A case report illustrating the challenges associated with the presence of multiple maternal antibodies against red blood cell (RBC) antigens in the context of hemolytic disease of the fetus and newborn (HDFN), was recently published in the Indian Journal of Hematology and Blood Transfusion.
“The above case presents the tip of the iceberg and there can be cases which are missed/ misinterpreted due to lack of confirming laboratory tests,” the authors wrote.
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The case involved a newborn born from a 32-year-old mother with no chronic disease or comorbidities. The mother had a history of a previous uneventful pregnancy. The boy was born preterm at 34.5 weeks due to premature membrane rupture, the patient required no resuscitation at birth. Both the patient and the mother were Rh AB positive, thus HDFN was not a concern at the moment of birth. However, the patient developed a yellowish coloration of the skin (jaundice) 372 hours after birth. Additionally, his hemoglobin levels dropped almost 8 points during those three days.
The patient was transferred to a specialized center to receive phototherapy. Despite treatment, his hemoglobin levels kept dropping. The direct antiglobulin test performed on the baby on his 15th day of life revealed Grade 4 positivity, which indicated the binding of maternal antibodies to his RBC.
A more detailed Rh and Kell antigen phenotyping panel revealed that the patient and the mother had a CcEe, K negative phenotype. Further testing identified anti-E antibodies in the patient’s serum and that the mother had antibody reactivity to multiple RBC antigens.
At this point, the patient required blood transfusions due to severe anemia, but there was uncertainty regarding what constituted compatible blood in light of the presence of multiple maternal alloantibodies. Due to the urgency of correcting anemia, the patient received RhD negative E- negative blood and was discharged after improvement in hemoglobin levels.
The authors remarked that this case highlights the importance of extensive antenatal HDFN screening irrespective of RhD status and of performing DAT in all umbilical cord samples.
“DAT is often not carried out leading to delayed diagnosis and management in case of immune HDFN. Hence, DAT should be performed in all neonates irrespective of RhD status, along with other routine investigations.” the authors wrote.
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