Alloantibodies causing Hemolytic Disease of the Newborn and Fetus.

1. Alloantibodies causing Hemolytic Disease of the Newborn and Fetus. Nancy Benitez, BS, MHS (ASCP)SBBCM Reference Laboratory Director June 6, 2013

2. Case Saturday Night (SN) The referring hospital transfusion service does not have any previous history on this patient as samples were received from the outpatient clinic. 32 years old Caucasian Female. Second Pregnancy

3. SN..cont… They reported that the antibody screen was positive with all cells tested, but due to the limited resources no further testing was performed. Samples were sent to our IRL lab for antibody Identification.

4. Objectives • Review the required serological techniques to determine the antibody specificity and clinical significance of alloantibodies causing Hemolytic disease of the fetus and Newborn. (HDFN) • Review the critical role that the Reference laboratory plays in the procurement of uncommon blood to transfuse the newborn. • Discuss the importance of the cooperation between patient, attending physician and the laboratory when alloantibodies are detected in the mother.

5. ABO-Rh DAT Screen (Liss and PEG) Panel Patient antigen testing. Routine Protocol- First Time Patients

6. ABO-Rh determination –O Pos

7. SN Screen Liss Screen PEG Screen

8. Patient phenotype

9. Initial Panel - LISS

10. Problems to resolve • Panel reacting with all cells tested. • Reactions with different strengths. • What do you think we should do next.

11. Let’s review the patient phenotype

12. FICIN Treated Panel

13. Selected Cell Panel: FICIN Treated Cells

14. 0.01 DTT TREATED PLASMA

15. Titration Studies

16. Summary of mom’s results

17. Why Patient follow up…… • Maternal IgGantibodies (anti-c, E) could be directed against the antigen(s) present on the fetal red blood cells. • IgG antibodies cross the placenta to coat fetal antigens, cause decreased red blood cell survival and produce anemia and HDNF. • Prevention for future pregnancies.

19. Case Saturday Night Baby (SNB) One of our local transfusion facilities requested testing for a baby sample with a possible Hemolytic Disease of the Newborn and Fetus. Mother’s records were immediately retrieve from the computer system

20. Case Saturday Night Baby (SNB) • The hospital also confirmed that the mother has a history of anti-c, -E. • RBCs fresh as possible, preferably <5 days old. • CMV and Hemoglobin S negative • Irradiated • Requested O Neg, c, E negative (extremely difficult combination)

21. Laboratory Hospital Findings- Baby • Positive Direct Antiglobulin Test • ABO-Rh: O Neg • Anemia • Hyperbilirubinemia • Reticulocytosis (6 to 40%) • Abnormal Smear

22. Baby ABO-Rh & DAT Results

23. SN Baby Elution

24. SN Baby Elution

25. Newborn- D testingEGA treated cell

26. Where could we find blood • Where and how will we find a unit of blood that is Rh(D) negative and also c negative, as most of the units are dce/dce. • Blood of this type was not available in the lab

27. The Rh complex • The D antigen always travel with the C, c and E or e • Antigens cannot be separated

28. Prevalence of Rh Haplotypes

29. Baby’s Rh Haplotype Baby is dce / dCe Heterozygous for the Cc Antigen

30. Prevalence Rh Haplotypes

31. Baby SN….Final outcome….. • Baby’s total serum bilirubin level was at 16 mg/dL and did not increase after phototherapy. • The Newborn was almost a Full-term an exchange transfusion was not necessary. • Baby was not severely affected because he was heterozygous for the c antigen.

32. Be ready…… • Think ahead, plan ahead, prepare ahead and work ahead. • Communication among the medical team and blood provider is crucial to prevent additional complications.

33. References Issitt PD, Anstee DJ. Applied Blood Group Serology. Montgomery Scientific Publications; Durham, NC; 1998. AABB Technical Manual, 17th edition. Mollison, PL; Engelfriet CP and Contreras M (1997). Blood Transfusion in Clinical Medicine (10th ed.). Oxford, UK: Blackwell Science.

34. Questions and comments.