Bombay phenotype (Oh ) and high-titer anti-H in pregnancy: two case reports and a review of the literature

Hemolytic disease of the fetus and newborn-a perspective of immunohematology

BACKGROUND

Hemolytic disease of the fetus and newborn is a public health problem caused by maternal-fetal incompatibility; no prophylaxis is available for most alloantibodies that induce this disease. This study reviews the literature regarding which antibodies are the most common in maternal plasma and which were involved in hemolytic disease of the fetus and newborn.

METHOD

Seventy-five studies were included in this review using a systematic search. Two independent authors identified studies of interest from the PubMed and SciELO databases.

MAIN RESULTS

Forty-four case reports were identified, of which 11 babies evolved to death. From 17 prevalence studies, the alloimmunization rate was 0.17 % with 161 babies receiving intrauterine transfusions and 23 receiving transfusions after birth. From 28 studies with alloimmunized pregnant women (7616 women), 455 babies received intrauterine transfusions and 21 received transfusions after birth.

CONCLUSION

Rh, Kell, and MNS were the commonest blood systems involved. The geographical distribution of studies shows that as these figures vary between continents, more studies should be performed in different countries. Investing in early diagnosis is important to manage the risks and complications of hemolytic disease of the fetus and newborn.

Alloimmune hemolytic disease of the fetus and newborn: genetics, structure, and function of the commonly involved erythrocyte antigens

Hemolytic disease of the fetus and newborn (HDFN) can occur when a pregnant woman has antibody directed against an erythrocyte surface antigen expressed by her fetus. This alloimmune disorder is restricted to situations where transplacental transfer of maternal antibody to the fetus occurs, and binds to fetal erythrocytes, and significantly shortens the red cell lifespan. The pathogenesis of HDFN involves maternal sensitization to erythrocyte "non-self" antigens (those she does not express). Exposure of a woman to a non-self-erythrocyte antigen principally occurs through either a blood transfusion or a pregnancy where paternally derived erythrocyte antigens, expressed by her fetus, enter her circulation, and are immunologically recognized as foreign. This review focuses on the genetics, structure, and function of the erythrocyte antigens that are most frequently involved in the pathogenesis of alloimmune HDFN. By providing this information we aim to convey useful insights to clinicians caring for patients with this condition.

Mechanisms of Formation of Antibodies against Blood Group Antigens That Do Not Exist in the Body

The system of the four different human blood groups is based on the oligosaccharide antigens A or B, which are located on the surface of blood cells and other cells including endothelial cells, attached to the membrane proteins or lipids. After transfusion, the presence of these antigens on the apical surface of endothelial cells could induce an immunological reaction against the host. The final oligosaccharide sequence of AgA consists of Gal-GlcNAc-Gal (GalNAc)-Fuc. AgB contains Gal-GlcNAc-Gal (Gal)-Fuc. These antigens are synthesised in the Golgi complex (GC) using unique Golgi glycosylation enzymes (GGEs). People with AgA also synthesise antibodies against AgB (group A [II]). People with AgB synthesise antibodies against AgA (group B [III]). People expressing AgA together with AgB (group AB [IV]) do not have these antibodies, while people who do not express these antigens (group O [0; I]) synthesise antibodies against both antigens. Consequently, the antibodies are synthesised against antigens that apparently do not exist in the body. Here, we compared the prediction power of the main hypotheses explaining the formation of these antibodies, namely, the concept of natural antibodies, the gut bacteria-derived antibody hypothesis, and the antibodies formed as a result of glycosylation mistakes or de-sialylation of polysaccharide chains. We assume that when the GC is overloaded with lipids, other less specialised GGEs could make mistakes and synthesise the antigens of these blood groups. Alternatively, under these conditions, the chylomicrons formed in the enterocytes may, under this overload, linger in the post-Golgi compartment, which is temporarily connected to the endosomes. These compartments contain neuraminidases that can cleave off sialic acid, unmasking these blood antigens located below the acid and inducing the production of antibodies.

Challenges in the transfusion management of a 15-month-old pediatric patient with Bombay blood group phenotype

Bombay blood group phenotype is often mistyped as O group which can lead to hemolytic transfusion reactions. There are a very few case reports of Bombay blood group phenotype in pediatric age group. Herein, we report an interesting case of Bombay blood group phenotype in a fifteen-month-old pediatric patient who presented with features of raised intracranial pressure and required an emergency surgery. The Bombay blood group was detected on detailed immunohematology work up which was further confirmed by molecular genotyping. The challenges faced in developing countries for transfusion management of such a case have been discussed.

ABO blood group antigens and differential glycan expression: Perspective on the evolution of common human enzyme deficiencies

Enzymes catalyze biochemical reactions and play critical roles in human health and disease. Enzyme variants and deficiencies can lead to variable expression of glycans, which can affect physiology, influence predilection for disease, and/or directly contribute to disease pathogenesis. Although certain well-characterized enzyme deficiencies result in overt disease, some of the most common enzyme deficiencies in humans form the basis of blood groups. These carbohydrate blood groups impact fundamental areas of clinical medicine, including the risk of infection and severity of infectious disease, bleeding risk, transfusion medicine, and tissue/organ transplantation. In this review, we examine the enzymes responsible for carbohydrate-based blood group antigen biosynthesis and their expression within the human population. We also consider the evolutionary selective pressures, e.g. malaria, that may account for the variation in carbohydrate structures and the implications of this biology for human disease.

Incidental Discovery of a Patient with the Bombay Phenotype

Bombay phenotype, an exceptionally rare blood type in individuals outside of Southeast Asia, occurs in approximately 1 in 1,000,000 individuals in Europe. This blood phenotype is characterized by the absence of the H antigen on red blood cells (RBCs) and in secretions. As the H antigen is the structure on which the ABO system is built, individuals lacking this antigen are unable to produce A or B antigens and appear as type O on routine ABO phenotyping. H deficiency does not cause ill effect; however, these individuals produce an anti-H alloantibody capable of causing severe acute hemolytic transfusion reactions when exposed to RBCs that express the H antigen. In this case study, we highlight the incidental discovery of a patient with Bombay phenotype in a North American hospital system, expected test results, the immunologic and genetic basis underlying the Bombay and para-Bombay phenotypes, and methods to ensure availability of compatible blood.

Navigating the challenges of Bombay phenotype (Oh ) and twin pregnancy; a case report and literature review

BACKGROUND

Bombay phenotype (O_h ) is a rare blood group and poses unique challenges during pregnancy, including an adequate supply of blood products in case of postpartum hemorrhage (PPH) and the risk of hemolytic disease of the fetus and newborn (HDFN). Case reports of antenatal care in this cohort are scarce. Herein, we present a case of twin pregnancy in an O_h woman and outline her multidisciplinary management. We summarize the literature to better inform decision-making and patient blood management in the antenatal care of O_h women.

CASE DESCRIPTION

A 22-year-old G1P0 presented at 15 weeks gestation with dichorionic diamniotic twins and known O_h phenotype. Hematinics were optimized to minimize anemia. Anti-H titers were tracked and were 1:256 at both 28 and 36 weeks gestation. Regular middle cerebral artery dopplers were performed to assess for fetal anemia. There was constant communication with obstetrics and anesthetics teams. Both autologous frozen and directly donated fresh red cells were available as part of a clear, detailed transfusion plan. Transfusion was not required and neither child was affected by HDFN. The neonates were group O, DAT negative, and group A, DAT positive. Maternal anti-A was detected in the neonatal eluate.

CONCLUSION

To our knowledge, this is only the second report of twin pregnancy in an O_h female and the first time a detailed transfusion plan has been published. Through employing patient blood management strategies, engaging a collaborative multidisciplinary approach, and establishing a clear delivery plan, the antenatal challenges of Bombay phenotype are surmountable.

Transfusion practice blind spot in para-Bombay: A case report

H-deficient phenotype individuals with absent or weak anti-H activity may remain undetected on standard routine blood grouping. We report a case of a 59-year-old-man presented with symptomatic anaemia secondary to upper gastrointestinal bleed with haemoglobin level of 68 g/L who required two units of packed red blood cells. He was previously grouped as O Rh D positive and had a history of uneventful multiple blood transfusions. His latest pre-transfusion investigations showed ABO discrepancy between forward and reverse blood grouping, pan-agglutination in both antibody screening and identification with negative direct Coombs test and autocontrol. Further testing including anti-H lectin test and saliva secretor study confirmed that the patient blood group was para-Bombay B RhD positive. This case highlights that the para-Bombay phenotype can be mistakenly labelled as "O" if further investigations are not performed.