Autoimmune hemolytic anemia in pregnancy

Abstract

Patient: 26-year-old female Past Medical History: Patient had a history of chronic hypertension (BP 132/78). She was not on any antihypertensive medication (such as Aldomet). On her initial crossmatch, she tested O positive with negative antibody screens and 2 immediate spin compatible red cells units were transfused. Two subsequent specimens submitted 3 and 5 days later tested the same, and no transfusions were necessary. Three weeks later, on a prenatal visit at 20 weeks gestation of her latest pregnancy, she presented with shortness of breath, fatigue, and dizziness and was found to be severely anemic (hemoglobin 5 g/dL, baseline 11 g/dL). She received blood transfusions at an outside institution and was subsequently transferred to our institution for further management. Initial laboratory results are shown below (Table 1). She was type O Rh positive with detectable anti-E, a strong panagglutinating warm autoantibody, and a history (from the sending hospital) of anti-C and -K. Phenotypically matched red blood cells negative for C, E, K, Fy(a), and S antigens were transfused. Serologic tests for HIV, HBsAg, and RPR were negative. Culture for Group B strep (Streptococcus agalactiae) was negative, and Chlamydia/gonorrhea was not detected. She was transfused with a total of 10 additional red cell units and was placed on high-dose intravenous steroids, which was later shifted to an oral preparation. Her other medications included prenatal vitamins and iron. She was poorly compliant with the steroid treatment, and due to severe anemia she required 3 hospitalizations during the pregnancy. She delivered a preterm male infant at 36 weeks gestation by normal spontaneous delivery 2 months later. During labor she was mildly pre-eclamptic and was given magnesium sulfate. The infant had good Apgar scores (8 and 9 at 1 and 5 minutes respectively) and was not jaundiced or anemic. He was type O Rh positive with a positive DAT. Elution studies were positive for the maternal warm autoantibody only. He was admitted to the newborn nursery, and on the second day of life he was noted to have mild abdominal distention with a slight drop of his temperature (from 97°F at birth to 96.4°F). As a result a possible infection was suspected. Blood cultures were obtained, and antibiotics were initiated. The abdominal distention subsequently resolved. His blood cultures were negative, hemoglobin remained stable at 16 g/dL (reference interval 13.5-19.5 g/dL), and no jaundice was observed. He was discharged from the hospital after a week of antibiotic treatment in stable condition. The mother had 3 subsequent transfusion episodes totaling 9 red cell units over the following 8 months. Principal Laboratory Findings: Table 1.