Successful management of severe red blood cell
alloimmunization in pregnancy with a combination of
therapeutic plasma exchange, intravenous immune globulin,
and intrauterine transfusion
Laura C. Nwogu ,
Kenneth J. Moise Jr,
Kimberly L. Klein,
and Yu Bai
Antibodies to Rhesus and Kell
antigens have been associated with severe hemolytic
disease of the fetus and newborn (HDFN) necessitating
intrauterine transfusion (IUT) of red blood cells (RBCs).
We report a case series of five women with severe HDFN
secondary to maternal RBC alloimmunization who were
successfully managed with therapeutic plasma exchange
(TPE), intravenous immune globulin (IVIG), and IUT.
STUDY DESIGN AND METHODS:
This is a
retrospective case series of five women with severe
HDFN who underwent a total of three TPE procedures
during Weeks 10 to 13 of pregnancy, followed by weekly
IVIG infusions. They were followed with serial middle
cerebral artery peak systolic velocity studies beginning at
16 weeks’ gestation to detect fetal anemia. For IUT,
fetuses were administered RBC units that fully matched
the maternal phenotype to D, C, E, K, Fy, Jk, and S
antigen groups. The delivery outcomes and newborn
information were followed.
Anti-D and anti-K alloantibodies were
implicated in HDFN. A two- to fourfold dilution reduction
in anti-D and anti-K titers was observed after TPE. IUT
was initiated between 21 to 27 weeks’ gestation. The
total number of IUTs for each patient ranged from four to
seven. All five women delivered healthy infants at 33 to
38 weeks’ gestation.
A combined regimen of TPE and IVIG
early in pregnancy and IUT later in pregnancy results in
successful management of severe maternal RBC
alloimmunization and HDFN. IUT with fully phenotypically
matched RBC units may help prevent further RBC
alloimmunization in complex cases of HDFN.
he antibodies most commonly associated with
severe hemolytic disease of the fetus and new-
born (HDFN) and necessitating intrauterine red
blood cell (RBC) transfusion are anti-D, anti-c,
anti-K, and anti-E.
The current practice of RhIG prophy-
laxis for D– women during pregnancy has decreased the
incidence of D-associated HDFN to 0.1% to 0.6%.
nal alloimmunization to certain non-D antigens, most
notably c and E antigens, and minor RBC antigens such as
Kell, Duffy, Kidd, and MNS antigens are now more com-
mon causes of HDFN because no prophylactic immune
globulins are available.
In this retrospective case series,
we report our experience with five patients diagnosed with
HDFN due to maternal RBC alloimmunization who were
ABBREVIATIONS: HDFN 5 hemolytic disease of the fetus
and newborn; IUFD 5 intrauterine fetal demise; IUT(s) 5
intrauterine transfusion(s); MCA-PSV 5 middle cerebral
artery peak systolic velocity; MoM 5 multiples of the
median; NICU 5 neonatal intensive care unit; NIPT 5
noninvasive prenatal testing; TPE 5 therapeutic plasma
Department of Pathology and Laboratory Medicine
Department of Obstetrics, Gynecology and
Reproductive Sciences, University of Texas McGovern Medical
School at Houston, Houston, Texas.
Address reprint requests to: Laura C. Nwogu, MD, Depart-
ment of Pathology and Laboratory Medicine, University of
Texas McGovern Medical School at Houston, 6431 Fannin
Street, MSB 2.262, Houston, TX 77030; e-mail: laura.c.nwogu@
Received for publication November 22, 2016; revision
received November 14, 2017, and accepted November 16, 2017.
Volume 58, March 2018 TRANSFUSION 677