Peripartum blood component management of severe IgA-deficient patient

Background

Allergic transfusion reactions (ATRs) occur during or shortly after blood derivatives application and are the leading cause of death associated with transfusion. Triggers for ATR are multifactorial. One factor predisposing to ATRs discussed in literature is the severe IgA-deficient patient (sIgAd, IgA levels below 0.01g/L) with a positive anti-IgA antibody (anti-IgAab) status a./o. a history of ATRs. SIgAd patients are susceptible to respiratory infections a./o. allergic reactions e.g. to drugs.

Methods

We present the peripartum management of a 39-y-old, sIgAd patient (G2P1, 34w+0d, fetus: breech position). SIgAd was diagnosed after a history of multiple allergic reactions (AR, grade II-III) following NSAID intake. Laboratory reevaluation of the IgA levels confirmed prior findings with IgA<0.01g/L. A low probability of the presence of anti-IgAabs was assumed (no prior transfusions) and confirmed with negative anti-IgA-ab testing (2.1 U/mL). With iron suppl. ferritin, haemoglobin levels were normalized prior to delivery. Due to the patient´s allergic susceptibility, the potential immunisation risk, it was interdisciplinary agreed to reduce the risk of IgA exposure. Sponateous vaginal delivery (SVD): IgAd donor RBCs. C-Section: washed RBCs.

Results

A C-section (38w+5d) was indicated (breech position) with moderate bleed risk. Tools of patient blood management (tranexamic acid, uterotonics, cell salvage) were applied. Finally, the blood loss was moderate (400 mL) and no allogenic blood transfusion was required. However, the patient developed an allergic reaction (AR, max. grade II, due to immediate anti-allergic treatment), which was most likely due to the administration of an intravenous opioid. Generally, patients requiring blood transfusion are often exposed to additional drugs concomitantly, thus it is challenging to reliably confirm the causality between the AR and the provoking allergen. (s. Figure 1: Diagnostic and treatment plan)

Conclusion

The mode of delivery impacts blood product management: The timing of SVD is difficult to predict, even with labor induction, and can outlast the shelf life of washed RBCs. Here, blood products from IgAd donors can be favourable. In elective situations, manufacturing and provision of washed products can be planned. In case of emergencies transfusion should not be delayed. If available products with low plasma content should be considered e.g. platelets in additive solution.

Offenlegung Interessenkonflikt:

No conclicts of interest.