PFM.51 Fatal transfusion-associated graft vs host disease (TA-GvHD) following emergency intrauterine transfusion of maternal blood: case report and survey of UK practice

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For intrauterine transfusion (IUT) specific red cells are provided by UK Blood Services, irradiated to prevent TA-GvHD.

A fetus (21/40) was referred to a fetal medicine centre (FMC), severely anaemic (parvovirus) requiring urgent IUT. Maternal blood was transfused to fetus. Following poor cardiac output, further emergency intracardiac transfusion gave improvement. At 32/40 baby was delivered, severely hydropic and pancytopenic (aplasia later confirmed by marrow aspirate). Hyperbilirubinaemia and fungal chest infection followed. Mother was HLA homozygous. Chimerism studies confirmed maternal engraftment and TA-GvHD. Baby underwent stem cell transplantation, but died of pneumonitis. The case was reported to the Serious Hazards of Transfusion (SHOT) national haemovigilance scheme.

A questionnaire was sent to the other 15 FMCs in England and Scotland to establish wider practice.

15/15 centres replied. 1/15 had used maternal blood (non-irradiated), once in 5 years, for bleeding during platelet IUT. 2/15 had used non-IUT blood (leucodepleted), for 8 IUTs: 1 irradiated neonatal exchange blood, rest non-irradiated neonatal ‘paedipacks’. 10/15 would transfuse alternative red cells if IUT units unavailable in emergency, 5/15 would not/had not. Preferred alternative varied, 3/11 would consider maternal blood.

This rare case of TA-GvHD occurred following high-risk transfusion: to a fetus, with fresh, HLA homozygous, maternal blood, neither irradiated or leucodepleted. Use of maternal blood for IUTs is unusual in UK centres. Maternal blood for IUT is not recommended in the UK. FMCs should develop transfusion protocols for emergency red cell provision for IUT. Alternatives include neonatal paedipacks or exchange transfusion units, irradiated whenever possible.

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