Blood Bank Case Studies

Intrauterine Fetal Transfusion

Sheri Hugan, MLS (ASCP) CM SBBCM

University of Michigan

Objectives

Testing performed in Blood Bank prior to IUT

Preparing a unit of blood for an IUT

Assist during the procedure

Our Patient

21 year old gravida 4, para 2-0-1-1

25 weeks gestation

Elevated peak systolic velocities of the middle

cerebral artery consistent with fetal anemia

Prenatal testing

Type and screen

Antibody identification

Titer antibodies known to cause HDFN

Type and Screen

Automated

Gel

Anti-A 4+

Anti-B 0

Anti-D 0

Rh Ct 0

A1 1+

B 4+

S I 4+

S II 4+

Initial Panel

Cell D C E c e K k Fy

a

Fy

b

Jk

a

Jk

b

Le

a

Le

b

S s M N P1

Gel

15’

37C

IgG

Ficin

Gel

15’

37C

IgG

1 R1R1 + + 0 0 + 0 + + 0 0 + 0 + + + + 0 + 4+

2 R1R1 + + 0 0 + + + + + + + + 0 + + + + 0 4+ 4+

3 R2R2 + 0 + + 0 0 + + 0 + + 0 0 0 + + + 0 4+ 4+

4 Ror + 0 0 + + 0 + 0 0 + + 0 0 0 + 0 + + 4+

5 r’r 0 + 0 + + 0 + + + + 0 + 0 + 0 + + + 3+ 4+

6 r’’r 0 0 + + + 0 + 0 + + + 0 0 + 0 + 0 + 2+ 0

7 rr 0 0 0 + + + + 0 + + 0 + 0 + + + + + +/- 0

8 rr 0 0 0 + + 0 + + 0 + 0 0 + 0 + + 0 + 2+ 0

9 rr 0 0 0 + + 0 + 0 + 0 + 0 + + 0 + 0 + 2+

10 rr 0 0 0 + + 0 + 0 + + 0 0 + 0 + 0 + +s 0

11 R1R1 + + 0 0 + 0 + 0 + 0 + 0 + 0 + + + + 4+

Auto 0

Selected Cells

Cell D C E c e K k Fy

a

Fy

b

Jk

a

Jk

b

Le

a

Le

b

S s M N P1

Gel

15’

37C

IgG

Ficin

Gel

15’

37C

IgG

1 rr 0 0 0 + + 0 + 0 + 0 + 0 + + 0 + 0 + 2+

2 rr 0 0 0 + + + 0 0 + 0 + 0 + 0 + 0 + + 0

3 rr 0 0 0 + + 0 + + + + + 0 + + + + 0 0 2+

4 r’’r 0 0 + + + 0 + + 0 + 0 0 + 0 + 0 + + 0

5 rr 0 0 0 + + 0 + + + + + 0 + + 0 0 + + 0

6 r’r 0 + 0 + + 0 + + + 0 + 0 + 0 + + + + 4+

7 r’’r 0 0 + + + 0 + 0 + + + 0 + + + + + + 0

8 r’r 0 + 0 + + 0 + + + 0 + 0 + 0 + + + + 4+

9 rr 0 0 0 + + + + 0 + + 0 + 0 + + + 0 + 0

10 ROr + 0 0 + + 0 + + 0 + + 0 + 0 + 0 + + 4+

11 ROr + 0 0 + + 0 + 0 0 0 + 0 0 0 + 0 + + 4+

Antigen Typing

D C E c e Ct

0 0 0 4+ 4+ 0

M N Ct

0 4+ 0

Blood Type Resolution:

Confirm Room Temp Anti-M Reactivity

Cell D C E c e K k Fy

a

Fy

b

Jk

a

Jk

b

Le

a

Le

b

S s M N P1 IS 15’ RT

1 r”r 0 0 + + + 0 + 0 + 0 + + 0 + 0 + 0 + 2+ 3+

2 rr 0 0 0 + + + 0 0 + 0 + 0 + 0 + 0 + + 0 0

3 rr 0 0 0 + + 0 + + + + + 0 + + + + 0 + 2+ 3+

4 rr 0 0 0 + + 0 + + 0 + 0 0 + 0 + 0 + + 0 0

Blood Type: A Neg

Patient Patient

Anti-A 4+ 4+

Anti-B 0 0

Anti-D 0 0

Anti-D 0 0

Rh Ct 0 0

A1 1+ 0 (A1 M-)

B 4+ 4+ (B M-)

Screening Method for Anti-M

Test in duplicate patient plasma with M+N+ cell

3 drops of plasma with 1 drop reagent cell

Incubate at 370C for 1 hour

Wash in cell washer

Add 2 drops anti-IgG to one tube and add 2 drops

saline to other tube

IgG tube < Saline tube

Antibody Titers

Select cell with heterozygous antigen expression

2 fold serial dilutions

IgG titer

critical value: titer >8

Titer: Anti-D >2,000 Anti-C= 2

Tube Dilution Anti-D R2R2 Anti-C r’r

1 1 4+ 2+

2 2 4+ 1+

3 4 4+ +/-

4 8 4+ 0

5 16 4+ 0

6 32 3+ 0

7 64 3+ 0

8 128 3+ 0

9 256 3+ 0

10 512 3+ 0

11 1024 2+ 0

12 2048 1+ 0

Obstetrical Evaluation

Fetal middle cerebral artery blood flow

Elevate blood flow for gestational age

may indicate high-output heart failure and risk of anemia

Ultrasound evaluation

Hydrops: abnormal accumulation of fluid in 2 or more fetal compartments

Estimated Hematocrit using peak velocity in fetal descending aorta, gestational age, and factor for hydrops

Preparing the blood

Fresh O Neg Red Cell (<5days)

Negative for Antigens to which mom has made an

antibody

Sickle Cell Negative

Irradiated

Hard spin Red Cell to remove the supernatant

Resuspend unit using AB Plasma to HCT 75% to 80%

Crossmatch Unit with Mom’s Plasma

Reconstituted

Blood

Cordocentesis

Laboratory Testing in OR

Confirm fetal blood

Perform quick Hematocrit

Confirm

Fetal blood

Anti-I

Anti-A,B

Other Antigen

CAUTION:

D antigen can be blocked

Fetal

Hematocrit

1 minute Spun

Micro Hematocrit

Back in the Lab

CBC with Reticulocyte count

ABO Rh

DAT

Extended antigen testing

Course of Treatment

35 weeks successful delivery

Weeks Gestation Transfused Blood (ml)

25 38

26½ 44

30 ½ 105

34 70

Post Delivery

Infant Jaundice Studies

ABO Rh

IgG DAT

Antibody identification of Cord Blood

Red Cell Transfusions

Group O

Fresh < 10 day old

Irradiated

Antigen negative for passive antibodies

(Anti-D, Anti-C, and Anti-M)

It Takes A Team