Transfusing pregnant patients

[labgirl153]

A situation arises where a physician wants to transfuse a

pregnant woman who just happens to have sickle cell disease.

The patient is at 23 weeks gestation, has a negative antibody

screen and is in crisis.

The transfusion service gets the order to set up two units

of leukoreduced, irradiated prbcs for this patient with no

further explanation.

Before filling the order, I call the facility where this

patient has been getting transfused for several years to

get more info. They've been transfusing the patient with

O Rh pos CMV- prbcs negative for C, E and K antigens.

I call my blood supplier and have them find units that fit this

description and have them irradiate them, plus have them

screen for Hgb S.

a) Why did the M.D. order irradiated blood?

Why did I further insist on CMV- blood?

c) Why did I ask for products that C-, E-, K-?

d) Regardless of disease state, WHAT should a pregnant woman

get transfused and what immunologic rationale would account for the

strategy?

Please give me your insights and experience with this...

had this scenario happen just last night...

:coffeecup

[donellda]

Hmmm. Interesting! We used to transfuse preterm pregnant women with CMV negative to avoid exposure to CMV for the baby. I don't remember giving irradiated units but it makes sense to avoid graft vs host for the baby also. The mom has sickle cell so the C, E and Kell negative units is a common practice with many transfusion services to help prevent formation of antibodies in multiple transfused African American individuals with sickle cell. I would also give Fya and Fyb negative if possible. I know our Childrens Hospital routinely uses this antigen profile for transfusing their sickle cell patients.

[labgirl153]

Think you're right on Donna...

The CMV= blood appears to be the "standard" now in the event of a pregnant woman needing transfusion. Found these sources:

The Institute for Transfusion Medicine (1994)

http://www.itxm.org/archive/tmu8-94.htm

and...the blood book crew:

http://www.bloodbook.com/

If anyone knows of other sources recommending CMV= blood for pregnant women, please post them.

Also, as Donna knows, I've put this question to the CBBS forum and hopefully, when responses come in, the moderator there will post both question and responses.

My question relates to discovering the rationale behind the M.D. having requested irradiated blood...I know in the past some physicians have requested irradiated blood for sicklers, but this is generally not indicated.

However, pregnancy plus a disease state may change all that. I do think that Donna's premise that transfusing irradiated blood to the mother might be more protective toward the immunosuppressed fetus is the true answer, but right now that's just an educated guess.

And...since pregnancy confers some degree of immunosuppression so as not to reject the fetus, WHEN does this "immunosuppression" end in the mother: just after delivery? several days after? or weeks?

Perhaps some of the M.D.s who read here can weigh in on this one too.

When CBBS posts everything I'll post the link here so any interested can get to it...

[bernvil]

The rationale for irradiating leucodepleted blood products to be transfused to pregnant women is to protect the fetus from possible deleterious effects of immunocompetent cells from the donor. As soon as the the baby has been delivered, the mother will no longer need irradiated products. MD, Denmark

[labgirl153]

Thanks for giving your valuable input on this...it's great to get an M.D.'s view...("bernvil" is a transfusion medicine physician in Denmark)...so in your view, the irradiation is really all about protecting the fetus and really nothing more.

It seems to be a point of common sense to transfuse irradiated blood to a pregnant woman, since the fetus is "immunosuppressed" and I would do this in a heartbeat simply out of common sense. However, some folks need hard documentation to convince them of this...I get frustrated explaining to co-workers what should be common sense from an immunologic standpoint and yet they still don't agree.

Am still searching in the literature for any studies related to this just so I can hand co-workers and higher-ups a "piece of paper" to show what should be pretty obvious. Anyone who can find some documentation...bring it on...

:writersbl

[labgirl153]

http://www.cbbsweb.org/enf/2006/irrad_pregnant.html

Here are some responses to my inquiry posted on CBBS forum...even though irradiation might seem to be common sense in regards to fetal health when transfusing a pregnant woman, there is no documentation or any case studies to support transfusing irradiated products to pregnant women. This was the consensus of the two physicians who replied. Of course, other physicians are free to disagree and order as they see fit, particularly where immunosuppression might be in the mother's history. Transfusing CMV= blood is the standard however for seronegative pregnant women and depending on the publication, even in seropositive women.

As an aside, I wrote to the moderator regarding the comment from one of the M.D.s concerning transfusion medicine committees and guidelines for physicians. In an ideal world, physicians would be open to guidelines set forth by pathologists and their staff, they would consult with them, and the nursing staff would be able to decipher lousy handwriting...however, in small to mid-sized facilities, such committees either don't exist or worse, the medical staff regards recommendations from pathologists as 'meddlesome' (my personal experience from having worked all over the country.

Yes, in the hallowed halls of academia, in prestigious institutions where it's not uncommon to have 20-30 pathologists or more, and where specialists abound, laboratories and their medical directors have the ear and respect of the medical staff. (I trained in a world-class facility so I can identify). But in the 'real world' (i.e. most medical facilities), this is a rare occurance.

I always appreciate hearing from folks who are experts in their field, and the forum answered my concerns. I certainly don't want to sound ungrateful!! In any case, for all interested, please refer to the link above.

[irshadaad]

[THe protocol for any sickler pt is we have to suply blood homologous to its Rh phenotype and kell for their susceptiblity for antibody production

every sickler should be given leukpcyte free/irreradiated blood for save the pt from HLA antibodies and cytokinase which give chances for non heamolytic transfusion reaction like allergetic reactions

we have to remember sickler pt are to go for transfusion therapy regularly so we should avoid from very begning to transfuse those antigens which are absent in the pts blood which are prone to antibody production