Hi all,

We recently received booking blood (10 weeks) sample from antenatal clinic. This is her second pregnancy and woman arrived from eastern Europe  Where her antibody identification look like anti- C+D. Therefore sample sent to reference lab for quantification and her antiD level  is 16.1 Iu/ml and Anti-G titre is 4. In terms of repeat sample reference lab advice us not to send any further sample but patient should be refer to FMC unit. 

I would be interested if anyone know how would they manage this fetus? Apart from IUT is there any other therapy? 

There have been several different methods used in an effort to "manage" the foetus over the years - most of which were aimed at controlling the maternal antibody levels.

One of these was the use of an Rh hapten and red cell stroma, but this met with very little success.

Promethazine hydrochloride was used, but, again, with very little success.

The use of IVIgG has been tried, and I did see this used with a certain amount of success myself.  I remember that it was a case where the maternal anti-D level was quite high (in the mid 30IUmL^-1) fairly early in the pregnancy, and the mother was given IVIgG throughout the pregnancy (I can't remember why they did not give an IUT, but there was a reason) and, at the end of the pregnancy, the maternal anti-D level had fallen to around 15IUmL^-1, and the baby was okay.  I believe I am correct in saying that this is a rare and expensive form of treatment (I certainly have only seen it used in one other case in my fairly long career.

Plasma exchange has been used to lower the maternal antibody levels (I remember Dr Cyril Levene using this technique on a pp lady with anti-PP₁P^k, who had experienced several early miscarriages, and who produced a healthy baby), but it is very rarely used, as it is expensive, tedious and very uncomfortable for the pregnant lady, and requires replenishment of clotting factors.  It is claimed that the antibody levels can be reduced by 75%, BUT, it needs to be done several times during the pregnancy, and the antibody levels are prone to rebound, as the IgG antibody comes back into the circulation from the interstitial spaces.  It is rarely used.

Therefore, the chances are that, should the foetus require management, an IUT would be performed.

If you want to know more, there are two books I would recommend.

The first is Hadley A, Soothill P.  Alloimmune disorders of pregnancy.  1^st edition, 2002, Cambridge University Press.  This is a bit old now, and may be difficult to obtain,, but it is still a good book.

The other is, of course, Klein HG, Anstee DJ.  Mollison's Blood Transfusion in Clinical Medicine.  12^th edition. 2014, Wiley Blackwell, Chapter 12.

This sounds like they are able to separate the anti-D from the anti-G activity in the reference lab testing?  If we can't tell if the patient has anti-G alone or anti-C plus anti-G or either of these plus anti-D we have had to consider the patient a RhIG candidate in case we can prevent her making anti-D.  We had a pregnant lady once that had only anti-G and anti-C but it of course looked like anti-D plus anti-C.

6 hours ago, Mabel Adams said:

This sounds like they are able to separate the anti-D from the anti-G activity in the reference lab testing?

It is actually quite easy to do this Mabel, as long as you have the right cells available.  You split the patient's plasma sample into two, and adsorb one of these with r'r red cells (which will remove anti-C and anti-G, but leave anti-D) and test this adsorbed plasma with R_o red cells to see if there is an anti-D present.  You adsorb the other one with R_o red cells (which will remove anti-D and anti-G, but will leave anti-C) and test this adsorbed plasma with r'r red cells to see if anti-C is present.  If both adsorbed plasma samples give negative results, it is a monospecific anti-G.  If both adsorbed plasma samples give positive results, you have an anti-D and anti-C +/- an anti-G - but, in this case, the anti-G is fairly irrelevant, as the clinical advice, both for the pregnancy and for any transfusions the mother or baby may require would be the same, whether there is an anti-G present or not.

Lady has delivered the baby and her final quantification level is 34.1 IU/mL . Baby had  single exchange transfusion and doing well.   Just wondering if baby required top up transfusion to treat late anaemia,  does top up pack has to be irradiated?  I know if baby had IUT then certainly required irradiated blood for top up transfusion.    But I am not sure about exchange transfusion. 

 

 

Edited April 27, 20178 yr by gagpinks

Strictly speaking, the BSH Guidelines state that there is no need to irradiate small volume transfusions for neonates, BUT, given that the baby has already had an exchange transfusion (which will have been irradiated) and is probably a little premature, irradiation will do no harm, and may do some good.

I may be speaking out of turn with the Guidelines, but, in this situation, I think "belt and braces" may be best.

On 4/27/2017 at 12:42 PM, gagpinks said:

Lady has delivered the baby and her final quantification level is 34.1 IU/mL . Baby had  single exchange transfusion and doing well.   Just wondering if baby required top up transfusion to treat late anaemia,  does top up pack has to be irradiated?  I know if baby had IUT then certainly required irradiated blood for top up transfusion.    But I am not sure about exchange transfusion. 

 

 

Hello, I am wondering what kind of method do you use to quantify anti-D in europe. here, we titer the maternal plasma with D+ cells and freeze an aliquot. Next visit, we would titer the fresh plasma parallel to thawed plasma, see if the titer has gone up compared to previous titer. Seems like having an assay to quantify the amount of anti-D and having a clinical cut off correlation is a better way to approach this. 

If you go to the Library Section of this site, Educational Material, second page Allo-Immune Haemolytic Disease of the Fetus and Newborn (HDF / HDN), and look at slides 45 to 60, you will see photographs of the continuous flow analysers sued within the NHSBT to perform quantification of anti-D and anti-c.  These photographs are of one of our older machines, as it allows you to see what is going on, whereas the newer machines are enclosed in the ubiquitous "black box", so you wouldn't be able to see anything.  Attached is a Word document that, I hope, explains the photographs.

Alloimmune Haemolytic Anaemia and Disease of the Foetus.doc