Haemolytic disease of newborn due to anti-Jka and the duration of antibody persistence

Irregular erythrocyte antibodies among antenatal women and their neonatal outcome at a tertiary care hospital in Northern India

BACKGROUND

Red blood cell alloimmunisation during the pregnancy is a significant cause for neonatal mortality and morbidity. This study was planned to determine the prevalence and specificity of irregular erythrocyte antibodies in antenatal mothers and their neonatal outcome.

METHODS

In this observational study, blood grouping and red cell antibody screening of mothers were performed at first visit and after 28 weeks of gestation and positive cases were identified and followed up monthly till delivery by repeating antibody titre and middle cerebral artery-peak systolic velocity. After delivery of alloimmunised mothers, cord blood haemoglobin, bilirubin and direct antiglobulin tests (DAT) were analysed and further outcome of neonate was recorded.

RESULTS

Among 652 registered antenatal cases, 18 multigravida women were found to be alloimmunised, accounting to prevalence of 2.8%. Most common alloantibody identified was anti D (>70%) followed by anti-Le^a, anti-C, anti-Le^b, anti-E and anti-Jk^a. Only 47.7% Rh D negative women received anti-D prophylaxis during previous pregnancies or whenever indicated. DAT was positive in 56.2% of neonates. Among nine DAT positive neonates, two early neonatal deaths due to severe anaemia were observed following birth resuscitation. Four antenatal mothers required intrauterine transfusion in view of fetal anaemia while three neonates received double volume exchange transfusion and top up transfusions after birth.

CONCLUSIONS

This study emphasises importance of red cell antibody screening for all multigravida antenatal women at registration of pregnancy and additionally at 28 weeks or later in high-risk cases irrespective of RhD status.

A case report of haemolytic disease of the foetus and newborn caused by Alloantibody D and Jka in a Rhesus D negative Nigerian woman: Justification for the implementation of universal access to prophylaxis and evidenced-based best practices

A case report of a 38 years old ABO group A and Rhesus D negative multiparous, gravidae 8 and para 2, Nigerian woman who had a case of premarital miscarriage and who was not offered anti-D prophylaxis as part of her management. Lady went on to develop alloantibody D and Jka. Lady has had 7 further pregnancies post the miscarriage. The first child who is B Rhesus D positive is the only surviving child. The surviving child was delivered severely jaundiced and needed management post-delivery for haemolytic disease of the foetus and newborn (HDFN). Lady has had a history of a stillbirth. She was given a non-clinically indicated anti-D prophylaxis during the second pregnancy despite having been previously sensitized. The second baby died 3 months after delivery from complications of HDFN. She had had a further history of 5 miscarriages. She has had challenge with conception since 2010. Alloantibody testing confirms the presence alloantibody D and anti-Jka. Finding from this is a clear case of sub-optimal laboratory, obstetric and neonatal care offered particularly to pregnant women who are Rh D negative and those with alloantibodies in Nigeria. The Nigerian government will need to implement evidenced-based best practices; determination of alloantibody status of pregnant women during their first antenatal visit; provision of facilities for alloantibody identification, titration, quantification and feto maternal haemorrhage testing (FMH); implementation of a policy on universal access to anti-D prophylaxis for pregnant Rh D negative women who are not previously sensitized; provision of facilities required for the optimal intrauterine management of HDFN (foetal genotype testing, intrauterine transfusion, doppler ultrasound to diagnose anaemia inutero and provision of donor blood that meet the minimum requirements for intrauterine transfusion); determination of Rh D status of women who require a termination of pregnancy and provision of prophylactic anti-D for those found Rh D negative within 72 hours of procedure and the optimization of the knowledge of Medical Laboratory Scientist, Obstetricians, Neonatologist, Pharmacist and Traditional Birth Attendants in a bid to reduce the residual number of women who become sensitized and the number of preventable deaths of babies with HDFN.

A systematic review of strategies to increase access to health services among children in low and middle income countries

Background

Universal Health Coverage is widely endorsed as the pivotal goal in global health, however substantial barriers to accessing health services for children in low and middle-income countries (LMIC) exist. Failure to access healthcare is an important contributor to child mortality in these settings. Barriers to access have been widely studied, however effective interventions to overcome barriers and increase access to services for children are less well documented.

Methods

We conducted a systematic review of effectiveness of interventions aimed at increasing access to health services for children aged 5 years and below in LMIC. Four databases (EMBASE, Global Health, MEDLINE, and PSYCINFO) were searched in January 2016. Studies were included if they evaluated interventions that aimed to increase: health care utilisation; immunisation uptake; and compliance with medication or referral. Randomised controlled trials and non-randomised controlled study designs were included in the review. A narrative approach was used to synthesise results.

Results

Fifty seven studies were included in the review. Approximately half of studies (49%) were conducted in sub-Saharan Africa. Most studies were randomised controlled trials (n = 44; 77%) with the remaining studies employing non-randomised designs. Very few studies were judged as high quality. Studies evaluated a diverse range of interventions and various outcomes. Supply side interventions included: delivery of services at or closer to home and service level improvements (eg. integration of services). Demand side interventions included: educational programmes, text messages, and financial or other incentives. Interventions that delivered services at or closer to home and text messages were in general associated with a significant improvement in relevant outcomes. A consistent pattern was not noted for the remaining studies.

Conclusions

This review fills a gap in the literature by providing evidence of the range and effectiveness of interventions that can be used to increase access for children aged ≤5 years in LMIC. It highlights some intervention areas that seem to show encouraging trends including text message reminders and delivery of services at or close to home. However, given the methodological limitations found in existing studies, the results of this review must be interpreted with caution.

Systematic review registration

PROSPERO CRD420160334200

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2180-9) contains supplementary material, which is available to authorized users.

Clinical Significance of Rare Maternal Anti Jka Antibody

We hereby report a rare case of HDFN because of antibody to Kidd (Jk) blood group system-anti Jka. An EDTA sample of a baby along with mother's sample was received in the Department for Direct Antiglobulin Test (DAT) alongwith blood requisition for double volume exchange transfusion. On blood grouping, baby's and mother's blood group was found to be B Rh D positive. DAT with polyspecific anti human globulin (AHG) was positive. Screening of mother's serum for irregular antibodies showed anti-Jka antibody. AHG phase titers using tube technique were 1:64. Mother was found to be Jka antigen negative; father and neonate were found to be Jka antigenpositive. Antibody was observed to be of IgG type on Dithiothreitol treatment. Baby had total serum bilirubin of 20.5 mg/dl on day 3 of life and phototherapy was started. Exchange transfusion was not required in the baby. The present case emphasises the significance of minor blood group antigens other than Rh blood group system as a cause of HDFN. Although HDFN due to Jk antibodies is rare, however, the clinician must be aware of the occurrence of these antibodies as they can lead to severe HDFN and persistent anemia in the infant.

Clinical aspects of urea transporters

Jk antigens, which were identified as urea transporter B (UT-B) in the plasma membrane of erythrocytes, and which determine the Kidd blood type in humans, are involved in transfusion medicine, and even in organ transplantation. The Jk(a-b-) blood type is a consequence of a silent Slc14A1 gene caused by various mutations related to lineage. In addition, the specific mutations related to hypertension and metabolic syndrome cannot be ignored. Genome-wide association studies established Slc14A1 as a related gene of bladder cancer and some genotypes are associated with higher morbidity. This chapter aims to introduce the clinical significance of urea transporters.