Pregnancy and idiopathic autoimmune haemolytic anaemia: a prospective study during 6 months gestation and 3 months post-partum

Anemia in Pregnancy: Screening and Clinical Management Strategies

ABSTRACT

Screening recommendations for anemia during pregnancy, etiologies of inherited and noninherited forms of anemia, their impact on maternal-fetal outcomes, and the clinical management of pregnant patients presenting with these conditions are reviewed. Anemia during pregnancy can cause adverse perinatal outcomes including preterm labor, premature rupture of membranes, and increased maternal and fetal mortality. Physiologic (dilutional) anemia and iron deficiency anemia are the two most common noninherited forms of anemia, and some cases may be the result of an underlying comorbidity such as diabetes or lupus. Aplastic anemia and autoimmune hemolytic anemia are uncommon forms of noninherited anemias that also merit discussion. Inherited forms of anemia include sickle cell disease, alpha-thalassemia, and beta-thalassemia. Timely diagnosis and treatment of anemia during pregnancy, whether inherited or noninherited, is imperative to protect mother and baby from potential adverse outcomes associated with these conditions.

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.

Presumed immune-mediated haemolytic anaemia associated with pregnancy in a cat

Case summary

A 7-year-old female entire Birman presented with acute-onset haemorrhagic vulvar discharge. Moderate, normocytic, normochromic, non-/pre-regenerative anaemia, along with a moderate mature neutrophilia, were seen on haematology. Saline test for agglutination was positive. No haemotropic mycoplasmas were identified. Serum biochemistry revealed severe hyperbilirubinaemia. Retroviral testing was negative. Serology for toxoplasmosis revealed a titre of 1:512. Abdominal ultrasound identified a large uterus, containing at least three advanced-stage fetuses, two of which failed to exhibit independent motion or cardiac activity. Ovariohysterectomy was performed. Histology demonstrated mild, multifocal suppurative placentitis, with Gram staining revealing no evidence of bacteria. Complete resolution of the anaemia was seen within 1.5 months of ovariohysterectomy.

Relevance and novel information

Immune-mediated haemolytic anaemia (IMHA) in association with pregnancy has not been previously reported in cats. This case represents a potential novel cause for IMHA in cats, which resolved following ovariohysterectomy.

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.

Thrombotic microangiopathies of pregnancy: Differential diagnosis

Thrombotic microangiopathy (TMA) disorders are characterized by microangiopathic hemolytic anemia, thrombocytopenia and end-organ injury. In pregnancy and postpartum, TMA is most commonly encountered with HELLP (hemolysis, elevated liver enzymes, low platelet count syndrome) or preeclampsia with severe features, but rarely TMA is due to thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic uremic syndrome (aHUS). Due to overlapping clinical and laboratory features, TTP and aHUS are often mistaken for preeclampsia or HELLP. Unfortunately, delays in appropriate diagnosis and treatment may be life-threatening. Our objective is to alert obstetrician-gynecologists, certified nurse midwives, family medicine providers, and subspecialty consultants, to the range of TMA disorders that may occur in and around pregnancy. To do this, we have provided a review of individual disorders that comprise the differential diagnosis of pregnancy TMA, and we have proposed a systematic approach to make an accurate diagnosis with readily available clinical and laboratory data. In complex or critical cases, we recommend a multidisciplinary team approach (e.g., Critical Care, Hematology, Maternal Fetal Medicine, Nephrology) to expedite diagnosis and treatment, which may be life-saving.

Pregnancy Induced Autoimmune Warm Antibodies Hemolytic Anemia: A Case Report

Background: Autoimmune haemolytic anaemia (AIHA), caused primarily by pregnancy, is poorly described in the literature. There is especially little information on coping with cases that are not responsive to glucocorticoid treatment, monitoring a fetal condition, and identifying fetal haemolytic anaemia as early as possible. Case: A case of pregnancy-induced autoimmune haemolytic anaemia is reported with major problems in differential diagnosis, treatment and the risks posed to both the mother and the fetus. The anaemia went into spontaneous remission of the disease several weeks after delivery. Conclusion: Autoimmune haemolytic anaemia is rarely reported in literature, but can be dangerous for both fetus and mother. It therefore should be described and discussed among obstetricians and gynaecologists, and the etiopathogenesis should be further studied.

Hematologic complications of pregnancy

Pregnancy induces a number of physiologic changes that affect the hematologic indices, either directly or indirectly. Recognizing and treating hematologic disorders that occur during pregnancy is difficult owing to the paucity of evidence available to guide consultants. This review discusses specifically the diagnosis and management of benign hematologic disorders occurring during pregnancy. Anemia secondary to iron deficiency is the most frequent hematologic complication and is easily treated with oral iron formulations; however, care must be taken not to miss other causes of anemia, such as sickle cell disease. Thrombocytopenia is also a common reason for consulting the hematologist, and distinguishing gestational thrombocytopenia from immune thrombocytopenia (ITP), preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), or thrombotic thrombocytopenic purpura (TTP) is essential since the treatment differs widely. Occasionally the management of mother and infant involves the expeditious recognition of neonatal alloimmune thrombocytopenia (NAIT), a condition that is responsible for severe life-threatening bleeding of the newborn. Additionally, inherited and acquired bleeding disorders affect pregnant women disproportionately and often require careful monitoring of coagulation parameters to prevent bleeding in the puerperium. Finally, venous thromboembolism (VTE) during pregnancy is still largely responsible for mortality during pregnancy, and the diagnosis, treatment options and guidelines for prevention of VTE during pregnancy are explored.

Evans' syndrome in pregnancy: a systematic literature review and two new cases

Evans' syndrome, the coexistence of immune thrombocytopenia (ITP) with autoimmune haemolytic anaemia (AIHA), is rare in pregnancy, with a few published cases. Concerns about the teratogenic effect of pharmacological agents used in the management of Evans' syndrome limit the treatment options in pregnancy. In this paper we performed a systematic review of the literature of all published cases with Evans' syndrome in pregnancy and we report two new cases. The review was performed by searching the electronic databases PubMed, EMBASE, Cochrane Library and Google scholar up to the end of December 2008. The selection criteria were Evans' syndrome in pregnancy; autoimmune haemolytic anaemia; immune thrombocytopenia. Thirteen papers reporting 14 pregnancies in women with Evans' syndrome have been published: 7 papers are written in English. Evans' syndrome can be diagnosed with a full blood count, film and Coombs testing. It runs a more benign course in pregnancy than in non-pregnant state (notably neutropenia does not occur) and very often resolves post-delivery. The fetal outcome may be less favourable: a minority of fetuses are affected by transplacental passage of antibody and have a significant morbidity and mortality. With appropriate treatment, women with Evans' syndrome can have successful pregnancies, with a good response to conventional treatment. More detailed studies of Evans' syndrome in pregnancy, especially of fetal outcome, are required.

Hemolytic anemia due to warm autoantibodies

The diagnosis of autoimmune hemolytic anemia (AHA) requires evidence of shortened red blood cell (RBC) survival mediated by autoantibodies directed against autologous RBCs. About 80 percent of patients with AHA have warm-reactive antibodies of the IgG isotype; the remainder exhibit cold-reactive autoantibodies. Typical patients exhibit anemia, reticulocytosis, spherocytes and polychromasia on the blood film and a positive direct antiglobulin test (DAT). Increased indirect serum bilirubin, urinary urobilinogen and serum lactate dehydrogenase (LDH), and decreased serum haptoglobin are not required for the diagnosis, but are frequently present. Patients with AHA and no underlying associated disease are said to have primary or idiopathic AHA. AHA in patients with associated autoimmune disease and certain malignant or infectious diseases is classified as secondary. The etiology of AHA is unknown. Patients with symptomatic anemia require transfusion of RBCs. Prednisone and splenectomy may provide long term remission. Rituximab, intravenous immunoglobulin, immunosuppressive drugs and danazol have been effective in refractory cases and for patients who are poor candidates for surgery.

Increased RBC autoantibody production in pregnancy

BACKGROUND

Autoimmunization against RBCs is generally believed to occur very rarely during pregnancy and to represent a high risk for those affected. The occurrence of benign RBC autoantibodies in pregnancy is reported.

STUDY DESIGN AND METHODS

The incidence of autoantibodies to RBCs in unselected pregnant and nonpregnant women were compared by the new standard gel hemagglutination method.

RESULTS

Data from a total of 22,782 pregnant and 12,903 nonpregnant women were analyzed. The antibody screen test was positive in 547 (2.40%) of the pregnant women. The positive test results were related to passive anti-D in 341 cases (1.50%), to clinically relevant alloantibodies in 43 cases (0.19%), to clinically irrelevant antibodies in 138 cases (0.61%), to autoantibodies in 23 cases (0.1%), and to autoantibodies plus alloantibodies in 2 cases (0.01%). In the cases of alloantibodies and/or autoantibodies, the DAT was invariably positive with anti-C3d and less commonly so with anti-IgG. The autoantibodies were first detected during pregnancy, they predominantly reacted with enzyme-treated RBCs, and none of the affected women or their infants appear to have developed clinically significant hemolysis. In the control group consisting of nonpregnant female blood donors, there were 3 cases (0.02%) of clinically insignificant IgG autoantibodies.

CONCLUSION

There is an increase in autoimmunization against RBCs during pregnancy. The resultant autoantibodies do not appear to cause significant RBC destruction. Further studies are required for precise characterization of this phenomenon.

[Danger of anti-erythrocyte antibodies during pregnancy]

INTRODUCTION

Red cell autoantibodies are very rarely observed in pregnant women. We report one case related to the presence of a lupus anticoagulant.

EXEGESIS

A 32-year-old woman had a history of two intrauterine deaths that had occurred at weeks 32 and 33, respectively. Due to the presence of a lupus anticoagulant, prednisone (20 mg/day) and subcutaneous calcium heparin were administered during her third pregnancy. The direct antiglobulin test remained positive throughout the pregnancy; however, hemolysis could not be detected. Caesarean section was done in emergency at week 29, due to fetal bradycardia related to severe fetal hemolysis.

CONCLUSION

When autoimmune hemolysis occurs during pregnancy, risks for the fetus increase with the severity of hemolysis in the mother. It is thought that child mortality reflects the existence of anemia, rather than the existence of hemolysis. Our observation suggests that severe fetal hemolysis may occur, despite the absence of hemolysis in the mother.

Macrophage Fcgamma receptors expression is altered by treatment with dopaminergic drugs

Macrophage Fcgamma receptors have an important role in host defense and the pathophysiology of immune mediated disorders. Alteration of splenic macrophage Fcgamma receptors expression predisposes to severe infection. Inhibition or blockade of splenic macrophage Fcgamma receptors is one of the mechanisms by which immune cytopenias improve. Dopaminergic drugs have clinically significant regulatory functions on the immune response. Using an experimental model in the guinea pig we assessed the effect of commonly used dopaminergic drugs on the expression of macrophage Fcgamma receptors. Three dopa-antagonists, bromocryptine, leuprolide, and pergolide, and seven dopa-antagonists, chlorpromazine, SCH 23390, metochlopramide, sulpiride, veralipride, alizapride, and cisapride, were studied. Following guinea pig treatment with dopaminergic drugs, the clearance of IgG-sensitized RBCs in vivo, the in vitro binding of IgG-sensitized RBCs by isolated splenic macrophages and flow cytometry with monoclonal antibodies were performed. Treatment with dopa-agonists enhanced the clearance of IgG-sensitized RBCs, the in vitro binding of IgG-sensitized RBCs by isolated splenic macrophages, and the cell surface expression of both macrophage Fcgamma receptors, and vice versa, dopa-antagonists impaired macrophage Fcgamma receptors expression. Macrophage FcgammaR1,2 was more sensitive than FcgammaR2 to such dopaminergic effect. These alterations of macrophage Fcgamma receptors expression are mediated by both D1 and D2 dopamine receptors, with a major participation of D2 receptors. Dopaminergic drugs alter the clearance of IgG-coated cells by an effect at the expression of splenic macrophage Fcgamma receptors.

Intravenous immunoglobulin as primary therapy or adjuvant therapy to intrauterine fetal blood transfusion: a new approach in the management of severe Rh-immunization

Maternal high dose intravenous immunoglobulin (IVIG) has shown promise in the management of severe Rh-immunization. Intravenous immunoglobulin, blocks Fe mediated antibody transport across the placenta and blocks destruction of fetal red cells and reduces maternal antibody levels. We have tried this new therapy in 6 patients with severe Rh-immunization, with high maternal antibody titres and previous hydrops and intrauterine deaths. Intravenous immunoglobulin was given from 13-18 weeks of gestation 3-4 weekly, till intrauterine transfusion (IUT) or delivery. Intensive fetal monitoring was done. No fetal hydrops or deaths occurred in any of the 6 cases. Only 2 cases needed intrauterine transfusion. IVIG delayed the onset of fetal anemia by 8-17 weeks thus deferring the need for IUT. All pregnancies continued till 32-36 weeks and all 6 babies did well in the neonatal period.

Autoimmune haemolytic anaemia during pregnancy

We describe a 31-year-old woman, who presented during her first pregnancy, with severe haemolytic anaemia due to auto-immune antibodies against erythrocytes. IgG warm-antibodies, as well as IgM antibodies were found in her serum. This idiopathic form of auto-immune haemolysis was successfully treated with glucocorticoids. During her second pregnancy auto-immune haemolysis again developed and was treated similarly. Two healthy children were born. The uneventful outcome we saw with our patient is in keeping with other reports in the literature.

Autoimmune disease and pregnancy

Autoimmune diseases are relatively common in women, and tend to occur in the childbearing years. These disorders fall broadly into two groups: (i) Multisystem diseases such as systemic lupus erythematosus (SLE) and related connective tissue disorders (CTD). This group includes the 'pre-clinical' antiphospholipid or lupus obstetric syndrome which may first manifest itself as a pregnancy disorder causing recurrent abortion, fetal death, fetal growth retardation and early onset severe pre-eclampsia. (ii) Tissue- or organ-specific disorders such as autoimmune thrombocytopaenic purpura (ATP), autoimmune thyroid disease (Graves' disease, Hashimoto's autoimmune thyroiditis, and post-postum thyroiditis), autoimmune haemolytic anaemia, and the very rare myasthenia gravis. The study of autoimmune diseases against the background of pregnancy as an experimental system of nature has provided important insights into the nature of the disease processes and the relevance or otherwise of circulating autoantibodies to pathological effects. Thus, for example, if neonatal manifestations of adult disease are causally related to the transfer of autoantibodies across the placenta, they will disappear over a time course consistent with the catabolism of IgG, providing no permanent damage is produced. Conversely, if autoantibodies are demonstrable in the neonate, in the absence of clinical effects, they may only be an epiphenomenon of the maternal disease. In addition, on occasions, disease manifestations may be seen in the baby when the mother shows none. This may occur when the mother is in remission, but still has circulating antibodies, or when she has an occult form of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Autoimmune haemolytic anaemia in pregnancy: a case report

A young primigravida had idiopathic warm antibody (IgG) autoimmune haemolytic anaemia (AIHA) occurring in the third trimester of pregnancy. Her haemolytic process was responsive to steroid therapy and no transfusion was needed. She delivered a healthy baby with no evidence to haemolysis, though his red cells were coated with IgG which was probably of maternal origin.

Effect of estradiol and steroid analogues on the clearance of immunoglobulin G-coated erythrocytes

Although the disproportionate frequency of several immunologic disorders among women is well recognized, the effect of sex steroids on immunologic processes is unclear. We used an animal model, which has helped to elucidate the effect of corticosteroids in vivo, to quantitatively assess the effect of estradiol and steroid analogues on the immune clearance of IgG-coated erythrocytes. While corticosteroids impaired the clearance of IgG-coated erythrocytes, estradiol, in doses comparable to those achieved during pregnancy, significantly enhanced the clearance. Estradiol, however, did not enhance the splenic clearance of heat-altered erythrocytes. Splenic macrophages isolated from estradiol-treated animals expressed enhanced receptor affinity for the Fc portion of immunoglobulin G [Fc(IgG)], an effect probably responsible for the enhanced in vivo clearance. No consistent effect of estradiol on the splenic macrophage C3 receptors was observed. The synthetic androgen danazol, the mineralocorticoid deoxycorticosterone, and the cortisol metabolite tetrahydrocortisone did not alter the clearance of IgG-coated cells after 7 d of therapy. The estrogen antagonist/agonist tamoxifen enhanced the clearance of IgG-coated cells, but to a lesser extent than estradiol. An effect of estrogens on macrophage Fc (IgG) receptor-mediated clearance may explain in part the variation in clinical expression of several autoimmune disorders during changes in hormonal state, such as pregnancy.

An association of pregnancy and autoimmune haemolytic anaemia

14 cases of pregnancy-associated autoimmune haemolytic anaemia were analyzed. 4 cases were diagnosed during pregnancy; 10 cases became pregnant during the remission period of the disease. 6 cases were secondary to systemic lupus erythematosus. In the first group, the anaemia developed in the third trimester whereas in the second group the Hb fell slightly in the first trimester and rapidly between the third and fourth month of gestation. Only 1 case could withstand the hazard of pregnancy uneventfully; 4 needed corticosteroid and delivered normal infants; 2 developed toxaemia of pregnancy; in 5, either therapeutic or spontaneous abortion was noted and 1 death occurred due to renal complication. Abortion was induced in 1 case due to socio-economic indications.

Erythrocyte autoantibodies, autoimmune haemolysis and pregnancy

The clinical and serological records of 20 pregnant patients with erythrocyte autoantibodies were critically reviewed and analysed. This series, the largest reported, confirmed an association between erythrocyte autosensitization and pregnancy, and suggested that this occurred on an average of 1 in 50,000 pregnancies. The clinical presentation varied from severe haemolytic anaemia to serological abnormalities discovered during the routine testing of well patients; overt haemolysis was present in 7 cases. Treatment was only necessary in 3 patients where the haemolysis was severe. 3 infants were mildly affected with haemolytic disease due to the maternal autoantibodies crossing the placenta but no treatment was needed. The risks to the infant were increased when other active autoimmune conditions (e.g., systemic lupus erythematosus) were present. With early diagnosis and appropriate treatment, outlook for mother and child is good.

Autoimmune haemolysis: an 18-year study of 865 cases referred to a regional transfusion centre

Clinical and serological records of 865 patients with confirmed autoimmune haemolysis (AIH)--a much larger series than any previously reported--were critically reviewed nd analysed. A proposed new classification for AIH based on serological findings differs from traditional classifications in that a new category of "mixed" AIH has been defined in which both "warm" and "cold" autoantibodies are present, and both are capable of causing haemolysis. Patients in this mixed group tend to have severe disease that may run a chronic intermittent course. The presentation of cold agglutinin disease is much more variable than has been seen in previous studies, haemolysis due to low titre autoantibodies being common. The AIH associated with pregnancy, usually considered as being of bad prognosis, is often mild and self limiting in the absence of other associated disorders.

Relapsing haemolytic anaemia of pregnancy with negative antiglobulin reaction

Four patients are described in whom seven episodes of haemolytic anaemia associated with pregnancy were observed during a follow-up period of 2 to 16 years. Normal haemoglobin levels were found both before and after pregnancy. Despite consistently negative antiglobulin tests, an autoimmune haemolytic mechanism is suggested by the rapid destruction of transfused blood, favourable response to corticosteroids and the development of transient haemolytic anaemia in three of the infants. In view of its unique clinical and laboratory features and relatively mild course, recognition of this condition as a distinct clinical entitity seems to be justified.