IVIgG causing HDN???

[janet]

We had a baby born with a hgb of 75, up to 113 after transfusion, now (2 days later). DAT negative but bilirubin was elevated, spherocytes and normoblasts present. Mom and baby are both A Rh: positive. Her Bilirubin peaked at 324umol/L about 12 hours after birth and is down to 204 today (almost normal).

Mother was being given weekly Gammunex infusions - she had a still born July 2007 due to inter-cranial hemorrhage. We did platelet antibody studies on her in December 2007 which were negative but the physician felt it was safest to give IvIg to prevent this pregnancy ending as the other one did (she felt it fit NAIT even though antibodies were not present - father was drawn too and our HLA reference lab does do a compatibility between mother and father). Mother's hgb mildly low through pregnancy at 102, plt around 80 to 140 but was 368 before treatments of IVIgG.

Our pathologist came in after he was asked to review the baby's smear - he asked if it was HDN, I told him about the IVIgG and how it can cause hemolysis in adults (mother does have a positive DAT (1+IgG), her reverse A cells react (1+), in October we had a weak antibody reacting with one of 14 cells, at delivery her antibody screen was negative, and all A units crossmatched were incompatible (O's fine)). Baby's DAT negative but we were thinking all those sensitized may have been cleared causing the anemia and hyper-bilirubinemia. I did testing on the cord plasma and it was negative with A cells and our antibody screen, only positive B cells. We are did an eluate today (just to see - I've read about eluates being positive even when DAT is negative) but it was negative!?!?

Do you have any thoughts - have you heard of HDN caused by IVIgG being given to a mother?

[Yanxia]

I had not encounter the IVIG cause HDFN, maybe it exist.

I think to do the elution of the mother's DAT pos cells is a way to find the hemolysis reason.

Edited January 15, 2009 by shily
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[rescyth]

i agree with shilly...do an eluate on MOM. Another possibility is that the infant may have "hereditary spherocytosis" . Patients with that disease exhibit inconstant signs of anemia, reticulocytosis, erythroblastosis, spherocytes in the blood smear, and increased mean corpuscular hemoglobin concentration. Especially with your case, that baby is having atypical Hyperbilirubinemia with whom we can rule out the ABO incompatibility is the cause. Hope this helps.

[janet]

Thanks for the thoughts.

We did elute Anti-A off the mother's cells.

Baby's bilirubin is normal today and I somehow missed saying her hgb was up to 169 yesterday. This quick turnaround makes me think it can't be a hemaglobinopathy or enzyme deficiency (do you agree?).

[rescyth]

as long as the baby is doing great now, im glad im wrong

[David Saikin]

Sometimes those Ig products are "contaminated" with blood group antibodies . . . it is entirely in the realm of possibility that your mom rec'd some that had an anti-A component.

[bbbirder]

Can you get any of the IVIG to test?

In our BB, we get a print out from pharmacy whenever IVIG is prescribed. We add a comment to the patient's BB history that they got IVIG and it may affect antibody screen results.

I think your case is a very puzzling one. Could there have been intrauterine bleeding that caused the neonate's anemia? and the elevated bilirubin just due to prematurity or something unrelated to red cells? Was there ever a K-B stain done on mom's blood?

Linda Frederick

[janet]

Ends up I was way off base......if only communication were better.

There was an inutero bleed when vilas sampling was done to do a platelet count (worrying about NAIT). This was done at a bigger centre than ours. There was a bleed into the baby's abdomen (from hepatic vein I think they said) and the blood that pooled there caused the increased biliburbin as it was cleared. That propbably explains the normoblasts too - trying to compensate for the post bleed anemia. Still not sure why all the spherocytes though.

Thanks for all your thoughts - I've learned to ask more questions before jumping to conclusions!