Pregnancy Induced Autoimmune Warm Antibodies Hemolytic Anemia: A Case Report

Pregnancy-associated haemolytic anaemia: A cause not to be forgotten

Anaemia in pregnancy is common, however, only a few cases of pregnancy-associated autoimmune haemolytic anaemia have been documented. Typically, such cases involve a positive direct antiglobulin test and have the potential to cause haemolytic disease of the fetus and newborn. Rarely, no autoantibodies are detected. We report two cases of direct antiglobulin test negative haemolytic anaemia occurring in multiparous women with no cause found. Both women had a haematological response to corticosteroid therapy and delivery.

Autoimmune Hemolytic Anaemias in Pregnancy: Experience in a Tertiary Care Hospital in South India

Background

Autoimmune hemolytic anaemia is very rare and there is limited data regarding their pregnancy outcomes. Hence we aimed to study the maternal and perinatal outcomes in pregnancies with autoimmune hemolytic anaemias (AIHA).

Methods

A retrospective descriptive study of pregnant women with AIHA, who delivered at SJMCH between January 2011 and January 2016 was carried out. Their antenatal and labour records were reviewed and demographic details noted.The primary outcome measures studied were-the prevalence of AIHA, gestational age at delivery, antepartum, intrapartum and postpartum complications, mode of delivery and requirement of transfusion of blood and blood products. The secondary outcome measures studied included neonatal outcomes such as low birth weight, intrauterine growth restriction and need for intensive care. The data is presented as descriptive statistics, including means and percentage.

Results

The prevalence of AIHA was (18/12,420) 0.14%. The mean gestational age at delivery was 34 weeks; 100%, 77% and 50% had antenatal, intra partum or postpartum complications, respectively. 44% had preeclampsia, 38% intrauterine growth restriction and 16% preterm labour. 83% required additional drugs for treatment of AIHA.72% had vaginal delivery; 28% had caesarean delivery; 33% were transfused antenatally and 22% postnatally; 50% of the babies were preterm and required intensive care, 66% had low birth weight. There was no maternal mortality.

Conclusion

Multidisciplinary approach, early diagnosis and detection of autoimmune hemolytic anaemia and complications, good antenatal care, judicious transfusions and delivery at tertiary care centre are the keys to successful outcomes.

Benefits and Risks of IgG Transplacental Transfer

Maternal passage of immunoglobulin G (IgG) is an important passive mechanism for protecting the infant while the neonatal immune system is still immature and ineffective. IgG is the only antibody class capable of crossing the histological layers of the placenta by attaching to the neonatal Fc receptor expressed at the level of syncytiotrophoblasts, and it offers protection against neonatal infectious pathogens. In pregnant women with autoimmune or alloimmune disorders, or in those requiring certain types of biological therapy, transplacental passage of abnormal antibodies may cause fetal or neonatal harm. In this review, we will discuss the physiological mechanisms and benefits of transplacental transfer of maternal antibodies as well as pathological maternal situations where this system is hijacked, potentially leading to adverse neonatal outcomes.

Pregnancy-associated immune-mediated hemolytic anemia in a dog

OBJECTIVE

To describe the clinical presentation, diagnostic investigations, and outcome of a dog with pregnancy-associated immune-mediated hemolytic anemia.

CASE SUMMARY

A 6-year-old, pregnant Bichon Frise was presented due to lethargy, inappetence, and progressive regenerative anemia with spherocytosis. The dog had been recently receiving ranitidine and amoxicillin/clavulanate. An in-house saline agglutination test identified marked agglutination and a urinalysis identified hemoglobinuria. Thoracic and abdominal imaging, as well as infectious diseases testing, was unremarkable. The bitch started whelping shortly following hospitalization, and the anemia progressively resolved without any other intervention. Ranitidine and amoxicillin/clavulanate were re-introduced within the following 2 months but the anemia did not reoccur. In light of these findings, a diagnosis of pregnancy-associated immune-mediated hemolytic anemia was made.

NEW OR UNIQUE INFORMATION PROVIDED

Pregnancy-associated immune-mediated hemolytic anemia should be considered in female dogs that develop severe hemolytic anemia during pregnancy and may resolve spontaneously following parturition.

Autoimmune hemolytic anemia and ovarian dermoid cysts in pregnancy

Ovarian teratoma is a rare cause of autoimmune hemolytic anemia (AIHA) by warm antibodies, resistant to corticosteroid therapy. This also implies that ovarian teratoma should be included in the differential diagnosis of AIHA, whether or not associated with pregnancy. We present a case of a primigravida who presented with ovarian dermoid cysts and AIHA at 24 weeks of gestation. The patient received corticosteroids, intravenous immunoglobulin, rituximab, and multiple blood transfusions, with no significant improvement. Hemoglobin levels returned to normal only after laparoscopic ovarian cystectomy. Autoimmune hemolytic anemia caused by dermoid cyst is a rare condition especially in pregnancy. However, in light of similar case reports and review of the existing literature, we conclude that surgical excision should be considered when AIHA and ovarian teratoma coexist.

A Case of Pregnancy Complicated with Evans Syndrome with Sequential Development of Autoimmune Warm Antibody Hemolytic Anemia and Idiopathic Thrombocytopenic Purpura

The simultaneous or sequential development of autoimmune hemolytic anemia (AIHA) and idiopathic thrombocytopenic purpura (ITP) is known as Evans syndrome. We experienced a case of Evans syndrome that developed AIHA during pregnancy and ITP long after delivery. The patient was a 35-year-old pregnant woman (gravida 2, para 1). A routine blood test at 28 weeks of gestation revealed moderate macrocytic anemia. Her haptoglobin level was markedly low, and a direct antiglobulin test (DAT) was positive. Based on these results, AIHA was considered. A healthy female newborn with bodyweight 3575 g was vaginally delivered uneventfully. After delivery, the DAT remained positive, but anemia did not develop. At 203 days after delivery, ITP was detected. Because AIHA and ITP developed sequentially, she was diagnosed with Evans syndrome. When AIHA occurs during pregnancy, long-term follow-up is needed because ITP can develop sequentially.

A Rare Case of Successfully Treated Coombs Negative Immune Haemolytic Anaemia in Pregnancy

Immune haemolytic anaemia in pregnancy, although rare, but it can be life threatening. Severe anaemia with jaundice, unresponsive to blood transfusion can clinch the diagnosis of immune haemolytic anaemia. Our patient was a 27-year-old second gravida, with all the above features, but there was diagnostic challenge as her Coombs test was negative. A high index of suspicion and rapid response to glucocorticoids, pointed towards the diagnosis. Thereafter, the course of pregnancy and postpartum period was uneventful. Thus, successful maternal and fetal outcome can be achieved with prompt diagnosis and treatment.