Prevention of Rh sensitization in the context of trauma: Two case reports

Abstract

Background: Transfusion of D1 red blood cells (RBCs) to D2 recipients can be accidental or necessary due to D2 RBC shortage. Alloimmunization can complicate future transfusions; implications for women of childbearing age are compounded by possible hemolytic disease of the fetus and newborn. Rh immunoprophylaxis is effective, and indicated, for preventing alloimmunization. Reports of massive D1 mismatch (e.g., in the case of fetalmaternal bleed) are limited, and standard recommendations for managing these rare events are lacking. The cases discussed herein of women of childbearing age who suffered severe trauma requiring emergency surgery illustrate the dilemma of determining the ideal strategy for Rh immunoprophylaxis. Case reports: The first patient received two units of mismatched RBCs and was treated with intravenous Rh immune globulin (IV RHIG; Rhophylac 1 , CSL Behring, Kankakee, IL) monotherapy beginning 49 h postsurgery. For the second patient, who received three units of D1 RBCs, partial RBC exchange transfusion, followed 48 h later by IV RHIG, was deemed appropriate based on the large volume of RHIG needed and concerns of hemolytic transfusion reaction and hyperbilirubinemia. Both patients recovered in full without further intervention; the first patient delivered a healthy child 11 months posttreatment. Conclusions: Rh immunoprophylaxis is effective, and indicated, for preventing alloimmunization in women of childbearing age to protect the mother, fetus, and newborn.

Critical updates in the 7th edition of the American Society for Apheresis guidelines

“…Thus, these patients may be at risk of anti‐D formation (∼20% for RBC transfusions and <4% for PLT transfusions [likely lower for apheresis PLTs]), which may be important in females with childbearing potential due to risk of severe HDFN in future pregnancies . Hence, therapies, such as Rh immunoglobulin (RhIG) and/or RBCx may be provided to remove such Rh(D)‐positive RBCs – this is typically done when the Rh(D)‐positive RBC content is >20% of the RBC volume based on the new ASFA guidelines, which were derived from successful case reports and small case series . If performed, both RBCx procedure and RhIG administration should be completed within 72 h from Rh(D)‐positive RBC exposure (deriving from RhIG usage during pregnancy) .…”

“…If large RhIG doses are necessary, they may be spaced out in 8 h intervals. Most patients did not show evidence of acute hemolysis although several patients experienced RhIG reactions, such as urticaria, achiness, and respiratory distress …”

“…[128][129][130] Hence, therapies, such as Rh immunoglobulin (RhIG) and/or RBCx may be provided to remove such Rh(D)-positive RBCsthis is typically done when the Rh(D)-positive RBC content is >20% of the RBC volume based on the new ASFA guidelines, which were derived from successful case reports and small case series. 10,[131][132][133][134][135][136][137] If performed, both RBCx procedure and RhIG administration should be completed within 72 h from Rh(D)-positive RBC exposure (deriving from RhIG usage during pregnancy). 138 However, the inherent risks of these therapies, e.g., acute intravascular hemolysis leading to renal failure, DIC, and other complications, should be balanced against the risk of alloimmunization, the likelihood/desire for future pregnancies, and/or the risk of HDFN.…”

“…Most patients did not show evidence of acute hemolysis although several patients experienced RhIG reactions, such as urticaria, achiness, and respiratory distress. 131,132,134 4.9 | Pruritus due to hepatobiliary diseases Chronic pruritus (or "itching") can occur due to many conditions, but it is especially common in patients with hepatobiliary disorders, such as primary biliary cirrhosis (PBC) and primary sclerosis cholangitis (PSC) with up to 80% of patients suffering from it. 10 The pathophysiology behind pruritus is unclear at this time; however, a recent study revealed that neuronal activator lysophosphatidic acid and autotaxin levels correlate with disease severity and response to treatment, but the reasons remain unclear.…”

Red cell exchange to mitigate a delayed hemolytic transfusion reaction in a patient transfused with incompatible red blood cells

“…Red cell exchange is a procedure that is indicated more commonly for acute exacerbations of sickle cell disease, and severe erythrocytic parasitemia in malaria or babesiosis . It has also been used rarely in the treatment of ABO hemolytic transfusion reactions and in preventing sensitization to Rh‐positive red blood cells following transfusion in two trauma cases . We report a case of a delayed hemolytic transfusion reaction due to anti‐e, an antigen in the Rh blood group system, after a liver transplant which was a consequence of receiving incompatible red blood cells (RBC) transfused emergently during surgery that was treated successfully using an automated red cell exchange.…”