Anti-PP1Pk (anti-Tja) and habitual abortion

Recurrent miscarriage associated with rare anti-PP1Pk antibody: a case series and literature review.. [DOI: 10.21203/rs.3.rs-2728370/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: The anti-PP1Pk antibody is a rare antibody associated with recurrent spontaneous abortion (RSA) in the first trimester. As it is a rare entity, few reports have been published, especially in China. Currently, there is no specific treatment for RSA associated with anti-PP1Pk antibody because it is a naturally occurring antibody. This study aims to report three cases of RSA associated with the anti-PP1Pk antibody to share our experiences with its management. Methods: The three patients' medical information was obtained from the medical records. Intravenous immunoglobulin and/or plasmapheresis was offered to the patients. We also made an extension research of the related literature about RSA associated with anti-PP1Pk antibody. Results: Although patients received intervention, the maternal anti-PP1Pk antibody titer remained stable and did not decrease. There were no live births. We summarized publications about pregnancy in women with anti-PP1Pk antibodies. Conclusions: Early initiation of plasmapheresis in high-risk patients with anti-PP1Pk antibodies should be strongly considered.

Multidisciplinary management of anti-PP1Pk or anti-P alloimmunization during pregnancy: A new case with anti-P and a literature review

BACKGROUND

Red blood cell alloimmunization is the first cause of fetal and neonatal anemia. Alloimmunizations with anti-PP1P^k or anti-P can cause recurrent miscarriages and hemolytic disease of the fetus and newborn in the 2nd and 3rd trimesters of pregnancy. We report on a pregnant patient immunized with anti-P and a history of recurrent miscarriages.

CASE REPORT

This P₂ ^k (GLOB:-1; P1PK:-1,3) patient had a first pregnancy marked by a caesarean at 38 weeks of gestation (WG) for non-reassuring fetal heart rate. Then, she had three early spontaneous miscarriages. The fifth pregnancy began with a high titer of anti-P at 128. Early initiation of treatment with Intravenous Immunoglobulins (IVIg) and plasma exchanges (PE) starting at 5 WG permitted us to reduce the titer of anti-P below 32. A healthy infant was delivered by caesarean at 38 WG without anemia at birth and no exchange transfusion was required.

DISCUSSION AND REVIEW OF THE LITERATURE

The P and P^k antigens are expressed on placental, trophoblastic, and embryonic cells. This explains why P₁ ^k (GLOB:-1; P1PK:1,3), P₂ ^k (GLOB:-1; P1PK:-1,3), or Tj(a-)/p (GLOB:-1; P1PK:-1,-3) patients are prone to recurrent abortions in the first trimester of pregnancy. A literature review demonstrated 87% (68/78) of miscarriages in p patients. However, publication biases are possible with the most severe cases being reported.

CONCLUSION

Immunizations to P and PP1P^k antigens differ from others in their physiopathology and precocity. The association of PE and IVIg seems to be an effective treatment in the management of anti-PP1P^k or anti-P fetomaternal incompatibilities.

Clinical consequences of the extremely rare anti-PP1Pk isoantibodies in pregnancy: a case series and review of the literature

BACKGROUND

The absence of the red cell antigens P, P1 and P^k , known as 'p', represents an extremely rare red cell phenotype. Individuals with this phenotype spontaneously form anti-PP1P^k isoantibodies, associated with severe haemolytic transfusion reactions, recurrent spontaneous abortion and haemolytic disease of the fetus and newborn (HDFN).

METHODS

We report a series of four successful pregnancies in three women with anti-PP1P^k isoantibodies, one complicated by HDFN, another by intrauterine growth restriction, all managed supportively. We also review the literature regarding the management of pregnancy involving anti-PP1P^k isoimmunization.

RESULTS

The literature surrounding anti-PP1P^k in pregnancy is limited to a very small number of case reports. The majority report management with therapeutic plasma exchange (TPE) with or without intravenous immunoglobulin. The relationship between titre and risk of pregnancy loss remains unclear, though a history of recurrent pregnancy loss appears important. Although a positive cord blood direct antiglobulin test is frequently noted, clinically significant HDFN appears uncommon, though possible.

CONCLUSION

Early initiation of TPE in high risk patients should be strongly considered. If possible, pregnancies should be managed in a high-risk obstetric or maternal fetal medicine service. The fetus should be monitored closely with interval fetal ultrasound and middle cerebral artery peak systolic volume Doppler to screen for fetal anaemia. Timely sourcing of compatible blood products is likely to be highly challenging, and both directed and autologous donation should be contemplated where appropriate. The International Red Cell Donor Panel may also provide access to compatible products.

Successful Pregnancy Outcome in Malaysian Woman with Rare p Phenotype and Anti-PP1P(k) Antibody

We report the first case of young woman with the p phenotype and anti-PP1P(k) antibody in the Malaysian population who was identified during a blood grouping and antibody screening procedure after her first miscarriage. Further family screening detected two other siblings who possessed the same rare phenotype and antibody. Because of difficulties in finding compatible units in the local population, the patient and her two siblings were advised to become regular blood donor. Their blood was frozen for future use. After she had two recurrent miscarriages, her third pregnancy was successfully managed using oral dydrogesterone, which was started from 10 weeks into the pregnancy. Her pregnancy was uneventful and she gave birth to a healthy term neonate.

The clinical management of repeated early pregnancy wastage

A rational systematic evaluation is essential to the management of a couple with repeated early pregnancy wastage. Psychologic support in the form of frequent discussions and sympathetic counseling are crucial to the successful evaluation and treatment of the anxious couple. A prompt and orderly evaluation will relieve anxiety. When no etiologic factor is identified, a 60% to 80% fetal salvage rate may be expected. Once a patient conceives, serial ultrasonography, beta-hCG determination, and estradiol determination may be useful in detecting the stage of the embryonic death if subsequent abortion occurs. A karyotypic analysis of the products of conception should be performed if fetal loss occurs.