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Anti-Inb

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A pregnant lady in her first prenancy  develop Anti-Inb at that time her titre was 8.  As far as I know anti-Inb doesn't cause HDFN but  it can cause HTR. In her first prenancy  we kept ready 2 unit of  ABO ,D Rh and K matched compatible blood. No blood required in first prenancy. But now in her second pregnancy her titre gone upto 64 at 28 weeks .   If  blood required  , does she need to have Inb negative blood ? 

 

Edited by gagpinks

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21 minutes ago, gagpinks said:

A pregnant lady in her first prenancy  develop Anti-Inb at that time her titre was 8.  As far as I know anti-Inb doesn't cause HDFN but  it can cause HTR. In her first prenancy  we kept ready 2 unit of  ABO ,D Rh and K matched compatible blood. No blood required in first prenancy. But now in her second pregnancy her titre gone upto 64 at 28 weeks .   If  blood required  , does she need to have Inb negative blood ? 

 

She almost certainly does.  If, however, it is the same woman as I dealt with in her previous pregnancy, good luck!  The lady I am thinking of was something of a "wanderer", who was booked with about five different hospitals covered by NHSBT-Tooting Centre, and finally gave birth in another hospital completely, in the NHSBT-Colindale Centre catchment area!  It made for a fun life for us, as there were only two units of In(b-) blood in the national frozen blood bank at the time, and I would be simply amazed if there are any more than two now!

I would let the NHSBT know pretty quickly about this woman, if you have not already so done!!!!!!!!!!!!!

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When you say let NHSBT know you mean reference lab or frozen blood bank? Reference lab are already aware of this case.

I was checking history and found the email communications where it suggested in her last pregnancy  that if patient show 2+ or>2 reaction then  need Inb negative blood. Do you think this is why we didn't provide Inb neg blood in her first pregnancy? 

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1 hour ago, gagpinks said:

When you say let NHSBT know you mean reference lab or frozen blood bank? Reference lab are already aware of this case.

I was checking history and found the email communications where it suggested in her last pregnancy  that if patient show 2+ or>2 reaction then  need Inb negative blood. Do you think this is why we didn't provide Inb neg blood in her first pregnancy? 

Hi Gagpinks,

As long as the Reference Laboratory know that the lady is pregnant, have had a sample to ensure that she hasn't produced any other "surprise presents" (in the form of an additional antibody specificity or specificities (always fun when the patient already has an antibody for which it is nigh on impossible to find compatible blood) and know her EDD, that should be enough.  It is now up to the likes of the NHSBT RCI Consultant, with special reference to Dr Rekha Anand, who does such a fantastic job, to find either frozen units or, in the case of Rekha, "tame" donors to cover the labour.  Otherwise, it is down to the equally fantastic Dr Therese Callaghan to import said units from elsewhere in the world.  All of this will go on in the background, and I would suggest that the hospital, let alone the patient, will not know it is happening.

If it was the lady of whom I was thinking, the reason blood was not supplied was because 1) she didn't need blood and 2) because she went to a hospital who had no idea about her antibody specificity (thank goodness).  The two units at the NFBB were never defrosted.

How many weeks is she pregnant now?  Don't be surprised if the titre of the antibody falls during the pregnancy, as the baby's Inb antigen will be expressed on the apical surface of the placenta, and so will adsorb out some of the maternal antibody anyway.

Keep us informed, if you don't mind.  This should be an interesting case for virtually everyone on this site - it is VERY rare (worth putting in an HSD portfolio, for example!).

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7 minutes ago, gagpinks said:

She is 28 weeks now and titre is 64. 

I'm sorry gagpinks, you already told us that didn't you!  Time for me to go to the opticians again!

Well, that gives ample time for NHSBT to organise a couple of units for her (as long as she STAYS at one hospital!), and I wouldn't worry about her antibody titre (from the point-of-view of the baby).  The interesting thing is the original comment about the strength of the reaction (whether or not it was 2 plus or stronger) because 1) it depends on who is reading the result (too many variables between individuals) and 2) so what anyway ( Dombrock antibodies tend to be weak, but that doesn't mean that they are not clinically significant - far from it)!

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Lady is at low risk bleeding at delivery so plan is to transfuse ABO and D and Rh compatible in case of emergency with methylprednisolone or if she is stable but need blood than frozen unit can be obtained. 

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10 hours ago, gagpinks said:

Lady is at low risk bleeding at delivery so plan is to transfuse ABO and D and Rh compatible in case of emergency with methylprednisolone or if she is stable but need blood than frozen unit can be obtained. 

That sounds reasonable.

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18 minutes ago, gagpinks said:

After all these preparation patient delivered at home. Baby and Mum didn't need any blood.

Tee, he, he!  I am glad neither required blood, but I am prepared to bet that it is the same lady as we dealt with a couple of years back.  We followed her around about five or so hospitals in the Tooting area, until she gave birth in a sixth (or whatever) in the Colindale area.  Have a look on Hematos (NHSBT computer programme, for those that don't know), and see if it is the same one (but, obviously, do not post her name here).

Thank you for the update!

:haha::haha::haha::haha::haha:

Edited by Malcolm Needs
I missed out a bit!

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1 hour ago, Malcolm Needs said:

Tee, he, he!  I am glad neither required blood, but I am prepared to bet that it is the same lady as we dealt with a couple of years back.  We followed her around about five or so hospitals in the Tooting area, until she gave birth in a sixth (or whatever) in the Colindale area.  Have a look on Hematos (NHSBT computer programme, for those that don't know), and see if it is the same one (but, obviously, do not post her name here).

Thank you for the update!

:haha::haha::haha::haha::haha:

Yes it is same lady. Now this time she delivered at home☺

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Don't you just LOVE patients like this!  You do your very best for them.  You get the situation explained to them (in their native language in this case, as well as English).  Still, they put themselves (and their baby) in danger, and, possibly, in other circumstances, waste some incredibly rare units of blood, so that they are no longer available for others.

RANT OVER!

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11 minutes ago, gagpinks said:

And guess what now she also developed anti-c . It will be so difficult if she get pregnant again. 

OMG!  Well, at least we know the anti-Inb will not affect future pregnancies, but an anti-c could do so.  The good news is that, as far as I can remember, the UK units of In(b-) blood are R1R1; the bad news is that there are only a couple.

I suggest we start planning now!!!!!!!!!!!!!!!!!!!!!!!!

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RCI will have to prepare as well for quantification.  Can't imagine every two weeks after 28 weeks.  How would they perform quantification?  Will they absorb anti Inb and then perform quantification? 

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17 minutes ago, gagpinks said:

RCI will have to prepare as well for quantification.  Can't imagine every two weeks after 28 weeks.  How would they perform quantification?  Will they absorb anti Inb and then perform quantification? 

No problem at all gagpinks.  Anti-Inb is sensitive to proteolytic enzymes, and quantification uses enzyme-treated red cells, so the anti-Inb will not interfere with the anti-c levels.  Now take a deep breath and RELAX!!!!!!!!!!!!

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Hi 

I was reading articles on social media regarding 2-year-old girl developed anti-Inb ( In a news article from the USA).  She has neuroblastoma and difficulty finding Inb negative blood.  If a patient is on chemotherapy and required regular transfusion it is hard to provide blood in these situations.  How severe anti-Inb can cause transfusion reactions especially when a patient is on chemotherapy? Can she have ABO and D compatible blood with methylprednisolone? 

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56 minutes ago, gagpinks said:

Hi 

I was reading articles on social media regarding 2-year-old girl developed anti-Inb ( In a news article from the USA).  She has neuroblastoma and difficulty finding Inb negative blood.  If a patient is on chemotherapy and required regular transfusion it is hard to provide blood in these situations.  How severe anti-Inb can cause transfusion reactions especially when a patient is on chemotherapy? Can she have ABO and D compatible blood with methylprednisolone? 

She very possibly can (although two things; it would most certainly depend on the titre of the anti-Inb prior to EACH transfusion [and that would have to be 1) a doctor's decision and 2) a bit of a guess, as anti-Inb is so rare) and also, I would suggest IvIgG, rather than methylprednisolone (or, possibly, both).  However, having said all this, there is NO DOUBT that anti-Inb is clinically significant in terms of haemolytic transfusion reactions, although the same is not the same for HDFN.

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Posted (edited)

Another strategy, which works for ABO incompatible kidney transplants in some cases, is a combination of immunosuppressive drug therapy, IVIgG and plasma exchange.   If it works for ABO, one would guess that it could work for Inb (or anything else, for that matter).  One also guesses that the antibody might be wholly or largely IgM if it only causes HTR and not HDN. If that were the case, plasma exchange could be particularly effective.

Edited by Neil Blumberg

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Posted (edited)
On 5/20/2019 at 3:28 PM, Neil Blumberg said:

Another strategy, which works for ABO incompatible kidney transplants in some cases, is a combination of immunosuppressive drug therapy, IVIgG and plasma exchange.   If it works for ABO, one would guess that it could work for Inb (or anything else, for that matter).  One also guesses that the antibody might be wholly or largely IgM if it only causes HTR and not HDN. If that were the case, plasma exchange could be particularly effective.

Sadly Neil, it is not the case that anti-Inb is wholly or largely IgM; indeed, it is almost always IgG.  It is thought that Indian Blood Group System antibodies do not cause HDFN because they bind to CD44 on foetal monocytes and macrophages and, therefore, have a blocking effect on FcγR1.  This being so, or likely to be so, plasma exchange is likely to be less effective that might be thought, because of rebound from the extra vascular spaces.

Edited by Malcolm Needs
Igm should have been IgM - of course!

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Another expensive but possibly effective approach would be to use one of the complement activation inhibitors, such as eculizamab, that is used to treat paroxysmal nocturnal hemoglobinuria, a disease with inadequate inactivation of complement components.  

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On 5/23/2019 at 11:27 AM, Malcolm Needs said:

Sadly Neil, it is not the case that anti-Inb is wholly or largely IgM; indeed, it is almost always IgG.  It is thought that Indian Blood Group System antibodies do not cause HDFN because they bind to CD44 on foetal monocytes and macrophages and, therefore, have a blocking effect on FcγR1.  This being so, or likely to be so, plasma exchange is likely to be less effective that might be thought, because of rebound from the extra vascular spaces.

Sorry to jump on an old post! 

Malcom, is the paper for this information as below? 

Garner SF, Devenish A. Do monocyte ADCC assays accurately predict the severity of hemolytic disease of the newborn caused by antibodies to high-frequency antigens? Immunohematology 1996;12:20–6.

I cannot find this paper anywhere, do you have any suggestions where I can access it? 

Thank you :) 

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Unfortunately, although that is the paper, I can't seem to access it on-line either, and I haven't got a copy I could scan for you.  On top of that, both Steve and Alan are retired, and I haven't got contact details for either of them.

Sorry.

You could try using the attached form?  

immunohematology_reprint_application_2019.pdf

Edited by Malcolm Needs

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