Patient Blood Management under Duress – Interdisciplinary Longtime Approach for a Pregnant Woman with Placenta Accreta Spectrum (PAS) Disorder Complicated by Anti-U

Prolonged blood supply for a bleeding patient with an antibody against a high frequent antigen is challenging, particularly if blood groups with high ethnic disparities are involved. Besides optimization of hematopoiesis and surgical blood saving techniques, availability of compatible blood units is essential during life-threatening clinical situations.

A 38-year-old female (G5 P3, 30th week of gestation WG) of African ancestry was admitted with vaginal bleeding due to PAS disorder. Lab results: Hb 10,5g/dl; Hct 31%; MCV 79 fl; MCH 27 pg; MCHC 34 g/dl; BG: 0 ccD.ee; Kell neg.; S-, s-. Anti-U (known since 2022), titer 16 (IAT, tube technique). GYPB-Genotyping: most consistent with GYPB*05N, homozygous. Anti-U follow-up titers: max titer 32 (IAT, 34th WG). Antibody dependent cell-mediated cytotoxicity < 10% predictive for no HDN-risk. The clinically unstable situation (bleeding risk, HDN-risk) made long-term PBM obligatory. The logistics had to last 4 weeks, up to operational delivery planned at 34th WG. Departments of obstetrics, prenatal medicine, anesthesiology, transfusion medicine and radiology were involved.

The patient got parenteral iron substitution. The national rare donor panel (RDP) revealed 4 pRBC¹ (frozen stored) and one walking donor², both with Uvar-phenotype (¹genotype GYPB*03N.04 homozygous, ²genotype not available). The frozen stored pRBC were crossmatch-negative (x-match), the blood of the walking donor was x-match positive (2-fold reaction, IAT, column agglutination technique). With the international RDP we obtained 4 totally compatible, U-neg. pRBC (liquid stored, 1 from NL, 3 from UK). At 34th WG the child was born by caesarean combined with hysterectomy and intraaortic balloon-insertion to prevent massive hemorrhage. The delivery was uneventful. Maternal blood loss was appr. 700 ml, therefore no pRBC were required.

Interdisciplinary PBM is the key approach for clinical situations with prolonged high volume bleeding risk and limited blood resources. In our case, the situation was complicated due to an antibody (Anti-U) corresponding to a high frequent blood group antigen. The provision of U-negative pRBC was time consuming and only possible with the use of international rare donor panels. Due to the increasing migration to Germany, ethnic diversification of our blood donor population is necessary for such cases.

We have no conflicts of interest to disclose.