International Journal of Gynecology & Obstetrics 60 Ž1998.

239]244

Article

Prenatal strategies for reducing severe thalassemia

in pregnancy

C. Wanapirak a,U , T. Tongsong a , P. Sirivatanapaa , T. Sa-nguansermsri b ,

R. Sekararithi a , A. Tuggapichitti a
a
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai Uni®ersity, Chiang Mai, Thailand
b
Department of Pediatrics, Faculty of Medicine, Chiang Mai Uni®ersity, Chiang Mai, Thailand

Received 7 October 1997; received in revised form 1 December 1997; accepted 3 December 1997

Abstract

Objecti®e: To describe the prenatal strategy in reducing new cases of severe thalassemia at Maharaj Nakorn
Chiang Mai Hospital. The study design involved a prospective descriptive analysis set in Maharaj Nakorn Chiang Mai
Hospital, Chiang Mai University. Subjects: Pregnant women attending antenatal clinic. Methods: The strategy
included: Ž1. carrier identification by retrospective Žhistory review. and prospective screening program; Ž2. the
couples at risk were counseled and offered cordocentesis; Ž3. analysis of fetal blood with high performance liquid
chromatography ŽHPLC. or electrophoresis; and Ž4. counseling for termination of pregnancy in case of affected
fetus. The prospective screening consisted of testing for a carrier by a simple erythrocyte osmotic fragility test
ŽEOFT. in women with no risk and testing the husbands of the women with abnormal tests. A pregnancy in which
both of the couple were carriers was considered a risk. Results: Cordocentesis was performed in 554 pregnancies at
risk, 252 and 302 from retrospective and prospective screening, respectively. Sixty of 252 of the first group had severe
thalassemia. In the prospective screening program of 12 680 women, 459 risk couples were identified, 302 pregnancies
underwent cordocentesis and 53 Ž17.5%. had severe thalassemia. This strategy enabled us to identify 113 cases of
severe thalassemia ŽHb Bart’s; 60, b-thal entities; 53. from 554 cases at risk. Conclusion: The strategy proves valuable
in the control of severe thalassemia. This extensive experience suggests the strategy be considered an effective way in
the control of severe thalassemia in high prevalence areas. Q 1998 International Federation of Gynecology and
Obstetrics

Keywords: Prenatal diagnosis; Thalassemia; Screening

U
Corresponding author.

0020-7292r98r$19.00 Q 1998 International Federation of Gynecology and Obstetrics

PII S0020-7292Ž97.00271-3
240 C. Wanapirak et al. r International Journal of Gynecology & Obstetrics 60 (1998) 239]244

1. Introduction

Thalassemia is the most common hematologic

genetic disease in Thailand. The prevalence of
a- and b-thalassemia and HbE genes in our
population are 20]30%, 3]9% and 13%, respec-
tively w1x. Approximately 500 000 Thai people are
affected and more than 15 million are carriers. By
the calculation of abnormal gene prevalence, the
couples at risk for having an affected child are
50 000 pregnancies per year. The common severe
types are homozygous b-thal, b-thalrHbE, Hb
Bart’s hydrops fetalis Žhomozygous a-thal1.. The
affected persons of the first two entities have a
low quality of life Žblood transfusion, gall stone,
etc.. and have an estimated average life ex-
pectancy of 10 and 30 years, respectively. Hb
Bart’s hydropic fetuses have never survived.
Fig. 1. Main scheme of Chiang Mai strategy in control of
Moreover, the mothers of the fetuses with Hb severe thalassemia.
Bart’s hydrops will suffer from obstetric complica-
tions such as pre-eclampsia, dystocia, post-partum
hemorrhage due to a large placenta and the psy- The main purpose of this study is to describe
chological burden for carrying a non-viable fetus the strategy in reducing the new cases of severe
to term. Therefore these three types of severe thalassemia syndrome ŽHb Bart’s hydrops fetalis,
thalassemia are justified to be controlled, espe- homozygous b-thal and b-thalrHbE. by means
cially by prenatal approach w2x in which obstetri- of prenatal approach.
cians play an important role.
Maharaj Nakorn Chiang Mai Hospital is the
largest tertiary care center of northern Thailand 2. Materials and methods
which has to face the problem of thalassemia due
to high prevalence of abnormal genes. Therefore
we developed the program to control the severe The strategy consisted of carrier identification,
types as described above. The program included prenatal diagnosis and termination of pregnancy
genetic counseling, carrier detection followed by as shown in Fig. 1. Carrier identification included
prenatal diagnosis ŽTable 1. of the risk couple both retrospective Žcomplete history review. and
and termination of pregnancy which most couples prospective screening Žscreening program for
with an affected child prefer w3x. women at no risk..

Table 1
Main categories of prenatal diagnosis and results

Number of Severe thalassemia syndrome

cordocentesis a 1ra 1 brb brE Total

Risk by retrospective program 252 35 12 13 60

Risk by prospective program 302 26 12 15 53
Total 554 61 24 28 113

Notes: a 1ra 1, Hb Bart’s disease; brb , homozygous b-thalassemia diease; brE, b-thalassemiarHb E disease.
 C. Wanapirak et al. r International Journal of Gynecology & Obstetrics 60 (1998) 239]244
Prenatal diagnosis for couples at risk was cor-
docentesis and fetal blood analysis with high per-
formance liquid chromatography ŽHPLC. or Hb
electrophoresis. Termination of pregnancy was
done with a conventional technique, mostly by
transvaginal misoprostol.
In part of the carrier identification by retro-
spective approach, the risk was documented by
previous history of an affected child, known car-
rier by testing in the past, known disease in the
couple, etc. In the case that one of the couple had
a known disease such as HbH, homozygous b-thal,
or b-thalrHbE disease, the other had to be tested
for a carrier. Many women in this group were also
referred from the peripheral hospitals.
For the prospective screening, the risk was
identified by EOFT screening program of early
pregnant women without known risk. The pro-
gram was carried out as follows: the asympto-
matic pregnant women attending the antenatal
clinic, Maharaj Nakorn Chiang Mai Hospital, were
counseled for screening severe thalassemia syn-
drome at first visit. After proper counseling, 2-ml
of blood was obtained and tested for erythrocyte
osmotic fragility test ŽEOFT. followed by de-
termining the HbA2 level in case of abnormal
EOFT as an algorithm in Fig. 2. EOFT is a rapid
and simple method for determination of red blood
cell osmotic fragility w4x. The case of an abnormal
test was eventually classified as a carrier for
a-thal1, b-thal and HbE gene. The husbands of
these carrier women were counseled and tested to
identify the carrier status in the same manner.
The couple at risk for having a baby with severe
thalassemia syndrome was the couple who both
were a-thal1 trait, both were b-trait, or one was
b-trait while the other was HbE trait. They were
at risk for having a child of Hb Bart’s hydrops
fetalis, homozygous b-thal or b-thal HbE disease,
respectively. It is widely accepted that other types
or combinations are not severe enough to be
appropriate for therapeutic termination of preg-
nancies and are not justified for prenatal diagno-
sis.
The couples at risk in both groups were coun-
seled for prenatal diagnosis. Those at risk for
having a child with Hb Bart’s may choose prena-
tal diagnosis by either cordocentesis at 18]22
241
Fig. 2. Algorithm for prospective screening.
gestational weeks or serial ultrasound every 2]3
weeks for early detection of fetal hydrops, which
usually occurs in the late second or early third
trimester from 22 to 33 weeks.. The pregnancies
at risk of homozygous b-thal or b-thalrHbE dis-
ease were offered cordocentesis. Those with no
risk were followed up by routine antenatal care.
Cordocentesis was performed under ultra-
sound-guided. Two milliliters of fetal blood was
collected and analyzed by HPLC technique or Hb
electrophoresis. The women were followed up by
routine antenatal care if the results of prenatal
diagnosis were negative for the disease and preg-
nancy was terminated if the fetuses were affected.
3. Results
Cordocentesis was performed on 554 cases
which consisted of two main groups, the group of
known risk by retrospective screening Ž252 cases
between January 1992 and July 1997. and by
prospective screening program Ž302 cases between
September 1993 and July 1997.. The mean gesta-
tional age Ž"S.D.. at the time of couseling and
cordocentesis was 14 " 3.5 and 19 " 3.4 weeks,
respectively. Sixty of 252 of the first group had
severe thalassemia including 35 Hb Bart’s, 12
homozygous b-thal and 13 b-thalrHbE disease.
All were counseled and terminated. During the
period of prospective screening program ŽTable
2., among 19 308 pregnant women attending ante-
natal clinic, 12 680 were screened with EOFT and
3634 cases Ž28.7%. had abnormal tests. Among
them, 2209 husbands were screened and 459 cases
had abnormal tests, considered at risk of having
an affected child. However, only 302 pregnancies
242 C. Wanapirak et al. r International Journal of Gynecology & Obstetrics 60 (1998) 239]244

Table 2 controlling these diseases. One of the control

Results of the prospective screening program
strategies is to increase the capacity of health
care sectors in diagnosis of the diseases prena-
Prospective screening program
tally.
Total women attending ANC 19 308 Carrier detection of thalassemia in asympto-
Total screened women 12 680 matic patients can be achieved by different meth-
Women with positive test 3634 Ž28.7%.
ods such as red blood cell ŽRBC. indices ŽMCV.,
haemoglobin electrophoresis, polymerase chain
Screened husbands 2209 reaction ŽPCR. technique and erythrocyte os-
Couples at risk 459 Ž20.78%. motic fragility test ŽEOFT.. In this study, EOFT
No prenatal diagnosis 96 was chosen to screen the patients because it is a
Abortion before 6
rapid Ž2-min., simple, very cheap and suitable for
prenatal diagnosis
Cordocentesis 302 mass screening w5,6x. One technician can do up to
Serial ultrasound 55 Žrisk for hydrops only. 150 tests per day. Abnormal EOFT could be
Early hydrops fetalis 10r55 Ž18.2%. found in Ž1. thalassemia carriers Žboth a-trait and
b-trait., Ž2. iron deficiency anemia, Ž3. sickle cell
Diagnosis
anemia, Ž4. chronic renal failure and Ž5. lead
Hb Bart’s 26
poisoning w6,7x. In this prospective screening pro-
Homozygous b-thalassemia 12 gram, EOFT was tested in pregnant women who
b-thalassemiarHbE 15 were healthy. We can exclude chronic renal fail-
Severe thalassemia syndrome 53r302
ure and lead poisoning by history taking, physical
examination and laboratory tests. It was assumed
that no sickle cell anemia was in this study be-
underwent cordocentesis. Among them, 53 cause of very low incidence in Thai population.
Ž17.5%. had severe thalassemia Ž26 Hb Bart’s, 12 Thus, in case of abnormal EOFT, we have to
homozygous b-thal, 15 b-thalrHbE. and all but differentiate thalassemia carriers, thalassemia
one were terminated. Serial ultrasound examina- disease and iron deficiency anemia. Thalassemia
tions were performed in 55 pregnancies at risk of disease can be diagnosed by clinical pictures, pe-
Hb Bart’s who did not accept cordocentesis and ripheral blood smears and Hb typing. Iron defi-
10 Ž18.2%. eventually developed hydrops fetalis ciency anemia can be diagnosed by low hemo-
which were detected at the mean gestational age globin concentration and abnormal laboratory test
of 24 " 3.6 weeks. This strategy enabled us to ŽMCV, serum iron, TIBC.. But in thalassemia
identify 113 cases of severe thalassemia ŽHb Bart’s carriers, they have no anemia, no thalassemic
60, b-thal entities; 53. from 554 cases at risk. facies and peripheral blood smears are usually
Fetal loss related cordocentesis in cases of con- normal. Therefore in this study we assumed that
tinuing pregnancies was 1.5% the study group were thalassemia carriers if they
have abnormal EOFT and normal hemoglobin
4. Discussion level on routine check-up at their first visit.
Less than 60% hemolysis at 90 s was used as a
Thalassemia is one of the most common health cut-off point of abnormal erythrocytes in this
problems in Thailand, particularly in the north, study because a screening test should have a low
where the incidence of abnormal globin gene is false negative rate. If we use a lower cut-off
rather high. This contributes to the high inci- point, some thalassemia carriers will have normal
dence of infants with a severe form of tha- EOFT and cannot be detected. However, for the
lassemia including homozygous b-thal and b- cut-off point used in this study some patients who
thalrHbE disease. These infants will grow and were normal may have had abnormal EOFT Žfalse
live with a poor quality of life. The ministry of positive test.. However, we admitted that there
Public Health had adopted a 20-year plan for might have been some false abnormal tests re-
 C. Wanapirak et al. r International Journal of Gynecology & Obstetrics 60 (1998) 239]244
cruited into the series. This may explain the
slightly lower incidence of the disease in cases of
cordocentesis Ž- 20%. when compared to the
theoretical incidence Ž25%.. To reduce false
abnormal EOFT, the other technique may be
used.
Among abnormal EOFT, we can easily differ-
entiate the type of carriers by HbA 2 levels. Due
to the high prevalence of a-thal1 trait in our
population and according to the previous report
w5x, we assumed that a person with abnormal
EOFT and normal HbA 2 level was a-thal1 trait.
This conclusion may not be used in other popula-
tions because of the different prevalence. How-
ever, detection of a-thal1 gene in this group by
PCR method to determine false positive test of
EOFT in the detection of a-thal1 trait will fur-
ther be studied.
Using only HbA 2 level may have a pitfall.
Some cases with elevated HbA 2 assumed to be
b-trait may have both b- and a-thal trait. We
found a couple of which one was assumed to be
b-thal trait and the other was a-thal1 trait, so
prenatal diagnosis was not offered and later the
fetus developed hydrops. This experience suggests
that a PCR technique would probably be useful
to detect a-thal1 gene in this situation.
Some pitfalls should be mentioned in this stud-
ies. First of all, we can not follow all of the
couples with no risk. However, none of them
became frank hydrops fetalis due to Hb Bart’s
except for one woman that had both a- and
b-trait and was misinterpreted to be at no risk.
Second, unfortunately, many pregnancies at risk
did not undergo prenatal diagnosis due to many
reasons. For example, the husbands of the wives
with abnormal EOFT did not come to be tested,
some couples at risk did not receive prenatal
diagnosis and many women first presented in late
pregnancies. These findings suggest systematic
education and counseling need further evalua-
tion.
The risk from prenatal diagnosis is another
subject to be discussed. In the aspect of success,
we found that only in six cases that fetal blood
could not be obtained and were classified into the
group of no prenatal diagnosis or serial ultra-
sound. Cordocentesis is relatively safe in experi-
243
enced hands. Fetal loss related to the procedure
Žamong the continuing pregnancies. was low in
this series and previous reports, only 1]2% w8,9x.
This risk is much less than that of an affected
baby among the couples at risk. However, it should
be done only by a skilled person. From our points
of view, in the mass screening, effective screening
both retrospective and prospective approaches
should be seriously carried out and prenatal diag-
nosis should be reserved for tertiary care center.
Fetal diagnosis could be done by DNA analysis
from chorion tissue or amniocytes to identify some
specific mutation. Although this technique has
been shown successful for prenatal diagnosis w10x,
it is so sophisticated and time-consuming that it
could not be put into practice for routine work,
especially in our population which have various
mutations of b-genes w11x. Therefore we analyzed
fetal blood by differenting hemoglobin types us-
ing HPLC which could differentiate types of
hemoglobin even in small amounts with high ac-
curacy w12x. However, the disadvantages of this
approach are its rather late procedure and some-
what higher fetal loss when compared to amnio-
centesis or chorionic villi sampling.
One should keep in mind that, although the
couples at risk could freely select the choice of
cordocentesis or not, they might change their
mind later. In this study, for example, one of the
couples with an affected fetus finally did not
accept the termination of their pregnancy. This
was due to the fact that they firstly hoped that the
result would be normal and not be worried
throughout the rest of pregnancy but they recon-
sidered the choice after knowing the abnormal
result.
From our preliminary but extensive experience,
we found that the incidence of frank hydrops
fetalis due to Hb Bart’s has dramatically dropped
in recent years. Moreover, the new cases of se-
vere b-thal at our pediatric department have been
observed to be apparently decreased, although
the exact incidence remains to be evaluated. It
appears that this strategy should be considered to
apply in the larger areas with high prevalence.
Although cordocentesis for prenatal diagnosis is
not available in every hospital, the screening test
is valuable anywhere. Only the women who are at
244 C. Wanapirak et al. r International Journal of Gynecology & Obstetrics 60 (1998) 239]244
risk should be counseled and referred to the
tertiary center for prenatal diagnosis. Until a
simpler way of prenatal diagnosis and the better
technique of carrier detection are developed, Chi-
ang Mai strategy proves valuable in reducing new
cases of severe thalassemia syndrome.
Various techniques of DNA analysis for tha-
lassemia are becoming widely developed w13]17x,
we hope that the technique of prenatal diagnosis
will change to the less invasive technique, chori-
onic villi sampling, amniocentesis, analysis of fetal
cells in maternal blood or even preimplantation
w18x. However, the screening test should still be
simple, rapid and inexpensive as we have been
doing.
To improve the efficacy of prevention of the
new cases, all pregnant women in the high preva-
lence areas should be tested for the carrier status.
To achieve this purpose, the carrier detection
policy should be extended to the premarriage or
preconceptional testing and early antenatal care
must be encouraged.
To summarize the strategy consisted of carrier
identification, prenatal diagnosis and termination
of pregnancy, we identified 554 pregnancies at
risk by retrospective screening and prospective
screening of 12 680 asymptomatic pregnant
women. We managed to prevent 113 cases of
severe thalassemia syndrome, if pregnancies had
continued expenditure in treatment would have
been high. Furthermore, when including the se-
rial ultrasound examination, we could detect 123
cases from 609 couples at risk. Prenatal diagnosis
is not the only way to reduce the new cases but
also to reassure the couples of normal fetuses.
References
w1x Fucharoen S, Winichagoon P. Hemoglobinopathies in
southeast Asia. Hemoglobin 1987;11:65]88.
w2x Fucharoen S, Winichagoon P, Thonglairoam V et al.
Prenatal diagnosis of thalassemia and hemoglobino-
pathies in Thailand: experience from 100 pregnancies.
Southeast Asian J Trop Med Public Health 1991;
22:16]29.
w3x Ratip S, Skuse D, Porter J, Wonke B, Yardumian A,
Modell B. Psychosocial and clinical burden of thalas-
saemia intermedia and its implications for prenatal diag-
nosis. Arch Dis Child 1995;72:408]412.
w4x Zanella A, Milani S, Fagnani G, Mariani M, Sirchia G.
Diagnostic value of the glycerol lysis test. J Lab Clin
Med 1983;102:743]750.
w5x Flatz SD, Flatz G. Population screening for beta-thalas-
semia. Lancet 1980;i:495]496.
w6x Gottfried EL, Robertson NA. Glycerol lysis time as a
screening test for erythrocyte disorders. J Lab Clin Med
1974;83:323]333.
w7x Posteraro A, Jr, Gottfried EL. The diagnostic signifi-
cance of prolonged erythrocytic glycerol lysis time
ŽGLT50.. AJCP 1978;70:637]641.
w8x Wanapirak C, Sirichotiyakul S, Kunavikatikul C, Piya-
monkol W, Sekararithi R. Cordocentesis in Chiang Mai
University Hospital: 286 cases experience. Thai J Obstet
Gynaecol 1996:79]86.
w9x Duffos F, Capella-Pavlovsky M, Forestier F. Fetal blood
sampling during pregnancy with use of a needle guided
by ultrasound: a study of 606 consecutive cases. Am J
Obstet Gynecol 1985;153:655]658.
w10x Xu X, Liad C, Liu Z et al. Antenatal screening and fetal
diagnosis of beta-thalassemia in a Chinese population:
prevalence of the beta-thalassemia trait in the
Guangzhou area of China. Hum Genet 1996;98:199]202.
w11x Laig M, Sa-nguansermsri T, Wiangnon S, Hundrieser J,
Page M, Flatz G. The spectrum of beta-thalassemia
mutations in northern and northeastern Thailand. Hum
Genet 1989;84:47]50.
w12x Samperi P, Testa R, Mancuso M, Schiliro G. Compara-
tive approach to the evaluation of HbA 2 by two differ-
ent methods: high-performance liquid chromatography
and DE-52 micromatography. Acta Haematol 1990;
83:179]182.
w13x Winichagoon P, Kownkon J, Yenchitsomanus P,
Thonglairoam V, Siritanaratkul N, Fucharoen S. Detec-
tion of beta-thalassemia and hemoglobin E genes in
Thai by a DNA amplification technique. Hum Genet
1989;82:389]390.
w14x Winichagoon P, Fucharoen S, Kanokpongsakdi S, Fuku-
maki Y. Detection of alpha-thalassemia1 Žsoutheast
Asian type. and its application for prenatal diagnosis.
Clin Genet 1995;47:318]320.
w15x Torcharus K, Sriphaisal T, Krutvecho T et al. Prenatal
diagnosis of Hb Bart’s hydrops fetalis by PCR tech-
nique: Pramongkutklao experience. Southeast Asian J
Trop Med Public Health 1995;26:287]290.
w16x Fucharoen S, Fucharoen G, Ratanasiri T, Jetsrisuparb
A, Fukumaki Y. A simple non radioactive method for
detecting beta-thalassemiarhbe disease: application to
prenatal diagnosis. Southeast Asian J Trop Med Public
Health 1995;26:278]281.
w17x Winichagoon P, Fucharoen S, Siritanaratkul N et al.
Prenatal diagnosis for beta-thalassemia syndromes using
HRP-labeled oligonucleotide probes at Siriraj Hospital.
Southeast Asian J Trop Med Public Health 1995;
26:282]286.
w18x Chang MY, Soong YK, Wang ML. Preimplantation di-
agnosis of alpha-thalassemia by blastomere aspiration
and polymerase chain reaction: preliminary experience.
J Formos Med Assoc 1996;95:203]208.