Plasmapheresis and intravenous immune globulin for the treatment of D alloimmunization in pregnancy

Abstract

The alloimmunized pregnancy can result in fetal and newborn mortality due to fetal anemia. Control of fetal anemia has not been possible until recently, and management consists of following the degree of fetal anemia during gestation until intrauterine transfusion is feasible to support the fetus until delivery. Cordocentesis and intrauterine transfusion have potential complications that have been well documented. Control of fetal anemia via immune modulation utilizing plasmapheresis and intravenous immune globulin administration has been attempted alone and in combination with varying results. We present a case report of an Rh(D) alloimmunized pregnancy, in which successful management consisted of initial therapeutic plasmapheresis (TPE) followed by intravenous immunoglobulin (IVIG) administration until delivery at 37 weeks gestation without the need for intrauterine transfusion.

Intrauterine transfusion and non-invasive treatment options for hemolytic disease of the fetus and newborn – review on current management and outcome

“…Maternal antibody titers were reduced, IUT seemed to be postponed and all babies were alive and well at birth [78]. Several case reports have been published with favorable outcome following this combined approach [86,[92][93][94][95][96]. Reported side effects of IVIG are rare but may include: headache, fever, myalgia and low back pain, rush or chills, urticaria, nausea and vomiting, tachycardia, chest tightness, hypotension and shortness of breath [42,50,97,98].…”

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

“…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] . A potential explanation for the enhanced perinatal survival reported in these series is that plasma exchange can remove the damaging antibodies but cannot inhibit further antigen stimulation; the adjuvant administration of IVIG would retain this decline in antibody levels, inhibiting a " rebound " effect soon after treatment in the majority of patients [66] .…”

Efficacy of Antenatal Intravenous Immunoglobulin Treatment in Pregnancies at High Risk due to Alloimmunization to Red Blood Cells

“…Several case series and case reports indicate a beneficial role of IVIG, at least in delaying the development of significant anemia [36]. Admittedly, focusing on the reported cases in the literature, the administration of IVIG varied considerably and was inadequate due to low doses, delayed administration (after fetal anemia was already present), and/or inconsequent administration in a number of cases (table 2) [30,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57]. Only one study has shown that the administration of 1 g/kg/week in four women with anti-D did not appear to improve outcomes of affected fetuses [58].…”