title: Management of isoimmunization in the presence of multiple maternal antibodies.
abstract: OBJECTIVE
  Evaluation and management of patients with multiple maternal antibody isoimmunization is unclear. The presence of > or = 1 maternal antibody may suggest a worse scenario. The objective of this study was 2-fold: first, to determine whether the presence of multiple antibodies predicts a more severe course than single antibodies and second, to determine the utility of the Queenan curves/protocol in evaluating multiple-antibody isoimmunization.
  
  
  METHODS
  Amniotic fluid DeltaOD(450) measurements were obtained from the antenatal testing logbook and confirmed by chart review. Cases were categorized 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 in 13; anti-D and -E in 1; anti-D and -Jka in 1; anti-c and -E in 1; and anti-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, and -C in 1). Eleven patients (46%) required at least 1 intrauterine fetal transfusion (mean initial fetal hematocrit, 15%; range, 4.9%-24%). In those not transfused, no DeltaOD(450) measurements occurred in the Queenan "fetal death risk" zone. Poorest outcomes (multiple transfusions/hydrops/fetal demise) were in patients with anti-D and anti-C, with or without anti-E. The absence of anti-D was associated with no need for fetal transfusions. The overall transfusion rate was significantly higher compared with a group of 57 isoimmunization patients with only anti-D (46% vs. 25%, P < or =.05).
  
  
  CONCLUSIONS
  The presence of anti-D appears to be the most significant factor guiding the course of isoimmunization with multiple antibodies. The presence of another antibody with anti-D appears to significantly increase the need for intrauterine fetal transfusions. The Queenan protocol can successfully treat patients with multiple maternal red blood cell antibodies.
authors.affiliation: Department of Obstetrics and Gynecology, Georgetown University, Washington DC, USA. spongc@exchange.nih.gov
authors.forename: C Y
authors.initials: CY
authors.lastname: Spong
authors.forename: A E
authors.initials: AE
authors.lastname: Porter
authors.forename: J T
authors.initials: JT
authors.lastname: Queenan
mesh_terms: D000653:Amniotic Fluid / Q000737:chemistry; D001787:Blood Group Incompatibility / Q000150:complications / Q000276:immunology; D001805:Blood Transfusion, Intrauterine; D004899:Erythroblastosis, Fetal / Q000276:immunology / Q000517:prevention & control / Q000628:therapy; D005260:Female; D005313:Fetal Death / Q000209:etiology; D005315:Fetal Diseases / Q000276:immunology / Q000628:therapy; D005865:Gestational Age; D006801:Humans; D007518:Isoantibodies / Q000097:blood*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000276:immunology*; D011256:Pregnancy Outcome; D012203:Rh Isoimmunization / Q000150:complications / Q000276:immunology; D013053:Spectrophotometry
chemical_list: D007518:Isoantibodies