title: Complementary therapy for severe Rh-alloimmunization.
abstract: OBJECTIVE
  This report describes successful treatment, using invasive and noninvasive techniques, of a 36-year-old woman (gravida 10, para 0) referred to our center at 13 weeks' gestation for severe Rh alloimmunization. Pre-pregnancy indirect Coombs titers ranged from 1:1024-2048. All nine past pregnancies (conceived with three different partners) had ended in abortion, intrauterine death or neonatal death
  
  
  METHODS
  The patient was treated with a single session of plasmapheresis (week 14) immediately followed by five days of immunoglobulin therapy and immunosuppressive therapy based on azathioprine and prednisone (weeks 15-22). Seven fetal transfusions (one intraperitoneal, six intravascular) were performed beginning at 16 weeks.
  
  
  RESULTS
  The pregnancy, which was characterized by insulin-dependent gestational diabetes, spontaneously resolving polyhydramnios and peak indirect Coombs titers of 1:65,536, ended at 27 weeks with cesarean section delivery of a viable female weighing 1,000 g. In spite of numerous neonatal complications, the child is physically well at age 3, with normal intellectual and psychomotor development.
  
  
  CONCLUSIONS
  In light of the negative outcomes of the patient's nine past pregnancies, our experience suggests that the early initiation of an integrated approach based on noninvasive and invasive techniques can play a potentially decisive role in the management of severe Rh-alloimmunization.
authors.affiliation: Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Noia
authors.forename: M
authors.initials: M
authors.lastname: De Santis
authors.forename: D
authors.initials: D
authors.lastname: Romano
authors.forename: A F
authors.initials: AF
authors.lastname: Cavaliere
authors.forename: M S
authors.initials: MS
authors.lastname: Ligato
authors.forename: A
authors.initials: A
authors.lastname: Petrone
authors.forename: G
authors.initials: G
authors.lastname: Fortunato
authors.forename: F
authors.initials: F
authors.lastname: Filippetti
authors.forename: A
authors.initials: A
authors.lastname: Caruso
authors.forename: S
authors.initials: S
authors.lastname: Mancuso
mesh_terms: D000328:Adult; D001379:Azathioprine / Q000008:administration & dosage; D001805:Blood Transfusion, Intrauterine; D016640:Diabetes, Gestational / Q000150:complications*; D004899:Erythroblastosis, Fetal / Q000097:blood* / Q000150:complications / Q000628:therapy*; D005260:Female; D006801:Humans; D007136:Immunoglobulins / Q000008:administration & dosage; D007231:Infant, Newborn; D007328:Insulin / Q000008:administration & dosage; D010956:Plasmapheresis; D011241:Prednisone / Q000008:administration & dosage; D011247:Pregnancy; D011256:Pregnancy Outcome; D011295:Prenatal Care; D012204:Rh-Hr Blood-Group System
chemical_list: D007136:Immunoglobulins; D007328:Insulin; D012204:Rh-Hr Blood-Group System; D001379:Azathioprine; D011241:Prednisone