PFM.51 Fatal transfusion-associated graft vs host disease (TA-GvHD) following emergency intrauterine transfusion of maternal blood: case report and survey of UK practice

Abstract

For intrauterine transfusion (IUT) specific red cells are provided by UK Blood Services, irradiated to prevent TA-GvHD. A fetus (21/40) was referred to a fetal medicine centre (FMC), severely anaemic (parvovirus) requiring urgent IUT. Maternal blood was transfused to fetus. Following poor cardiac output, further emergency intracardiac transfusion gave improvement. At 32/40 baby was delivered, severely hydropic and pancytopenic (aplasia later confirmed by marrow aspirate). Hyperbilirubinaemia and fungal chest infection followed. Mother was HLA homozygous. Chimerism studies confirmed maternal engraftment and TA-GvHD. Baby underwent stem cell transplantation, but died of pneumonitis. The case was reported to the Serious Hazards of Transfusion (SHOT) national haemovigilance scheme. A questionnaire was sent to the other 15 FMCs in England and Scotland to establish wider practice. 15/15 centres replied. 1/15 had used maternal blood (non-irradiated), once in 5 years, for bleeding during platelet IUT. 2/15 had used non-IUT blood (leucodepleted), for 8 IUTs: 1 irradiated neonatal exchange blood, rest non-irradiated neonatal ‘paedipacks’. 10/15 would transfuse alternative red cells if IUT units unavailable in emergency, 5/15 would not/had not. Preferred alternative varied, 3/11 would consider maternal blood. This rare case of TA-GvHD occurred following high-risk transfusion: to a fetus, with fresh, HLA homozygous, maternal blood, neither irradiated or leucodepleted. Use of maternal blood for IUTs is unusual in UK centres. Maternal blood for IUT is not recommended in the UK. FMCs should develop transfusion protocols for emergency red cell provision for IUT. Alternatives include neonatal paedipacks or exchange transfusion units, irradiated whenever possible.

How do we perform intrauterine transfusions?

“…71 Although transfusion reactions with IUT are rare and likely under recognized, there have been a few reports of TA-GVHD following IUT. 72,73 Accurate linkage of blood components from a donor to a recipient is critical for ensuring patient safety by permitting lookback and product withdrawal investigations if the donor is subsequently found to be at risk of relevant transmissible diseases or ineligible for donation. 74 An ethical consideration for IUT is documentation of a transfusion for a fetus that is not yet born.…”

“…All transfusions must be documented in the patient's medical record with information that includes component name, donation identification number (DIN), volume transfused, transfusion start and end date and times, patient monitoring, and any transfusion‐related adverse events 71 . Although transfusion reactions with IUT are rare and likely under recognized, there have been a few reports of TA‐GVHD following IUT 72,73 . Accurate linkage of blood components from a donor to a recipient is critical for ensuring patient safety by permitting lookback and product withdrawal investigations if the donor is subsequently found to be at risk of relevant transmissible diseases or ineligible for donation 74…”