anti-D Research Articles

Perinatal outcomes of intrauterine transfusion for foetal anaemia due to red blood cell alloimmunisation

The aim of this study was to evaluate the maternal and neonatal outcomes of patients who underwent intrauterine transfusion (IUT) for foetal anaemia due to red blood cell alloimmunisation and to determine the factors that affected the outcomes. All pregnancies that were treated with IUT due to Rh immunisation between January 2015 and June 2018 in the Kanuni Sultan Süleyman Training and Research Hospital, Department of Obstetrics and Gynaecology, were evaluated retrospectively. IUT due to non-Rh alloimmunisation, parvovirus B19 infection, chronic fetomaternal haemorrhage and foetal anaemia due to homozygous alpha-thalassemia were not included in the study. The perinatal and neonatal outcomes of the patients were retrospectively analysed. The gestational age, ultrasonography findings before and after IUT, laboratory results, complications related to IUT, and data on the newborns were recorded. The cases were divided into two groups, those with complication and those without complications, and their perinatal outcomes were compared. A total of 110 IUTs were performed in 42 foetuses. The survival rate after transfusion was 80.95%. Procedure-related complications were found in 12.7% of cases. There were no significant differences between the demographic and clinical characteristics of the patients with and without complications. The survival rate was lower and perinatal mortality was higher in foetuses with hydrops fetalis. IUT is a safe and effective procedure that can be used in the treatment of foetal anaemia in experienced centres. Survival rates can be increased by referring patients to experienced perinatology centres, by improving the IUT technique, and by reducing technique-related complications.Impact statementWhat is already known on this subject? The predominant use of IUT is to treat foetal anaemia due to red blood cell alloimmunisation. Despite the decrease after anti-D immune globulin prophylaxis, Rh immunisation is still a major cause of foetal anaemia. However, foetal survival rates have increased with the use of IUT.What do the results of this study add? The survival rates were increased after the development of a high-resolution ultrasound. Because foetal monitoring can be performed by ultrasonography, cord accidents and overload findings can be detected during transfusion, which allows for early interventions and increases survival rates.What are the implications of these findings for clinical practice and/or further research? The IUT procedure can be used in the treatment of foetal anaemia in experienced centres. After the technique was improved, the complication rates related to the procedure were decreased and foetal survival rates were increased. Further studies on the use of different IUT techniques will extend our findings.

Prevalence and specificity of clinically significant red cell alloantibodies in pregnant women - a study from a tertiary care hospital in Southeast Michigan.

BackgroundMaternal red cell IgG antibodies can cross the placenta and cause hemolysis of fetal red cells in case of antigenic differences between maternal and fetal RBCs, leading to hemolytic disease of the fetus and newborn (HDFN). Although the incidence of anti-D associated HDFN has drastically reduced with Rh immune globulin prophylaxis, HDFN due to other maternal red cell alloantibodies still remains a concern. Prevalence and specificities of clinically significant red cell alloantibodies in pregnant females have rarely been reported in the USA.MethodsA retrospective chart review was conducted to determine the prevalence and specificity of clinically significant red cell alloantibodies in pregnant females who delivered at Beaumont Hospital Royal Oak between May 1, 2017 and December 31, 2017. A total of 4548 pregnant females were screened using electronic medical records. One female above 50 years age and two females with invalid ABO type were excluded from the study per IRB approved protocol. The remaining 4545 pregnant females with a valid ABO/RhD type and valid red cell antibody screen were included.ResultsOut of the 4545 included females, 440 had a positive red cell antibody screen. Of these 440 females, 34 had clinically significant alloantibodies, giving an overall prevalence of 0.74%. Anti-E was the most frequently identified significant alloantibody followed by anti-K. The most prevalent significant alloantibodies in RhD positive and RhD negative females were anti-E and anti-K, respectively. Significant association (p-value <0.001) was found between RhD type and the presence of clinically significant alloantibodies amongst females with positive antibody screen.ConclusionOur study aims to reiterate the importance of maternal red cell antibody screening during early pregnancy to help identify and manage high-risk pregnancies. Minimizing the exposure of childbearing age females to incompatible red cell antigens through unnecessary transfusions can help reduce the incidence of red cell alloimmunization and the risk of HDFN.

Single dose v two-dose antenatal anti-D prophylaxis: a randomised controlled trial.

To compare rates of detectability of circulating Rh(D)-immunoglobulin (anti-D) at delivery with single and two-dose antenatal anti-D prophylaxis (RAADP) regimens; to compare compliance with the two regimens. Open label, randomised controlled trial between May 2013 and November 2015. 277 women who attended a tertiary obstetric referral hospital in Perth for antenatal care and were at least 18 years of age, less than 30 weeks pregnant and yet to receive RAADP, Rh(D)-negative (negative antibody screen), and who intended to deliver their baby at the hospital. Exclusion criteria were prior anti-D sensitisation, any contraindication of anti-D administration, and a history of isolated IgA deficiency. One 1500IU anti-D dose at 28 weeks of pregnancy (single dose regimen); two doses of 625IU each at 28 and 34 weeks of pregnancy (two-dose regimen). The primary outcome was the proportion of women with detectable anti-D levels at delivery; the secondary outcome was compliance with the allocated RAADP regimen. Circulating anti-D was detectable at delivery in a greater proportion of women in the two-dose group (111 of 129, 86%) than in the single dose group (70 of 125, 56%; P<0.001). Compliance was not significantly different between the single dose (86 of 138, 61%) and two-dose groups (70 of 139, 50%; P=0.06). The two-dose RAADP schedule currently recommended in Australia provides better protection against Rh(D) sensitisation than a one-dose regimen. Australian and New Zealand Clinical Trials Registry (ACTRN12613000661774).

A case of mild HDFN caused by anti-C, anti-D, and anti-G: Diagnostic strategy and clinical significance of distinguishing anti-G from anti-D and anti-C

Anti-G is commonly present with anti-D and anti-C and can confuse serological investigations. The differentiation of anti-G from anti-D and anti-C is particularly essential for the accurate diagnosis of hemolytic disease of the fetus and newborn (HDFN) and appropriate administration of anti-D immunoglobulin prophylaxis in Rhesus (Rh) negative women. We reported a rare case of anti-G together with anti-D and anti-C in a pregnant woman and her female neonate. The titers of IgG anti-D, anti-C, and anti-G in the woman were 256, 128, and 32, respectively. While the titers of IgG anti-D, anti-C, and anti-G in the neonate were 16, 8, and 4, respectively. The neonate experienced mild HDFN and only received phototherapy during hospitalization. This report discusses the diagnostic strategy and clinical significance of differentiating anti-G from anti-D and anti-C.

Use of Fetal Hemoglobin Quantitation for Rh-Positive Pregnant Females: A National Survey and Review of the Literature.

The Kleihauer-Betke (KB) test is validated for estimating the dose of Rh immune globulin needed for Rh-negative pregnant females. However, some clinicians are also ordering the test for Rh-positive women. The degree to which this practice occurs is unknown. To evaluate the number of laboratories that perform the KB test on Rh-positive pregnant women, and to establish current ordering practices for this indication. We added 9 supplemental questions regarding KB test use for fetomaternal hemorrhage to the 2016 College of American Pathologists proficiency test survey. We also reviewed the available literature regarding the diagnostic utility of the KB test for Rh-positive women. A total of 1578 surveys were evaluated and revealed that 52% (824) of respondents perform these tests for Rh-positive women, and more than 50% (440 of 819; 53.7%) of these laboratories report that the results for Rh-positive women are treated as important or very important. The KB test is commonly used for Rh-positive women, and the information obtained from the test is considered as urgent and important. However, the available literature in support of this practice is still nonconclusive.

Frequency and characterization of RHD variants in serologically D- Surinamese pregnant women and D- newborns.

Numerous RHD variant genes affect the expression of D on the red blood cell surface. In Suriname, 4.3% of pregnant women were D-, ranging from virtually zero to 7% among ethnic groups. Characterization of RHD variants, which are associated with a variable potential to induce anti-D, is of practical clinical importance especially in case of limited access to preventive measures. Here we report on the occurrence of RHD variant genes in Surinamese serologically D- pregnant women and their D- newborns from different ethnic groups. The RheSuN study is a cross-sectional cohort study in D- pregnant women and their newborns, who visited hospitals in Paramaribo, Suriname, during routine pregnancy care. The presence of RHD variants was investigated using quantitative polymerase chain reaction targeting RHD Exons 5 and 7 and RH-multiplex ligation-dependent probe amplification. Seven RHD variant genes were detected in 35 of 84 women and four RHD variant genes in 15 of 36 newborns. The RHD*03 N.01 and RHD*08 N.01 variants represented 87% of a total of 62 variant genes. Variants were comparably frequent among ethnicities. In four cases genotyping would have changed anti-D prophylaxis policy: one woman with a RHD*01EL.01 variant, not associated with anti-D formation and three D- newborns with RHD*09.01 and RHD*09.03.01 variants, potentially capable of inducing anti-D. RHD variants at risk for anti-D are common among serologic D- individuals from African descent in Suriname. While genotyping D- women has limited added value, it may be considered in newborns from D- women.

141 Total bilirubin rate of rise of in moderate preterm neonates: impact of gestational age

Abstract Background As compared to term neonates, those &amp;lt; 35 weeks gestation (wks GA) are at greater risk for both acute and chronic bilirubin encephalopathy (ABE, CBE). Among these with postnatal total bilirubin rate of rise, (TB ROR) at age 0 to 72 hours has been observed because of either loss placental elimination system or increased postnatal production due to hemolysis. The ranges are known to vary &amp;gt; 8.5 umol/L/h in neonates with Rh disease to &amp;gt;3.4 umol/L/h at the 95th percentile track of the hour-specific nomogram. TB ROR in healthy term neonates is &amp;lt;3.4 umol/L/h. Objectives To determine the GA ranges on TB ROR to explore predictive TB ROR in preterm neonates who are more vulnerable with each &amp;lt;35 wks GA. Design/Methods A multi-site observational study to quantify TB ROR in preterm infants between 28 to 35 weeks. 1804 infants born between January 2013- March 2018 at 28–35 wks GA from three canadian perinatal centres were included and those with Rh disease were excluded. Analysis included infants &amp;gt;27 weeks with at least one TB prior to the initiation of treatment for severe hyperbilirubinemia treatment. Feeding patterns, birth history and maternal health conditions were documented. Results The TB ROR were compared by two prematurity GA groups (28–31 weeks and 32–35 weeks) then per individual gestational age in four time periods in hours, 0–24, 24–48, 48–96, and 96 -120 in 1049 preterm infants using 3065 TB samples. Infants &amp;lt;28 weeks GA were excluded since they represented a more diverse population. TB ROR by prematurity groups over all was higher in 32–35 weeks group at 0–12 hours (3.85 umol/L/h) and 25–36 hours (2.81umol/L/h) and decreased at 49–72 hours (0.24umol/L/h) time period as compared to the less mature group. Conclusion Though TB ROR were of similar patterns between prematurity groups (28–31 weeks and 32–35 weeks) it was at higher rate of rise between 13–36 hours and decreasing from 36–72 hours, with a plateau after 72 hours of age. There was a significant difference in the magnitude of TB ROR between prematurity groups at 0–24 hours. Additional research into the clinical care impact on the TB ROR should be conducted to study impact of production and elimination.

The continuing burden of Rh disease 50 years after the introduction of anti-Rh(D) immunoglobin prophylaxis: call to action

Severe morbidity and death because of Rh disease have only been reduced by approximately 50% globally during the last 50 years, despite the advent of anti-Rh(D) immunoglobin prophylaxis, which has resulted in >160,000 perinatal deaths and 100,000 disabilities annually. This apparent failure to take appropriate preventive measures is of great concern. Thus, there is a great need to do much better. We wish to draw attention to the unnecessary continuing burden of Rh disease, to discuss some of the reasons for this failure, and to provide suggestions for a better way forward.

PROPORTION OF RHESUS BLOOD TYPE PHENOTYPES OF ROUTINE BLOOD DONORS AT BLOOD DONOR UNIT INDONESIAN RED CROSS IN BANDUNG CITY

Blood type phenotype incompatibility including Rhesus between donors and patients may result in cross-matching problems, triggering alloimmunization, and caused Hemolytic Transfusion Reaction (HTR). Rhesus blood type incompatibility between mother and fetus may cause Hemolytic Disease of Fetus and Newborn (HDFN). Pretransfusion phenotypic blood groups matching also reduce cost efficiently which means antibody screening is no longer needed. The purpose of the study is to find the proportion Rhesus blood type phenotypes in routine blood donors at Blood Donor Unit, Indonesian Red Cross in Bandung city, Indonesia.The study is a descriptive and observational with cross sectional design. The study was done at Blood Donor Unit, Indonesian Red Cross in Bandung city from April 2016 to September 2017. The subjects were 142 routine blood donors, blood sampling was done simultaneously with blood donation. Rhesus antigen examination of ethylenediaminetetraacetic acid (EDTA) blood was done by gel method. Subjects characteristics were male (68%) and female (32%), with the mean age was 39 years. Examination of Rhesus antigen were found antigen D(100%), antigen e(98,6%), antigen C(97,9%), antigen c(38,7%) and antigen E(31,7%). Results of Rhesus phenotypes were DCe/DCe(61,3%), DCe/DcE(29,6%), DCe/dce(7%), DcE/DcE(1,4%) and DcE/dce(0.7%). The distribution of Rhesus blood type were affected by factors such as genetics, race, ethnicity, marriage, demography, and migration. Rhesus blood phenotypes proportion in routine blood donors at Blood Donor Unit, Indonesian Red Cross in Bandung city sorted from the most are DCe/DCe, DCe/DcE, DCe/dce, DcE/DcE and DcE/dce.Keywords: blood donor, phenotype, Rhesus

Noninvasive fetal RHD genotyping to guide targeted anti-D prophylaxis-an external quality assessment workshop.

Fetal RHD genotyping of cell-free fetal DNA from RhD-negative pregnant women can be used to guide targeted antenatal and postnatal anti-D prophylaxis for the prevention of RhD immunization. To assure the quality of clinical testing, we conducted an external quality assessment workshop with the participation of 28 laboratories. Aliquots of pooled maternal plasma were sent to each laboratory. One sample was positive, and the second sample was negative for fetal RHD, verified by pre-workshop testing using quantitative real-time PCR (qPCR) analysis of RHD exons 4, 5, 7 and 10. Plasma samples were shipped at room temperature. A reporting scheme was supplied for data collection, including questions regarding the methodological setup, results and clinical recommendations. Different methodological approaches were used, all employing qPCR with a total of eight different combinations of RHD exon targets. The samples were tested blindly. Fetal RHD genotyping was performed with no false-negative and no false-positive results. One inconclusive result was reported for the RHD-positive sample, and four inconclusive results were reported for the RHD-negative sample. All clinical conclusions were satisfactory. This external quality assessment workshop demonstrates that despite the different approaches taken to perform the clinical assays, fetal RHD genotyping is a reliable laboratory assay to guide targeted use of Rh prophylaxis in a clinical setting.

Fetal anaemia: two clinical cases with fetal blood transfusion

Fetal anaemia in pregnancy, although less prevalent since the introduction of anti-D immunoglobulin, remains a clinical issue. In this article the authors describe two clinical cases of challenging fetal anaemia; the first following a parvovirus B19 infection during pregnancy and the second after Rh isoimmunization (due to Rh positive maternal transfusions in childhood), sooner and more severe in a second pregnancy. A brief review of the topic was also conducted.

Fetal Outcome in Pregnancies Complicated with Polyhydraminos: Study Done in Pokhara, Nepal

Introduction: Amniotic fluid plays an important role in the development of fetus. Any abnormality in the production amniotic fluid may have adverse effect on the fetus and the mother. Polyhydraminos is one of the common complications occurring during pregnancy and complicates around 0.2 - 2% of pregnancies.&#x0D; Methods: It is a prospective study conducted in Manipal Teaching Hospital, Pokhara, Nepal from January 2013 to December 2015. All the pregnant ladies irrespective of gestational age with amniotic fluid index (AFI) 25 cm or more were enrolled for the study. According to the AFI, polyhydraminos was classified as mild (25 – 30 cm), moderate (30.1 - 35 cm) and severe (&gt;35 cm). Fetal outcome, mode of delivery, presence of congenital anomalies, NICU admission and maternal glucose intolerance were recorded.&#x0D; Results: Out of 8232 deliveries, 24 were diagnosed and admitted with the diagnosis of polyhydraminos. Mild polyhydraminos, 50% (n=12) occurred after 37 weeks of gestation and 12.5% (n=3) had severe polyhydraminos. All pregnant ladies 50% (n=12), beyond 37 weeks gestation had cesarean section, whereas 25% (n=6) had vaginal deliveries. 33.3% (n=8) had preterm labor, 12.5% (n=3) had premature rupture of membrane, 25% (n=6) had congenital anomalies, one IUFD, one case of Rh isoimmunisation and one case of twin pregnancy. NICU admission needed in 20.5% (n=5). Pregnant ladies with impaired glucose intolerance were 8.3% (n=2).&#x0D; Conclusions: Polyhydraminos is associated with increased incidence of cesarean section, preterm labor, fetal malformation and NICU admission.

The viral safety of intravenous immune globulin

The viral safety of intravenous immune globulin (IVIG) preparations has been investigated since 1983 when it was discovered that non-A, non-B hepatitis (NANBH) could be transmitted by an experimental IVIG preparation. Recently, it has been demonstrated that the virus causing NANBH is the hepatitis C virus (HCV). A number of subsequent episodes of HCV transmission by IVIG have been reported, but not all the factors that have led to this transmission are clearly understood. However, based on two episodes of HCV transmission by anti-D immune globulin (formulated for intravenous administration), it appears that cold ethanol fractionation is important in ensuring viral safety because both of the implicated anti-D immune globulin preparations were manufactured without cold ethanol fractionation. Other HCV transmission episodes have been associated with chromatography (particularly DEAE-Sephadex chromatography) as a separation step carried out to further purify IgG, after cold ethanol fractionation, and it is possible that such a procedure has only a marginal partitioning capacity for infective HCV virions. The role of anti-HCV screening in improving the viral safety of IVIG preparations remains unclear, but a recent transmission episode by a previously safe IVIG preparation suggests that the absence of anti-HCV antibodies during plasma fractionation may affect the partitioning characteristics of HCV and may also cause a loss of neutralizing antibody against HCV. All of the IVIG preparations associated with HCV transmission have been formulated as freeze-dried preparations and this may have been important in stabilizing HCV during the period prior to administration to patients. No other viruses appear to have been transmitted by IVIG preparations, but prior to seroconversion, HCV-infected plasma donors may continue to contaminate plasma pools used for the manufacture of blood products, despite anti-HCV screening, and additional viral inactivation steps such as incubation at pH4 or solvent-detergent treatment should be incorporated into the production process of all IVIG preparations.

Rh immune globulin: an interfering substance in compatibility testing

Immunoglobulin therapy that interferes with pretransfusion testing may complicate the interpretation of test results and adversely affect patient management. Rh immune globulin (RhIG) should be considered an interfering immunoglobulin therapy when it is detected in an antibody detection test of a sample from a patient who has been treated with RhIG. Frequently, detection occurs in mother's or newborn's plasma. Because an antenatal injection of RhIG is indicated for pregnant Rh-negative women, anti-D is detected frequently by today's highly sensitive antibody screen methods when the mother's plasma is tested subsequently at delivery. Ascertaining the source of anti-D is complicated by the inability of routine clinical laboratory methods to distinguish anti-D due to RhIG from alloimmune anti-D. A combination of qualitative and quantitative test methods, as well as a complete clinical history, is necessary for accurate diagnosis and patient management.

Severe neonatal hyperbilirubinemia in the southeast region of Turkey

Severe neonatal hyperbilirubinemia is an important cause of morbidity and mortality in developing countries. The aim was to assess etiologic reasons for development of severe hyperbilirubinemia and define risk factors for exchange transfusion and acute bilirubin encephalopathy (ABE) in Şanlıurfa located in the southeast region of Turkey. An observational cohort study included 115 infants with ≥35 weeks of gestation admitted with diagnosis of severe hyperbilirubinemia in a period of 18 months. Potential risk factors associated with exchange transfusion and development of ABE were analyzed. Among 115 infants, 67 (58.3%) received exchange transfusion and 45 (39.1%) developed ABE. Rh isoimmunization (OR: 24.6, 95% CI = 2.2–271, P = 0.009), glucose-6-phosphate dehydrogenase deficiency (G6PD) (OR: 21.1, 95% CI = 1.8–238.4, P = 0.01), early discharge (OR: 14.4, 95% CI = 4.2–48.9, P ≤ 0.001), and male sex (OR: 4.3, 95% CI = 1.3–14.1, P = 0.02) were independently associated with an increased risk for exchange transfusion. Being a refugee (OR: 6.8, 95% CI = 1.8–25.8, P = 0.005) and G6PD deficiency (OR: 9.9, 95% CI = 1.3–71.9, P = 0.02) were associated with development of ABE. Early discharge, Rh isoimmunization, and G6PD deficiency are significant risk factors for severe hyperbilirubinemia and exchange transfusion. Prevention of early hospital discharges, family education to increase awareness for hazardous effects of hyperbilirubinemia, and early follow-up visits after discharge would reduce the disease burden.

Resolution of blood group discrepancy and transfusion support to a nontransfusion-dependent thalassemia patient with anti-C and anti-N alloantibodies

Nontransfusion-dependent thalassemia (NTDT) patients generally do not require regular blood transfusion, but may be transfused before surgery. Blood group discrepancy exists when forward grouping and reverse grouping do not match. Pretransfusion testing includes ABO/Rh typing, antibody screening, and cross-matching. Forward grouping and reverse grouping were done using monoclonal anti-A, anti-B, and anti-D (Tulip Diagnostics, Goa, India) and in-house prepared 5% A, B, and O cell by conventional tube test method, respectively. Antibody screening and identification were done using 3-cell panel and 11-cell panel (Ortho Clinical Diagnostics, USA), respectively. In our case, we found a discrepancy in reverse grouping and incompatibility due to anti-c and anti-N alloantibodies. Three units of O positive, c and N antigen negative blood units were transfused to this patient. The patient was also managed by hematinics, antibiotic, and bed rest. Antiglobulin cross-matching must be done in all types of compatibility testing of RBC units. Rh and K phenotype-matched PRBC reduced the chances of alloimmunization. Proper coordination between the physician and specialist in transfusion medicine is required in case of alloantibody formation.

Spectrum of alloimmunization among multitransfused beta-thalassemia major patients

Introduction: The development of alloantibodies is a major problem among thalassemia major individuals due to periodic blood transfusions. The current study assessed the frequency and specificity of erythrocytes alloimmunization and also the variables affecting the extent of alloimmunization in repeatedly transfused thalassemia patients. Materials and Methods: This prospective, cross-sectional study was conducted at the Department of Blood Transfusion Services and Thalassemia Centre of Pakistan Institute of Medical Sciences from August 2017 to February 2018. Of the 475 thalassemia major patients, alloantibodies were screened and identified by 3-red cell antigen panel and afterward by an extended 11-cell antigen panel. The data analysis was done through SPSS version 20.0. Chi-square test was employed. Results: Alloantibodies were detected in 77 (16.2%) patients, 5 (6.5%) patients were found with double alloantibodies. Anti-D (31.1%) and Anti-E (29.9%) antibodies had the highest incidence and were found in 24 and 23 patients, independently. Anti-K antibody was observed in 11 (14.3%) and Anti-C in 3 (3.9%) patients. Anti-C (2.6%), Anti-E (2.6%), and Anti-Kpa (2.6%) all were found in two patients, individually. Similarly, Cw (1.3%), k (1.3%), Jka (1.3%), Anti-Fyb (1.3%), and Anti-s (1.3%) antibodies were detected in one patient each. Alloantibodies were common in males, splenectomized patients, in those who initiated their transfusions before 2 years of age, in patients receiving nonleukoreduced blood and in B and O blood group patients. Conclusion: The proper management and prudence are needed for thalassemia patients due to hemolytic nature of these alloantibodies. New techniques should be introduced to reduce the incidence of red blood cell alloimmunization.

Hydrops fetalis with septated cystic hygroma

Hydrops fetalis is excess accumulation of fluid in the fetus, and fetal cystic hygroma is a manifestation of early lymphatic obstruction. Depending on the severity and cause of hydrops, there may be anasarca of fetus, placentomegaly, ascites, pleural effusions, and/or pericardial effusions. Fetal hydrops and cystic hygroma can be diagnosed in the second trimester of gestation and is associated with a higher incidence of aneuploidy and high mortality. Previously, most cases of hydrops were caused by severe erythroblastosis fetalis secondary to Rh isoimmunization. At present, hydrops fetalis is caused by other conditions and is known as nonimmune hydrops. Here, we present a case of an 18-week pregnancy with fetal cystic hygroma and nonimmune hydrops fetalis.

Hyporegenerative anemia and other complications of rhesus hemolytic disease: to treat or not to treat is the question

Rhesus hemolytic disease of the newborn is rarely found after the implementation of anti-D immunoglobulin prophylaxis. However, it may lead to cholestasis, elevated liver transaminases, iron overload and late hyporegenerative anemia when it occurs. Etiology of this type of anemia is not defined yet and treatment is controversial. It is typically recognized after two weeks of life which is characterized by low hemoglobin and reticulocyte count. We have reported a case of a neonate with Rh hemolytic disease with late hyporegenerative anemia that was noted at day 18 of life. We treated this anemia by erythropoietin (EPO) 250 U/kg three times per week. Two weeks after initiation of erythropoietin treatment, a stable hemoglobin was noted along with an increased reticulocyte count. The patient required one further blood transfusion in the third week of therapy. Other associated findings were self-limited. A year of follow-up showed an appropriate development for age.

Blocked D in RhD hemolytic disease of fetus and newborn

A 3-day-old term neonate was admitted to our hospital for the evaluation of neonatal jaundice. The neonate was born to an RhD-negative multiparous mother who had never received anti-D prophylaxis. The neonate's direct antiglobulin test was 4+. Blood group was B, and Rh D typing was negative using tube technique and positive (2+) using gel card. The mother had anti-D, and anti-D titers were 1:1024. After heat elution, RhD typing of the neonate was positive using tube (2+) and gel technique (4+). The eluate was shown to have anti-D. As the red cells of the neonate were saturated with maternal anti-D, commercial monoclonal anti-D could not bind to D antigen which resulted in false-negative D typing in the neonate. Such blocking phenomenon is rare. The discrepancy was identified while using two different techniques (tube and gel) which aided in early diagnosis and tailored an appropriate treatment. The neonate improved after the initiation of a combination of intravenous immunoglobulin and phototherapy.