Hemolytic disease of the fetus/neonate

Giancarlo Mari, Farhan Hanif and Kathryin Drenman KEY POINTS The formation of maternal antibodies to fetal red blood cell (RBC) antigens is called RBC alloimmunization and can lead to hemolytic disease and anemia of the fetus/neonate. The most common antigens causing alloimmunization in the United States today are Rh(D) and Kell. Rh(D) alloimmunization occurs when a pregnant woman develops an immunological response to a paternally derived Rh(D) antigen foreign to the mother and inherited by the fetus. The IgG antibodies cross the placenta, bind to the antigens on the fetal RBCs, and can lead to hemolysis. Kell alloimmunization is usually caused by previous blood transfusions but may also occur by maternal-fetal hemorrhage during pregnancy. Anti-D immune globulin prophylaxis prevents >99% of cases of Rh(D) alloimmunization if given both antepartum and postpartum. It should be given to all Rh(D)-negative women with a negative antibody screen at 28 weeks, and if the neonate is Rh(D) positive, within 72 hours after birth. Anti-D immune globulin can be given as late as 28 days postpartum if previously not given but indicated. Anti-D immunoglobulin prophylaxis is 300 g (1 g = 5 IU) at 28 weeks, as well as after delivery if the neonate is Rh(D) positive. A 100 g dose administered at 28 and 34 weeks is also used. However, there are no trials to directly compare the different regimes. Mothers who are weak D positive (formerly called Du) do not need anti-D prophylaxis. A KleihauerBetke (KB) test should be done to determine the number of fetal cells that has entered the maternal circulation, and hence the appropriate dose of anti-D immune globulin in certain high-risk situations (abdominal trauma, abruption, manual extraction of the placenta, etc.), or when the 100 g dose is used, after delivery of an Rh(D)-negative, nonalloimmunized woman. Currently, there is no prophylactic immune globulin to prevent Kell alloimmunization. If Rh(D) antibodies are detected in the maternal circulation on the antibody screen, the patient is considered alloimmunized. Management of the alloimmunized pregnancy is shown in Figure 52.1. This is based initially on genotyping of the fetus' father and, if necessary, fetal Rh(D) status determination, usually by polymerase chain reaction (PCR) from amniocytes. Maternal blood for fetal DNA testing is also available.

The critical titer for Rh(D) antibody should be determined in each laboratory. Ultrasound using the middle cerebral artery peak systolic velocity (MCA-PSV) has 100% sensitivity for detecting significant fetal anemia (95% CI: 0.861.00), and is the screening method of choice in RBC alloimmunized pregnancies, if available and quality assurance can be confirmed. Compared with amniocentesis for delta OD450, the MCA-PSV assessment is associated with approximately 70% to 80% reduction in the number of invasive tests. Screening with MCA-PSV can be started as early as 15 weeks. If the MCA-PSV is 1.5 multiple of the median (MOM), fetal blood sampling (FBS) is indicated. When a cordocentesis is performed at >24 weeks' gestation, corticosteroids for fetal lung maturation should be considered before the procedure. Blood transfusions should be initiated for fetal hemoglobin 5th percentile. If adequately trained sonographers are not available, screening for anemia should be done with amniocentesis using OD450 values. In Kell-alloimmunized pregnancies, maternal titers do not correlate well with fetal disease. OD450 levels also do not correlate with fetal anemia. However, MCA-PSV screening is predictive and accurate for the diagnosis of fetal anemia from Kell alloimmunization. DEFINITION RBC alloimmunization, formerly known as isoimmunization, or erythroblastosis fetalis, is the formation of maternal antibodies to fetal RBC antigens (1). Maternal RBC alloimmunization can cause hemolytic disease of the fetus/neonate. EPIDEMIOLOGY/INCIDENCE The most common antigen causing alloimmunization is Rh(D) followed closely by the Kell antigen (2, 3). The Rh(D)-negative blood group is found in about 15% of whites, 3% to 5% of black Africans, and is rare in Asians. Spontaneous fetomaternal hemorrhages occur in increasing frequency and volume with advancing age. In 3%, 12%, and 46% of women, 0.01 mL or more of fetal cells in each of the three successive trimesters have been noted using the Kleihauer assay (4). The risk of Rh(D) alloimmunization during or immediately after a first pregnancy is about 0.7% to 1%. The risk of fetal anemia from RBC alloimmunization is about 0.35%, of which about 10% of cases require transfusion. Rh(D) alloimmunization affects 6.7 out of every 1000 live births (5). The Kell (K1) antigen is found on red cells of 9% of Caucasians and 2% of people of African descent. Kell alloimmunization occurs in 1 to 3 per 1000 fetuses (6).

GENETICS Rh(D)-negative pregnant women have a deletion of the sequence on both copies of the short arm of chromosome 1. The Kell glycoprotein is a type II membrane protein with homology to zinc endopeptidases (M13 family) (7). ETIOLOGY/BASIC PATHOPHYSIOLOGY Maternal Rh(D) alloimmunization occurs when a pregnant woman develops an immunologic response to a paternally derived RBC antigenfor example, Rh(D) that is foreign to the mother and inherited by the fetus. The immunoglobulin G (IgG) antibodies cross the placenta, bind to the antigens present on the fetal RBCs, and can cause hemolysis. Hemolysis then causes anemia which, if severe, leads to fetal cardiac failure, edema, hydrops, and eventually fetal death. Other antigens (irregular antigens) than Rh(D) can cause RBC alloimmunization. Alloimmunization of the Kell antigen may be caused by previous blood transfusion or by maternal-fetal hemorrhage during the pregnancy with a fetus who is a Kell antigen carrier (8, 9). The Kell glycoprotein is expressed very early in erythropoiesis (10). Antibody to Kell appears to inhibit erythropoiesis, suggesting another functional role for Kell in addition to its endopeptidase activity (11). NATURAL HISTORY About 17% of Rh(D)-negative women who do not receive prophylaxis become immunized. Over 90% of this immunization occurs from fetomaternal hemorrhage at delivery, and the majority of the remaining 10% occurs in the third trimester. Most of this immunization is caused by 0.1 mL of fetomaternal hemorrhage. Before anti-D immune globulin prevention, hemolytic disease of the fetus/neonate affected 9% to 10% of pregnancies, and was a major cause of perinatal mortality. The risk of RBC alloimmunization from different clinical situations is shown in Table 52.1.

PREGNANCY MANAGEMENT PREVENTION (Anti-D Immunoglobulin) The ABO type, the Rh(D) status, and the antibody screen should be determined in all pregnant women at the initial prenatal visit. If the woman is Rh-negative and the antibody screen is negative, the patient should receive Rh(D) immune globulin. Anti-D immunoglobulin prophylaxis properly given prevents >99% of cases of alloimmunization. It is controversial whether the antibody screen should be repeated at 28 weeks before the administration of immune globulin. The advantage of this second screening test is the detection of those rare cases in which immunization occurs early in pregnancy. After delivery, if the neonate is Rh(D) positive, the patient should receive immune globulin. If the patient has never received immune globulin and the screening test is positive, the patient is at risk for having an anemic baby in the current pregnancy (if she has not delivered yet) or in a future pregnancy if she already has delivered. Usually, the effect of the immune globulin is not present 12 weeks after its administration.

Anti-D immune globulin prophylaxis properly given prevents the majority of cases of alloimmunization. Unfortunately, there is no immune globulin available for prevention of RBC antigens other than Rh(D). Anti-D immune globulin is extracted by cold alcohol fractionation from plasma of individuals with high-titer D IgG antibodies. The risk of transmission of viral infections or side effects is minimal to absent and clinically not a significant factor. The accepted regimes of anti-D immune globulin prophylaxis are (i) 100 g at 28 and 34 weeks and after delivery if the neonate is Rh(D) positive, or (ii) 300 g at 28 weeks and after delivery if the neonate is Rh(D) positive and delivery occurs at least three weeks after the first administration. There are no trials to directly compare these two different regimes, but they probably both achieve >99% prevention of Rh(D) alloimmunization. The half-life of anti-D immune globulin is 16 to 24 days. When the 300 g dose is used and delivery does not occur within 12 weeks of injection, a second 300 g dose of anti-D immunoglobulin should be given. The antibody titer obtained at term is occasionally still positive (1:1, 1:2 titer) after anti-D immunoglobulin at 28 weeks' gestation. When indicated, a second dose of immune globulin is administered after delivery, even in cases of preterm delivery. Mothers who are weak D positive with D present in reduced quantities (formerly called Du) do not need anti-D prophylaxis. Mothers who are partial D positive (lacking some epitopes of D) should receive anti-D immunoglobulin, since they are at risk for hemolytic disease (13). In those cases where the father of the fetus/neonate is definitely known to be Rh(D) negative, neither antepartum nor postpartum anti-D prophylaxis is administered. Evidence for dosing and timing After birth Anti-D immune globulin given within 72 hours after birth is associated with a 96% decreased incidence of Rh(D) alloimmunization six months after birth, and by a 88% decreased incidence of Rh(D) alloimmunization in a subsequent pregnancy in Rh(D)negative women who have given birth to an Rh(D)-positive infant (14). These benefits are seen regardless of the ABO status of the mother and baby. Higher doses (up to 200 g) are more effective than lower doses (up to 50 g) in preventing Rh(D) alloimmunization (14). Anti-D immune globulin can be given as late as 28 days postpartum if indicated but not previously given. Anti-D immune globulin is given to all Rh(D)- negative women after confirmation from cord blood of Rh(D)-positive status of the neonate. Even when

immune globulin is correctly administered and with higher doses, alloimmunization can still occur (antepartum) in up to 2% of these women if only postpartum anti-D is administered. Before birth The addition of anti-D immune globulin 100 g (500 IU) prophylaxis at 28 and 34 week lowers this risk (about 12%) to about 0.2% without any adverse effects (1517). When women receive anti-D immune globulin at 28 and 34 weeks' gestation, there is a trend for less immunization (i) for all women (RR: 0.42, 95% CI: 0.151.17); and (ii) for women giving birth to an Rh-positive infant (RR:0.41, 95% CI: 0.161.04), compared with no prophylaxis (1517). In trials that used a 100 g dose of anti-D immune globulin, there was a nonsignificant reduction in immunization at 2 to 12 months following birth of an Rh-positive infant in women who had received anti-D (RR: 0.14, 95% CI: 0.021.15). However, women receiving anti-D were significantly less likely to have a positive KB test (which detects fetal cells in maternal blood) both in pregnancy (RR: 0.60, 95% CI: 0.41 0.88) and at the birth of an Rh-positive infant (RR: 0.60, 95% CI: 0.460.79) (16). No data were available for the risk of Rh(D) alloimmunization in a subsequent pregnancy. No differences were seen for neonatal jaundice. There are no trials using the 300 g dose, or trials comparing just 28 week versus both 28 and 34-week prophylaxis. Even with antepartum and postpartum prophylaxis, the risk of Rh(D) alloimmunization remains because of inadvertent antepartum or postpartum omission, failure to use the drug for other antenatal complications, and insufficient dosing at delivery in cases of large fetomaternal hemorrhage. Practice guidelines in the United States recommend that anti-D immune globulin be administered early in the third trimester: 300 g at 28 weeks. This practice reduces the incidence of antenatal alloimmunization from 2% to 0.1% (2, 3). In the United Kingdom, 100 g of anti-D immune globulin is given at 28 and 34 weeks (13). In Canada, 100 to 120 g is administered at 28 and 34 weeks.

Special Clinical situations In addition to antepartum and postpartum prophylaxis, other indications for the use of anti-D immune globulin include those situations in which there is significant risk of fetomaternal hemorrhage. These indications are listed in Table 52.1. A repeat dose is unnecessary after prophylaxis if delivery occurs 3 weeks from the last dose. Anti-D immune globulin 300 g protects against 30 mL of fetal whole blood or 15 mL of fetal RBCs in the maternal circulation. In certain high-risk situations in which excessive fetomaternal bleeding may have occurred (e.g., abruption, manual removal of the placenta, abdominal trauma), this dose may be inadequate, and a KB test should be done to determine the amount of fetal cells that have entered the maternal circulation and, hence, the appropriate dose of anti-D immune globulin to be given. Some clinicians have advocated the KB test for all Rh(D)-negative women at delivery, since 50% of cases requiring more than the standard postpartum dose of anti-D immunoglobulin can be missed by high-risk situation screening only (18). The risk of fetomaternal hemorrhage >30 mL is about 0.1% to 0.2%. The anti-D immunoglobulin available in the United States and other countries (RhoGAM, Rhophylac, WinRho, and BabyRho-D) are all very effective, with none shown to be significantly more effective in the prevention of hemolytic disease than the others. Thus cost and route of administration intramuscular (IM) or intravenous (IV) may be the only factors determining choice. Management of RBC allommunized pregnancies Counselling If Rh(D) antibodies are detected in the maternal circulation, for example, positive indirect Coombs, the patient is considered alloimmunized. Among Rh(D) alloimmunized pregnancies, mildto- moderate hemolytic anemia and hyperbilirubinemia occur in 25% to 30% of fetuses/neonates, and 25% of these can develop hydrops (19). With correct management, the perinatal survival rate in cases of anemia is >90%; when fetal hydrops is present, the survival rate is >80%. There is no trial that has assessed the best management for RBC alloimmunized pregnancies; however, fetal transfusion is probably the most beneficial of all the available therapies. Although it is reported that the risk of fetal demise is between 1% and 2% for each FBS, there are situations in which the risk is much higher, such as when cordocenteses and transfusions are performed at gestational ages (GAs) as early as 15 to 18 weeks.

Work-up/investigations required Management of the alloimmunized pregnancy is shown in Figure 52.1. In patients at risk for fetal anemia because of red cell alloimmunization, it is important to perform a first-trimester ultrasound to establish the GA. Assessment for risk of fetal anemia depends on history of previous Rh complications in pregnancies, titer of RBC antibodies, and MCA-PSV values (20, 21). The genotype of the fetus' father can be determined by zygosity testing. The most likely zygosity can also be predicted by evaluating the pattern of C, D, and E loci, since they are inherited together and some combinations are more common than others, but this is not 100% exact and not very useful clinically. If the father is Rh(D) negative, no further testing or intervention is necessary. If the father is heterozygous for the Rh(D) antigen, fetal Rh(D) testing is indicated. If the father is Rh(D) homozygous, the fetus is assumed to be Rh(D) positive and no fetal Rh(D) testing is necessary. Of course, the paternity should be certain; otherwise, fetal testing is indicated. Fetal Rh(D) status can be determined by PCR from amniocytes with >95% accuracy (sensitivity and specificity). This is available in the United States in several centers. One of them is the Blood Center of Southwestern Wisconsin (http://www.bloodcenter.com). This is also available for many other antigens, such as c, E, Kell, M, N, etc. Chorionic villus sampling (CVS) is not advised, as it results in high risk of worsening alloimmunization from fetomaternal hemorrhage. Determination of fetal Rh(D) status can also be obtained noninvasively, with fetal DNA analysis from maternal blood (22, 23). This can be done through the International Blood Group Reference Laboratory in Bristol, United Kingdom (Molecular.Diagnostics@nhsbt.nhs.uk; http://ibgrl.blood.co.uk/), or, currently under a research basis, the Blood Center of Southeastern Wisconsin. Rh(D) antibody titers correlate somewhat with risk of anemia/hydrops, with 1:16 = 10%, 1:32 = 25%, 1:64 = 50%, and 1:128 = 75% risk of anemia. The critical titer should be determined in each laboratory. Unfortunately large differences in titer can be seen in the same woman between laboratories. In most laboratories, the critical titer is 1:16 in albumin or 1:32 in indirect antiglobulin (indirect Coombs test). If the titer is less than 1:16, the fetus is not in jeopardy at that time. However, serial titers should be obtained every four weeks. If the patient has had a prior affected pregnancy, and the fetus is known to be Rh(D) positive, titers are not necessary. The MCAPSV is used to detect those fetuses that are going to develop anemia (24). The presence of additional antibody(ies) with anti-D increases the need for intrauterine fetal transfusions (25).

Ultrasound is the screening method of choice for fetal anemia. With fetal anemia, decreased blood viscosity leads to increased venous return, consequent increase in cardiac output, with increased blood flow velocity in all vessels. Degrees of blood velocity (Table 52.2) correlate with anemia (Table 52.3). The vessel to study is the middle cerebral artery (MCA). The main advantage of the MCA is that it is easy to measure at a 0 angle. In the biparietal diameter view, the MCA can be visualized with color Doppler. The MCA-PSV should be measured at its proximal point, after the origin from the internal carotid artery, at a 0 angle (avoiding angle correction). Measurement at this point allows the lowest intra- and interobserver variability as well as standardization of the measurement (26). Multiples of the median for the hemoglobin concentration and MCA-PSV correct for the effect of GA on the measurement. The MCA-PSV had a sensitivity of 100% (95% CI: 0.86 1.0) for detection of significant fetal anemia with a false-positive rate of 12% at 1.50 MOM in one study (21). Other studies have reported lower sensitivity, but in general above 85% to 90% (27). The number of false-positives increases following 35 weeks' gestation (28). The number of falsepositive cases after 35 weeks may be decreased by looking at the trend of the MCA-PSV (24). Compared with amniocentesis for OD450, the MCA-PSV assessment is associated with a 70% to 80% reduction in the number of invasive tests (21). The MCA-PSV is more accurate than amniocentesis in detecting fetal anemia (27, 2931). The correction of fetal anemia with intrauterine transfusion decreases significantly and normalizes the value of fetal MCA-PSV (32, 33) because of an increased blood viscosity and an increased oxygen concentration in fetal blood. The MCA-PSV may be used in fetuses previously transfused (34, 35). Accuracy with the MCA-PSV can only be achieved with appropriate training and quality assurance. If adequately trained sonographers are not available, screening for anemia should be done with amniocentesis (see below). Screening with MCA-PSV can be started as early as 15 weeks (36). The MCA-PSV can also be used for other causes of anemia, including parvovirus infection, nonimmune hydrops, fetal-maternal hemorrhage, and twin-twin transfusion syndrome. The steps for the correct measurement of the MCA-PSV are the following: (i) An axial section of the head is obtained at the level of the sphenoid bones; (ii) Color Doppler evidences the circle of Willis; (iii) the circle of Willis is enlarged; (iv) the color box is placed around the MCA; (v) the MCA is zoomed; and, (vi) the MCA flow velocity waveforms are displayed and the highest point of the waveform (PSV) is measured. The waveforms should be all similar. The above sequence is repeated at least three times in each fetus. There should be an absence of fetal movement or fetal breathing during measurement of the MCA-PSV.

Severe intrauterine growth restriction also shows an increased MCA-PSV (37). Therefore, this should be taken into account when the MCA-PSV is used to diagnose fetal anemia. However, it is very unlikely that an anemic fetus is also a severe IUGR fetus. Moderate to severe anemia may also be suggested by hydropic signs (at least two of pericardial or pleural effusion, ascites, or skin edema), an increase in the size of fetal liver or placental thickness, or tricuspid regurgitation. Amniocentesis for OD450 measurement is used if accurate MCA screening is not available. The OD450 measurement can be evaluated using either the Liley (38) or Queenan (39) charts. There is controversy over which one is best before 27 weeks, the extended Liley curve or the Queenan curve (40). The guidelines for the amniocentesis are arbitrary and serial MCA-PSV measurements are superior in terms of sensitivity, specificity, and positive and negative predictive values to both the Liley and the Queenan curve (27). If the MCA-PSV test cannot be done and the patient opts for an amniocentesis, the following are general guidelines for managing the Liley curve readings: Zone 1: repeat amniocentesis in two to four weeks. If zone 1, follow with ultrasound every one or two weeks until delivery. Zone 2 (low/middle third): repeat amniocentesis in about two weeks. If low zone 2, follow with ultrasound every week until delivery. If upper third zone 2, consider FBS. Zone 2 (upper third): consider FBS or repeat amniocentesis in 7 days. If again upper third zone 2 or higher, FBS. Zone 3: FBS. The advantage of using Queenan's curve is that it can be used following 14 weeks' gestation. Amniocentesis is associated with a 2% to 3% (up to 15%) risk of fetomaternal hemorrhage. Following fetal transfusions the maternal antibody titer rises significantly.

Fetal intervention An IV transfusion is indicated when the MCA-PSV is >1.5 MOM. (Table 52.2). Other ultrasonographic signs of hydrops may also suggest fetal anemia, or, if OD450 is being used for screening instead of the MCA-PSV, a value in the upper third of zone 2 or zone 3 is an indication for FBS. Transfusion is performed at the umbilical vein either at the placental insertion or inside the abdomen. Intraperitoneal transfusion is rarely performed and it is contraindicated in the hydropic fetus because of the poor absorption of blood. Corticosteroids for fetal maturation should be considered before the procedure when FBS is performed at or after 24 weeks. Type O, Rh(D) negative, cytomegalovirus negative, washed, leukoreduced, irradiated packed RBCs cross-matched against maternal blood should be used. The blood usually contains 75% to 85% RBCs, to allow minimal blood volume for the transfusions (41). The procedure is performed under continuous ultrasound guidance. Prophylactic antibiotics can be given, although no trial has evaluated their efficacy. Following 24 weeks, the procedure should be performed in a location close to the OR and the anesthesiologist consulted should an emergency occur. Tubing and syringes should be heparinized. Maternal skin can be anesthesized with 1% lidocaine at the point of needle entry. A 20- or 22-gauge needle is used for the procedure. After entering the umbilical vein, a sample of fetal blood is withdrawn and the hemoglobin immediately (within one or two minutes) determined. Fetal blood is confirmed by a mean corpuscular volume (MCV) >110 m3. Then the fetus is given a paralytic agent (e.g., pavulon 0.1 mg/kg) to stop fetal movements (42). If the hematocrit is below the fifth percentile (0.84 MOM) for GA, blood is transfused in a sterile fashion. A computer program (e.g., http://www.perinatology.com/protocols/rhc.htm) can be used to estimate the amount of blood to transfuse based on the initial fetal hematocrit, the estimated fetal weight and the concentration of the blood transfused (43, 44). The following formula is used: A final fetal blood sample is taken a few seconds after the transfusion has been completed. If the fetus is hydropic, it is better to perform more than one transfusion at a distance of three to five days to increase the hematocrit to the median hematocrit value for GA. At and after 24 weeks, the fetal heart rate should be monitored for the next two to three hours until fetal movements resume.

The risk of fetal death is 1% to 2% even with ultrasound guidance, expert operators, and accurate management. Thrombocytopenia, even at levels 100,000/mm3, can be found in about 9% of Rh(D) alloimmunized fetuses at times of fetal sampling (45). Thrombocytopenia is associated with fetal hydrops, and with perinatal mortality (45). Intravenous immunoglobulin in addition to fetal transfusion has been studied insufficiently, and is not currently recommended (46). Hematocrit decreases about 1 point per day posttransfusion in the anemic alloimmunized fetus, and this knowledge helps to assess when to repeat the transfusion. If the fetus is nonhydropic, the second transfusion is often necessary 14 days after the first, but after the second/third transfusion, longer intervals of three weeks may be possible as the fetal RBCs are replaced by adult RBCs. Following three transfusions, 99% of the fetal blood is represented by the adult transfused blood. Maternal phenobarbital 30 mg three times per day for 7 to 10 days to enhance fetal liver maturity and ability to conjugate bilirubin is still unconfirmed by large studies (47). Fetal monitoring/testing Fetal testing with nonstress tests (NSTs) or biophysical profiles (BPPs) is started around 32 weeks or earlier if indicated. Its benefit has not been confirmed in a specific trial. Fetuses with very severe anemia (hemoglobin 2 g/dL) due to RBC alloimmunization may develop brain injury (e.g.intracerebellar hemorrhage). Therefore, clinicians have advocated fetal neuroimaging by ultrasound and/or MRI (48). The surfactant/albumin ratio for fetal lung maturity (FLM) cannot be used since high amniotic fluid bilirubin can affect this result. The other tests for FLM are reliable (see also chap. 57). Delivery/anesthesia S e e Figure 52.1 for the timing of delivery. The mode of delivery depends on obstetrical indications. If fetal anemia is suspected during a trial of labor, procedures such as scalp FHR monitoring, scalp pH, and operative delivery should be avoided if possible.

Neonatology management Anemic neonates are usually treated with transfusions or exchange transfusions as necessary. They often need light therapy for hyperbilirubinemia. Breast-feeding is not contraindicated. A hearing screening test is indicated during the neonatal period and at two years of age given that hyperbilirubinemia can cause sensorineural hearing loss. Children who survive severe hemolytic disease (even with hydrops and/or necessitating transfusions) often have a normal neurologic outcome (49). OTHER ATYPICAL ANTIBODIES There are many atypical (irregular) blood group antibodies that are capable of producing hemolytic disease. Given their rarity, and the absence of large studies or any trial, the management of antibodies known to cause hemolytic disease other than Rh(D) is based on poor evidence. Many aspects of management are unknown or similar to Rh(D) alloimmunization, except for the details below. It should be acknowledged that the critical titer for antibodies other than Rh(D) has not been well-established. Kell alloimmunization The incidence of Kell alloimmunization is about 0.1% to 0.3% in pregnant women. Kell alloimmunization is usually caused by prior transfusion. Over 90% of partners of Kellimmunized women are Kell negative. In the white population, only 9% of fathers are Kell positive, and only 0.2% are homozygous. Maternal titers do not correlate well with fetal alloimmune disease. Severe anemia can be diagnosed in fetuses whose mothers had a titer as low as 1:2. OD450 levels also do not correlate with fetal anemia. This is because fetal anemia is not caused by hemolysis, but by suppression of erythropoiesis at the progenitor-cell level. Anti-Kell antibodies specifically inhibit the growth of Kell-positive erythroid burstforming units and colony-forming units (11). In fact, anti-Kell anemic fetuses have lower reticulocyte counts and bilirubin levels compared to anti-D anemic fetuses. The Kell blood group is complex, consisting of over two dozen antigens. Kell 1 (Kell, or K1) and its allelic partner Kell 2 (Cellano, or K2) are strong immunogens. Poor fetal outcome occurs in about 1.5% to 3% of Kell-alloimmunized pregnancies, an incidence that is possibly higher than that of other RBC antigens. The management of Kell sensitization is somewhat controversial. Genotyping of the father of the baby (FOB) is extremely important.

Most will be Kell negative, and, if paternity is certain, no further testing is necessary. The vast majority of Kell-positive FOBs are heterozygote, so the fetal Kell status needs to be determined, usually by amniocentesis PCR. MCA-PSV screening is predictive and accurate for the diagnosis of fetal anemia from Kell alloimmunization (21, 50). MCAPSV monitoring should start at 15 weeks, and be performed as suggested in Figure 52.1. OD450 measurements from amniocentesis are inaccurate and should not be used. Other CDE system antigens c (small): This antigen carries a 65% risk of hemolytic disease; 80% of FOBs are positive, of which half are homozygous, half heterozygous. C (big): This antigen is associated with a 32% risk of hemolytic disease. E (big): E-positive individuals have a 31% risk of hemolytic disease. Maternal titers do not correlate well with fetal hemolytic disease. MNS system Only 1% of titers ever rise to 1:64. Only five cases of severe anemia from anti-M alloimmunization have ever been reported, such that, even if sensitized, the incidence of severe anemia is probably 1%. Others Other rare, but potentially lethal, antigens are Duffy (Fya, Fyb, Fy3, etc.), and Kidd, as well as others.a