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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 105-107

A successful pregnancy occurred after isolating the offending antibody(s) and choosing appropriate sperm donor of similar phenotype


1 Department of Immunohaematology and Blood Transfusion, Medical College and Hospital, Kolkata, West Bengal, India
2 Transfusion Centre Eastern Command, Kolkata, West Bengal, India
3 Department of Blood Bank, AMRI Hospitals, Kolkata, West Bengal, India

Date of Web Publication22-Apr-2019

Correspondence Address:
Dr. Prasun Bhattacharya
Department of Immunohaematology and Blood Transfusion, Medical College and Hospital, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_55_18

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  Abstract 


Sensitization against Rh(D )is the most common cause of haemolytic disease of fetus and newborn (HDFN). Now a days, a widespread use of antenatal and postnatal Rh immunoglobulin has resulted in marked decrease in prevalence of Rh(D) alloimmunization. Fetal loss due to other red cell antigens gain importance as there are no prophylactic immunoglobulin are available. Here, we present a case of primary infertility associated with non Rh(D) alloimmunization which was detected in a 30 year old housewife during her ongoing infertility treatment. The antibody identification workup showed patient is having multiple alloantibodies , probable anti-c, and anti-Fya. The extended phenotype shows that the husband is mismatched with the wife's phenotype in “c” and Fya. Also the probable antibody in the mother's serum are anti-c and anti-Fya which are noted to cause HDFN as per literature.

Keywords: Direct antiglobulin test, hemolytic disease of the fetus and newborn, in vitro fertilization, intrauterine insemination


How to cite this article:
Mukherjee S, Biswas D, Bhattacharya P, Biswas A, Chatterjee K. A successful pregnancy occurred after isolating the offending antibody(s) and choosing appropriate sperm donor of similar phenotype. Glob J Transfus Med 2019;4:105-7

How to cite this URL:
Mukherjee S, Biswas D, Bhattacharya P, Biswas A, Chatterjee K. A successful pregnancy occurred after isolating the offending antibody(s) and choosing appropriate sperm donor of similar phenotype. Glob J Transfus Med [serial online] 2019 [cited 2019 Sep 16];4:105-7. Available from: http://www.gjtmonline.com/text.asp?2019/4/1/105/256771




  Introduction Top


Sensitization against Rh (D) blood group system is the most common cause of hemolytic disease of the fetus and newborn (HDFN). Nowadays, a widespread use of antenatal and postnatal Rh immunoglobulin has resulted in a marked decrease in the prevalence of RHD alloimmunization. Fetal loss due to other red cell antigens gains importance as there is no prophylactic immunoglobulin available. More than 50 different red cell antigens have been reported to be associated with HDFN. Besides RHD, anti-c and anti-Kell (K1) are found to be associated with severe fetal outcomes.[1]

Here, we present a case of primary infertility in a 30-year-old housewife, who had undergone in vitro fertilization (IVF) twice, which resulted in midtrimester fetal loss.


  Case Report Top


She was married for 8 years and underwent treatment for primary infertility. She first conceived in 2013 via IVF. It was a triplet pregnancy. One of the fetuses was reduced, and pregnancy continued up to 22nd weeks of gestation. It was followed by missed abortion. Again, she conceived in 2015 via IVF. It was a singleton pregnancy. A male baby was born at 28 weeks of gestation, following premature rupture of membrane.

The baby's birth weight was 1.2 kg, direct antiglobulin test (DAT) was positive, and the baby expired on 29th day in a newborn intensive care unit due to sepsis. Her husband is a 31-year-old service personnel without any chronic diseases or comorbidities. However, his semen analysis report on June 2016 revealed azoospermia; hence, she was advised for intrauterine insemination (IUI). She did not have any history of major illness or blood transfusion. Thalassemia trait or other hemoglobinopathy screening of both husband and wife was found negative (by high-performance liquid chromatography).

She was referred to us for an evaluation of the cause of previously DAT-positive premature newborn.

Laboratory workup

A set of ethylenediaminetetraacetic acid (EDTA) and clotted samples (3 ml each) was collected from both husband and wife. On workup, her blood group was A+ (Subtype A1) and her husband was B+. Her DAT and autocontrol were negative, but indirect antiglobulin test (IAT) was strongly positive. IAT was done by conventional tube technique method using pooled O cells.[2] The titer was ≥2048. Antibody screening was done on IgG Card (monospecific), the test results were pan reactive to 3 cell (Bio-Rad, Switzerland). The preliminary workup showed that she was isoimmunized against high-incidence antigens. Her EDTA blood sample was further analyzed for antibody identification using 11-cell panel (Bio-Rad, Switzerland) as well as 16-cell panel and 10-cell panel (Solid Phase Red Cell Adherence Assay, Immucor, USA). An extended phenotype of both husband and wife was done simultaneously. The antibody identification workup showed that the patient has multiple alloantibodies, probable anti-c, and anti-Fya. However, the other possibilities of anti-Leb and anti-S could not be ruled out. Husband and wife's extended Rh and minor blood group phenotypes show vide [Table 1] and [Table 2].
Table 1: Red cell phenotyping results of the wife

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Table 2: Red cell phenotyping results of her husband

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From the above tables, the extended phenotype shows that the husband is mismatched with the wife's phenotype in “c” and Fya. Furthermore, the probable antibodies in the mother's serum are anti-c and anti-Fya, both of which are noted to cause HDFN as per the literature.[3]

She was counseled and advised by the transfusion medicine department to choose semen donors who were compatible to her phenotype as well as ABO blood group. On regular screening of 15-blood group O+ semen donors, three individuals were found to have the same phenotype of the lady. IUI was performed and her pregnancy period was uneventful.

The lady delivered twin babies at 37 weeks of gestation by planned cesarean section, both are male and birth weight was 1780 g approximately. No significant morbidities or jaundice developed after delivery. No blood transfusion was required for both mother and babies. Till date, they are doing well!! Both the babies are shown in [Figure 1].
Figure 1: Picture of the twins, baby 1 and baby 2

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  Discussion Top


The widespread use of Rh immunoglobulin has resulted in a major reduction of RHD alloimmunization. Hence, the significance of other blood group antigens may impart a leading importance to bad obstetric history, which resulted in perinatal morbidity and mortality.

As per the recommendations of Royal College of Obstetrics and Gynaecology, 2014, when a clinically significant antibody capable of causing HDFN is present in a maternal sample, determining the father's phenotype may provide useful information to predict the likelihood of the fetus expressing the relevant red cell antigens.[2] In this lady, who was having multiple antibodies like anti-c and anti-Fya of high titer has the potential to cause HDFN.[1] Hence, the semen donors were selected considering the ABO and other minor red cell antigen phenotypes compatible with the wife, ignoring the normal recommendations of selection of semen donors.[4] O-blood group donors were chosen because it was compatible to both husband and wife. Also, O blood group red cell is most commonly used in case of exchange transfusion or intrauterine transfusion. Clinically significant alloantibodies other than anti-D such as anti-c occur in 1:300 pregnancies and risk of HDFN caused by these antibodies is 1:500; there is probability that 1 in 500 cases to develop HDFN.[5]

One of the limitations of our investigations may be that we could not pinpoint the offending antibody; hence, we have chosen the ABO-compatible and wife's phenotype-matched donors.

Informed consent was obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moise KJ. Fetal anemia due to non-rhesus-D red-cell alloimmunization. Semin Fetal Neonatal Med 2008;13:207-14.  Back to cited text no. 1
    
2.
Saran RK. Transfusion Medicine Technical Manual. New Delhi: Directorate General of Health Services; 2003. p. 105-6.  Back to cited text no. 2
    
3.
Moise KJ. Management of rhesus alloimmunization in pregnancy. Am Coll Obstet Gynaecol 2002;100:600-11.  Back to cited text no. 3
    
4.
Gong D, Liu YL, Zheng Z, Tian YF, Li Z. An overview on ethical issues about sperm donation. Asian J Androl 2009;11:645-52.  Back to cited text no. 4
    
5.
Usman AS, Mustaffa R, Ramli N, Diggi SA. Hemolytic disease of the fetus and newborn caused by anti-E. Asian J Transfus Sci 2013;7:84-5.  Back to cited text no. 5
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