Anti-E alloimmunization in pregnancy: management dilemmas

Hemolytic disease of the fetus and newborn caused by irregular antibody: A mortality case report and case series during the past 15 years in NCKUH

OBJECTIVE

Hemolytic disease of the fetus and newborn (HDFN) caused by irregular antibodies is a rare, but possibly life-threatening condition. We report a case of severe intrauterine hemolysis caused by anti-E alloimmunization, and review 16 cases in the past 15 years of our hospital.

CASE REPORT

A woman with gestational age 28 weeks and 5 days, received emergent Cesarean section because of fetal distress. The baby was expired at the next day after delivery and the comprehensive study showed severe anemia and alloimmunization related hemolysis caused by anti-E due to high antibody titer (1: 4096).

CONCLUSION

Anti-E antibody is one of the most common non-Rhesus D antibodies in the pathogenesis of HDFN, but rarely leads to severe hemolysis. However, our case has the highest reported anti-E titer in HDFN and is the first case of mortality during the past 15 years in NCKUH.

Haemolytic disease of the fetus and newborn diagnosed after delivery of a baby to a mother with low anti-E antibody titres

The authors report a term male neonate who was born in unexpectedly poor condition with low Apgar scores and low venous cord gas pH. He required admission to the neonatal unit and was found to have developed haemolytic anaemia with associated hydrops, following a presumed severe antenatal insult. Antenatally, low levels of anti-E antibodies (titre 8) had been detected at 28 weeks' gestation. Following the British Society for Haematology and local neonatal team guidance, advice was given for cord direct antiglobulin test, full blood count and bilirubin at delivery. This case highlights the rare case of haemolytic disease of the fetus and newborn on a background of maternal low titre anti-E antibodies.

Hydrops Fetalis and Persistent Pulmonary Hypertension in a Neonate with Anti-E Alloimmunization

Anti-E alloimmunization is the third most common cause of neonatal hemolytic disease, typically causing mild to moderate hemolytic anemia. We report an unusual case of severe hydrops fetalis and persistent pulmonary hypertension (PPHN) in a neonate with anti-E alloimmunization. Our case emphasizes the importance of close surveillance for development of severe fetal hemolytic anemia and possible need for antenatal intervention. These neonates may also need vigilant monitoring for PPHN.

Hyperbilirubinemia due to minor blood group (anti-E) incompatibility in a newborn: a case report

In addition to Rh and ABO incompatibilities subgroup incompatibilities may rarely play a role among the causes of hemolytic anemia and indirect hyperbilirubinemia in newborns. The most common minor blood group antigens that cause blood incompatibility between the mother and baby are C, c, E, e, Kell, Duffy, Diego, Kidd and MNSs antigens. In this article, a newborn in whom hyperbilirubinemia due to anti-E minor blood group incompatibility developed and was treated with phototherapy succesfully is presented and minor blood group incompatibilities due to anti-E are reviewed.

Hemolytic disease of fetus and newborn due to maternal red blood cell alloantibodies in the Malay population

Background:

Maternal red blood cell (RBC) alloimmunization may lead to production of harmful antibodies that result in hemolytic disease of fetus and newborn (HDFN). There is insufficient data on the prevalence of HDFN due to RBC alloantibodies in the Malay neonatal population.

Aim:

The aim of this study was to determine the incidence of HDFN in the Malay neonatal population due to clinically significant RBC alloantibodies.

Subjects and Methods:

A cross sectional study was conducted in Transfusion Medicine Unit, Hospital Universitiy Sains Malaysia over one year period from January to December 2009. A total of 5163 Malay pregnant women who attended labor room for delivery were collected and analyzed prospectively. The blood samples were subjected to the standard immunohematological procedure for RBC antibody screening and identification using reagents of Diamed-ID Gel microtyping system. All the newborns with RBC alloantibody were investigated for the evidence of HDFN.

Results:

Thirty (0.58%) women were found to have clinically significant RBC alloantibodies. Most of the alloantibodies belonged to Rhesus (Rh) system (56.7%) where anti-E (33.3%) was the most common followed by anti-D (10.0%). Rh antibodies were the main cause of HDFN in fourteen (0.27%) neonates. Anti-D and anti-c were identified to cause moderate to very severe HDFN.

Conclusions:

With the low prevalence of clinically significant RBC alloantibodies and HDFN, routine antenatal antibody screening practice may not be advised as a routine practice at present, preferably reserved for those women of RhD negative or with history of HDFN, significantly of those attributed to anti-c.

Anti-e alloimmunization: a rare cause of severe fetal hemolytic disease resulting in pregnancy loss

We report a case of severe intrauterine hemolysis caused by sole anti-E alloimmunization. A 36-year-old multipara woman presented with hydrops fetalis at 27 weeks of gestation. She had a history of previous neonatal death. In this pregnancy, she was found to have very high titer of anti-E antibody. Ultrasonography detected marked skin edema, cardiomegaly, hepatosplenomegaly, pleural effusion, ascites, placentomegaly, and polyhydramnios. The Doppler peak systolic velocity in the middle cerebral artery was 0.8 m/s, indicating severe fetal anemia. Multiple intrauterine transfusions for the anemic fetus were administered. However, persistent severe fetal anemia and placentomegaly caused poor neonatal death and mirror syndrome in the mother. Uncommon red blood cell alloimmunization has to be watched for early in any population, especially in a woman with a history of unexplained perinatal loss.

Management of Pregnancies Complicated by Anti-E Alloimmunization

OBJECTIVE

There is limited information published about anti-E alloimmunization. We review our experience at The Ohio State University to determine appropriate management strategies.

METHODS

We reviewed records from June 1959 to April 2004 to identify pregnancies managed for anti-E alloimmunization. Information collected included antibody titers, DeltaOD450 values, Liley zones, middle cerebral artery peak systolic velocity, fetal and neonatal hemoglobin (Hb) and antigen typing, fetal and neonatal direct antiglobulin test, and outcomes. Pregnancies affected only by anti-E alloimmunization with a positive direct antiglobulin test or positive E antigen typing in the fetus or newborn were included.

RESULTS

A total of 283 pregnancies were identified with anti-E. Of these, 32 pregnancies in 27 women were at risk for hemolytic disease of the fetus or newborn from anti-E only and had complete records. Sixteen of these pregnancies had titers greater than or equal to 1:32, with amniocenteses performed for DeltaOD450 in 15 pregnancies. Values of DeltaOD450 in zone IIB or zone III in combination with serologic titers identified all pregnancies with fetal or neonatal anemia. Five of 32 (15%) fetuses had Hb less than 10 g/dL and 1 fetus had hydrops fetalis due to anti-E alloimmunization. There was 1 perinatal death attributable to anti-E hemolytic disease of the fetus or newborn. Middle cerebral artery peak systolic velocity was measured in 2 cases and corroborated information obtained from amniocentesis.

CONCLUSION

Anti-E alloimmunization can cause hemolytic disease of the fetus or newborn requiring prenatal intervention. Based on our population, clinical strategies developed for Rh D alloimmunization using maternal serology, amniotic fluid spectrophotometry, and fetal blood sampling are useful in monitoring E alloimmunization.