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Beating the odds – Multi disciplinary team effort resulted in survival of a neonate, despite mother having multiple iso-immunizations (Anti-D, C, E) with Methylenetetrahydrofolate reductase (MTHFR) deficiency and Antiphospholipid syndrome
Abstract Number: T 72
Abstract Type: Case Report/Case Series
Rh-D iso-immunization has decreased significantly due to widespread use of Rh-D immunoglobulin, but has led to the relative increase in the presentation of Rh-C and E iso-immunization as a cause for Hemolytic Disease of Newborn (HDN). We present a survival of newborn, who received multiple Intra Uterine Transfusions (IUT) and exchange transfusions for HDN, despite mother being developed Anti-D, Anti-C, and Anti-E antibodies in her blood. She was also diagnosed with Methylenetetrahydrofolate reductase (MTHFR) deficiency and Antiphospholipid Syndrome (APS).
Case Description & Management
A 28 yr old G5 P1122 was admitted at 26 weeks gestation with severe HDN for IUT and fetal anemia was diagnosed due elevated peak systolic velocity (PSV) of middle cerebral artery (MCA).
The mother was Rh-D, C and E negative and developed Anti-D, Anti-C and Anti-E antibodies from allo-immunization with Antiphospolipid syndrome and MTHFR heterozygote. Her obstetric history included two abortions, one full term and one pre-term baby.
The obstetric management of this pregnancy included intra-uterine transfusions at 26, 28 and 29 weeks, under combined spinal epidural anesthesia. Patient delivered a preterm baby at 30 weeks and 2 days by Cesarean section under spinal anesthesia with 1, 5 & 7 apgar, Hb 4.6 and Hct 13.8. The neonate was admitted to NICU, received two partial exchange blood transfusions and two platelet transfusions. Against all these odds, the baby was discharged home in stable condition on the 34th post-delivery day.
Both MTHFR and APS cause thrombophilia leads to early abortion, coronary artery occlusions, and venous thrombosis in parturient, requiring anti-coagulation throughout pregnancy . Neuraxial block in an anti-coagulated patient is a challenge for anesthetic management, particularly in this patient who required multiple interventions under regional anesthesia. Most cases of allo-immunization with Anti-C and Anti-E are resulted in mild to moderate HDN, except few cases requiring intrauterine transfusion as reported in literature . We believe that timely coordinated multidisciplinary team effort is the key for successful management of complicated cases like this leading to good outcome.
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reductase mutation in women with recurrent spontaneous abortions: a new path to thrombophilia?
Sao Paulo Med J. 2005 Jan 2;123(1):15-20
2. Murki S, Kandraju H, Devi SA. Hemolytic disease of the newborn- anti c antibody induced
hemolysis.Indian J Pediatr. 2012 Feb; 79(2):265-6