The targeted RAAPD program was implemented effectively in the national maternity care program in Finland. An accurate fetal RHD screening test allows discontinuation of newborn testing without risking the postnatal prophylaxis program. In the future, the main area to investigate will be the clinical effect of RAADP on subsequent pregnancies.

Although overall survival is comparable with previous studies, our concern is procedure-related infections and preterm births. Close collaboration between the university hospitals is needed to ensure timely treatment, operator skills and systematic follow-up of the children.

Prophylactic anti-D is a very safe and effective therapy for the suppression of anti-D immunization and thus prevention of haemolytic disease of the foetus and newborn. However, migration from countries with low health standards and substantial cuts in public health expenses have increased the incidence of anti-D immunization in many "developed" countries. Therefore, this forum focuses on prenatal monitoring standards and treatment strategies in pregnancies with anti-D alloimmunization. The following questions were addressed, and a response was obtained from 12 centres, mainly from Europe.

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Introduction: Targeted routine antenatal anti-D prophylaxis was introduced to the national prophylaxis program in Finland in late 2013. The aim of this study was to assess the incidence, time-points, and risk factors for Rhesus D immunization after the implementation of routine antenatal anti-D prophylaxis, in all women in Finland with antenatal anti-D antibodies detected in 2014-2017. Material and methods:In a nationwide population-based retrospective cohort study, the incidence, time-points, and risk factors of anti-D immunizations were analyzed.Information on antenatal screening was obtained from the Finnish Red Cross Blood Service database, and obstetric data from hospital records and the Finnish Medical Birth Register. Results:The study included a total of 228 women (197 with complete data for all pregnancies). After the implementation of routine antenatal anti-D prophylaxis, the prevalence of pregnancies with anti-D antibodies decreased from 1.52% in 2014 to 0.88% in 2017, and the corresponding incidence of new immunizations decreased from 0.33% to 0.10%. Time-points for detection of new anti-D antibodies before and after 2014 were the first screening sample at 8-12 weeks of gestation in 52% vs 19%, the second sample at 24-26 weeks in 20% vs 50%, and the third screening at 36 weeks in 28% vs 32%. Conclusions:The incidence of new anti-D immunizations decreased as expected after the implementation of routine antenatal anti-D prophylaxis. True failures are rare and they mainly occur when the prophylaxis is not given appropriately, suggesting a need for constant education of healthcare professionals on the subject.

Background: Ula, part of the Kell blood group system, is a low-frequency antigen found predominantly in the Finnish population. Anti-Ula is a rare antibody to cause hemolytic disease of the fetus and newborn (HDFN). Methods and Findings:We report one woman with two pregnancies in which anti-Ula caused severe HDFN requiring intrauterine (IU) transfusions. In the first affected pregnancy, two IU transfusions were performed, but the cause of fetal anemia was unknown at the time and an immune-based mechanism was not suspected. In the following pregnancy, anti-Ula with a titer of 1-2 was identified, and as the fetus was anemic, six IU transfusions were performed. The detection of anti-Ula is difficult, because it is not usually included in the antibody screening cells. Conclusions:The possibility of a rare antibody as the cause of severe HDFN should be kept in mind in cases in which the antibody screening has been negative, and further antibody detection studies should be performed as part of fetal anemia investigations. If anti-Ula is identified in a pregnant woman, close ultrasound monitoring of the fetus is important because HDFN may develop even when the antibody titers are low.

Anti-G is commonly present with anti-D and/or anti-C and can confuse serological investigations. In general, anti-G is not considered a likely cause of severe hemolytic disease of the fetus and newborn (HDFN), but it is important to differentiate it from anti-D in women who should be administered anti-D immunoglobulin prophylaxis. We report one woman with three pregnancies severely affected by anti-C+G requiring intrauterine treatment and a review of the literature. In our case, the identification of the correct antibody was delayed because the differentiation of anti-C+G and anti-D+C was not considered important during pregnancy since the father was D-. In addition, anti-C+G and anti-G titer levels were not found to be as reliable as is generally considered in Rh immunization.Severe HDFN occurred at a maternal anti-C+G antibody titer of 8 and anti-G titer of 1 in comparison with the critical titer level of 16 or more in our laboratory. Close collaboration between the immunohematology laboratory and the obstetric unit is essential. In previously affected families, early assessment for fetal anemia is required even when titers are low. Immunohematology 2015;31:123-127.

Evidence from earlier studies suggested insulin-treated T1DM patients are unable to achieve HbA1c targets despite optimization of insulin MDI. However, widespread adoption of CSII with little evidence of treatment superiority compared with MDI. The present study was designed to perform a systematic review of health economic studies to assess the effectiveness of CSII vs. MDI. Methods: A systematic literature search in Embase, Medline, Cochrane CENTRAL, NHS EED and HTA databases through Ovid was conducted to identify studies comparing CSII with MDI. Two independent reviewers performed the screening. The Incremental Cost-Effectiveness Ratios (ICERs) of CSII and MDI in T1DM patients were compared. The quality of the economics studies was appraised through the Quality of Health Economics Studies (QHES) tool. Results: Of 1444 retrieved articles, 12 studies which met the inclusion criteria were included. The results of the systematic search reported that CSII was cost-effective compared to MDI with a mean (95% CI) ICER of $ 45678 (23500-67900) and V 37802 (17900-57700) per QALY gained. CSII was associated with an improvement in QALY gained of 0.91-12.88 in patients compared to MDI patients. Improvement in glycemic control from CSII led to lower incidence of diabetic complications (cardiovascular and renal); the incurred CSII implementation costs are hence offset to a substantial degree by cost savings in complication treatment. The mean QHES score of the included studies was 81 6 8.06, and more than 50% of them had a QHES score of more than 80. Conclusions: Results from the included studies suggest that CSII is cost-effective compared to MDI in T1DM patients across multiple settings. Further cost-effectiveness studies are required to justify the reimbursement of CSII in T1DM patients.