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Transfusion management in a pregnant patient with IgA deficiency undergoing cesarean delivery
Abstract Number: SUN-06
Abstract Type: Case Report/Case Series
Introduction: IgA deficiency is associated with anaphylaxis following blood transfusion. We present a case of a parturient scheduled for repeat cesarean delivery who had combined variable immunodeficiency (CVID) with IgA deficiency and discuss the relevant blood component therapy considerations.
Case: 27 year-old G3P2 presented at 39.1 weeks for her scheduled third cesarean delivery. Her medical history was notable for CVID diagnosed in the interval between her second and third pregnancies. Her symptoms included multiple bouts of sinusitis, pneumonia and empyema that required a thoracotomy. She was being treated with 35g of immune globulin (IVIg) every 3 weeks. She also had A2 gestational diabetes mellitus, well controlled on glyburide. Her most recent IgA levels were from 2014 and were <25 mg/dL (normal>70 mg/dL). The blood bank pathologist recommended drawing anti-IgA antibodies and IgA levels, and noted that she would require single-washed packed red blood cells (pRBCs) and double-washed platelets if clinically indicated. IgA deficient fresh frozen plasma (FFP) and cryoprecipitate (cryo) were not immediately available, and would have to be requested from a regional blood bank center, taking several hours to days to procure. Given her low risk for postpartum hemorrhage, we proceeded with cesarean delivery after cross-matching for 2 units of single-washed pRBCs, and it was uneventful with no transfusions required.
Discussion: The incidence of IgA-related anaphylactic reactions to blood transfusions is approximately 1 in 50,000 (1). Although more common in patients with undetectable IgA levels (<0.05 mg/dL) or those with a history of previous reactions, it is important to be aware of blood product availability and transfusion management in parturients presenting for cesarean delivery. Considerable time is needed for single-washed pRBCs (at least 1 hour) and double-washed platelets (at least 2 hours). FFP and cryo must be procured from IgA deficient patients, which can be very difficult depending on location and blood bank supply. The American Rare Donor Program tracks availability and regulates the supply of IgA-deficient plasma, and generally requires demonstration of anti-IgA antibodies prior to dispensation. The overall predictive value of anti-IgA antibodies causing anaphylaxis is questionable, with anaphylaxis occurring in only 2.4% of patients with positive antibodies, and antibodies detected in only 18.1% of patients with presumed IgA-related anaphlyaxis (2). This case demonstrates the importance of preanesthesia consultation and communication between the multiple disciplines in all complicated patients.
1) Review: IgA anaphylactic transfusion reactions. R Vassallo Immunohematology, 2004 Vol.20(4), p226-233
2) IgA anaphylactic transfusion reactions. SG Sandler D Mallory R Malamut Eckrich. Transfusion medicine reviews 1995, Vol.9(1), p1-8