severe anemia in the fetus, most commonly caused by hemolytic disease of the newborn due to Rh incompatibility or ABO incompatibility between the mother and fetus.
During the procedure, ultrasound guidance is used to insert a thin needle through the mother's abdomen and uterus and into the umbilical vein of the fetus. The blood is then transfused slowly, allowing the fetal body to adjust to the increased volume. The procedure may need to be repeated every 2-4 weeks until the baby is mature enough for delivery.
IUT is a highly specialized procedure that requires significant expertise and experience in maternal-fetal medicine and interventional radiology. It carries risks such as preterm labor, infection, fetal bradycardia (abnormally slow heart rate), and fetal loss, but it can be life-saving for the fetus when performed appropriately.
An erythrocyte transfusion, also known as a red blood cell (RBC) transfusion, is the process of transferring compatible red blood cells from a donor to a recipient. This procedure is typically performed to increase the recipient's oxygen-carrying capacity, usually in situations where there is significant blood loss, anemia, or impaired red blood cell production.
During the transfusion, the donor's red blood cells are collected, typed, and tested for compatibility with the recipient's blood to minimize the risk of a transfusion reaction. Once compatible units are identified, they are infused into the recipient's circulation through a sterile intravenous (IV) line. The recipient's body will eventually eliminate the donated red blood cells within 100-120 days as part of its normal turnover process.
Erythrocyte transfusions can be lifesaving in various clinical scenarios, such as trauma, surgery, severe anemia due to chronic diseases, and hematologic disorders. However, they should only be used when necessary, as there are potential risks associated with the procedure, including allergic reactions, transmission of infectious diseases, transfusion-related acute lung injury (TRALI), and iron overload in cases of multiple transfusions.
Percutaneous umbilical cord blood sampling
Postpartum chills
Fetal-maternal haemorrhage
Hydrops fetalis
Rh blood group system
John Maxwell Bowman
List of MeSH codes (C16)
List of MeSH codes (C15)
Blood type
Neonatal alloimmune thrombocytopenia
Microchimerism
Rose Payne
Rho(D) immune globulin
CD59
Massive Fetomaternal Transfusion (FMT): Case Reports and Review of the Literature | American Academy of Forensic Sciences
Percutaneous umbilical cord blood sampling - Wikipedia
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Acute and Chronic Fetal Anemia as a Result of Fetomaternal Hemorrhage
Non-invasive Prenatal Diagnosis of Feto-Maternal Platelet Incompatibility by Cold High Resolution Melting Analysis - PubMed
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Hemorrhage8
- Fetomaternal hemorrhage occurs commonly in pregnancy but rarely results in fetal compromise. (devdrawer.com)
- A more significant (0.1 ml) fetomaternal hemorrhage occurs in approximately 1% and is a potential cause of red cell isoimmunisation. (devdrawer.com)
- A Kleihauer‑Bethke test was positive, and suggested approximately 10ml of fetomaternal hemorrhage. (devdrawer.com)
- WinRho® SDF is used to suppress the immune response of non-sensitized Rh o (D) negative individuals following exposure to Rh o (D) positive RBCs by fetomaternal hemorrhage during delivery of a Rh o (D) positive infant, abortion (spontaneous or induced), amniocentesis, abdominal trauma, or mismatched transfusion. (theodora.com)
- Alternatively, each vial or syringe may be administered at intervals, provided the entire calculated dose is administered within 72 hours of the fetomaternal hemorrhage or incompatible blood transfusion. (pdr.net)
- Fetomaternal transfusions (or fetomaternal hemorrhage) results in the recognition of these antigens by the mother's immune system as non-self, with the subsequent generation of allo-reactive antibodies which cross the placenta. (checkorphan.org)
- Fetomaternal hemorrhage: evaluation of recurrence within a large integrated healthcare system. (amedeo.com)
- The woman's routine postpartum blood sample result was strongly positive by a rosette fetal bleed screening test, suggesting the presence of D + fetal red blood cells in her circulation (fetomaternal hemorrhage). (allenpress.com)
Intrauterine6
- A repeat intrauterine transfusion of 18ml, lifted the hemoglobin to 6.7g/dL. (devdrawer.com)
- STUDY DESIGN AND METHODS: We conducted a multinational retrospective study of women with offspring affected by severe HDFN requiring neonatal exchange transfusion and/or intrauterine transfusion. (mcmaster.ca)
- Intrauterine transfusion (IUT) is the treatment of choice in case of fetal anemia, but it cannot be performed early during pregnancy. (bvsalud.org)
- MATERIAL AND METHODS: A cohort study analyzed 128 fetuses treated with intrauterine transfusion (IUT), until the early neonatal period. (bvsalud.org)
- Available management options include administration of intravenous immunoglobulins or corticosteroids to the mother or intrauterine transfusion of antigen compatible platelets to the fetus. (ox.ac.uk)
- Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial. (amedeo.com)
Exchange transfusion2
- The infant subsequently underwent successful treatment with IVIG, phototherapy and exchange transfusion and was discharged 7 weeks later without neurological deficits. (bvsalud.org)
- A cautious correction of anemia with packed red blood cells (RBCs) or by exchange transfusion is necessary to prevent circulatory overload. (medscape.com)
Haemorrhage2
- In most pregnancies the transplacental haemorrhage is less than 0.1 mL, and thus women can get sensitised as a result of small undetectable fetomaternal haemorrhage. (ndtv.com)
- OBJECTIVES: To determine the optimal antenatal treatment of fetomaternal alloimmune thrombocytopenia to prevent fetal and neonatal haemorrhage and death. (ox.ac.uk)
College of American1
- In this issue, Sandler and colleagues 1 report the results of the College of American Pathologists (CAP) J-B Transfusion Medicine (Comprehensive) and Educational Survey, in which more than 3100 institutions describe how they perform Rh typing for blood donors, pregnant women, and hospital patients. (allenpress.com)
Neonatal3
- I neonatal hyperbilirubinemia overproduction undersecretion mixed uncertain mechanism z polycythemia fetomaternal or fetofetal transfusion delayed clamping of the central portion of daily living. (easternpropane.com)
- Platelet transfusion in neonatal alloimmune thrombocytopenia. (ijrcog.org)
- Conclusion: Maternal hydration therapy can be of value to improve the fetomaternal outcome in pregnancies with oligohydramnios by preventing preterm termination and reducing cesarean deliveries with good neonatal outcomes. (who.int)
Alloimmune thrombocytopenia5
- Antenatal interventions for fetomaternal alloimmune thrombocytopenia. (ox.ac.uk)
- BACKGROUND: Fetomaternal alloimmune thrombocytopenia occurs when the mother produces antibodies against a platelet alloantigen that the fetus has inherited from the father. (ox.ac.uk)
- Antenatal management of fetomaternal alloimmune thrombocytopenia centres on preventing severe thrombocytopenia in the fetus. (ox.ac.uk)
- AUTHORS' CONCLUSIONS: There are insufficient data from randomised controlled trials to determine the optimal antenatal management of fetomaternal alloimmune thrombocytopenia. (ox.ac.uk)
- The incidence and outcomes of fetomaternal alloimmune thrombocytopenia: a UK national study using three data sources. (ijrcog.org)
Platelet1
- Alloreactive anti-human leukocyte antigen (HLA) antibodies formed during pregnancy are a major cause of acute rejection in organ transplantation and of adverse effects in blood transfusion, such as febrile non-hemolytic transfusion reactions, immunological platelet refractoriness or transfusion-related acute lung injury (TRALI) ( 1 , 2 ). (frontiersin.org)
Alloimmunization2
- With the introduction of widespread immunoprophylaxis for red blood cell alloimmunization and the use of in-utero transfusions for immune hydrops therapy, nonimmune causes have become responsible for at least 85% of all cases of fetal hydrops. (medscape.com)
- Most alloimmunization (83%) was attributed to previous pregnancy: 3% to transfusion (two cases at MATCH, six at NoMATCH centers) and 14% undetermined (both antecedent transfusion and pregnancy). (mcmaster.ca)
Platelets1
- If you expect to get questions regarding blood products, get a copy of the local cutoffs for approving transfusions of red blood cells, platelets and plasma, and keep it so that you can quickly look it up when needed. (patholines.org)
Fetal blood2
- Fetal hemoglobin (light gray area) and transfusions ( + = transfusions of packed red cells, - = withdrawals of fetal blood). (devdrawer.com)
- fetoscopy was used and refined between 1974 and 1983 as a prenatal test to determine fetal status as well as obtain fetal blood and perform transfusions in some cases. (wikipedia.org)
Pregnancy2
- Guidelines have been established for the recommended use of Anti-D in pregnancy and postpartum, these recommendations are endorsed by RANZCOG, Australian Red Cross Blood Services, National Health and Medical Research Council, and Australasian/New Zealand Blood Transfusions Guidelines. (peninsulahealth.org.au)
- During pregnancy the formation of alloreactive anti-human leukocyte antigen (HLA) antibodies are a major cause of acute rejection in organ transplantation and of adverse effects in blood transfusion. (frontiersin.org)
Antigens2
- This type of reaction occurs when a patient without certain red cell antigens is exposed to these antigens through blood transfusion, resulting in the development of new antibodies and haemolysis after 3-14 days. (passmed.uk)
- Medical management of this patient will involve screening for a wider range of possible antigens and access to a blood bank with a sufficient number of available units for a clean transfusion. (passmed.uk)
Twin-twin tra4
- Magnetic resonance neuroimaging after laser for twin-twin transfusion syndrome with single fetal demise. (amedeo.com)
- Twin-twin transfusion syndrome and the definition of recipient polyhydramnios. (amedeo.com)
- Amniotic fluid microRNA profiles in twin-twin transfusion syndrome with and without severe recipient cardiomyopathy. (amedeo.com)
- Prevalence, risk factors, and outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome: a large single-center case series. (amedeo.com)
Fetoscopic laser1
- The Arabin cervical pessary for the prevention of preterm birth in twin-to-twin transfusion syndrome treated by fetoscopic laser coagulation: a multicenter randomized controlled trial. (amedeo.com)
Antibodies4
- To inform transfusion centers responsible for making decisions about matching policies for FCPs, the causal stimulus of the antibodies implicated in severe hemolytic disease of the fetus and newborn (HDFN) must be determined. (mcmaster.ca)
- Mothers at the MATCH centers do not appear to be protected from HDFN due to K, C, c, and E antibodies, although the low number of FCPs who received transfusions precluded drawing firm conclusions. (mcmaster.ca)
- Detection of incomplete antibodies in serum before pretransfusion screening or titration of the antibody (Cross-matching for blood transfusion). (labpedia.net)
- The major purpose of this test is to detect if the recipient or the patient has serum antibodies other than the ABO / Rh system to RBC before receiving the blood transfusion. (labpedia.net)
Incompatible1
- Incompatible blood transfusion. (labpedia.net)
Organ Transplantation1
- Organ Transplantation and Blood Transfusion in 20th Century America Oxford: Oxford University Press. (yorku.ca)
Amniocentesis1
- Sensitisation can also occur as a result of a previous miscarriage, amniocentesis and blood transfusion and is more likely if mother and foetus are ABO compatible. (ndtv.com)
Reactions2
- This can potentially cause severe anaphylactic transfusion reactions. (transfusions.org)
- Other potential transfusion-related reactions and their approximate time-course include hyperacute (minutes to hours), acute (hours to days), and late (days or longer). (passmed.uk)
Commonly1
- Only two of these, however, (the ABO and the Rh) can commonly cause haemolytic transfusion reaction (HTR) as well as haemolytic disease of the newborn (HDN). (ndtv.com)
Complications1
- Serious complications of blood transfusion are rare due to screening techniques, leukocyte depletion, and improved collection and storage. (passmed.uk)
Fetus1
- An 18ml packed red blood cell transfusion was given to the fetus via the umbilical vein on the same day (fig. 2). (devdrawer.com)
Practice2
- Fostering excellence in the practice and safety of transfusion medicine. (cap.org)
- 3 , 9 , 10 The CAP Transfusion Medicine Resource Committee (TMRC) reviewed this practice in the context of the current state of science for RHD genotyping. (allenpress.com)
Mother1
- 2010. "Microchimerism in the Mother(land): Blurring the Borders of Body and Nation in Fetomaternal Cell Trafficking. (yorku.ca)
Reaction2
- The rise in bilirubin without a corresponding increase in liver enzymes suggests haemolysis from a delayed transfusion haemolysis reaction. (passmed.uk)
- Bacterial sepsis is a possible reaction that would occur most likely in the acute time course, but it does not explain the minimal increase in haemoglobin following a 3-unit transfusion. (passmed.uk)
Routine1
- This is the test for screening purposes in routine blood transfusion. (labpedia.net)
Patients1
- The section is responsible for blood counts and provision of safe blood for transfusion to all patients. (nairobihospital.org)
Occur1
- Small fetomaternal hemorrhages resulting in a positive Kleihauer‑Bethke test occur in at least 60% of pregnancies. (devdrawer.com)
Medicine1
- Resources and educational material in the field of transfusion medicine. (cap.org)
Center2
- The Blood Center would likely consult with the transfusion center prior to authorizing the release of IgA deficient plasma units, as the plasma is not manufactured to be IgA deficient, it is retrieved through Rare Donor Program operations from IgA deficient donors. (transfusions.org)
- Depending on the transfusion center, fresh units of Red Blood Cells may be substituted for washed units in hyperkalemic scenarios. (transfusions.org)
Research1
- The IBGRL has a distinguished record of research in blood transfusion science. (blood.co.uk)
Small1
- Although extended RBC matching for FCPs may impart some protection from allosensitization, we were unable to show a positive effect, possibly because matching policies are not uniform and there was a small number of mothers who previously received transfusions. (mcmaster.ca)
Services2
- In accordance with American Association of Blood Banks (AABB) Standards for Blood Banks and Transfusion Services , 2 most hospital laboratories reported that they do not routinely perform a serologic weak-D test on pregnant women or transfusion recipients. (allenpress.com)
- The IBGRL was established in 1946 to provide Reference Services related to blood transfusion. (blood.co.uk)
Results1
- 1 The TMRC concluded that selective integration of RHD genotyping of weak D phenotypes could improve the accuracy of Rh typing results, thereby reducing unnecessary administration of RhIG in women with a weak D phenotype, and decrease transfusions of Rh − red blood cells in recipients with a weak D phenotype. (allenpress.com)
Field1
- It seems to me in reviewing the Sunquest manual that the field for Patient Transfusion Requirements is not an available field to add to the Unit Tag. (pathlabtalk.com)
Include1
- Any Sunquest users figure out how to comply with new CAP regs to include Special Transfusion Requirements on the Unit Tag form? (pathlabtalk.com)
Study1
- Single fetal demise following fetoscopic ablation for twin-to-twin transfusion syndrome-cohort study, systematic review and meta-analysis: a comment. (amedeo.com)