Management of isoimmunization in the presence of multiple maternal antibodies

OBJECTIVE: Evaluation and management of patients with multiple maternal ant ibody isoimmunization is unclear. The presence of greater than or equal to 1 maternal antibody may suggest a worse scenario. The objective of this stu dy was 2-fold: first, to determine whether the presence of multiple antibod ies predicts a more severe course than single antibodies and second, to det ermine the utility of the Queenan curves/protocol In evaluating multiple-an tibody isoimmunization. STUDY DESIGN: Amniotic fluid Delta OD450 measurements were obtained from th e antenatal testing logbook and confirmed by chart review. Cases were categ orized by antibody type and clinical outcomes obtained by chart review. RESULTS: Twenty-four pregnancies with isoimmunization and multiple maternal antibodies were Identified; of these, 17 had 2 antibodies (anti-D and -C i n 13; anti-D and -E In 1; anti-D and -Jka in 1; anti-c and -E in 1; and ant i-c and -Jka in 1), and 7 had > 2 antibodies (anti-D, -C, and -E in 4; anti -D, -C, and -N In 1; anti-c, -E, and -FYA in 1; and anti-E, -K, -Fya, -S, a nd -C in 1). Eleven patients (46%) required at least 1 Intrauterine fetal t ransfusion (mean initial fetal hematocrit, 15%; range, 4.9%-24%). In those not transfused, no Delta OD450 measurements occurred in the Queenan "fetal death risk" zone. Poorest outcomes (multiple transfusions/hydrops/fetal dem ise) were in patients with anti-D and anti-C, with or without anti-E. The a bsence of anti-D was associated with no need for fetal transfusions. The ov erall transfusion rate was significantly higher compared with a group of 57 isoimmunization patients with only anti-D (46% vs 25%, P less than or equa l to .05). CONCLUSIONS: The presence of anti-D appears to be the most significant fact or guiding the course of isoimmunization with multiple antibodies. The pres ence of another antibody with anti-D appears to significantly increase the need for intrauterine fetal transfusions. The Queenan protocol can successf ully treat patients with multiple maternal red blood cell antibodies.