|Year : 2017 | Volume
| Issue : 1 | Page : 56-58
Oh Rh (D)-Negative in vitro fertilization pregnancy: Obstacles surmounted
Ambuja Kantharaj, Shivaram Chandrashekar
Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||22-Mar-2017|
Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
We report a rare case of Oh (D)-negative female with in vitro fertilization (IVF) pregnancy. Blood grouping was reported as O Rh (D) negative elsewhere and was referred at 28 weeks gestation for anti-D titration to our center. Blood grouping repeated at our laboratory was Oh Rh (D) negative. Owing to the absence of H antigen-negative cells, we did anti-H adsorption studies on the patient serum to look for underlying red cell alloantibodies, which were absent. The Ig (G) anti-H titer was 256, but there were no signs of fetal anemia as seen on the fetal middle cerebral artery (MCA) peak systolic volume studies also. The patient was on follow-up with anti-H titers and fetal MCA-Doppler studies every 2 weeks. The patient was started on oral iron and erythropoietin as hemoglobin was 8.5 g% which then improved to 11.5 g% after two doses of erythropoietin. Owing to risk of bleeding due to low-lying placenta, the treating obstetrician wanted to keep two units of red cell concentrate ready before elective lower segment cesarean section. Hence, close family members of the patient were screened for Oh phenotype, but none of them were found to be of Oh phenotype. Hence, autologous predeposit with fetal monitoring was considered but not implemented owing to legal and patient concerns. Pregnancy was uneventful and a healthy female baby was delivered at term. The baby did not have any signs of hemolytic disease of newborn. Blood grouping of baby was O positive and direct antiglobulin test done at the referring center was negative.
Keywords: Bombay phenotype, pregnancy, red cell alloantibodies
|How to cite this article:|
Kantharaj A, Chandrashekar S. Oh Rh (D)-Negative in vitro fertilization pregnancy: Obstacles surmounted. Glob J Transfus Med 2017;2:56-8
| Introduction|| |
Following the reporting of Oh (Bombay) phenotype by Bhende in 1952, this rare phenotype has been reported consistently by various study groups, and the incidence in India varies from 1 in 7600 in Maharashtra to 1 in 278 among the Bhuyan tribal population in Orissa. In Karnataka, the incidence has been reported as 0.005%.
Anti-H in Oh phenotype has been reported to cause hemolytic disease of newborn (HDN).
We present a case of Oh (Bombay) Rh (D)-negative blood group in an IVF pregnancy and its management.
| Case Report|| |
We received a sample of a 38-year-old female with 28 weeks gestation, from a referral hospital for anti-D titration. Blood group reported as O Rh (D) negative, and indirect Coomb's test reported as positive in their laboratory. The obstetrician suspected the presence of anti-D antibodies and sent the patient's sample for anti-D titration to our center. The patient was a primigravida with no history of prophylactic anti-D administration, no history of abortions, and no history of previous transfusion. The patient had a mild subchorionic bleed at the time of referral.
Although only anti-D titration was asked for, at our center, blood grouping, antibody screening, and identification were done as per protocol.
Blood grouping was performed by gel technique (Tulip Diagnostics, Goa, India). The cell grouping was consistent with O Rh(D) negative. Serum grouping showed a positive reaction A1 cells and B cells, consistent with O group. The patient's autocontrol (patient's own cells and serum) put up along with blood group was negative. Weak-D testing at 37°C done using AHG gel cards (Tulip Diagnostics) was negative. Antibody identification was done using a 3-cell panel (Tulip Diagnostics) by IAT technique using gel cards (Tulip Diagnostics). An autocontrol was also put up with the 3 cell panel.
A 3+–4 + reaction was noted with all three-cell panels. However, the autocontrol was negative. Hence, we suspected the presence of an antibody to a high-frequency antigen or presence of multiple red cell alloantibodies. Testing using an 11-cell panel also showed positive reaction with all cell panels. We suspected the presence of antibodies to high-frequency antigens such as anti-k, anti-Kp(b), and anti-Lu(b).
Antigen phenotyping was done using gel cards containing the corresponding antisera (Tulip Diagnostics and Bio-Rad Technologies, California, USA), the results of which are as shown in [Table 1].
We also did a subgrouping using anti-H lectin using gel card at this point as we wanted to rule out Oh phenotype. H antigen was negative which confirmed Oh (Bombay) phenotype. Blood grouping was repeated using O cells in serum grouping. The presence of anti-H in serum was determined by demonstrating positive reaction with O cells. The positive reaction with 3-cell and 11-cell panels was probably due to anti-H with or without coexisting alloantibodies. The absence of autoantibodies was confirmed by direct antiglobulin test (DAT) testing as well.
Since the patient was Rh(D) negative, we had to rule out coexisting anti-D. Owing to the nonavailability of Oh Rh(D) negative and positive screening cells to rule out coexisting anti-D, we carried out adsorption studies with O Rh(D)-negative cells to adsorb the anti-H in the patient's serum. After three adsorptions, anti-H was not detected in the serum and the serum was used for repeat antibody screening with 3-cell panels to look for anti-D. Antibody screening was negative ruling out the presence of anti-D or other clinically significant red cell antibodies. Anti-H titration was done by tube technique. The IgG anti-H titers obtained after DTT treatment of serum was 256. Nonsecretor status of the patient was confirmed by doing salivary inhibition studies. The Lewis antigen status of patient was found to be Le (a)-(b)-.
Further details obtained from the clinician were that this was a case of in vitro fertilization (IVF) using a donor oocyte and spouse's sperm. The blood group of oocyte donor was reportedly O Rh(D) positive. However, there was no way to recheck the same in view of patient confidentiality.
Fetal middle cerebral artery (MCA) Doppler studies did not show any signs of fetal anemia. The patient was on follow-up with anti-H titers and fetal MCA-Doppler studies every 2 weeks until delivery. Anti-H titers remained 256 throughout the pregnancy. As the hemoglobin of the patient at this time was 8.5 g%, she was started on oral hematinics by the treating obstetrician. The patient was given two doses of erythropoietin at 1-week interval, following which her hemoglobin (Hb) improved to 11.5 g%. Despite this Hb, the obstetrician insisted on having two units of red cell concentrate ready owing to low-lying placenta. The close family members of the patient were screened for Oh phenotype, but none of them were found to be of Oh phenotype. Hence, autologous predeposit with fetal monitoring as reported in literature was considered but not implemented owing to legal and patient concerns.
The rest of the pregnancy was uneventful. Two donors were kept on standby one from different cities. On the insistence of the obstetrician, one donor was bled and his blood was kept on standby at a nearby blood bank. Another unit was air-lifted from a different city.
The patient delivered a healthy female baby at term by elective lower segment caesarean section. No blood was used intra- or post-operatively. Blood group of baby was O Rh(D) positive, total bilirubin was 1.84 mg/dL, and direct bilirubin was 0. 54 mg/dL on the second day of birth. DAT was negative as reported in the laboratory of the referral hospital.
| Discussion|| |
Anti-H in Oh phenotype mothers is implicated in causing HDN as reported in a few case reports,, and unlike other red cell antibodies, it is known to affect the first pregnancy also. Ours was a rare case of anti-H in an Oh(D)-negative precious IVF pregnancy. Here, it was important to rule out the presence of other clinical significant red cell antibodies such as anti-D coexisting with anti-H. In the absence of H antigen-negative cell panels and nonavailablity of Oh-negative cells for screening, tedious procedures such as multiple adsorption studies had to be done to rule out other presence of red cell alloantibodies. As in alloimmunized mothers with clinically significant red cell antibodies, this patient too was followed up with anti-H titers and fetal MCA-Doppler studies during her pregnancy. Although the IgG anti-H titer was 256, the fetus did not show any signs of fetal anemia, nor did the baby develop any signs of HDN, a negative DAT also confirmed the same. This was probably due to the weakened expression of H antigen on the fetal red cells.
Meeting the blood requirements of patients of Oh phenotype is a big challenge to blood bank. In this case, as the patient was in the second trimester of pregnancy correction of anemia was done using combination of oral iron and erythropoietin. Studies have shown the efficacy of using erythropoietin in the treatment of moderate-to-severe anemia in pregnancy. Autologous predeposit could not be done owing to the legal validity of the same in our country though its safety and efficacy have been demonstrated in pregnancy by various studies.
| Conclusion|| |
This case highlights the importance of doing a blood grouping and subgrouping by a good technique to avoid unnecessary workup of the patient and also the importance of red cell antibody screening in pregnancy. Our case also highlights the importance of taking a detailed history from patient about previous pregnancy, history of transfusions, and also history of IVF from donor sperm or oocyte to predict the possibility of the fetus being affected by red cell alloantibodies in the mother bearing the child. Further, use of erythropoietin in managing severe anemia in pregnancy and considering the possibilities of an autologous predeposit in pregnancy which can help in effective management of cases with rare phenotypes can be considered as a possibility.
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Conflicts of interest
There are no conflicts of interest.
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