Rh isoimmunization in Sub-Saharan Africa indicates need for universal access to anti-RhD immunoglobulin and effective management of D-negative pregnancies

Characterization of blood bank and transfusion medicine practices for pregnant individuals with fetuses at risk of hemolytic disease in the United States

BACKGROUND

Hemolytic disease of the fetus and newborn (HDFN) is caused by maternal alloantibody-mediated destruction of fetal/neonatal red blood cells (RBCs). While the pathophysiology has been well-characterized, the clinical and laboratory monitoring practices are inconsistent.

METHODS

We surveyed 103 US institutions to characterize laboratory testing practices for individuals with fetuses at risk of HDFN. Questions included antibody testing and titration methodologies, the use of critical titers, paternal and cell-free fetal DNA testing, and result reporting and documentation practices.

RESULTS

The response rate was 44% (45/103). Most respondents (96%, 43/45) assess maternal antibody titers, primarily using conventional tube-based methods only (79%, 34/43). Among respondents, 51% (23/45) rescreen all individuals for antibodies in the third trimester, and 60% (27/45) perform paternal RBC antigen testing. A minority (27%, 12/45) utilize cell-free fetal DNA (cffDNA) testing to predict fetal antigen status. Maternal antibody titers are performed even when the fetus is not considered to be at risk of HDFN based on cffDNA or paternal RBC antigen testing at 23% (10/43) of sites that assess titers.

DISCUSSION

There is heterogeneity across US institutions regarding the testing, monitoring, and reporting practices for pregnant individuals with fetuses at risk of HDFN, including the use of antibody titers in screening and monitoring programs, the use of paternal RBC antigen testing and cffDNA, and documentation of fetal antigen results. Standardization of laboratory testing protocols and closer collaboration between the blood bank and transfusion medicine service and the obstetric/maternal-fetal medicine service are needed.

Prevalence of fetomaternal Rhesus incompatibility at the tertiary care hospital: a cross-sectional study

Background

Fetomaternal Rhesus incompatibility is a medical condition that affects the pregnant woman [of blood group (A, B, AB, O) and a negative Rhesus] and the foetus (of positive Rhesus). The objective of this study is to determine the prevalence and to present the clinical characteristics of fetomaternal Rhesus incompatibility in a tertiary care hospital.

Methods

The authors conducted a retrospective cross-sectional study and 37 participants were recorded during the study period of 4 years.

Results

A total of 11 898 pregnant women admitted to the maternity and 37 of them (women with blood groups A, B, AB or O and with a negative Rhesus) participated in our study, including a frequency of 0.31%. Thirty cases of fetomaternal Rhesus incompatibility were recorded in new-borns. 27 (73%) of the women are from the urban region and the age group between 21 and 25 is the most affected with 37.8%. Twenty-two (59.5%) of pregnant women have blood group O (and negative Rhesus) and primiparous women are the most affected with 64.9%. For the discovery of allo-immunization, 43.2% of women discovered it during the second pregnancy and 48.7% women received a single infusion of Anti-D serum during the first pregnancy. Twelve (40%) new-borns developed jaundice as a perinatal prognosis.

Conclusion

Fetomaternal Rhesus incompatibility remains a major problem of maternal health because it is likely to lead to the formation of antibodies in women, which by crossing the placental barrier, they destroy red blood cells and thus cause serious complications.

Magnitude of Red Blood Cell Alloimmunization Among Pregnant Women Attending Antenatal Care at Wolaita Sodo University Comprehensive Specialized Hospital, Southwest Ethiopia

Background

Maternal red cell alloimmunization occurs when a woman's immune system becomes sensitive to unfamiliar red blood cell antigens. This leads to the production of alloantibodies, which can have serious implications for the fetus and newborn. However, there is a lack of comprehensive information about the extent of red cell alloimmunization in underdeveloped countries like Ethiopia. Therefore, this study aimed to determine the magnitude of red cell alloimmunization among pregnant women attending antenatal care at Wolaita Sodo University Comprehensive Specialized Hospital from September 01 to November 30, 2022.

Methods

In this institutional-based cross-sectional study, 422 pregnant women were participated and recruited using a systematic random sampling technique. Data on sociodemographic characteristics, obstetric history, and other clinical information were collected using structured questionnaires through face-to-face interview. Blood grouping and indirect antihuman globulin tests were performed. The relationship between red cell alloimmunization and the independent variables was determined using the chi-square test. P-value <0.05 was considered statistical significance.

Results

In this study, the blood group distributions among the participants were as follows: O, 177 (41.9%); A, 124 (29.4%); B, 76 (18%); and AB, 45 (3.86%). Among the pregnant women included in the study, a total of 51 (12.08%) were identified as RhD-negative. Out of these RhD-negative women, 5 (9.8%) were found to have developed alloimmunization with red blood cell antigens. Miscarriage and post-partum hemorrhage were found to be important factors associated with the occurrence of red cell alloimmunization in these women.

Conclusion

This study showed that one out of ten pregnant women was alloimmunized. Therefore, antenatal blood grouping and indirect antihuman globulin screening should be performed routinely to manage and minimize the undesirable outcomes of alloimmunization during pregnancy.

Perinatal Outcome of Pregnant Women with RhD Sensitization: A Five-Year Cross-Sectional Study at a Tertiary Care Hospital in Ethiopia

Background

Isoimmunization is a process of immunizing an antigen-negative pregnant individual with a paternally derived fetal antigen. Although the Rh systems contain many antigen subtypes (D, C, c, E, e), the RhD antigen is highly immunogenic. This research aimed to investigate the perinatal Outcome of pregnant women with RhD sensitization at St. Paul's Hospital Millennium Medical College (SPHMMC), Ethiopia.

Methodology

A facility-based retrospective cross-sectional study was conducted on 98 pregnant women with RhD alloimmunization at SPHMMC from September 11, 2016, to September 10, 2021. SPSS 26 was used for data analysis. Descriptive statistics were utilized to assess the perinatal outcome of pregnant women with RhD alloimmunization. Fisher's exact test was used to determine which association, and a P value <0.05 was considered statistically significant.

Results

From the 98 pregnancies (06 - hydropic, 92 - non-hydropic) at high risk for fetal anemia, 45.9% of cases had MCA-PSV above 1.5MoM. Among these, 21.42% of all fetuses received an intrauterine transfusion. Forty-three IUTs were performed in 21 fetuses. The median number of transfusions per fetus was two. About 52.4% of the transfused fetuses had severe anemia, and 28.6% had moderate anemia. Prediction of MCA PSV ≥1.5MOM in diagnosing moderate-severe anemia in pregnant women with RhD sensitization 81%. General neonatal survival of alloimmunizations was 93.8%, 90.5% with IUT, 50% with hydrops fetalis, and 96.7% without hydrops.

Conclusion

This research provides evidence that MCA PSV ≥1.5MoM is modest predictor of moderate-severe anemia in untransfused fetuses. This study was a step toward the development of more extensive and multicenter studies on the Perinatal Outcome of pregnant women with RhD sensitization in Ethiopia. Extra studies are needed to evaluate strategies for estimates of fetal anemia after blood transfusion as a result of the absence of information on the IUT database.

Antenatal screenings and maternal diagnosis among pregnant women in Sao Tome & Principe-Missed opportunities to improve neonatal health: A hospital-based study

Newborn mortality and adverse birth outcomes (ABOs) in Sao Tome & Príncipe (STP) are overwhelmingly high, and access to quality-antenatal care (ANC) is one of the strategies to tackle it. This study aimed to fill the gaps in ANC screenings with a focus on how to improve neonatal outcomes. We conducted a retrospective hospital-based study in which ANC pregnancy cards were reviewed. Screenings were described and compared according to the total number of ANC contacts: 1-3 (inadequate), 4-7 (adequate), and ≥8 (complete). The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Statistical significance was considered at a p-value ≤0.05. A total of 511 ANC pregnancy cards were reviewed. Mothers' mean age was 26.6 (SD = 7.1), 51.7% had a first trimester early booking, 14.9% (76) had 1-3 ANC contacts, 46.4% (237) had 4-7 and 38.7% (198) ≥8. Screening absence was found in 24%-41%, lack of money was registered in 36%. Pregnant women had no screening performed for HIV in 4.5%, syphilis in 8.8%, HBV 39.3%, malaria 25.8%, hemoglobin 24.5%, blood glucose 45.4%, urine 29.7%, stool exams 27.8% and 41.1% had no ultrasound. Screening completion for blood group, HIV, malaria, urine, hemoglobin, and coproparasitological exam were found to have a statistically significant difference (p<0.001) for the complete ANC group when compared to other groups. Antenatal problems identified were: 1) bacteriuria (43.2%); 2) maternal anemia (37%); 3) intestinal parasitic infections (59.2%); 4) sickle cell solubility test positive (13%); and 5) a RhD-negative phenotype (5.8%). Missed-ANC treatments were up to 50%. This study reveals a coverage-quality gap in STP since no pregnant woman is left without ANC contact, although most still miss evidence-based screenings with an impact on neonatal outcomes. Strategies such as implementing a total free ANC screening package in STP would enhance maternal diagnosis and prompt treatments.

Pattern of serum bilirubin changes following double volume exchange blood transfusion in neonates at a tertiary health facility in Nigeria

Introduction

exchange blood transfusion (EBT) is a form of massive transfusion useful in rapidly reducing serum bilirubin levels, but serum bilirubin levels frequently rebound within hours of completing the procedure, due to equilibration of extravascular bilirubin as well as on-going hemolysis. The study was carried out to determine the pattern of reduction in serum bilirubin levels following EBT among neonates with severe hyperbilirubinemia, as well as the factors contributing to this pattern, so as to establish evidence-based expectations following EBT.

Methods

a retrospective descriptive study covering a two-year period in a Nigerian tertiary hospital. Details of the EBT procedures, including serial serum bilirubin levels, were obtained from the hospital records of all newborn babies who had double volume EBT done for severe hyperbilirubinaemia during the study period. Data was analyzed using the statistical software SPSS version 21.0.

Results

the mean total serum bilirubin (TSB) before EBT in the 36 babies was 17.9 ± 6.3 mg/dl. The mean percentage decrease in TSB immediately following EBT was 44.3 ± 10.2%. Six hours after EBT, TSB levels had increased from the immediate post-EBT values by an average of 57.5 ± 32.2%. Twenty-four hours after the procedure, TSB values in most (87.1%) cases were still higher than the immediate post-EBT values, but lower than the pre-EBT values. Post-EBT anemia was recorded among 33.3% of the babies.

Conclusion

EBT is effective in rapidly reducing serum bilirubin levels and preventing acute bilirubin encephalopathy in neonates with severe hyperbilirubinemia, despite the rebound increase that occurs in TSB values after the procedure.

Prevalence of rhesus D-negative blood type and the challenges of rhesus D immunoprophylaxis among obstetric population in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Transplacental or fetomaternal hemorrhage (FMH) may occur during pregnancy or at delivery and lead to immunization to the D antigen if the mother is Rh-negative and the baby is Rh-positive. This can result in hemolytic disease of the fetus and newborn (HDFN) in subsequent D-positive pregnancies. Therefore, the aim of this systematic review and meta-analysis was to estimate distribution of ABO and Rh (D) blood groups among pregnant women in Ethiopia.

METHOD

We searched PubMed, Google Scholar, EMBASE, Cochrane Library, HINARI, AFRO Library Databases, and African Online Journal databases for all available studies using the following keywords: "High rhesus (Rh(D)) negative frequency", "ABO blood group distribution", "haemolytic disease of the newborn (HDN)", "rh isoimmunization", "anti-RhD immunoglobulin", "D-negative pregnancies", "Frequency", "ABO and Rh blood group distribution", "feto-maternal hemorrhage", "rhesus D negative pregnant mothers", "kleihauer-betke test (KBT)", "Neonatal Hyperbilirubinemia", "non-sensitized RhD-negative pregnant women", "antenatal anti-D immunoglobulin prophylaxis", "Hemolytic disease of the newborn (alloimmunization), Ethiopia. The search string was developed using "AND" and "OR" Boolean operators. All published and unpublished observational studies reporting the distribution of ABO and Rh (D) blood groups among pregnant women in Ethiopia were included. The study participants were all pregnant women in Ethiopia, and the main outcome measure of this systematic review and meta-analysis was Rhesus D-negative blood type and ABO blood group distribution among pregnant women in Ethiopia. The data was extracted by the author (AAA) by using a standardized JBI data extraction format. Microsoft Excel (2016), and Stata version 11.0 (Stata Corporation, College Station, Texas, USA) software were used for data entry and analysis, respectively. The random effect model was used for estimating the pooled effects, and the publication bias was assessed by visual inspection of the funnel plots and objectively by using the Egger's test (i.e. p < 0.05).

RESULTS

One hundred thirty-two articles were identified through electronic database searching. Of which, 34 were excluded due to duplication, 65 through review of titles and abstracts, and 22 full-text articles were excluded for not reporting the outcome variable and other reasons. Finally, 7 were included to estimate the distribution of ABO and Rh (D) blood groups among pregnant women in Ethiopia. The pooled distribution of Rh-negative blood group among pregnant women in Ethiopia was 10.8% (95%CI: 7.53-14.07, I2 = 85%, p < 0.001). In the ABO system, type O was the most prevalent 39.9% (37.51-42.38), followed by A (30.59% (26.00-35.18)), B (23.04% (20.03-26.05)), and AB the least (4.82%(3.17-6.47)), in the pattern O > A > B > AB.

CONCLUSION

The pooled distribution of Rh-negative blood group among pregnant women in Ethiopia was high. Rh alloimmunization remains a major factor responsible for perinatal morbidity in Ethiopia and may result in the compromise of the woman's obstetric care due to the unaffordability of anti-D immunoglobulin. There is the urgent need for the implementation of universal access to anti-D immunoglobulin for the Rh-negative pregnant population in Ethiopia.

"They Merely Prescribe and I Merely Swallow": Perceptions of Antenatal Pharmaceuticals and Nutritional Supplements Among Pregnant Women in Bamako, Mali

OBJECTIVES

New international guidelines for antenatal care (ANC) will likely result in an increase in nutritional supplements and preventative medications for pregnant women in low and middle-income countries. Our objective was to understand how pregnant women in Mali perceive and experience multi-drug regimens in ANC in order to reveal factors that may influence uptake and adherence.

METHODS

We conducted 29 semi-structured interviews and three focus groups with 21 pregnant women in two urban ANC sites in Bamako, Mali. Interviews focused on perception of purpose of ANC pharmaceuticals (particularly iron supplements, sulfadoxine-pyrimethamine as intermittent prevention of malaria and antiretroviral therapy for HIV), beliefs regarding efficacy and risk, and understanding of dosage and regimen. Transcripts were inductively coded and analyzed using the 'Framework' method.

RESULTS

Participant descriptions of medication purpose, understanding of dosing, and beliefs about risks and efficacy varied widely, revealing that many pregnant women lack complete information about their medications. While some were burdened by side effects or complex regimens, women generally held favorable attitudes toward ANC medications. Responses suggest major barriers to adherence lie in the health system, namely insufficient patient-provider communication and inconsistent prescribing practices.

CONCLUSIONS FOR PRACTICE

National health programs looking to improve maternal and child health with ANC pharmaceuticals need to place greater attention on patient counseling and consistent implementation of administration guidelines. Communication that positions pharmaceuticals as beneficial to mother and child, while presenting understandable information about purpose, dosing and potential side effects can promote uptake of multi-drug regimens and ANC services in general.

Red Blood Cell Alloimmunization in the Pregnant Patient

Alloimmunization to red blood cell (RBC) antigens represents a challenge for physicians caring for women of child bearing potential. Exposure to non-self RBC antigens may occur during transfusion or pregnancy leading to the development of antibodies. If a subsequent fetus bears that antigen, maternal antibodies may attack the fetal red blood cells causing red cell destruction and clinically significant hemolytic disease of the fetus and newborn (HDFN). In the most severe cases, HDFN may result in intrauterine fetal demise due to high output cardiac failure, effusions and ascites, known as "hydrops fetalis". This article reviews strategies for management and prevention of RBC alloimmunization in women of child bearing potential.

Detection of membrane-bound and soluble antigens by magnetic levitation

Magnetic levitation is a technique for measuring the density and the magnetic properties of objects suspended in a paramagnetic field. We describe a novel magnetic levitation-based method that can specifically detect cell membrane-bound and soluble antigens by measurable changes in levitation height that result from the formation of antibody-coated bead and antigen complex. We demonstrate our method's ability to sensitively detect an array of membrane-bound and soluble antigens found in blood, including T-cell antigen CD3, eosinophil antigen Siglec-8, red blood cell antigens CD35 and RhD, red blood cell-bound Epstein-Barr viral particles, and soluble IL-6, and validate the results by flow cytometry and immunofluorescence microscopy performed in parallel. Additionally, employing an inexpensive, single lens, manual focus, wifi-enabled camera, we extend the portability of our method for its potential use as a point-of-care diagnostic assay.

Occurrence of anti-D alloantibodies among pregnant women in Kasese District, Western Uganda

OBJECTIVES

This study was undertaken to determine the distribution of ABO/RhD (rhesus D antigen) blood phenotypes, prevalence of anti-D alloantibodies, and the risk factors for alloimmunization among pregnant women in Kasese District, Western Uganda.

MATERIALS AND METHODS

Ethylenediamine tetraacetic acid-containing plasma samples and serum samples were taken from pregnant women attending the antenatal clinic. The blood groups were identified using the microplate grouping method, while the presence of anti-D alloantibodies was detected by the indirect antiglobulin test (IAT). Data were also collected from the pregnant women on the risk factors associated with anti-D alloantibody formation.

RESULTS

Among the 726 participants, the blood group distribution was as follows: O: 356 (49.%); A: 190 (26.%); B: 152 (21%); and AB: 28 (4%). A total of 28 (3.86%) pregnant women were RhD negative. Anti-D alloantibodies were detected in 88 (12.1%) of the participants; and of these, 13 (14.8%) were RhD negative. Statistically significant risk factors for anti-D alloimmunization included miscarriage, stillbirth, and postpartum hemorrhage.

CONCLUSION

Blood group O was the most common among the pregnant women in this study and the prevalence of Rh negativity was 3.8%. The frequency of anti-D alloimmunization among pregnant women in Kasese District was 12.12%, with 85.5% of these being RhD positive. Risk factors such as a history of stillbirths, miscarriages, and incidence of postpartum hemorrhage were significantly associated with anti-D alloimmunization. There is a need to routinely carry out antenatal blood grouping and IAT screening on pregnant women in Uganda to detect anti-D alloimmunization. Given the high prevalence of anti-D alloantibody formation among RhD-positive women, we recommend additional research studies on the role of autoimmunity among antigen-positive women, as well as the occurrence of RhD variants plus their implications on hemolytic disease of the fetus and newborn, in Uganda.

Assessment of feto-maternal hemorrhage among rhesus D negative pregnant mothers using the kleihauer-betke test (KBT) and flow cytometry (FCM) in Addis Ababa, Ethiopia

BACKGROUND

This study aimed to assess fetomaternal hemorrhage (FMH) among RhD negative pregnant mothers using two techniques, Kleihauer-Betke (KBT) and Flow cytometry (FCM). To determine if patient-specific doses of prophylactic anti-D warrant further investigation in Ethiopia and wider Africa.

METHODS

Hospital- based cross-sectional study was conducted among 75 RhD negative pregnant mothers using convenient sampling technique.

RESULT

FMH has been detected in 52% and 60% by KBT and FCM techniques, respectively. The volume of FMH quantified in the majority of the cases (92.5% and 87%) was <10 mL fetal blood while >30 mL in 1.3% (1/75) and 2.7% (2/75) as calculated by KBT and FCM, respectively. The FMH calculated by the two methods have good correlation; r = 0.828 (p = 0.000) for categorized and r = 0.897 (p = 0.000) for continuous values and the agreement between the FCM and KBT was moderate with kappa (κ) value of 0.53 (p = 0.000).

CONCLUSION

Most of FMH calculated (<10 mL) could have been neutralized by lower doses which might have lower costs than administering 300 μg dose which is currently in practice in our country for affording mothers. Besides, it also showed that the volume of FMH was >30 mL in 1.3% and 2.7% of the cases as calculated by KBT and FCM, respectively, which need more than 300 μg dose RhIG for neutralization. Further investigation into the cost- effectiveness and scalability of patient- specific dosing of prophylactic anti-D appears warranted.

Urgent global opportunities to prevent birth defects

Birth defects are an urgent global health priority. They affect millions of births worldwide. But their prevalence and impact are largely under-ascertained, particularly in middle- and low-income countries. Fortunately, a large proportion of birth defects can be prevented. This review examines the global prevalence and primary prevention methods for major preventable birth defects: congenital rubella syndrome, folic acid-preventable spina bifida and anencephaly, fetal alcohol syndrome, Down syndrome, rhesus hemolytic disease of the fetus and the newborn; and those associated with maternal diabetes, and maternal exposure to valproic acid or iodine deficiency during pregnancy. Challenges to prevention efforts are reviewed. The aim of this review is to bring to the forefront the urgency of birth defects prevention, surveillance, and prenatal screening and counseling; and to help public health practitioners develop population-based birth defects surveillance and prevention programs, and policy-makers to develop and implement science-based public health policies.