ABO incompatibility: its impact on pregnancy and neonate

Abstract

ABO incompatibility is one of the most common cause of haemolytic disease of fetus and new-born (HDFN). The expression of ABO incompatibility in most of the cases is mild due to the lower expression of A and B Antigens on fetal red cells. ABO incompatibility has affected the first pregnancy and is milder in the subsequent pregnancies. However, we describe this case with unusually severe form of ABO incompatibility which had an effect not only in her first pregnancy but also in all her subsequent pregnancies, evident as recurrent abortions and both her neonates developed pathological jaundice requiring exchange transfusion. It also emphasizes the fact that ABO incompatibility is not always a benign condition and should be considered in all babies whose mothers have O blood group, even in the presence of a negative DAT. Anticipation of ABO incompatibility not only in the first pregnancy but also in the subsequent pregnancies is necessary. Early diagnosis with cord blood bilirubin can prevent neonatal morbidity.

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February 2019 · Volume 8 · Issue 2 Page 766
International Journal of Reproduction, Contraception, Obstetrics and Gynecology
Nagashree U et al. Int J Reprod Contracept Obstet Gynecol. 2019 Feb;8(2):766-768
www.ijrcog.org
pISSN 2320-1770 | eISSN 2320-1789
Case Report
ABO incompatibility: its impact on pregnancy and neonate
U. Nagashree1*, Swetha P.1, Sumana Manohar1, Latha Kanchi Parthasarathy2
INTRODUCTION
Haemolytic disease of fetus and new-born occurs most
commonly in ABO and Rh incompatibility. The
implementation of RhD immunoprophylaxis has reduced
maternal D alloimmunization from 14% to1-2% and
further reduction up to 0.1% is seen by antenatal
prophylaxis.1 Hence, ABO incompatibility has now
become the single largest cause of HDFN in the western
world.2 Many Asian countries have identified
alloantibodies other than anti D as a cause of moderate to
severe haemolytic disease.3,4 ABO and Rh
incompatibility can be differentiated by their
presentation. (Table 1). Theoretically, selection in ABO
incompatibility may operate at various stages from
fertilization through pregnancy.5
It may extend its impact on the neonate. It produces a
spectrum of haemolytic disease extending from cases in
which there is little laboratory evidence of erythrocyte
sensitization, haemolysis to cases of severe haemolytic
disease.
Table 1: Comparison of Rh and ABO incompatibility.
Rh HDN
ABO HDN
Frequency
Less common
More common
Blood group
Mother
Rh negative
O
Fetus
Rh positive
A or B
Pregnancy
affected
Usually second
Usually first
Severity
Severe
Mild
Blood smear
Erythroblastosis
Spherocytosis
DCT
Strongly positive
Weakly positive
or negative
Prevention
Rh immune
globulin
Not available
ABSTRACT
ABO incompatibility is one of the most common cause of haemolytic disease of fetus and new-born (HDFN). The
expression of ABO incompatibility in most of the cases is mild due to the lower expression of A and B Antigens on
fetal red cells. ABO incompatibility has affected the first pregnancy and is milder in the subsequent pregnancies.
However, we describe this case with unusually severe form of ABO incompatibility which had an effect not only in
her first pregnancy but also in all her subsequent pregnancies, evident as recurrent abortions and both her neonates
developed pathological jaundice requiring exchange transfusion. It also emphasizes the fact that ABO incompatibility
is not always a benign condition and should be considered in all babies whose mothers have O blood group, even in
the presence of a negative DAT. Anticipation of ABO incompatibility not only in the first pregnancy but also in the
subsequent pregnancies is necessary. Early diagnosis with cord blood bilirubin can prevent neonatal morbidity.
Keywords: ABO incompatibility, Anemia, Hemolytic disease
1Department of Obstetrics and Gynecology, Apollo Womens Hospitals, Chennai, Tamil Nadu, India
2Department of Pediatrics and NICU, Apollo Childrens Hospitals, Chennai, Tamil Nadu, India
Received: 23 October 2018
Revised: 28 December 2018
Accepted: 11 January 2019
*Correspondence:
Dr. U. Nagashree,
E-mail: dr.nagashree@yahoo.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20190321

Nagashree U et al. Int J Reprod Contracept Obstet Gynecol. 2019 Feb;8(2):766-768
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 8 · Issue 2 Page 767
Clinically, significant jaundice >12mg/dl occurs in only
4% of such pregnancies. Disease is mild in most of the
cases manifesting as neonatal hyperbilirubinemia within
24 hours of life which can be managed with phototherapy
alone. An exchange transfusion is necessitated in only 1
in 1000 to 1 in 4000 pregnancies. Kernicterus can occur
with an early onset and rapidly rising hyperbilirubinemia
unless recognized.3
CAES REPORT
A 38-year-old G6P1L1A4 at 37 weeks 3 days gestation.
She has been married for 12 years and it’s a non-
consanguineous marriage. Her blood group is O positive.
She has no medical comorbidities. Both her parents are
diabetic and hypertensive. Her first conception was in
2007, it was a spontaneous abortion at 2 months of
amenorrhea and dilatation and Curettage done. The
second was a natural conception in 2010 and she
delivered a girl baby of 2.7kg by a normal vaginal
delivery. The baby developed neonatal jaundice,
kernicterus and exchange transfusion was done. The child
had developmental delay. The child was extensively
investigated for the cause of jaundice and it was
attributed to ABO incompatibility. The third, fourth and
fifth conceptions were spontaneous abortions at early
weeks of gestation. The present pregnancy was a natural
conception and the antenatal period was uneventful. She
was admitted at 37weeks gestation in latent labor, she
was taken up for LSCS on patient’s request after covering
prophylactic steroids. She delivered an alive boy baby
weighing 2.65kg with Apgar 8/10;9/10. Delayed cord
clamping was done, and post-operative period was
uneventful. In view of sibling having history of severe
neonatal jaundice, cord blood serum bilirubin was
measured and was high (4.5mg/dl) and triple surface
phototherapy was started. Baby’s blood group was found
to be A Positive and DCT was negative. Further serial
serum bilirubin values done at 6th hourly intervals showed
a steady increase reaching up to 6.6mg/dl, IV
immunoglobulin therapy was started and double volume
exchange transfusion with O negative blood was done at
15 hours of life (Figure 1).
Figure 1: Neonate on phototherapy and exchange
transfusion.
Post exchange levels of bilirubin were at an acceptable
level and phototherapy was continued till 3 days of life.
Screening for Inborn errors of metabolism-flowing panel
and tests for jaundice within 24 hours was done.
Everything was negative. Baby was discharged after 3
days of phototherapy. Follow up bilirubin was normal,
done till 30 days of life. Neurological examination and
hearing screening test were normal. The pathological
jaundice in this infant was most probably due to ABO
incompatibility. Further follow up at 3 months, 6 months
and 1 year was advised.
DISCUSSION
Hemolytic disease of fetus and newborn occurs when
there is trans-placental passage of maternal antibodies
resulting in hemolysis of fetal/neonatal red cells.
Implicated Ab could be naturally occurring (Anti A, Anti
B) or immune antibodies developed following
sensitization. This occurs in 15-20% of all pregnancies.
This hemolytic process results in fetal
anemia/hyperbilirubinemia in 10% of the cases.
ABO incompatibility mostly occurs exclusively in infants
of blood group A or B born to O group mothers because
IgG anti A, anti B occur more commonly in O group than
group A or B individuals. An ABO incompatible mating
in which father is A, mother is O; may produce a
compatible O or an incompatible A fetus. ABO
incompatibility may lead to fetal hemolysis in the first
pregnancy because of preexisting antibodies in mother
from infancy.
The incidence of O type mothers with ABO
incompatibility most likely to have a spontaneous
abortion (between 40 days to 135 days) in British
Columbia. Several other studies examined relationship
between ABO incompatibility and reproductive failure;
possibility of incompatibility of antigen present in red
cell membrane of husband and wife may play some role
in abortions.6
Another study in India in 2009-Couple combinations
having O type wives, A or B type husbands showed
maximum fetal loss. Abortion is higher in A type
husband and O type wife. Stillbirths higher in A type
husband and B type wife.7 Total pregnancy wastage was
higher in ABO incompatible mating (24.59%) than
compatible mating (8.45%). Positive direct Coombs test
and positive family history of neonatal jaundice or
previous abortion strongly predict ABO
incompatibility.8,9
Bilirubin level >12mg/dl for full term infant is
worrisome-hyperbilirubinemia associated with
neurological abnormalities, hearing loss and motor
abnormalities. The diagnosis of ABO incompatibility is
with onset of hyperbilirubinemia within 24 hours of birth,
fetomaternal AO incompatibility, laboratory evidence of
erythrocyte sensitization i.e. positive DCT, nevertheless a

Nagashree U et al. Int J Reprod Contracept Obstet Gynecol. 2019 Feb;8(2):766-768
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 8 · Issue 2 Page 768
negative DCT can’t rule out ABO incompatibility and
exclusion of other causes of early onset of jaundice like
G6 PD deficiency and Rh isoimmunization.
Management: New modalities like improved
phototherapy and IVIgG therapy altered clinical course of
the disease.10 IVIgG therapy may reduce the need for
exchange transfusion.11 An exchange transfusion is
necessitated only 1 in 1000 to 1 in 4000 pregnancies.
CONCLUSION
Early detection with high level of suspicion in ABO
incompatible couples should help us avoid HDFN in
developing countries. Proper awareness and screening
measures can help in early management and to avoid
catastrophes in new-born.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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Cite this article as: Nagashree U, Swetha P,
Manohar S, Parthasarathy LK. ABO incompatibility:
its impact on pregnancy and neonate. Int J Reprod
Contracept Obstet Gynecol 2019;8:766-8.