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Golshahi F, Sharbaf FR, Shirazi M, Sahebdel B, Golshahi J, Dadoun S, Aalipour S, Haddadi M. Severe fetal hemolytic disease due to anti-M alloimmunization: A case report and literature review. Case Rep Womens Health 2024; 42:e00620. [PMID: 38855719 PMCID: PMC11157218 DOI: 10.1016/j.crwh.2024.e00620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/11/2024] Open
Abstract
Fetal hemolysis is caused by maternal antibodies that cross the placenta. Anti-M antibodies can rarely cause severe forms of alloimmunization in the fetus and newborn. We present a case of severe anti-M alloimmunization requiring a total of 8 intrauterine transfusions, in a patient with a prior poor obstetrical history. A 35-year-old Iranian pregnant woman with a prior obstetrical history of one abortion and two stillbirths was found to have had anti-M antibody titers 1:8 and accompanying elevated middle cerebral artery peak systolic velocity (MCA-PSV) of 1.9 MoM suggestive of severe fetal anemia at 17 weeks of gestation. Persistently elevated fetal MCA-PSV was noted despite intraperitoneal transfusion at 17, 19, and 22 weeks. Fetal blood sampling at 27 weeks confirmed severe fetal anemia (3 g/dL), which required additional intravascular and intraperitoneal blood transfusion. At 37 weeks, elective cesarean section was performed. Neonatal hemoglobin immediately after delivery was 10.1 g/dL. In addition to standard supportive care, the neonate required two additional transfusions and remained in the neonatal intensive care unit (NICU) for 23 days. Anti-M antibodies are a rare cause of severe alloimmunization. We present a case in order to improve management.
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Affiliation(s)
- Fatemeh Golshahi
- Maternal, Fetal, and Neonatal Research Center, Yas Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Fatemeh Rahimi Sharbaf
- Maternal, Fetal, and Neonatal Research Center, Yas Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Mahboobeh Shirazi
- Maternal, Fetal, and Neonatal Research Center, Yas Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Behrokh Sahebdel
- Maternal, Fetal, and Neonatal Research Center, Yas Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Jafar Golshahi
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Science, Isfahan, Iran
| | | | | | - Mohammad Haddadi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Quraishy N, Sapatnekar S. Immunohematological testing and transfusion management of the prenatal patient. Adv Clin Chem 2023; 117:163-208. [PMID: 37973319 DOI: 10.1016/bs.acc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The primary indication for immunohematological testing in the prenatal patient is to detect and identify maternal red cell antibodies. If there are antibodies that are expected to hemolyze the fetus' red cells, their strength of reactivity must be tested, and the fetus' antigen status determined. After delivery, testing is performed to assess the extent of fetomaternal hemorrhage, as a large hemorrhage may require other therapeutic interventions. Another major role for immunohematological testing is to select blood components appropriately when intrauterine transfusion is required for fetal anemia resulting from maternal alloimmunization or some other cause. Supplementation with molecular methods has transformed the practice of immunohematology, particularly as it applies to typing for the D antigen of the Rh blood group system. Notwithstanding the advances in testing, close coordination and communication between the transfusion service and the obstetrics service are the foundation for ensuring the finest care for prenatal patients, and for new mothers and their infants. This review describes testing and transfusion practices for prenatal patients, using case presentations to highlight the management of selected immunohematological findings. It also includes a discussion of key patient management topics that are currently unresolved.
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Affiliation(s)
- NurJehan Quraishy
- Section of Transfusion Medicine, Department of Laboratory Medicine, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Suneeti Sapatnekar
- Section of Transfusion Medicine, Department of Laboratory Medicine, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States.
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Pan W, Wu H, Chen J, Mo X, Wang H, Fang Q, Li Y, Huang Y. Fetal and neonatal outcome in severe alloimmunization managed with intrauterine transfusion: 18-year experience in a tertiary referral hospital in China. Front Pediatr 2023; 11:1157004. [PMID: 37124190 PMCID: PMC10130633 DOI: 10.3389/fped.2023.1157004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Background Hemolytic disease of the fetus and newborn (HDFN) due to red cell alloimmunization, is an important cause of fetal and neonatal morbidity and mortality. However, fetal and neonatal outcome of HDFN managed with intrauterine transfusion (IUT) in China are unknown. In addition, fetal and neonatal outcomes according to the type of maternal red cell alloantibodies involved and outcomes of hydrops fetalis are also unclear. Objectives The objective of this study was to evaluate fetal and neonatal outcomes of severe red-cell alloimmunization treated by IUT, to compare the outcomes according to the type of antibody, and to investigate the perinatal and postnatal outcomes of hydrops fetalis due to red cell alloimmunization. Methods A retrospective study of pregnancies affected by HDFN and managed with IUT at a tertiary care university hospital in China between January 2001 and December 2018 was performed. Fetal and neonatal outcomes were investigated, and comparison of outcomes depending on the type of antibody and comparison of outcome between hydrops fetalis and fetuses without hydrops were also conducted. Results 244 IUTs were performed in 81 fetuses from 80 pregnancies. Anti-RhD was the major etiology of HDFN requiring IUT (71.6%). The fetal survival rate was 90.1%. The survival rate of the hydropic fetuses was significantly lower than those of the non hydropic fetuses (61.2% vs. 95.6%) (P = 0.002**). Compared with non hydropic fetuses, hydropic fetuses had significantly lower gestational age and lower hemoglobin level at first IUT. The neonatal survival rate was 98.6%. Exchange transfusions were required in 26% of the neonates. 30.1% of neonates had late anemia and required top-up transfusions, and hydropic fetuses required more late top-up transfusions than fetuses without hydrops. No significant difference in fetal and neonatal outcomes was found among the four subgroups stratified by the antibody involved. Conclusion Our study demonstrates that IUT is an effective and safe therapy for severe HDFN at our institution. Early detection and treatment of hydrops is critical for perinatal outcomes. Particular attention should be paid to late postnatal anemia in affected neonates and top-up transfusion is still commonly needed.
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Affiliation(s)
- Wenxu Pan
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haiyan Wu
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Junlin Chen
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xinyue Mo
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hongxin Wang
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qun Fang
- Fetal Medicine Centre, Department of Obstetrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yijuan Li
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuefang Huang
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Correspondence: Yuefang Huang
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Kapnosa Hasani R, Abdurazak G, Pribadi A. Serial intrauterine transfusion for severe fetal anemia due to anti-M alloimmunization. Asian J Transfus Sci 2022. [DOI: 10.4103/ajts.ajts_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Yu M, Tang T, Zheng R, Situ M, Feng J. A comparative study on perinatal outcomes of red blood cell-alloimmunized pregnancies with anti-RhD in combination and anti-RhD alone in China. Vox Sang 2021; 117:268-274. [PMID: 34111300 DOI: 10.1111/vox.13161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 05/05/2021] [Accepted: 05/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES The advent of intrauterine transfusion (IUT) has improved the survival of severe foetal anaemia. The aim of this study was to compare the perinatal outcomes of red blood cell (RBC)-alloimmunized pregnancies with anti-RhD in combination and anti-RhD alone in China. MATERIALS AND METHODS A retrospective study was conducted involving RBC-alloimmunized pregnancies with anti-RhD in combination and anti-RhD alone admitted to The First Affiliated Hospital, Sun Yat-sen University, between January 2007 and December 2019. Obstetric data and neonatal outcomes were compared. RESULTS A total of 165 alloimmunized pregnancies were identified, with 32 pregnancies in the anti-RhD-in-combination group (25 pregnancies with anti-RhD + anti-RhC and 7 pregnancies with anti-RhD + anti-RhE) and 133 pregnancies in the anti-RhD-alone group. The anti-RhD-in-combination group had significantly higher frequency of IUTs than the anti-RhD-alone group (59.4% [19/32] vs. 30.1% [40/133]; p < 0.01). The postnatal frequency of top-up transfusions was significantly higher in the anti-RhD in combination group than the anti-RhD-alone group (90.6% [29/32] vs. 70.7% [94/133]; p = 0.02). There was no significant difference in the frequency of exchange transfusions (ETs) between the two groups (15.6% [5/32] vs. 17.3% [23/133]; p = 0.82). CONCLUSIONS Compared to alloimmunized pregnancies with anti-RhD alone, pregnancies with anti-RhD in combination with anti-RhC or anti-RhE have an increased requirement for antenatal IUTs and postnatal top-up transfusions but do not have an increased need for ETs.
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Affiliation(s)
- Muxue Yu
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tonghui Tang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rujiang Zheng
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Miaoqiong Situ
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiali Feng
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Sapatnekar S, Lu W, Bakdash S, Quraishy N. Implementation of a Standardized Prenatal Testing Protocol in an Integrated, Multihospital Health System. Am J Clin Pathol 2021; 155:133-140. [PMID: 32880652 DOI: 10.1093/ajcp/aqaa120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES When our institution grew into an integrated multihospital health system, we were faced with the need to standardize laboratory processes, including blood bank processes, across all locations. The purpose of this article is to describe our experience of standardizing the protocols for prenatal testing. METHODS For each hospital in the system, we established service tiers to define tests offered on site or referred to another location. For each prenatal test, we examined the related processes for ways to improve uniformity, efficiency, and reliability. Throughout this process of standardization, we collaborated with the clinical services to gain concurrence on the interpretation and reporting of results. RESULTS We created and implemented a uniform protocol for testing prenatal patients. The protocol standardized the definition of critical titer, instituted criteria to identify passively acquired anti-D, and established a process for the follow-up of women with inconsistent serologic results on Rh(D) typing. CONCLUSIONS Close collaboration with the clinical services ensured that our testing protocol is aligned with the needs of the integrated obstetrics service in the health system. The approach described in this article may provide a plan outline for pathologists facing similar challenges at other integrated health systems.
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Affiliation(s)
- Suneeti Sapatnekar
- Section of Transfusion Medicine, The Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Wen Lu
- Section of Transfusion Medicine, The Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Suzanne Bakdash
- Section of Transfusion Medicine, The Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - NurJehan Quraishy
- Section of Transfusion Medicine, The Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
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Yamada C, Takeshita A, Ohto H, Ishimaru K, Kawabata K, Nomaguchi Y, Haraguchi Y, Abe M, Sobue K, Takenouchi H, Takadate J, Kamimura M, Katai A, Kasai D, Minami Y, Sugimoto T, Michino J, Nagai K, Kumagai M, Hasegawa Y, Ishizuka K, Ohtomo N, Yamada N, Muroi K, Matsushita T, Takahashi K. A Japanese multi‐institutional collaborative study of antigen‐positive red blood cell (RBC) transfusions in patients with corresponding RBC antibodies. Vox Sang 2020; 115:456-465. [DOI: 10.1111/vox.12906] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/05/2020] [Accepted: 02/10/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Chiaki Yamada
- Transfusion and Cell Therapy Hamamatsu University School of Medicine Hamamatsu Japan
| | - Akihiro Takeshita
- Transfusion and Cell Therapy Hamamatsu University School of Medicine Hamamatsu Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology Fukushima Medical University Fukushima Japan
| | - Ken Ishimaru
- Blood Service Headquarters Japanese Red Cross Society Minato‐ku Japan
| | - Kinuyo Kawabata
- Department of Blood Transfusion and Transplantation Immunology Fukushima Medical University Fukushima Japan
| | - Yuriko Nomaguchi
- Division of Transfusion Medicine Fukuoka University Fukuoka Japan
| | - Yasue Haraguchi
- Department of Blood Transfusion Medicine and Cell Therapy Kagoshima University Kagoshima Japan
| | - Misao Abe
- Blood Transfusion & Cell Therapy Kansai Medical University Moriguchi Japan
| | - Koki Sobue
- Division of Blood Transfusion Toho University Ota‐ku Japan
| | - Hiroyuki Takenouchi
- Department of Transfusion and Cell Therapy University of Miyazaki Miyazaki Japan
| | - Junko Takadate
- Division of Central Clinical Laboratory Iwate Medical University Morioka Japan
| | - Masami Kamimura
- Division of Blood Transfusion Niigata University Niigata Japan
| | - Akiko Katai
- Department of Transfusion Medicine Aichi Medical University Aichi‐gun Japan
| | - Daisuke Kasai
- Department of Clinical Laboratory Nagano Municipal Hospital Nagano Japan
| | - Yumiko Minami
- Division of Transfusion Medicine Osaka Medical College Takatsuki Japan
| | - Tatsuya Sugimoto
- Division of Medical Technology and Department of Blood Transfusion Service Tokai University Isehara Japan
| | - Junko Michino
- Division of Clinical Laboratory, Transfusion Medicine and Cell Therapy University of Toyama Toyama Japan
| | - Kazuhiro Nagai
- Transfusion and Cell Therapy Unit Nagasaki University Nagasaki Japan
| | - Mikako Kumagai
- Division of Blood Transfusion Akita University Akita Japan
| | - Yuichi Hasegawa
- Department of Transfusion Medicine University of Tsukuba Tsukuba Japan
| | - Keiko Ishizuka
- Transfusion and Cell Therapy Hamamatsu University School of Medicine Hamamatsu Japan
| | - Naoki Ohtomo
- Center for Transfusion Medicine and Cell Therapy Tokyo Medical and Dental University Bunkyo‐ku Japan
| | - Naotomo Yamada
- Department of Transfusion Medicine Saga University Saga Japan
| | - Kazuo Muroi
- Division of Cell Transplantation and Transfusion Jichi Medical University Shimotsuke Japan
| | | | - Koki Takahashi
- Blood Service Headquarters Japanese Red Cross Society Minato‐ku Japan
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Li S, Mo C, Huang L, Shi X, Luo G, Ji Y, Fang Q. Hemolytic disease of the fetus and newborn due to alloanti-M: three Chinese case reports and a review of the literature. Transfusion 2018; 59:385-395. [PMID: 30520533 DOI: 10.1111/trf.15054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/04/2018] [Accepted: 09/17/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Alloanti-M was once regarded as not clinically significant, with a few exceptions in extremely rare cases. However, an increasing number of cases of severe hemolytic disease of the fetus and newborn (HDFN), resulting in fetal hydrops and recurrent abortion caused by alloanti-M, have been reported mainly in the Asian population. STUDY DESIGN AND METHODS Three pregnant Chinese women with a history of abnormal pregnancy with hydrops fetalis were encountered. During this pregnancy, a series of clinical examinations and an alloantibody identification against RBCs and platelets were conducted. Intrauterine transfusion and postnatal transfusion were then performed in the fetuses. In addition, the HDFN cases caused by alloanti-M reported in different ethnic groups as well as their clinical and serologic features are also summarized. RESULTS Three pregnant women were identified with an M-N+ phenotype and IgM mixed with IgG alloanti-M in serum. Their fetuses were found by ultrasound examination and cord blood testing to have severe anemia. Additionally, an M+N+ phenotype and IgG alloanti-M were detected in the cord blood of the three fetuses with titers ranging from 1:1 to 1:128. Moreover, low reticulocyte counts and negative direct antiglobulin tests were also shown in two of the fetuses. After receiving intrauterine transfusions and postnatal transfusions several times, these three fetuses eventually survived and then healthfully developed in the follow-up tracking. CONCLUSION Alloanti-M immunization can cause severe HDFN with hyporegenerative anemia, often seen in the Asian population, and suppression of erythropoiesis might account for it.
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Affiliation(s)
- Si Li
- Fetal Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510000, China
| | - Chunyan Mo
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, 510095, China
| | - Linhuan Huang
- Fetal Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510000, China
| | - Xiaomei Shi
- Guangdong Women's and Children's Hospital, Guangzhou, 510010, China
| | - Guangping Luo
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, 510095, China
| | - Yanli Ji
- Guangzhou Blood Center, Insititute of Clinical Blood Transfusion, Guangzhou, 510095, China
| | - Qun Fang
- Fetal Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510000, China
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