title: Therapeutic plasma exchange and intravenous immunoglobulin as primary therapy for D alloimmunization in pregnancy precludes the need for intrauterine transfusion.
abstract: BACKGROUND
  Maternal D alloimmunization detected in early gestation requires aggressive intervention to prevent severe fetal anemia. An intrauterine transfusion (IUT) is indicated to prevent fetal death once severe fetal anemia has been detected, but is not without risk. Protocols combining therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIG) have been described, but they usually bridge to IUT.
  
  
  METHODS
  We describe a 27-year-old G4, P0-1-2-0 Caucasian female with a history of ruptured ectopic pregnancy presented at 12 weeks' gestation with a very high anti-D titer (2048). TPE was performed on that week and twice more in the following week, with a fourth final exchange during Week 14. A loading dose of IVIG (2 g/kg) was administered over 2 days after the third TPE and then 1 g/kg per week until Week 28 (total, 14 doses).
  
  
  RESULTS
  The antibody titer decreased to 256 by the beginning of 15 weeks' gestation and remained stable at that level for the remainder of the pregnancy. Doppler ultrasonographic measurements of the fetal middle cerebral artery peak flow velocity performed throughout gestation showed no evidence of fetal anemia. A healthy male infant was delivered at 37 weeks' gestation with mild immune-mediated hemolysis. The infant underwent successful treatment with an IVIG dose of 750 mg/kg and a red blood cell exchange.
  
  
  CONCLUSIONS
  Our unique TPE-IVIG protocol was successful at preventing the onset of severe fetal anemia in a patient with high titer anti-D. Since IUT may be fatal, our approach offers a safer and less-invasive treatment regime that can adequately sustain a fetus until term.
authors.affiliation: Division of Transfusion Medicine, Department of Pathology, North Shore University Hospital and Hofstra North Shore-LIJ School of Medicine, Manhasset, New York.
authors.forename: Michael
authors.initials: M
authors.lastname: Bellone
authors.forename: Fouad N
authors.initials: FN
authors.lastname: Boctor
mesh_terms: D000328:Adult; D000743:Anemia, Hemolytic / Q000175:diagnosis / Q000196:embryology / Q000517:prevention & control; D001783:Blood Flow Velocity; D001805:Blood Transfusion, Intrauterine; D005260:Female; D005315:Fetal Diseases / Q000175:diagnosis / Q000517:prevention & control; D005865:Gestational Age; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007231:Infant, Newborn; D008297:Male; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000196:embryology; D010951:Plasma Exchange; D011247:Pregnancy; D011248:Pregnancy Complications / Q000276:immunology / Q000628:therapy*; D012203:Rh Isoimmunization / Q000628:therapy*; D017585:Ultrasonography, Doppler, Transcranial
chemical_list: D016756:Immunoglobulins, Intravenous