 |
 |
 |
|
| home | CME | help | feedback | subscriptions | archive |
|
© 1999 The Journal of Bone and Joint Surgery, Inc. Hemolytic Disease of the Newborn Caused by Transfusion of a Husband's Directed Blood Donation. A CASE REPORT*   Investigation performed at the Departments of Pathology, Obstetrics and Gynecology, and Surgery, College of Medicine, Ohio State University, Columbus
The demand for directed blood donation in the United States is small but consistent20,21. However, with our current knowledge of alloimmunization and graft-versus-host disease, directed blood donation has been shown to have adverse effects in some recipients1,10,19. To prevent graft-versus-host disease, the Standards Committee of the American Association of Blood Banks1 now requires gamma irradiation of blood that has been donated by the blood relatives of patients. Furthermore, the latest edition of the Technical Manual of the American Association of Blood Banks advises that a woman who is planning to bear children should not receive a transfusion of red blood cells from her sexual partner or his blood relatives19. We report a case of hemolytic disease of the newborn that was caused by the transfusion of red blood cells from a husband to his wife after she had an elective total hip replacement five months before becoming pregnant.
In 1990, a twenty-five-year-old woman had insertion of a non-porous-coated titanium Omniflex femoral prosthesis and a dual-geometry acetabular component (Osteonics, Allendale, New Jersey) at a large medical center in another state. Around 1992, she began to have pain in the anterior aspect of the thigh. In 1994, the patient had radiographic evidence of distal femoral osteolysis adjacent to the bullet tip of the prosthesis. She also had proximal femoral metaphyseal osteolysis and acetabular osteolysis. During November 1994, the patient donated three units of autologous blood and her husband donated one unit of directed-donor blood. At the time of the preadmission testing on November 22, 1994, the hemoglobin level was ninety-three grams per liter and the hematocrit was 27.2 percent. On December 7, 1994, the patient had excision of the old scar; complete synovectomy of the hip with removal of the osteolytic capsule, reactive synovial tissue, and granulomatous debris; and débridement, curettage, and bone-grafting at the sites of the osteolytic lesions of the anterior column of the pelvis and the proximal end of the femur. A revision total hip replacement was performed with use of a size-15 Prodigy hip system with an 8.5 (twenty-eight-millimeter) Articul/eze ceramic ball and a fifty-eight-millimeter Duraloc cup with an Enduron 10-degree-elevated-lip polyethylene liner (all components manufactured by DePuy, Warsaw, Indiana). During the procedure, 1870 milliliters of shed blood was processed with a Cell Saver (Haemonetics, Braintree, Massachusetts) and 520 milliliters of processed blood was returned to the patient; the hematocrit was 29 percent. In the recovery room, the hemoglobin level was eighty-eight grams per liter and the hematocrit was 26 percent. One unit of autologous blood was transfused. On the next day, the hemoglobin level was eighty-one grams per liter and the hematocrit was 23.3 percent, and the second unit of autologous blood was transfused. On the third day, the hemoglobin level was seventy-eight grams per liter and the hematocrit was 22.7 percent; the third unit of autologous blood and the unit of directed-donor blood were transfused. During the rest of the stay in the hospital, the hemoglobin level and the hematocrit were stable. On the day of discharge, December 14, 1994, the hemoglobin level was 103 grams per liter and the hematocrit was 30.0 percent. The rehabilitation was uncomplicated. On June 13, 1995, the patient (gravida I, para 0) was seen by her obstetrician for her first prenatal visit at five weeks of gestation. Blood was collected and sent to our transfusion service for routine typing and screening. She was typed as O Rh(D)+ and found to have the alloantibody anti-c, which titered to 128 with the use of saline-to-antihuman-globulin technique. She typed as C+ and c-. Her husband was typed as O Rh+, C+, and c+. At eleven weeks of gestation, amniotic fluid was sent for DNA analysis, which predicted that the fetus was heterozygous Cc. Amniocentesis was performed every two to three weeks during the second and third trimesters to measure the bile pigments in the amniotic fluid. The results indicated that the fetus had mild hemolytic disease (high in zone I in the modified Liley graph13) until thirty-three weeks of gestation, when the analysis indicated moderately severe hemolytic disease (middle of zone II). Labor was induced at thirty-four weeks of gestation. At birth, the infant weighed 2480 grams and had an Apgar score of 9 points. The blood in the umbilical cord was found to be type O Rh+ with a 2+ direct antiglobulin (Coombs') test. The total bilirubin level was 107 millimoles per liter (normal, 0.0 to 25.6 millimoles per liter), the hemoglobin level was 119 grams per liter (normal, 139 to 196 grams per liter), and the hematocrit was 34.5 percent (normal, 41.7 to 58.8 percent). The serum bilirubin level increased to 263 millimoles per liter (normal, 17.1 to 102.6 millimoles per liter) by thirteen hours after birth. A two-volume exchange transfusion was performed, which reduced the serum bilirubin level to 174.4 millimoles per liter on the second day after birth and to 138.5 millimoles per liter on the third day after birth. The baby was otherwise healthy and was discharged to home on the fifth day after birth.
Patients are concerned about transfusions because of widespread media attention on the transmission of the human immunodeficiency virus through blood and blood products. However, as has been stated numerous times in recent years, the blood supply has never been safer. In a study published in 1996, the authors estimated that the risk of giving blood during an infectious window period was one in 493,000 for the human immunodeficiency virus, one in 103,000 for the hepatitis-C virus, and one in 63,000 for the hepatitis-B virus15. Patients believe that the safest donors are those whom they know intimately. Studies have shown, however, that directed donors are no safer than anonymous community donors6,9. The potential problems and disadvantages associated with directed donation are many. Donors may believe that they were coerced into donating blood or that their answers will not be kept confidential and thus they may not tell the truth about risk factors, which increases rather than decreases the risk to the patient. Donors may not be compatible with the patient with respect to either the ABO or the Rh type, so that the patient may be unable to recruit enough donors or may need to recruit a large number of donors to obtain the required number of units11. According to a recent multi-institutional study7, the cost of blood from directed donors is about 33 percent higher than that from volunteer community donors; the additional cost associated with directed donation may be passed on to the patient or borne by the medical center. Furthermore, the use of blood relatives as donors has the added risk of graft-versus-host disease because these donors may share HLA haplotypes with the recipient1. There is also a risk of future hemolytic disease of the newborn if a husband or one of his blood relatives is the donor10. Many physicians have argued against directed donation, pointing out the many just mentioned disadvantages and the few advantages3,12,14,17,22. The consensus is that the principal advantage is psychological. Goldfinger presented data that supported directed donation and argued that the main advantage was the peace of mind of the patient8. However, if the patient has an adverse outcome because of the directed donation, that argument is not valid. One patient sued successfully because he was infected with the human immunodeficiency virus after receiving blood from a directed donor22. It could be debated whether the transfusions of autologous and directed-donor blood in the present study were necessary, particularly since the patient was an otherwise healthy twenty-nine-year-old woman. Guidelines for the transfusion of red blood cells were recently published by the American Society of Anesthesiologists2 and the College of American Pathologists16. Both groups recommend transfusion when the hemoglobin level is less than sixty grams per liter. When the hemoglobin level is sixty grams or more per liter, transfusion is reserved for patients who have cardiovascular disease or another condition that requires a higher oxygen-carrying capacity and for patients who have symptoms attributed to anemia. Our patient received four units of red blood cells, and she had a hemoglobin level of 103 grams per liter at the time of discharge; we estimated that the hemoglobin nadir would have been about sixty grams per liter without the transfusion. A small group of transfusion-medicine specialists recently contended that the transfusion trigger has become too low and suggested that transfusion should be performed to achieve hemoglobin levels closer to 100 grams per liter18. The case of our patient demonstrates the danger of using the husband as the blood donor for his wife. In 1946, Coombs et al. reported anti-K antibodies in a woman who had received a transfusion of her husband's blood5. In 1949, Chown also reported on a woman who had anti-K antibodies that had been stimulated by her husband's blood4. Chown concluded: "Never transfuse a woman with her husband's blood." We now reiterate that advice of fifty years ago. Kanter and Hodge calculated the relative risk of hemolytic disease of the newborn resulting from directed donations from relatives10. For white couples, a directed donation from the husband had the highest risk (59 percent). For black couples, a directed donation from the husband had a risk of 24 percent. The risk remained more than 10 percent for all of the relatives of the husband, including cousins, nieces, and nephews. Hemolytic disease of the newborn is caused by the transport, across the placenta, of maternal IgG antibodies specific for paternal antigens on the fetal red blood cells. The production of these maternal antibodies is stimulated by previous transfusion or pregnancy. When the husband's blood is transfused to the wife, the red blood-cell, white blood-cell, and platelet antigens not shared by the wife can be antigenic and stimulate the production of alloantibodies. These same unshared antigens can be inherited by the fetus, potentially resulting in hemolytic disease of the newborn, neonatal alloimmune neutropenia, or neonatal alloimmune thrombocytopenia. Hemolytic disease of the newborn is the most common of these. The severity of hemolytic disease of the newborn depends on the titer, avidity, and other characteristics of the IgG antibodies. In addition, when hemolytic disease of the newborn has occurred during a pregnancy, future pregnancies usually are affected, with similar or increased severity. Severely affected fetuses require intrauterine transfusions, which are technically difficult, are not without risk to the fetus, and are performed at only a few medical centers that have a high-risk-pregnancy program.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
#Ohio State University, 317 Doan Hall, 410 West Tenth Avenue, Columbus, Ohio 43210.
  CiteULike  Connotea  Del.icio.us  Facebook  Technorati  Twitter What's this?
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Top
Introduction
Case Report| home | CME | help | feedback | subscriptions | archive | site index |
|
Stanford University Libraries' HighWire Press (TM) assists in the publication of JBJS Online. |