Hydrops fetalis and intrauterine deaths due to anti-M

A single-center, retrospective analysis of 17 cases of hemolytic disease of the fetus and newborn caused by anti-M antibodies

OBJECTIVE

We aimed to summarize the laboratory findings and clinical features of hemolytic disease of the fetus and newborn (HDFN).

METHODS

We retrospectively analyzed the data for 17 infants with anti-M-induced HDFN (anti-M-HDFN) diagnosed between June 2013 and May 2019. Their maternal history, neonatal diagnosis on admission, and laboratory test results were compared with those of 15 infants with HDFN involving the ABO blood group system, 15 infants with HDFN involving the Rh system, and 15 premature infants.

RESULTS

In the anti-M-HDFN group, 94.12% (16/17), 35.29% (6/17), and 17.65% (3/17) had free antibodies in plasma, a positive direct antiglobulin test, and a positive elution test, respectively. In 12 infants, free antibody reactions were stronger at 4°C than at 37°C, and the antibody titer at 4°C ranged from 1 to 512. All 17 infants with anti-M-HDFN developed anemia: 14 were treated with blood transfusion and 1 with neonatal exchange transfusion. Sixteen infants improved, and one died. Anti-M-HDFN had a higher rate of maternal stillbirth, lower gestational age, lower birthweight, and higher incidence of respiratory distress than other HDFN types.

CONCLUSION

Anti-M may cause HDFN. It may present with varying degrees of anemia, low regenerative anemia, and low bilirubin levels. In addition, infants with anti-M-HDFN may have a negative elution test and direct antiglobulin test. These tests are helpful in examining antibody responses at a low temperature of 4°C.

Hemolytic disease and reticulocytopenia of the newborn attributable to maternal immunoglobulin G anti-M reacting optimally at cold temperatures

BACKGROUND

Hemolytic disease of the fetus and newborn (HDFN) attributable to anti-M is rare, although case reports implicate anti-M in varying severities of HDFN, including fetal hydrops and intrauterine death.

CASE DESCRIPTION

We describe the case of a newborn with HDFN associated with an atypical immunoglobulin (Ig) G anti-M that reacted best at cold temperatures. The maternal antibody detected in pregnancy was not reactive at 37°C, and a direct antiglobulin test (DAT) on red blood cells (RBCs) from the newborn was negative, suggesting an anti-M that should not have been clinically relevant. However, the infant developed hyperbilirubinemia (bilirubin level, 17.6 mg/dL), hemolytic anemia (hemoglobin nadir, 5.5 g/dL), and reticulocytopenia. Laboratory testing demonstrated the presence of an IgG anti-M in maternal and neonatal samples reacting best at 4°C. This passively acquired IgG anti-M provoked hemolytic anemia in the infant and likely suppressed erythropoiesis, resulting in reticulocytopenia with prolonged anemia. He was treated for IgG anti-M HDFN with 10 intravenous Ig infusions and 10 days of oral prednisone followed by a taper. He required seven transfusions with M- RBCs. His hemoglobin level normalized at 3 months of age. Follow-up at 2 years revealed no hematologic or neuro-developmental concerns.

CONCLUSION

To our knowledge, this is the second report of HDFN attributable to an IgG anti-M reacting preferentially at cold temperature with no 37°C reactivity. Clinically relevant IgG anti-M may elude standard testing. Early recognition and testing for cold-reacting IgG anti-M should be considered for newborns with hemolysis, a negative DAT, and prolonged anemia.

Recurrent fetal hydrops with maternal M alloimmunisation: not a benign condition

Haemolytic disease of the fetus and newborn (HDFN) is associated with red cell antibodies. Anti-M usually results in a mild haemolysis and is rarely clinically significant. There is no established consensus on management of pregnancies with anti-M. A case of recurrent HDFN with maternal M alloimmunisation was identified at a tertiary hospital in Australia. We collected the patient and neonate's clinical and pathological data and interpreted the case with available literature. This is the first case in literature of recurrent fetal hydrops in the setting of M alloimmunisation. Neonate was delivered in a poor condition, intubated and admitted to the neonatal intensive care unit for ionotropic support, red cell transfusion and plasma transfusion for coagulopathy. Direct Coombs test was positive, confirming HDFN. Although anti-M rarely causes HDFN, accurate history, fetal surveillance and monitoring is essential for identification of fetal anaemia. Concurrent placental disease may increase fetal risk from anti-M antibodies.

Hemolytic disease of the fetus and newborn due to alloanti-M: three Chinese case reports and a review of the literature

BACKGROUND

Alloanti-M was once regarded as not clinically significant, with a few exceptions in extremely rare cases. However, an increasing number of cases of severe hemolytic disease of the fetus and newborn (HDFN), resulting in fetal hydrops and recurrent abortion caused by alloanti-M, have been reported mainly in the Asian population.

STUDY DESIGN AND METHODS

Three pregnant Chinese women with a history of abnormal pregnancy with hydrops fetalis were encountered. During this pregnancy, a series of clinical examinations and an alloantibody identification against RBCs and platelets were conducted. Intrauterine transfusion and postnatal transfusion were then performed in the fetuses. In addition, the HDFN cases caused by alloanti-M reported in different ethnic groups as well as their clinical and serologic features are also summarized.

RESULTS

Three pregnant women were identified with an M-N+ phenotype and IgM mixed with IgG alloanti-M in serum. Their fetuses were found by ultrasound examination and cord blood testing to have severe anemia. Additionally, an M+N+ phenotype and IgG alloanti-M were detected in the cord blood of the three fetuses with titers ranging from 1:1 to 1:128. Moreover, low reticulocyte counts and negative direct antiglobulin tests were also shown in two of the fetuses. After receiving intrauterine transfusions and postnatal transfusions several times, these three fetuses eventually survived and then healthfully developed in the follow-up tracking.

CONCLUSION

Alloanti-M immunization can cause severe HDFN with hyporegenerative anemia, often seen in the Asian population, and suppression of erythropoiesis might account for it.

Anti-M Alloimmunization: Management and Outcome at a Single Institution

Objective  The objective of this study was to review the management strategies and outcomes in gravidas with anti-M alloimmunization over 15 years. Study Design  Data collected from 195 pregnant patients with anti-M antibodies from July 2000 through June 2016 were reviewed retrospectively. We analyzed indirect antiglobulin test titer results, paternal or fetal/neonatal M antigen status, antepartum course, and perinatal outcomes. Results  Anti-M antibodies were found in 146 women and 195pregnancies. Among those with positive indirect antiglobulin tests, 193 pregnancies had titers at or below 1:4. Only one patient with an initial low titer experienced a more than twofold increase to a titer 1:64. Two women underwent an amniocentesis and cordocentesis. Ninety-five (73.6%) of the 129 infants tested were positive for the M antigen. Nine infants required phototherapy. There were no cases of hemolytic disease of the fetus or newborn, mild or severe. Conclusion  The incidence of severe hemolytic disease of the newborn due to anti-M is extremely low. We found no cases in our review of 195 pregnancies, despite several cases of severe hemolytic disease of the newborn reported in the literature. We have created an algorithm for the management of anti-M antibodies in pregnancy based on our data and extensive literature review.

Maternal anti-M induced hemolytic disease of newborn followed by prolonged anemia in newborn twins

Allo-anti-M often has an immunoglobulin G (IgG) component but is rarely clinically significant. We report a case of hemolytic disease of the fetus and newborn along with prolonged anemia in newborn twins that persisted for up to 70 days postbirth. The aim was to diagnose and successfully manage hemolytic disease of newborn (HDN) due to maternal alloimmunization. Direct antiglobulin test (DAT), antigen typing, irregular antibody screening and identification were done by polyspecific antihuman globulin cards and standard tube method. At presentation, the newborn twins (T1, T2) had HDN with resultant low reticulocyte count and prolonged anemia, which continued for up to 70 days of life. Blood group of the twins and the mother was O RhD positive. DAT of the both newborns at birth was negative. Anti-M was detected in mothers as well as newborns. Type of antibody in mother was IgG and IgM type whereas in twins it was IgG type only. M antigen negative blood was transfused thrice to twin-1 and twice to twin-2. Recurring reduction of the hematocrit along with low reticulocyte count and normal other cell line indicated a pure red cell aplastic state. Anti-M is capable of causing HDN as well as prolonged anemia (red cell aplasia) due to its ability to destroy the erythroid precursor cells. Newborns with anemia should be evaluated for all the possible causes to establish a diagnosis and its efficient management. Mother should be closely monitored for future pregnancies as well.

Report of two cases of anti-M antibody in antenatal patients

Anti-M is a relatively common naturally occurring antibody reacting optimally at 4°C and weakly or nonreactive at 37°C. It is usually clinically insignificant but can be active at 37°C because of thermal amplitude of IgM component or presence of IgG component. It can cause or delayed hemolytic transfusion reactions or hemolytic disease of newborn. At our center we have encountered two cases of anti-M antibodies- one presenting as crossmatch incompatibility and other as blood grouping discrepancy in the last 8 months.

Associations of Rhesus and non-Rhesus maternal red blood cell alloimmunization with stillbirth and preterm birth

BACKGROUND

Although the risks of adverse pregnancy outcomes associated with anti-D antibodies are well-recognized, much less is known concerning alloimmunization with other red blood cell antibodies detected during routine maternal screening. To date, most reports of adverse pregnancy outcomes associated with non-anti-D antibodies have been from small case studies. The aim of this study was to examine the associations of maternal alloimmunization with specific red blood cell antibodies and the risks of preterm birth and stillbirth in the Swedish population.

METHODS

All antibody screening, outcome and covariate data were obtained through linkages of Swedish national health and data registers. Follow-up in these population-based registers was available up to 31 December 2002. The final study sample consisted of 1,022,569 singleton births from 668,952 mothers during 1987-2002.

RESULTS

In total, 1.3% of the 1,022,569 study pregnancies were alloimmunized. In adjusted logistic regression models, compared with having no antibodies, alloimmunization with anti-D, anti-E, anti-C and anti-c was associated with increased risk of both stillbirth and preterm birth. In addition, anti-Kell was associated with increased risk of preterm birth and anti-Lea with increased risk of stillbirth. Compared with firstborn children, risk of preterm birth associated with alloimmunization was greater in subsequent births

CONCLUSIONS

In the largest study to date, alloimmunization with Rhesus, K- and -Lea red blood cell antibodies increased the risk of preterm birth and/or stillbirth. The association of anti-Lea with stillbirth was an unexpected finding. Further study of the consequences of non-anti-D alloimmunization is warranted.

Fetal anemia due to non-Rhesus-D red-cell alloimmunization

Although anti-RhD was once the major etiology of hemolytic disease of the fetus/newborn (HDFN), the widespread adoption of antenatal and postpartum Rhesus immune globulin has resulted in a marked decrease in the prevalence of alloimmunization to the RhD antigen in pregnancy. Maternal alloimmunization to other red cell antigens continues to play a role as the cause of fetal disease since no prophylactic immune globulins are available to prevent the formation of these antibodies. An increasing incidence of the Kell (anti-K1) antibody has been noted in the United States. Guidelines for intervention in cases of irregular red cell antibodies are limited by the bias of anecdotal reports in the literature in favor of severe cases of HFDN. Although most diagnostic protocols used in the management of the RhD-alloimmunized pregnancy can be applied in cases of non-RhD sensitization, Kell (K1 and K2) alloimmunization should be managed more conservatively.

Anti-M: Report of two cases and review of literature

Anti-M is a fairly common naturally occurring antibody with rarely causing hemolytic transfusion reactions or hemolytic disease of the newborn. Most anti-M are not active at 37 degrees C and can generally be ignored in transfusion practice. However, we did not find this antibody to be fairly common and detected only two cases of anti-M in the past three years. We describe these two cases; one 'immunizing' type and other 'naturally occurring' and review the literature. The immunizing type was reactive at 37 degrees C as well as AHG phase of testing with IgG component, and showing dosage effect while the other was 'naturally occurring' reactive well below 37 degrees C. Though rare, sometimes these antibodies can be of clinical significance when the antibody detected is reactive at 37 degrees C and AHG phase. When the antibody is active at 37 degrees C, M antigen negative cross match compatible red cell unit should be given.

Fetal hemolytic anemia and intrauterine death caused by anti-M immunization

BACKGROUND

Antibodies with anti-M specificity are detected in 10 percent of pregnant women with a positive antibody screen, but anti-M is only rarely associated with hemolytic anemia in the fetus.

STUDY DESIGN AND METHODS

This study reports on three pregnancies in one family that all resulted in severe fetal anemia. The first fetus died in utero with hydrops fetalis during the 20th gestational week and the second child was delivered after 28 weeks of gestation with hydrops fetalis and a hemoglobin level of 16 g per L whereas the third affected child was treated with intrauterine red cell (RBC) transfusions before delivery at 28 weeks of gestation.

RESULTS

The direct antiglobulin test was negative but anti-M in a low titer was detected through the three pregnancies, and its clinical relevance, which initially was uncertain, was confirmed by pronounced in vivo hemolysis in maternal blood of chromate ((51)Cr)-labeled M+ RBCs and normal survival of (51)Cr labeled M- RBCs.

CONCLUSION

It is concluded that anti-M immunization in a few cases may cause severe fetal hemolytic anemia and intrauterine death. It remains to be elucidated why a normally clinically insignificant antibody is this aggressive in a small proportion of cases. Because the condition is treatable, anti-M must be considered as a possible cause of fetal anemia and intrauterine death.

Non-anti-D antibodies in red-cell alloimmunization

OBJECTIVE

Review the fetal/neonatal outcome and management of pregnancies associated with alloimmunization to irregular anti-red-cell antibodies.

STUDY DESIGN

Computerized MEDLINE search using keywords that included hemolytic disease of the newborn (HDN) and the specific family of anti-red-cell antibody, such as anti-Kell antibody.

RESULTS

A review of the prevalence of antibodies associated with HDN in reproductive age women revealed a marked decrease in the incidence of anti-RhD. An increasing incidence of anti-K1 antibody has been noted in the US, a trend not seen in other countries. Guidelines for intervention in cases of irregular antibodies are limited by the bias of anecdotal reports in the literature in favor of severe cases of HDN.

CONCLUSIONS

In cases of Kell, M, Duffy and Kidd alloimmunization, DNA techniques using amniotic fluid can be used to exclude antigen-negative fetuses. Kell (K1 and K2) alloimmunization should be managed somewhat differently from RhD due to the unique ability of these antibodies to suppress the fetal erythropoietic response.