A case report of haemolytic disease of the foetus and newborn caused by Alloantibody D and Jka in a Rhesus D negative Nigerian woman: Justification for the implementation of universal access to prophylaxis and evidenced-based best practices

Abstract

A case report of a 38 years old ABO group A and Rhesus D negative multiparous, gravidae 8 and para 2, Nigerian woman who had a case of premarital miscarriage and who was not offered anti-D prophylaxis as part of her management. Lady went on to develop alloantibody D and Jka. Lady has had 7 further pregnancies post the miscarriage. The first child who is B Rhesus D positive is the only surviving child. The surviving child was delivered severely jaundiced and needed management post-delivery for haemolytic disease of the foetus and newborn (HDFN). Lady has had a history of a stillbirth. She was given a non-clinically indicated anti-D prophylaxis during the second pregnancy despite having been previously sensitized. The second baby died 3 months after delivery from complications of HDFN. She had had a further history of 5 miscarriages. She has had challenge with conception since 2010. Alloantibody testing confirms the presence alloantibody D and anti-Jka. Finding from this is a clear case of sub-optimal laboratory, obstetric and neonatal care offered particularly to pregnant women who are Rh D negative and those with alloantibodies in Nigeria. The Nigerian government will need to implement evidenced-based best practices; determination of alloantibody status of pregnant women during their first antenatal visit; provision of facilities for alloantibody identification, titration, quantification and feto maternal haemorrhage testing (FMH); implementation of a policy on universal access to anti-D prophylaxis for pregnant Rh D negative women who are not previously sensitized; provision of facilities required for the optimal intrauterine management of HDFN (foetal genotype testing, intrauterine transfusion, doppler ultrasound to diagnose anaemia inutero and provision of donor blood that meet the minimum requirements for intrauterine transfusion); determination of Rh D status of women who require a termination of pregnancy and provision of prophylactic anti-D for those found Rh D negative within 72 hours of procedure and the optimization of the knowledge of Medical Laboratory Scientist, Obstetricians, Neonatologist, Pharmacist and Traditional Birth Attendants in a bid to reduce the residual number of women who become sensitized and the number of preventable deaths of babies with HDFN.