Appropriate surveillance and treatment during pregnancy have led to decreased rates of fetal morbidity and mortality linked to hemolytic disease of the fetus and newborn (HDFN), according to the analysis of a case study published recently in NeoReviews.
The study described a 37-year-old woman who has had five pregnancies. Three of the pregnancies resulted in term births. She experienced no preterm births, two miscarriages and two abortions.
An antibody screen performed at her last pregnancy was negative, and at 28 weeks’ gestational age (GA) she was treated with Rhesus (Rh) immune globulin. At that time, she gave birth to an Rh-positive baby and received intravenous immunglobulin (IVIG) following delivery.
Read more about HDFN testing and diagnosis
In the present situation, the patient became pregnant via in vitro fertilization. At 10 weeks’ GA, she exhibited anti-D antibodies. Following detection of these antibodies, her husband underwent D-antigen genotyping and was ultimately shown to be heterogeneous for the D antigen.
Based on a 50% risk of the fetus being Rh positive, the mother underwent amniocentesis for assessment of fetal D-antigen genotyping. Findings revealed that the fetus was D-positive as well.
Because the patient was at high risk for early-onset HDFN, at 13 weeks’ GA, she underwent Doppler ultrasonography of the fetal middle cerebral artery peak systolic velocity (MCA-PSV), plasmapheresis (plasma exchange) and IVIG treatment.
Treatment with plasmapheresis and transfusion
Initially, the pregnant patient’s MCA-PSV was right below the threshold of 1.5 multiples of the median (MOM), thus offering reassurance that no significant fetal anemia was present.
After undergoing two plasmapheresis sessions, the patient began to receive weekly IVIG treatments until 26 weeks’ GA. Although her antibody titers declined following the plasma exchange and IVIG therapy, her anti-D antibody titers increased once again at 26 weeks’ GA.
At 27 weeks’, two days’ GA, her MSA-PSV was elevated, and the patient was scheduled for fetal blood sampling and a possible transfusion. Findings from the testing were indicative of severe fetal anemia. The fetus received a transfusion; MCA-PSV values declined to near normal after the transfusion.
Repeat PUBS at 29 weeks’, four days’ GA showed an elevation in the MCA-PSV MOM once again. During the PUBS procedure, prolonged fetal bradycardia was detected, which led to the early delivery of a male infant via urgent cesarean section, with no complications.
The baby was hospitalized in the neonatal intensive care unit. He received give packed RBC transfusions and phototherapy. Neither IVIG nor exchange transfusion was required.
The newborn was discharged home at 41 days of age.
“Management of alloimmunization in pregnant patients should be protocol-driven,” the study author stated. “Current strategies for assessment and therapies allow for more thorough and less invasive management with risks to mother and fetus.”
