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Slootweg YM, Walg C, Koelewijn JM, Van Kamp IL, De Haas M. Knowledge, attitude and practices of obstetric care providers towards maternal red-blood-cell immunization during pregnancy. Vox Sang 2019; 115:211-220. [PMID: 31884705 PMCID: PMC7187211 DOI: 10.1111/vox.12883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 11/29/2022]
Abstract
Background and objectives A successful routine RBC alloantibody screening programme should not lead to unnecessary emotional burden during pregnancy due to inadequate counselling on the risk of severe haemolytic disease of the foetus and the newborn (HDFN). Rareness of this disease may result in insufficient knowledge and subsequent inadequate information transfer to women, diagnosed with RBC antibodies. We investigated the current knowledge, views and experiences of Dutch obstetric care providers regarding RBC alloimmunization during pregnancy. Materials and methods We performed a quantitative cross‐sectional study, using a structured digital questionnaire to measure knowledge, attitude and practices (KAP) regarding maternal RBC alloimmunization among Dutch obstetric care providers in 2016. Results About 10% of obstetric care providers completed the questionnaire. A sufficient level of knowledge was found in 7% of all participants (N = 329). Knowledge about RhD immunisation and prophylaxis was sufficient in 60% of the responders. Knowledge gaps were found concerning the relevance of non‐RhD RBC antibodies, the indications for giving extra RhD prophylaxis and the interpretation of laboratory test results. Healthcare providers estimated their own level of knowledge ‘sufficient’ (primary/secondary care) to ‘good’ (tertiary care), and all participants considered their professional role important within the screening programme. Conclusion Dutch obstetric care providers showed a lack of knowledge regarding maternal RBC immunization. Awareness of the lack of knowledge is necessary to help obstetric care providers to be careful in giving information and even to decide to contact the expert centre before counselling the patient.
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Affiliation(s)
- Yolentha M Slootweg
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands
| | - Chawa Walg
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joke M Koelewijn
- Department of Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands.,Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Inge L Van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja De Haas
- Department of Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands.,Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
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Slootweg YM, Lindenburg IT, Koelewijn JM, Van Kamp IL, Oepkes D, De Haas M. Predicting anti-Kell-mediated hemolytic disease of the fetus and newborn: diagnostic accuracy of laboratory management. Am J Obstet Gynecol 2018; 219:393.e1-393.e8. [PMID: 30063902 DOI: 10.1016/j.ajog.2018.07.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/21/2018] [Accepted: 07/24/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is controversy on critical cut-off values of laboratory testing to select pregnancies at increased risk for anti-Kell-mediated hemolytic disease of the fetus and newborn. Without early detection and treatment, anti-Kell-mediated hemolytic disease of the fetus and newborn may result in progressive fetal anemia, fetal hydrops, asphyxia, and perinatal death. OBJECTIVE We aimed to determine the value of repeated anti-Kell titer determination and biological activity measurement using the antibody-dependent cellular cytotoxicity test determination in the management of pregnancies at risk for anti-Kell-mediated hemolytic disease of the fetus and newborn. STUDY DESIGN This was a retrospective cohort study of pregnancies with anti-Kell and a Kell-positive fetus, identified from January 1999 through April 2015. Laboratory test results and clinical outcome were collected from the Dutch nationwide screening program and the national reference center for fetal therapy in The Netherlands, the Leiden University Medical Center. Diagnostic accuracy was measured (receiver operating characteristic curves, sensitivity, specificity, positive and negative predictive values) for anti-Kell titers and antibody-dependent cellular cytotoxicity test. The relationship between the titer and antibody-dependent cellular cytotoxicity measurements and the 2 foregoing measurements were computed with a Pearson product-moment correlation coefficient. RESULTS In a 16-year unselected cohort, representing screening results of 3.2 million pregnancies resulting in live births in The Netherlands, we identified 1026 Kell-immunized pregnancies. In all, 93 pregnant women had anti-Kell and a Kell-positive child, without other red cell alloantibodies. In all, 49 children (53%) needed intrauterine or postnatal transfusion therapy. The first anti-Kell titer showed already a high diagnostic accuracy with an area under the curve of 91%. The optimal cut-off point for the titer was 4 (sensitivity 100%; 95% confidence interval, 91-100), specificity 27% (95% confidence interval, 15-43), and positive predictive value 60% (49-71%). The antibody-dependent cellular cytotoxicity test was not informative to select high-risk pregnancies. Linear regression showed no significant change during pregnancy, when antibody titer and antibody-dependent cellular cytotoxicity test results were compared with every 2 foregoing measurements (P < .0001). CONCLUSION Early determination of the anti-Kell titer is sufficient to select pregnancies at increased risk for hemolytic disease of the fetus and newborn with need for transfusion therapy. If the Kell status of the fetus is known to be positive, a titer of ≥4 can be used to target intensive clinical monitoring.
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Affiliation(s)
- Yolentha M Slootweg
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Irene T Lindenburg
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joke M Koelewijn
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands; Department of Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
| | - Inge L Van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja De Haas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands; Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands; Department of Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
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Zonneveld R, Kanhai HH, Lamers M, Brand A, Zijlmans WC, Schonewille H. D antibodies in pregnant women in multiethnic Suriname: the observational RheSuN study. Transfusion 2017; 57:2490-2495. [DOI: 10.1111/trf.14235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/04/2017] [Accepted: 05/24/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Rens Zonneveld
- Scientific Research Center Suriname
- Department of PediatricsAcademic Hospital Paramaribo
| | - Humphrey H.H. Kanhai
- Faculty of Medical Sciences of the Anton the Kom University of SurinameParamaribo Suriname
- Department of Obstetrics
| | - Margriet Lamers
- Faculty of MedicineRadboud UniversityNijmegen the Netherlands
| | - Anneke Brand
- Department of Immunohematology and Blood TransfusionLeiden University Medical CenterLeiden the Netherlands
| | - Wilco C.W.R. Zijlmans
- Scientific Research Center Suriname
- Faculty of Medical Sciences of the Anton the Kom University of SurinameParamaribo Suriname
- Department of Pediatrics, Diakonessen HospitalParamaribo Suriname
| | - Henk Schonewille
- Department of Experimental ImmunohematologySanquin ResearchAmsterdam the Netherlands
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Ree IMC, Smits-Wintjens VEHJ, van der Bom JG, van Klink JMM, Oepkes D, Lopriore E. Neonatal management and outcome in alloimmune hemolytic disease. Expert Rev Hematol 2017; 10:607-616. [DOI: 10.1080/17474086.2017.1331124] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Isabelle M. C. Ree
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
- Sanquin Blood Supply, Clinical Transfusion Research, Leiden, Zuid-Holland, The Netherlands
| | | | - Johanna G. van der Bom
- Sanquin Blood Supply, Clinical Transfusion Research, Leiden, Zuid-Holland, The Netherlands
| | | | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Management of severe fetal anemia by Doppler measurement of middle cerebral artery: are there other benefits than reducing invasive procedures? Eur J Obstet Gynecol Reprod Biol 2015; 192:27-30. [DOI: 10.1016/j.ejogrb.2015.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/31/2015] [Accepted: 06/12/2015] [Indexed: 11/21/2022]
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de Haas M, Thurik FF, Koelewijn JM, van der Schoot CE. Haemolytic disease of the fetus and newborn. Vox Sang 2015; 109:99-113. [PMID: 25899660 DOI: 10.1111/vox.12265] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 01/11/2015] [Accepted: 02/02/2015] [Indexed: 12/12/2022]
Abstract
Haemolytic Disease of the Fetus and Newborn (HDFN) is caused by maternal alloimmunization against red blood cell antigens. In severe cases, HDFN may lead to fetal anaemia with a risk for fetal death and to severe forms of neonatal hyperbilirubinaemia with a risk for kernicterus. Most severe cases are caused by anti-D, despite the introduction of antental and postnatal anti-D immunoglobulin prophylaxis. In general, red blood cell antibody screening programmes are aimed to detect maternal alloimmunization early in pregnancy to facilitate the identification of high-risk cases to timely start antenatal and postnatal treatment. In this review, an overview of the clinical relevance of red cell alloantibodies in relation to occurrence of HDFN and recent views on prevention, screening and treatment options of HDFN are provided.
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Affiliation(s)
- M de Haas
- Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands.,Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - F F Thurik
- Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - J M Koelewijn
- Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of General Practice, University Medical Centre, Groningen, the Netherlands
| | - C E van der Schoot
- Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Yasuda H, Ohto H, Nollet KE, Kawabata K, Saito S, Yagi Y, Negishi Y, Ishida A. Hemolytic disease of the fetus and newborn with late-onset anemia due to anti-M: a case report and review of the Japanese literature. Transfus Med Rev 2013; 28:1-6. [PMID: 24262303 DOI: 10.1016/j.tmrv.2013.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 10/08/2013] [Accepted: 10/08/2013] [Indexed: 11/15/2022]
Abstract
Hemolytic disease of the fetus and newborn (HDFN) attributed to M/N-incompatibility varies from asymptomatic to lethally hydropic. Case reports are rare, and the clinical significance of anti-M is not completely understood. A challenging case of HDFN due to anti-M prompted an investigation of the Japanese literature, in order to characterize the clinical spectrum of M/N-incompatibility pregnancies in Japan and report results to English-language readers. Japanese reports of HDFN attributed to M/N incompatibility were compiled. Abstracted data include maternal antibody titers at delivery, fetal direct antiglobulin test, hemoglobin, total bilirubin, reticulocyte count at birth, and therapeutic interventions. We investigated characteristics of HDFN due to M/N-incompatible pregnancies in Japan after encountering a case of severe HDFN along with late-onset anemia in an infant born to a woman carrying IgG anti-M with a titer of 1. In total, thirty-three babies with HDFN due to anti-M and one due to anti-N have been reported in Japan since 1975. The median maternal antibody titer was 64 at delivery and was 16 or less in 10 of 34 women (29%). Five of 34 babies (15%) were stillborn or died as neonates. Twenty-one of 29 survivors (72%) had severe hemolytic anemia and/or hydrops fetalis. The reticulocyte count of neonates with anemia stayed below the reference interval. Sixteen (55%) developed late-onset anemia and 14 (48%) were transfused with M-negative RBCs. Significant positive correlation (P < .05) between the hemoglobin value and the reticulocyte count within 4 days of birth was obtained in 16 babies with anti-M HDFN. In the Japanese population, 21 of 34 cases of M/N-incompatible HDFN (72%) have manifested as severe hemolytic anemia and/or hydrops fetalis. Low reticulocyte count in neonates with late-onset anemia is consistent with suppressed erythropoiesis due to anti-M.
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Affiliation(s)
- Hiroyasu Yasuda
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan.
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Kenneth E Nollet
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan; Radiation Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Kinuyo Kawabata
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Shunnichi Saito
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Yoshihito Yagi
- Division of Central Laboratories, Gifu Prefectural Tajimi Hospital, Tajimi Japan
| | - Yutaka Negishi
- Department of Pediatrics, Gifu Prefectural Tajimi Hospital, Tajimi Japan
| | - Atsushi Ishida
- Department of Pediatrics, Gifu Prefectural Tajimi Hospital, Tajimi Japan
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Affiliation(s)
- M. de Haas
- Department of Immunohaematology Diagnostics; Sanquin Diagnostic Services; Amsterdam; the Netherlands
| | - E. van der Schoot
- Department of Experimental Immunohaematology; Sanquin Research Amsterdam and Landsteiner laboratory; Academic Medical Centre; University of Amsterdam; Amsterdam; the Netherlands
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Jain V, Clarke G, Russell L, McBrien A, Hornberger L, Young C, Chandra S. A case of alloimmune thrombocytopenia, hemorrhagic anemia-induced fetal hydrops, maternal mirror syndrome, and human chorionic gonadotropin-induced thyrotoxicosis. AJP Rep 2013; 3:41-4. [PMID: 23943709 PMCID: PMC3699162 DOI: 10.1055/s-0032-1331379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 08/11/2012] [Indexed: 01/30/2023] Open
Abstract
Fetal/neonatal alloimmune thrombocytopenia (FNAIT) can be a cause of severe fetal thrombocytopenia, with the common presentation being intracranial hemorrhage in the fetus, usually in the third trimester. A very unusual case of fetal anemia progressed to hydrops. This was further complicated by maternal Mirror syndrome and human chorionic gonadotropin-induced thyrotoxicosis. Without knowledge of etiology, and possibly due to associated cardiac dysfunction, fetal transfusion resulted in fetal demise. Subsequent testing revealed FNAIT as the cause of severe hemorrhagic anemia. In cases with fetal anemia without presence of red blood cell antibodies, FNAIT must be ruled out as a cause prior to performing fetal transfusion. Fetal heart may adapt differently to acute hemorrhagic anemia compared with a more subacute hemolytic anemia.
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Affiliation(s)
- Venu Jain
- Division of Maternal-Fetal Medicine Royal Alexandra Hospital, University of Alberta, Edmonton, Alberta, Canada
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Macher HC, Noguerol P, Medrano-Campillo P, Garrido-Márquez MR, Rubio-Calvo A, Carmona-González M, Martin-Sánchez J, Pérez-Simón JA, Guerrero JM. Standardization non-invasive fetal RHD and SRY determination into clinical routine using a new multiplex RT-PCR assay for fetal cell-free DNA in pregnant women plasma: results in clinical benefits and cost saving. Clin Chim Acta 2011; 413:490-4. [PMID: 22133782 DOI: 10.1016/j.cca.2011.11.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 11/08/2011] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Among negative RhD mothers it is essential to know the fetal RhD status in order to avoid the possibility of hemolytic disease of the newborn. In this regard, the detection of fetal DNA in maternal plasma might become a new diagnostic tool. In the current study, we have evaluated the standardization of a Multiplex-PCR targeted towards two exons of the RHD and one SRY gene to monitor RhD negative women. The current study addresses questions concerning feasibility and applicability of this approach into the clinical practice. MATERIALS AND METHODS Both single and multiplex real-time PCRs targeting RHD exons 5 and 7 and SRY were applied for the detection of fetal-specific RHD sequences and sex in maternal plasma. A large cohort of 2127 women was studied between 10 and 28 weeks of pregnancy. 134 of them were used for single TaqMan PCR studies and 1993 were evaluated using Multiplex TaqMan PCR studies. All of them were serologically typed as RhD negative according to Spanish guidelines. Single and multiplex real-time PCR results were compared with postnatal serology and sex identification. RESULTS There was a 100% concordance between results obtained with single and multiplex real-time PCR assays. At present, 1012 of the 1993 pregnant women studied gave birth and the results of RHD status obtained with the multiplex TaqMan PCR assay were confirmed postpartum by serological methods showing that sensitivity, specificity, and accuracy of the multiplex assay were 100, 98.6, and 99.3%, respectively. This procedure improved the speed of the assay, avoided over-treatment among RhD negative pregnant women bearing RhD negative fetus, and reduced the requirements for clinical and biological monitoring, resulting in a clinical benefit and cost saving. CONCLUSIONS The routine determination of fetal RHD status and SRY in maternal plasma, using multiplex real-time PCR, is feasible. The use of multiplex real-time PCR allows improving the response of the laboratory, saving time and reagent costs, opening the door to a complete automatization of the process.
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Affiliation(s)
- Hada C Macher
- Department of Clinical Biochemistry, The Virgen del Rocío University Hospital (IBiS/CSIC/SAS/University of Seville), Seville, Spain
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The controversy about controls for fetal blood group genotyping by cell-free fetal DNA in maternal plasma. Curr Opin Hematol 2011; 18:467-73. [DOI: 10.1097/moh.0b013e32834bab2d] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tiblad E, Kublickas M, Ajne G, Bui TH, Ek S, Karlsson A, Wikman A, Westgren M. Procedure-Related Complications and Perinatal Outcome after Intrauterine Transfusions in Red Cell Alloimmunization in Stockholm. Fetal Diagn Ther 2011; 30:266-73. [DOI: 10.1159/000328683] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 04/19/2011] [Indexed: 11/19/2022]
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Raymond FL, Whittaker J, Jenkins L, Lench N, Chitty LS. Molecular prenatal diagnosis: the impact of modern technologies. Prenat Diagn 2010; 30:674-81. [PMID: 20572117 DOI: 10.1002/pd.2575] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Originally prenatal diagnosis was confined to the diagnosis of metabolic disorders and depended on assaying enzyme levels in amniotic fluid. With the development of recombinant DNA technology, molecular diagnosis became possible for some genetic conditions late in the 1970s. Here we briefly review the history of molecular prenatal diagnostic testing, using Duchenne muscular dystrophy as an example, and describe how over the last 30 years we have moved from offering testing to a few affected individuals using techniques, such as Southern blotting to identify deletions, to more rapid and accurate PCR-based testing which identifies the precise change in dystrophin for a greater number of families. We discuss the potential for safer, earlier prenatal genetic diagnosis using cell free fetal DNA in maternal blood before concluding by speculating on how more recent techniques, such as next generation sequencing, might further impact on the potential for molecular prenatal testing. Progress is not without its challenges, and as cytogenetics and molecular genetics begin to unite into one, we foresee the main challenge will not be in identifying the genetic change, but rather in interpreting its significance, particularly in the prenatal setting where we frequently have no phenotype on which to base interpretation.
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Affiliation(s)
- F Lucy Raymond
- Cambridge Institute for Medical Research, Department of Medical Genetics, University of Cambridge, Cambridge, UK
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