Clinically significant hemolytic disease of the newborn secondary to passive transfer of anti‐D from maternal RhIG

• DOI: 10.1111/trf.12698
• Publication Date: 2014-05-14T10:21:01Z
• Authors: Daniel N. Cohen; Mary S. Johnson; Wayne H. Liang; Heather L. McDaniel; Pampee P. Young
• Keywords: Adult; L-Lactate Dehydrogenase; Rho(D) Immune Globulin; Infant, Newborn; Prenatal Care; 3. Good health; Erythroblastosis, Fetal; 03 medical and health sciences; 0302 clinical medicine; Isoantibodies; Pregnancy; Humans; Female; Hyperbilirubinemia

BackgroundRhIG is used worldwide to reduce the incidence of alloimmunization to D during pregnancy. We report a case of clinically significant neonatal hemolysis mediated by maternally administered RhIG.Case ReportA 25‐year‐old, O–, primigravid mother with a negative antenatal antibody screen delivered a 6‐lb 4‐oz, blood group A, D+ baby girl at 36.5 weeks' gestation. Prenatal care included a dose of intramuscular RhIG at 28 weeks' gestation. At delivery, the newborn was markedly jaundiced with a total bilirubin of 6.3 mg/dL, which reached more than 20 mg/dL after 6 days. The newborn's lactate dehydrogenase (LDH) was 485 U/L (normal, <226 U/L) and further laboratory studies revealed reticulocytosis (17.2%; normal range, 0.36%‐1.9%) and a hemoglobin (Hb) of 14.3 g/dL (normal for age range, 13.4‐19.8 g/dL) that decreased to 11.5 g/dL (normal for age range, 13.5‐22.6 g/dL) by Day‐of‐life 7. Although the maternal antibody screen was negative, the newborn's direct antiglobulin test (DAT) was positive for immunoglobulin (Ig)G, with an anti‐D identified by elution studies. The possibility of hemolytic disease of the newborn (HDN) due to anti‐A was considered, but ultimately ruled out by the absence of anti‐A1 in the eluate. The newborn's hyperbilirubinemia was adequately managed with phototherapy. Analysis of the mother's plasma 10 days postpartum revealed an anti‐D titer of 8. Two months after birth, the child's laboratory studies, DAT, antibody screen, and peripheral smear were unremarkable.ConclusionIn the context of neonatal anemia, elevated LDH, and reticulocytosis, a positive IgG DAT with anti‐D identified in the eluate suggests RhIG‐mediated HDN. This appears to be a rarely reported event.