Challenges in Providing Transfusion Support

Kylie RushfordBlood Bank Senior Scientist

Case Notes

• Ms TS• 39 year old female• G7P2• Referred from Eastern Health for management

of high risk pregnancy• A Rh(D) Positive• Anti-Coa identified by the Blood Service• Due 27-Nov-2017

Results

• Group A Rh(D) Positive• Antibody screen Positive (score 3)• All panel cells tested Positive (score 3)• Auto negative

Auto

Anti-Coa

• Described in 1967• CO locus on chromosome 7p• 99.8% of the population is Co(a+)

Antigen Name Frequency Nucleotide Exon Amino Acid

CO1 Coa High 134C 1 Ala 45

CO2 Cob 8.5% 134T 1 Val 45

Problems

• Report from the Blood Service

• What are the risks for•The fetus •The baby•The mother

What is the Risk to the Fetus

• 17-May-17 Titre = 32 (Lab A)• 21-June-17 Titre = 32 (Lab A)• 19-July-17 Titre = 1024 (Lab B)• 03-August-17 Titre = 256 (Blood Service)

• Report from the Blood Service• Mild to Severe HDFN

Risk to the Fetus

• Action • Phenotype the father• He is Co(a+b-)• The fetus is an obligate heterozygote

• Review the obstetric history • Were the two previous neonates affected• Has the anti-Coa titre risen since then

What are the Risks

• Risk of HDFNB• Mild to severe (rare)

• Risk of Transfusion Reaction • No to Moderate / Delayed• Immediate / Haemolytic

What are the Risks

What are the Risks

• Many examples of anti-Coa have been identified. They are generally IgG.

• Anti-Coa has caused severe HDFN and has been implicated in acute and delayed HTRs.

• In vivo survival studies and monocyte monolayer functional assays also predict that anti-Coa has the potential to cause HTRs and Co(a-) red cells should be selected for transfusion to patients with anti-Coa

What are the Risks

Transfusion Medicine 2016, 150 - 152

What are the Risks

Transfusion Medicine 2016, 150 - 152

Management Plan

• Titre is high• Monitor with MCA-PSV by Doppler• Plan for possible IUT• Plan for possible exchange transfusion• Review obstetric risk of blood loss –

management plan for delivery

Blood for IUT

• Extended Maternal Phenotype• C+,c+,E+,e+,K-,Fy(a+b+),Jk(a+b+),M+N-S+s-

Blood for IUT

• August 2017• One suitable donor available now• May be used by NSW on 17-Sep-17

• Another donor will become available on 14-Oct-17

Plan for IUT

• Please keep both donors on hold as “walking donors” to be collected fresh as required

• May not be suitable to donate on the day (influenza season)

• May not still be CMV seronegative

• Good news – NSW did not need the blood. Two donors are available

Plan for IUT

• Updated September 2017• One donor deferred until January• One donor travelling overseas so not available

• No suitable donors in Australia

• Will check possibility of International donation• Problems with < 5 days for international transit

• Have suitable units frozen

Blood for an IUT

Mum is Rh(D) Positive – should we do RhD zygosity testing. If she is

homozygous we can give O Rh(D) Positive blood

Can you Irradiate a deglycerolised frozen unit

Can we use CMV antibody positive as “CMV safe”

Was the frozen unit frozen within 5 days of collection – Is it “fresh”

Get a pre transfusion sample from the fetus (if possible) to open up the donor pool for subsequent IUTs.

Doppler MCA-PSV

Doppler MCA-PSV

Doppler MCA-PSV

Reference Range for PSV MoM

Fetal Doppler Results

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60

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80

90

100

110

24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

MC

A Pe

ak S

ysto

lic V

eloc

ity

(cm

/sec

)

Gestational Age (weeks)

PatientMoM 1.00MoM 1.29MoM 1.50

Mari G. Noninvasive Diagnosis by Doppler Ultrasonography of Fetal Anaemia due to Red Cell Alloimmunization. N Eng J Med 2000. 342 : 9 - 14

Fetal Doppler Results

Obstetric Plan

• Are there obstetric complications• What delivery is planned : caesarean or vaginal• Are there any obstetric risk factors• Is the patient anaemic

• Two previous deliveries with no major blood loss• Induce labour at 37 weeks • 8 to 10-November-17• Hb normal (119 g/L) but borderline Ferritin 15 g/L (15-180)

: patient put on oral iron therapy.: May need for iron infusion if suboptimal response

Transfusion Therapy in Post Partum Haemorrhage at Monash Health

0

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70

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Num

ber o

f Cas

es

Number of Units of RBC

Post Partum Haemorrhage : are we following the Guidelines? Maclachlan K, Rushford K and Wood EM.Poster Presentation. Pathology Update. 2014.

Plan for Delivery Day

• Two units of Co(a-) blood suitable for maternal use.

• One additional unit O Rh(D) Positive unit suitable for neonatal use

• Fresh (< 5 days), CMV seronegative and Irradiated• Cell salvage on standby

Testing the Maternal Plasma

• Reactive with all available panel cells• Coa resistant to denaturation by papain, trypsin,

chymotrypsin, pronase, sialidase and AET• How to detect additional underlying

alloantibodies• Phenotype matched adsorption• IAT Crossmatch against any available units• Do I need to buy some antiserum to check the

phenotype of my donor units

Any Questions?