A patient from New Delhi, India, developed hemolytic disease of the fetus and newborn (HDFN) associated with a rare alloantibody—anti-Rhesus (Rh)17, according to a recent study.
This case study, which was recently published in the journal Cureus, is considered unique because of the help provided by the Japanese Red Cross society, social health workers, the administration, and nongovernment agencies to attain a favorable outcome.
Although it is highly unusual to witness the involvement of antibodies to high-frequency antigens in the development of HDFN, these alloantibodies do present a challenge to clinical staff and transfusion medicine specialists alike—particularly in recognizing the relevant antibody and arranging for compatible blood for administering an intrauterine transfusion (IUT).
The current case report depicts an individual who presented to the India Institute of Medical Sciences at 19 weeks’ gestational age (GA) with an Rh-isoimmunized pregnancy. Throughout the pregnancy, she received a total of 6 IUTs at various intervals.
In most HDFN cases, antibodies to the Rh blood group system are involved. Unlike in developed nations, however, antibodies to the Rh1 (anti-D) blood group are nonetheless implicated in the majority of cases of HDFN in India, despite the availability of Rh immunoglobulin.
Read more about HDFN testing and diagnosis
The patient described initially presented to the center in New Delhi, India, in 2018. She had been referred from a different center because of the development of severe anemia and fetal intrauterine death on day seven. She had experienced five pregnancies, with four terminating in intrauterine death at 28 to 36 weeks’ GA and one being a spontaneous abortion at 10 weeks’ GA. Throughout all of her prior pregnancies, she had never undergone an IUT.
Despite cross-matching numerous units of blood, the center was unable to locate compatible blood for the patient. Thus, the decision was made to decrease her antibody titer via serial plasma exchanges, which were followed by the transfusion of incompatible units using high-dose intravenous immunoglobulin (IVIG) if necessary. The utilization of 2 plasma exchanges of 1.5 volumes each on alternating days was able to decrease her titer from 1:64 to 1:124. The mother delivered a “macerated male hydropic baby of 748 grams vaginally” without the need for a blood transfusion.
The patient was advised to consume an iron-rich diet and to visit the center for preconception counseling prior to contemplating any future pregnancies. She did not report her seventh pregnancy, however, which was associated with an abortion at 10 weeks’ GA.
In her current, eighth pregnancy, she underwent Doppler ultrasound of the middle cerebral artery-peak systolic velocity (MCA-PSV) at 19 weeks’ GA. The fetus was reported to have an MCA-PSV of >1.5 MoM and no evidence of hydrops. The patient received 2 cycles of IVIG, administered 1 week apart.
An immunohematologic workup revealed that the mother’s blood type was B RhD positive. Phenotyping for the presence of minor blood group antigens demonstrated the absence of RH2, RH3, RH4, and RH5 antigens. Thus, a presumptive diagnosis of D– phenotype with an anti-Rh17 antibody was rendered. The International Blood Group Reference Laboratory, Bristol, United Kingdom, verified that the patient’s Rh phenotype was D- C- c- E- e- Rh17- Rh29+.
With no rare donor registry existing in India, the Japanese Red Cross was contacted and ultimately delivered several O D– red blood cell units to the center at various times throughout the patient’s pregnancy, to be used for IUT.
The fetus developed a non-reassuring non-stress test at 31 weeks and thus was delivered by cesarean section. The female baby weighed 1415 grams at birth and fared well in the neonatal period.
“With great efforts and support from social health workers, the Japanese Red Cross society, the administration, and non-government organizations, the impossible became possible,” the authors noted. “Establishing a rare blood group registry in developing nations is the need of the hour, as procuring rare blood was the biggest hurdle.”
