Cefotetan-induced hemolysis associated with antibiotic prophylaxis for cesarean delivery

Immunohematological testing and transfusion management of the prenatal patient

The primary indication for immunohematological testing in the prenatal patient is to detect and identify maternal red cell antibodies. If there are antibodies that are expected to hemolyze the fetus' red cells, their strength of reactivity must be tested, and the fetus' antigen status determined. After delivery, testing is performed to assess the extent of fetomaternal hemorrhage, as a large hemorrhage may require other therapeutic interventions. Another major role for immunohematological testing is to select blood components appropriately when intrauterine transfusion is required for fetal anemia resulting from maternal alloimmunization or some other cause. Supplementation with molecular methods has transformed the practice of immunohematology, particularly as it applies to typing for the D antigen of the Rh blood group system. Notwithstanding the advances in testing, close coordination and communication between the transfusion service and the obstetrics service are the foundation for ensuring the finest care for prenatal patients, and for new mothers and their infants. This review describes testing and transfusion practices for prenatal patients, using case presentations to highlight the management of selected immunohematological findings. It also includes a discussion of key patient management topics that are currently unresolved.

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.

The Changing Spectrum of Drug-Induced Immune Hemolytic Anemia

Drug-induced immune hemolytic anemia (DIIHA) occurs rarely. To date, about 100 drugs have been implicated in causing DIIHA and/or a positive direct antiglobulin test (DAT). The most common drugs associated with DIIHA in the 1970s were methyldopa and penicillin; currently, they are cefotetan and ceftriaxone. Drug antibodies fall into two types: drug-independent ("autoantibodies") and drug-dependent ("penicillin type" or "immune complex type"); some patients have combinations of these antibodies. Some drugs cause nonimmunologic protein adsorption onto drug-treated red blood cells (RBCs). This is known to be the cause of positive indirect antiglobulin tests and is suspected to be a cause of positive DATs. This mechanism may be associated with hemolytic anemia. Twelve cephalosporins have been reported to cause DIIHA; five (primarily cefotetan and ceftriaxone) have been associated with fatalites. Patients with DIIHA due to cefotetan may only have received one dose of the drug prophylactically with surgery. Antibodies to cefotetan react to very high titers against drug-treated RBCs (and at lower titers against untreated RBCs without and/or with drug present). Patients with ceftriaxone-induced DIIHA have received the drug previously; reactions in children often occur minutes after ceftriaxone administration. Antibodies to ceftriaxone are only of the "immune complex type."

Cross-reactivity of cefotetan and ceftriaxone antibodies, associated with hemolytic anemia, with other: cephalosporins and penicillin

Most drug-induced immune hemolytic anemias since the late 1980s have been caused by the second- and third-generation cephalosporins, cefotetan and ceftriaxone, respectively. Cross-reactivity of cefotetan and ceftriaxone antibodies with other cephalosporins or penicillin has been studied only minimally. We tested 7 serum samples previously identified to contain cefotetan antibodies and one serum sample previously identified to contain ceftriaxone antibodies against 9 other cephalosporins, penicillin, and 7-aminocephalosporanic acid in the presence of RBCs and also used hapten inhibition to indicate cross-reactivity. Serum samples containing cefotetan antibodies showed some cross-reactivity with cephalothin and cefoxitin (and to a much lesser extent with penicillin and ceftazidime). The ceftriaxone antibodies showed very weak cross-reactivity with cefotaxime, cefamandole, and cefoperazone. There was very little cross-reactivity between cefotetan antibodies and the drugs tested in the present study. We have no data to determine whether the in vitro data relate to in vivo reactivity.