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Placental abruption and autoimmune haemolytic anaemia in a parturient who had undergone lymphocyte immunization therapy
Abstract Number: SUN-02
Abstract Type: Case Report/Case Series
A 42-year-old woman with a complex obstetric and hematological history presented to labor ward with acute shortness of breath, at 24 weeks’ gestation. She was G26 P0, with 4 previous intrauterine deaths and 21 miscarriages. The patient was on treatment dose low molecular weight heparin for a pro-thrombotic state despite a negative thrombophilia screen. The patient was undergoing lymphocyte immunization therapy (LIT) injection of her husband and 3rd parties’ blood subcutaneously with the aim to prevent further miscarriage. She walked into the delivery suite with BP 115/60mmHg, HR 126 b/min and Hb 37g/L. Further labs revealed a hematocrit 0.124%, MCV 93.9fL, MCHC 338g/L, platelets 198x109/L and LDH 444 U/L, with a normal clotting profile and fibrinogen of 4.8 mg/dL. Immediate resuscitation was commenced with packed red cells (PRCs). Urgent advice from hematology was sought, but with little was known about complications of LIT. After 90 minutes of resuscitation (4 units PRCs, 1 L crystalloid), venous blood gas demonstrated Hb 50 g/L and a lactate of 4 mmol/L. Ongoing bleeding was suspected, so caesarean delivery under general anesthesia was commenced. Despite 2L of intra-uterine blood and evidence of placental abruption, a live infant was delivered. The patient was transfused a further 8 units PRCs, 4 units FFP and fibrinogen concentrate without the need for vasopressors. She was transferred to intensive care and extubated at 6 hours. There was a good recovery despite developing autoimmune hemolytic anaemia (AIHA) on day 3, requiring treatment with intravenous immunoglobulin.
LIT is an immunotherapy involving exposure to paternal or 3rd party antigens to ameliorate immunological rejection of the fetus. Concerns have been raised regarding the manufacturing and preparation of the cells administered, leading to transmission of communicable disease. There are contrasting studies on the benefits of LIT. One study showed a higher rate of subsequent miscarriage compared to placebo.1 A Cochrane review did not support the use of LIT to improve live birth rate after recurrent miscarriage.2 Severe anaemia in this patient did not improve despite blood transfusion which suggested ongoing bleeding. Recent invasive allogenic immunotherapy potentially complicated further blood product transfusion. AIHA may have been precipitated or exacerbated by LIT and further blood transfusion.
In summary, LIT may have contributed to the placental abruption and subsequent AIHA in this patient. Further work is needed to investigate the hematological side-effects of this procedure on patients with previous allogenic immunotherapy or hematological intervention.
1. Ober C et al. Mononuclear-cell immunisation in prevention of recurrent miscarriages: a randomised trial. The Lancet. 1999;354:365.
2. Wong LF, Porter, TF, Scott JR. Immunotherapy for recurrent miscarriage. Cochrane Review, Cochrane Pregnancy and Childbirth Group. 21st October 2014. DOI: 10.1002/14651858.CD000112.pub