Intravenous Immunoglobulin as Primary Therapy or Adjuvant Therapy to Intrauterine Fetal Blood Transfusion: A New Approach in the Management of Severe Rh‐Immunization

Abstract

Maternal high dose intravenous immunoglobulin (IVIG) has shown promise in the management of severe Rh-immunization. Intravenous immunoglobulin, blocks Fe mediated antibody transport across the placenta and blocks destruction of fetal red cells and reduces maternal antibody levels. We have tried this new therapy in 6 patients with severe Rh-immunization, with high maternal antibody titres and previous hydrops and intrauterine deaths. Intravenous immunoglobulin was given from 13-18 weeks of gestation 3-4 weekly, till intrauterine transfusion (IUT) or delivery. Intensive fetal monitoring was done. No fetal hydrops or deaths occurred in any of the 6 cases. Only 2 cases needed intrauterine transfusion. IVIG delayed the onset of fetal anemia by 8-17 weeks thus deferring the need for IUT. All pregnancies continued till 32-36 weeks and all 6 babies did well in the neonatal period.

Therapeutic management of fetal anemia: review of standard practice and alternative treatment options

“…Nevertheless, all nine fetuses subsequently required IUTs but to a later gestational age compared with the previous affected pregnancy, and a more pronounced increase in fetal Hct was achieved with the fi rst therapy. These fi ndings are consistent with other reports, which confi rm that early plasmapheresis followed by the use of high-dose maternal IVIG could be benefi cial in early treatment of severe Rh-alloimmunized pregnancies [16,34] . There are also three articles reporting a total of eight patients with poor obstetrical history who were treated with both plasmapheresis and IVIG administration according to their antibody titers, and all had live-born infants without undergoing transfusion therapy [23,54,91] .…”

“…20 weeks of gestation) [75] . There are few reports in the literature, based on a small series of patients, that suggest the use of combination treatment with plasma exchange and IVIG in severe pregnancy alloimmunization in an attempt to prolong pregnancy to a gestational age at which IUT is technically possible [1,16] . This combined approach has fi rst been described in a variety of immune-mediated diseases such as systemic lupus erythematosus, Sjogren disease, and Guillain-Barr é syndrome [13] .…”

Plasma from human mothers of fetuses with severe arthrogryposis multiplex congenita causes deformities in mice

“…There are several other conditions in which maternal antibodies are known to be pathogenic, including hemolytic disease of the newborn, due to the transfer of antibodies against the rhesus antigen on fetal red blood cells (30,31); neonatal idiopathic thrombocytopenia purpura (32); and heart block that results from transfer of antibodies against Ro or La antigens (33,34). Interestingly, in the congenital heart block, the mother may have systemic lupus erythematosus but is often asymptomatic at the time.…”

Direct Fetal Intravenous Immunoglobulin Infusion as an Adjunct to Intrauterine Fetal Blood Transfusion in Rhesus-Allommunized Pregnancies: A Pilot Study

“…Maternal administration of IVIG reduces the Fc-mediated antibody transport across the placenta and hence reduces hemolysis of fetal RBCs. One study reported that maternal IVIG delayed the onset of fetal anemia by 8-17 weeks, and thus deferring the need for IUT [3]. …”

“…Several investigators have reported the usefulness of maternal high-dose intravenous immunoglobulin (IVIG) therapy in Rh-immunized pregnancies [3,4,5]. However, since IVIG is very expensive, this is not an economically viable option, especially in developing countries.…”