1. A Mysterious Case of Persistent Hemolytic Disease of the Fetus/Newborn
Blood Centers of the Pacific
BloodSource
United Blood Services
A Mysterious Case of Persistent Hemolytic Disease of the Fetus/Newborn
Marissa Li, MD
Medical Director
United Blood Services

3. Agenda Case report Breastfeeding and breast milk
Statistics
Professional organization recommendations
Composition and benefits
Hemolytic disease of the fetus/newborn (HDFN)
Etiology
HDFN effects on fetus/neonate
Prevention
Diagnosis
Management

4. Case Report

5. Mother’s clinical history
32 year old G3P3 O negative female with anti-D, anti-G and recurrent history of HDFN
First pregnancy resulted in a near term intrauterine fetal demise
Second pregnancy resulted in a preterm, severely anemic child requiring postnatal exchange transfusions
Current pregnancy complicated by evidence of intrauterine hydrops fetalis due to high titer anti-D
She other underwent two intrauterine transfusions (O neg RBC) in June 2015, the first when fetal Hb was 2.0 g/dL and the second when the fetal Hb was 3.8 g/dL
Despite two intrauterine transfusions fetus continued to display signs of distress
Minimal improvement of MCA doppler result and persistent fluid accumulation
She delivered a 1,740 gram, 28 week gestation preterm male on 06/21/2015 via Cesarean section

6. Mother and neonate’s serologic findings
O neg
Anti-D in plasma (high titer, not further quantified)
Anti-D in breast milk (4+)
Neonate
B pos
Anti-D in plasma (3+)
Positive IgG DAT (3+)
Eluate not performed

7. Neonate’s clinical history
Date
Labs
Exchange or simple transfusions
Additional treatment for HDFN
Nutrition
06/21/15 (day one of life)
Hb 4.8 g/dL g/dL
T-bili 4.7 mg/dL; D-bili 0.6 mg/dL; I-bili 4.1 mg/dL
Normal LFT
Double volume exchange transfusion (O neg RBC)
Phototherapy
IVIg
NPO, TPN
06/26/15
Hb 10.5 g/dL g/dL
T-bili 8.0 mg/dL
Two simple transfusions (25 mL and 30 mL O neg RBC)
06/29/15
Hb 10.9 g/dL g/dL
07/02/15
Started maternal breast milk feeding
07/08/15
Hb 11.5 g/dL g/dL
T-bili 8.8 mg/dL mg/dL
Discontinued oral feeding for exchange transfusion and concerns for NEC
07/09/15
Identified anti-D in breast milk
07/17/15
Hb 8.4 g/dL g/dL Anemia secondary to bloody stool & iatrogenic causes
Simple transfusion (40 mL O neg RBC)
07/20/15
Stable Hb
Started donor breast milk feeding
11/02/15 (discharge)
Hb 11.5 g/dL
T-bili 1.0 mg/dL
Infant formula started at 1month and 15 days of age till discharge

9. Breast milk & breastfeeding

10. Trivia question
Which of the following is the most abundant component of the breast milk
Protein
Carbohydrate
Fat
Water
Vitamins

11. Breastfeeding statistics
~38% of infants are exclusively breastfed in the world
In the US
75% of infants initiate breastfeeding from birth
67% of infants rely on infant formula for some portion of their nutrient by 3 months of age
43% of mothers breastfeed for the first 6 months but only 13% breastfeed exclusively
Martin CR, et al. Nutrients 2016

12. Professional organization view points on breastfeeding
WHO
Recommends exclusive breastfeeding for first 6 months of life
American Academy of Pediatrics
Recommends breastfeeding for ≥ 12 months
Academy of Nutrition and Dietetics
Recommends exclusive breastfeeding for first 6 months of life and complement with food from 6 months until ≥ 12 months of life
Martin CR, et al. Nutrients 2016

13. Breast milk composition
Water: 87%
Carbohydrates: 7%
Human milk oligosaccharides are anti-microbial and protect against gut pathogens such as Salmonella, Listeria and Campylobacter
Fat: 3.8%
Most important composition of milk by supplying energy and helping with CNS development
Protein: 1%
Vitamins
Minerals
Digestive enzymes
Hormones
Immune cells
Bioactive molecules
Martin CR, et al. Nutrients 2016

14. Immune composition of breast milk
Human milk contains immune cells and antibodies protective against numerous pathogens the mother has been exposed to throughout her lifetime
Antibody level falls throughout lactation but the amount of immunoglobulins received by the child remains unchanged due to increase milk intake
Palmeira P and Carneiro-Sampaio, M. Rev Assoc Med Bras 2016

15. Immunoglobulin compositions in breast milk
All classes of immunoglobulins are found in milk (IgA > IgM > IgG)
IgA/SIgA (secretory IgA) is the most important in relation to concentration and biological properties
Make up 80-90% of total immunoglobulins in human milk
Only 10% is absorbed in the intestines and transferred to the bloodstream
Defend mucous membranes and prevent entry of microorganisms into tissues
Anti-inflammatory
IgM
Reactive with viruses and bacteria
Protect mucosal surfaces
IgG
Neutralizing and opsonizing activity
Activate complement system and antibody-dependent cytotoxicity
Palmeira P and Carneiro-Sampaio, M. Rev Assoc Med Bras 2016

16. Benefits of breast milk
Protect against infections such as otitis media, upper and lower respiratory track infections, gastroenteritis, sepsis and meningitis
Convenient, inexpensive, provide bonding experience for mother and infant
Breast milk oligosaccharides and antibodies can help protect against diseases commonly afflicting premature and underweight infants
Sepsis, meningitis and necrotizing enterocolitis
Martin CR, et al. Nutrients 2016
Palmeira P and Carneiro-Sampaio, M. Rev Assoc Med Bras 2016

17. HDFN Overview

18. Trivia question
Which maternal antibody(ies) is the most common cause of HDFN
Anti-E
Anti-K
ABO antibodies
Anti-D
Anti-c

19. Etiology HDFN is caused by maternal red cell antibodies
Naturally occurring ABO antibodies & alloantibodies developed through prior pregnancies, transfusion or transplant
Rate of hemolysis and severity of disease is determined by the following factors
Antibody class
IgM: not transported into fetal circulation
IgG subclass
IgG is actively transported across the placenta (class 1 & 3 are most efficiently transported)
Amount of antibody
Number of antigenic sites on the fetal/neonatal red cells
AABB Technical Manual 18th Edition

20. HDFN effects on fetus & infants
Fetus affected by HDFN develop
Anemia and compensatory erythropoiesis
Anti-K also cause erythroid progenitor cell destruction in the marrow which prevents compensatory erythropoiesis
Hyperbilirubinemia
In utero: maternal liver metabolizes the bilirubin
Postnatal: infant hepatic enzyme insufficient at metabolizing elevated bilirubin, this may lead to kernicterus
Organomegaly
Hydrops fetalis
Fetal skin/organ edema and eventually intrauterine death
De Haas, M et al. Hemolytic disease of the fetus and newborn. Vox Sanguinis 2015

21. De Haas, M et al. Hemolytic disease of the fetus and newborn
De Haas, M et al. Hemolytic disease of the fetus and newborn. Vox Sanguinis 2015

22. Prevention Prenatal maternal ABO/Rh typing and antibody screen/ID
If mother is Rh(D) negative then initiate RhIg prophylaxis at 28 weeks
92% of women develop anti-D ≥ 28 week gestation
Decrease the risk of Rh(D) alloimmunization from 16% to <0.1%
If mother’s antibody screen is positive with specific alloantibody
If alloantibody is known to potentially cause HDFN
Close monitoring of fetus for signs of anemia
Close monitoring of maternal alloantibody titer
If alloantibody is NOT known to cause HDFN
May choose to repeat antibody screen/ID during pregnancy to monitor for change in antibody class or new antibody development
AABB Technical Manual 18th Edition

23. Diagnosis
Diagnosis of HDFN can be made by identifying clinically significant alloantibody during pregnancy
Antibody screen/ID and titer as appropriate
Consider non-invasive fetal blood group typing with cell free fetal DNA from maternal plasma if available OR
Changes in fetal/neonatal well being
Intrauterine: decrease fetal movement, sudden death
Postnatal: neonatal jaundice and anemia
AABB Technical Manual 18th Edition
De Haas, M et al. Hemolytic disease of the fetus and newborn. Vox Sanguinis 2015

24. Impact of antibody specificity on severity of HDFN
De Haas, M et al. Hemolytic disease of the fetus and newborn. Vox Sanguinis 2015

25. Management Prenatal management options Postnatal management options
Measure middle cerebral artery peak systolic velocity to detect fetal anemia
Moderate to severe anemia: velocity >1.5 multiples of the median (MoM)
Intrauterine transfusions
Pros
Correct anemia
Reduce the burden of antigen positive red blood cells
Reduce the amount of maternal alloantibody
Cons
Further alloimmunization in 25% of mothers despite matching for Rh/K
Postnatal management options
Phototherapy
Reduce unconjungated bilirubin and risk for kernicterus
Exchange transfusions
Reduce unconjungated bilirubin
Remove maternal alloantibodies
Correct anemia
Simple transfusions
De Haas, M et al. Hemolytic disease of the fetus and newborn. Vox Sanguinis 2015

26. Case conclusion

27. Differential diagnosis of HDFN in this neonate
Anti-D associated HDFN
Anti-D from maternal breast milk
Maternal breast milk contained high concentration of anti-D
Maternal breast milk cessation is well correlated with neonate’s Hb recovery
Late hyporegenerative anemia caused by ongoing intramedullary hemolysis of Rh positive neonatal erythroid precursor and/or marrow suppression by the high titer anti-D
Ongoing clinical evidence of hemolysis (i.e. elevated bilirubin and persistent anemia) in the presence of negative DAT in the neonate
Anti-D from maternal circulation
GI track absorption of immunoglobulin is variable
High titer anti-D from maternal circulation may have persisted despite 3 double volume exchange transfusions and numerous simple transfusions
ABO associated HDFN (Mom: O neg; Neonate: B pos)
Severity of hemolysis despite transfusing O neg RBC
History of anti-D mediated HDFN
High titer anti-D in current pregnancy
a study of neonates breast fed by mothers with immune thrombocytopenic purpura demonstrated that sufficient amount of IgA class anti-platelet antibodies can be effectively absorbed by neonatal GI track leading to persistent thrombocytopenia4. Moreover, a murine model of passively acquired maternal alloantibody (IgA and IgG) via breast milk suggests that perhaps the intestinal absorbance of immunoglobulin in human neonates may be more efficient than previously reported3.

28. The End……..