ALLOIMMUNIZATION

IN PREGNANCY
Brooke Grizzell, M.D.
PGY-2
OBGYN Department, UKSM
September 28th, 2005
 Objectives
 1. Understand history of HDFN
 2. Learn correct terminology
 3. Outline ABO and CDE blood groups “Major
blood group antigens”
 4. Discuss Minor blood group antigens, including
Kell, Lewis, Duffy, and various others
 5. Review clinical management
 6. Compare Delta OD 450 and MCA-PSV
 7. Provide Rh alloimmunization management
summary
 8. Learn prevention strategies
 History of HDFN
1609: First case of HDFN described
1939: Levine & Stetson described antibody
1941: Levine demonstrated causal relationship
between anti-D antibodies and HDFN
1945: Neonatal exchange transfusion began
1956: Bevis proposed amniotic fluid assessment
1961: Liley proposed amniotic fluid assessment
1963: Liley introduced intraperitoneal fetal transfusion
1968: Rh immune globulin (RhoGAM) introduced
1980’s: Real-time ultrasound
1990’s: Genetic techniques to perform fetal RBC typing
 Correct Terminology
 “erythroblastosis fetalis” vs.
“hemolytic disease of the fetus and
newborn” (HDFN)

 “alloimmunization” vs.
isoimmuniation”
 Pathophysiology
1st antigenic exposure, memory
 After
B lymphocytes recognize appearance
of RBC’s containing the antigen in
subsequent pregnancies

B lymphocytes - plasma cells - IgG

 Initial IgM response changes to IgG
Pathophysiology- Continued
 Maternal antibodies cross placenta-
attach to fetal RBC’s- lead to RBC
destruction
 Sequestration by macrophages in
fetal spleen-extravascular
hemolysis-produces fetal anemia
 ABO Blood Group
 Invariablycauses only mild disease
 Treatment generally limited to
phototherapy
 No need for antenatal detection
 CDE (Rhesus) System
 Very important!!!
 Includes c, C, D, e, E
 D negativity defined as absence of
D antigen
 Only 87% of Caucasians carry the
D antigen
Various Other Antibodies
 Antigens such as A, P, Le (a), M, I,
IH, and Sd (a) are innocuous
 Most are IgM
 Lewis antibodies and cold
agglutinins of I are prevalent but
not clinically significant
 Antibodies Associated
with HDFN
 Anti-c, Anti-D, Anti-E, and Anti-
Kell
 RhoGAM has decreased HDFN
caused by anti-D, but Anti-D
antibody is still MOST
COMMON CAUSE of red cell
alloimmunization
 Minor RBC Antigens
 Kell is most common of minor
 Responsible for 10% of cases of
severe antibody-mediated anemia
 Mechanism of anemia two-fold
1. Hemolysis
2. Suppression of erythropoiesis
**Transfuse women with Kell(-) blood**
 Minor RBC Antigens
(continued)
 Lewis antigen also a common minor
RBC antigen
 Most anti-Lewis antibodies are IgM
antibodies
 Mothers with anti-Le (a) antibodies
who require transfusion, need blood
negative for the Le(a) antigen
 Minor RBC Antigens
(continued)
 Duffy antigens Fy(a) and Fy(b)
 Only anti-Fy(a) antibody
associated with HDFN- may range
from mild to severe
 ACOG: treat sensitization to
minor RBC antigens similar to
those with Rh alloimmunization
 Minor Antigens (continued)
 MNS system = M, N, S, s, U
antigens
 Anti-M and anti-N naturally
occurring- no clinical significance
 Anti-S, anti-s, and anti-U
antibodies ~ mild to severe HDFN
 Clinical Management
 1. Routine blood type &AB screen
 2. Repeat AB screen at 24-28 wga
for Rh (-) women prior to receiving
RhoGAM (some recommend repeat
screens for Rh (+) women also)

 3.
If AB screen is (+), identify
antibody and potential for HDFN
Clinical Management (cont)
 4.Elicit risk factors for
alloimmunization (past pregnancies,
transfusions, shared needles)

 5. Determine father’s RBC antigen

status and zygosity
 6. If paternity unknown or father is
(+) for antigen, fetus is at RISK
Clinical Management (cont)
 6. (cont)Obtain antibody titer~ the
reciprocal of the highest dilution
still giving a positive reaction

ACOG: Consider invasive testing at

titer of 1:32 or greater by indirect
Coombs (1:16 most often used)
**Titers less reliable after a sensitized
pregnancy**
Clinical Management (cont)
 7. If AB titer remains below critical
titer- invasive testing can be
deferred and pt. evaluated by serial
AB titers
 Serial titers before 18-20 wga not
necessary
 If critical titer noted at first visit,
amnio for delta OD450 at 22-24
wga
Clinical Management (cont)
 8.Obtain amniocytes to determine
fetal blood type if father is
heterozygous for the antigen
responsible for alloimmunization

 9.MCA-PSV can be used as early

as 18 wga ~ if greater than 1.5
MoM, consider fetal blood
sampling
Clinical Management (cont)
 10.
Serial amnio to measure delta
OD450 and plot values on Liley or
Queenan graph

 Delta
OD450 vs.
MCA-PSV
 Delta OD450
 Spectral analysis of amniotic fluid
at 450 nm proposed in 1961 by
Liley- measures change in OD
 Measures the level of bilirubin and
predicts severity of hemolytic
disease after 27 wga
 Delivery or intrauterine transfusion
if delta OD450 falls into zone III
or upper zone II
 Queenan Method
 Proposedanother method of using
delta OD450

 Suggested four zones in his graph

 Limitations of spectral
analysis
 Kell-antigen sensitized pregnancies
 Erythroid suppression and
hemolysis
 Not an accurate prediction of fetal
anemia
 MCA-PSV
 Velocityof blood flow in brain
increased with anemia b/c of
1. Increased cardiac output
2. Vasodilation in the brain
3. Decreased blood viscosity
 Prospective studies
111 fetuses~ 100% sensitivity
125 fetuses~ 88% sens. and 98% NPV
 Correct Technique for
MCA Doppler
 Fetus resting
 Circle of Willis imaged in axial
image using color doppler
 Entire length of MCA
 Close to origin of internal carotid
artery
 Limitations of Each
Method
 Delta OD450 falsely elevated in
presence of mec or blood
 Delta OD450 misleadingly low
after inadvertent exposure to light
or in Kell alloimmunization
 MCA accuracy diminishes after 35
wga and after multiple transfusions
 Comparison Studies?
 Few have been completed
 Small retrospective studies
28 pregnancies~ 100% sens. using
Doppler MCA-PSV vs. 80% sens. using
amnio and delta OD450
Another study with 28 pregnancies~
75% sens and 60% PPV using MCA-PSV
vs. 75% and 53% respectively for delta
OD450
 Cordocentesis
 Gold standard for detection of fetal
anemia
 Complications!
 2.7% total risk of fetal loss
 Reserved for patients with
increased MCA-PSV or delta
OD450
Advantages of MCA-PSV
 Non-invasive
 Mother not put at risk for
worsening alloimmunization
 Can be used with alloantibodies
other than RhD, including anti-Kell
antibodies
 Summary of Management for
Rh Alloimmunization
 Monthly indirect coombs titer (in first
sensitized pregnancy)
 If critical titer reached, determine
paternal and fetal antigen status
 Amniocentesis and delta OD450 OR
MCA-PSV

** For 2nd or greater sensitized pregnancy,

initiate amnio or MCA at 18-20 wga**
 Rh Alloimmunization
management (cont)
 Ifusing MCA-PSV, and initial is
less than 1.5 MoM, do weekly
testing x 3 wks
 Regression line/slope
 Repeat testing Q 1-4 wks
 Cordocentesis or delivery once
MCA-PSV reaches 1.5 MoM
 Prevention of
Alloimmunization
 ACOG recommends RhoGAM for
Rh (-) pts after 1st trimester loss
 RhoGAM for threatened abortion
controversial- no evidence based recomm.
 50 mcg dose protects against 2.5 ml of
Rh (+) RBC’s
 300 mcg dose protects against 15 ml of
RBC’s or 30 ml of Rh (+) blood
 Prevention (cont)
 Give 300 mcg dose within 72 hrs
of delivery to unsensitized Rh (-)
women (Rh positive infant)
 ACOG: 300 mcg at 28 wga
UNLESS father known to be Rh (-)
 Repeat Antibody Screen ?
 Prevention (cont)
 Test for excessive fetal-maternal
hemorrhage after blunt trauma,
abruption, cordocentesis, and bleeding
assoc. with previa
 Kleihauer Betke or rosette test
 Give RhoGAM for partial molar
pregnancy, SAB, TAB, ectopic,
chorionic villus sampling, external
version
 Conclusions
 Remember the instances in which to
consider RhoGAM
-SAB, TAB, threatened AB (controversial),
ectopic, previa/bleeding, abruption, partial molar,
CVS, blunt trauma, cordocentesis
 Clinically important antibodies: Anti-c,
Anti-D, Anti-E, and Anti-Kell, Rarely Anti-
Duffy Fy(a)
 Usually not associated with severe HDFN:
Anti-Lewis, ABO incompatibilities, Anti-
Duffy(Fy-b) antibodies, (Duffy Fy-a causes mild
to severe HDFN), Anti-A, Anti-P, Anti-M, Anti-I,
Anti-IH, Anti-Sd(a)
 Conclusions (cont)
 Anti-D still most common cause of red cell
alloimmunization, despite RhoGAM
 Kell = most common minor antigen
*anemia mechanism 2-fold
 Critical titer most often used is 1:16 by
indirect coombs
 Amnio with delta OD450 vs. MCA-PSV
 Liley or Queenan graphs
 Remember AB screens and indications for
RhoGAM!!
 References
1. Gabbe Obstetrics – Normal and Problem
Pregnancies, 4th edition.
2. Creasy R., Resnik R., Iams J., Maternal Fetal
Medicine Principles and Practice, 5th edition.
3. ACOG Compendium 2005
4. Harkness U., Spinnato J., Prevention and
Management of RhD isoimmunization. Clinics in
Perinatology, Dec 2004 31:4.
5. Pereira L., Jenkins T., Conventional management of
maternal red cell alloimmunization compared
with management by Doppler assessment of
MCA-PSV. American Journal of Obstetrics and
Gynecology, Oct 2003 189:4.
 References (cont)
6. Cohen D., Hemolytic disease of the newborn:
RBC alloantibodies in pregnancy and
associated serologic issues. Up to Date, Oct
2004.
7. Barss V., Moise K., Significance of minor red
blood cell antibodies during pregnancy. Up
to Date, Apr 2005.