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Year : 2023  |  Volume : 3  |  Issue : 3  |  Page : 142-145

Hemolytic disease of newborn following anti-C and anti-S alloimmunization: A case report with review of literature

Department of Neonatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission15-Feb-2023
Date of Decision16-May-2023
Date of Acceptance23-May-2023
Date of Web Publication14-Aug-2023

Correspondence Address:
Pankaj Kumar Mohanty
Department of Neonatology, All India Institute of Medical Sciences, Bhubaneswar - 753 019, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipcares.ipcares_39_23

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Background: Non-Rhesus D antigen non-ABO, minor blood group alloimmunization in pregnant women is being increasingly recognized as a significant contributor to the development of the hemolytic disease of the fetus and newborn (HDFN). We report severe HDFN in a neonate born to an Rh-positive mother with sickle cell disease, following anti-C and anti-S alloimmunization. Clinical Description: A male baby born to a repeatedly transfused mother with sickle cell disease developed severe jaundice at 22 h of life. The baby was found to have severe anemia and indirect hyperbilirubinemia, but no encephalopathy, hepatosplenomegaly, or features of sepsis. Management and Outcome: His blood group was O positive and the direct Coombs test was 4+. Minor blood group typing showed the presence of anti-C and anti-S antibodies. The baby improved after receiving a double-volume exchange transfusion with matched blood and phototherapy. Conclusion: Severe hemolytic disease of the newborn (HDN) may be caused by minor blood group alloimmunization, especially seen in mothers with a history of multiple transfusions. Antenatal screening for alloimmunization in high-risk mothers can ensure timely diagnosis and treatment of HDN and prevent the harmful effects of neonatal hyperbilirubinemia.

Keywords: Direct Coombs test, hemolytic anemia, hemolytic disease of the fetus and newborn, hemolytic disease of the newborn, neonatal jaundice

How to cite this article:
Kar S, Pradhan M, Som T, Mohanty PK. Hemolytic disease of newborn following anti-C and anti-S alloimmunization: A case report with review of literature. Indian Pediatr Case Rep 2023;3:142-5

How to cite this URL:
Kar S, Pradhan M, Som T, Mohanty PK. Hemolytic disease of newborn following anti-C and anti-S alloimmunization: A case report with review of literature. Indian Pediatr Case Rep [serial online] 2023 [cited 2023 Sep 30];3:142-5. Available from:

Hemolytic disease of the fetus and newborn (HDFN) is an immune-mediated disorder, in which there is hemolysis due to maternal antibodies directed against blood group antigens on the surface of the fetal or neonatal red blood cells (RBC). With the widespread use of anti-D immunoprophylaxis, there has been a substantial decrease in the prevalence of Rhesus D antigen (RhD) alloimmunization from 14% to 1%–2% across the globe.[1] While RhD alloimmunization still remains the leading cause of HDFN, the proportion of HDFN due to ABO incompatibility and non-RhD, non-ABO, minor blood group alloimmunization, is steadily rising. Clinically, minor blood group incompatibility may have a variable presentation, ranging from subclinical hemolysis to frank hemolysis with severe anemia and hydrops fetalis. We present the case of a neonate, born to a multiply transfused mother of sickle cell disease, who developed severe hemolytic disease of the newborn (HDN) due to minor blood group alloimmunization with a rare combination of anti-C and anti-S antibodies.

  Clinical Case Description Top

A 2.2 kg-male baby, born out of nonconsanguineous marriage, to a 23-year-old primigravida mother, at 35 weeks of gestation presented with icterus at 22 h of life. The mother had a history of sickle cell disease, for which she had received multiple packed RBC transfusions previously. The father was asymptomatic with no known comorbidities. Antenatally, the mother presented with severe anemia (hemoglobin 6 g/dL) at 28 weeks of gestation. The availability of compatible blood products had been challenging due to multiple non-RhD antibodies isolated on extended blood group typing. Indirect Coomb's test was strongly positive (4+). Her blood group was O positive, and her HIV/hepatitis B surface antigen status was negative. The antenatal period was otherwise uneventful. The baby was delivered by emergency lower segment cesarean section due to the appearance of fetal bradycardia. The baby cried immediately at birth and had a smooth perinatal transition with APGAR scores of 9 and 10 at 1 and 5 min, respectively. Breastfeeding was initiated within 30 min of birth. The baby was shifted to the mother's side thereafter. He passed meconium and urine within the first 12 h of life.

At 22 h of life, the baby was found to be grossly icteric with stained palms and soles. The total bilirubin measured was 24 mg/dL with indirect bilirubin of 21.9 mg/dL (exchange cutoff 15 mg/dL). The baby was shifted to the neonatal intensive care unit (NICU) for intensive phototherapy. At admission, the baby had a temperature of 36.2°C, heart rate of 138/min, respiratory rate of 42/min, oxygen saturation of 96% (room air), and capillary refill time of <2 s. The baby had a length of 47 cm, head circumference of 33 cm, mild pallor, no edema, and no evidence of cephalohematoma or subgaleal bleed. No external stigmata of intrauterine infections were seen. On systemic examination, the liver and spleen were not palpable. No features of congestive cardiac failure were present. Tone, activity, and cry patterns were normal, with preserved reflexes. The umbilicus was healthy. The differentials considered at this juncture were immune (blood group incompatibility) and nonimmune (glucose-6 phosphatase deficiency or G6PD) hemolysis and congenital infections.

  Management and Outcome Top

The baby's blood group was O positive. The blood group of the mother and father were O positive and A positive, respectively. The hemogram revealed mild anemia (hemoglobin of 10 g/dL, total leukocyte count of 5690/mm3, and total platelet count of 255,000/mm3). The reticulocyte count was 2.9%. Peripheral smear was suggestive of moderate anisocytosis with polychromatophilia. Lactate dehydrogenase was elevated (1812 IU/L). Direct Coombs test was strongly positive (4+). The G6PD enzyme activity sent on the 2nd day of life was within normal range. Liver function test showed indirect hyperbilirubinemia with normal transaminase levels (total bilirubin 24 mg/dL, indirect bilirubin 22.9 mg/dL, serum glutamic oxaloacetic transaminase 28 IU/L, serum glutamic pyruvic transaminase 36 IU/L, and serum albumin 3.6 mg/dL). Thus, the etiology of severe hyperbilirubinemia was attributed to hemolysis. Given the mother's history of multiple blood transfusions, a likelihood of immune hemolysis, following minor blood group incompatibility, was considered. On extended blood group typing, anti-C (1:256 titers) and anti-S antibodies were isolated in the mother against the respective RBC antigens of the baby.

After the baby was shifted to the NICU, intensive phototherapy was initiated. Double-volume exchange transfusion was arranged and completed in the next 4 h. Since the bilirubin levels were significantly above the exchange levels, intravenous immunoglobulin (Ig) levels were not considered. Following the exchange transfusion, total bilirubin levels reached 10 mg/dL (phototherapy cutoff was 11.5 mg/dL). Serum calcium levels were normal postexchange transfusion. The repeat hemogram after 24 h was normal (hemoglobin 12.9 g/dL, total leukocyte count 6890/mm3, and total platelet count 215,000/mm3). The subsequent postnatal period was uneventful. The baby was discharged on the 5th postnatal day on direct breastfeeds. Neurological examination was normal at discharge. Hearing evaluation (automated auditory brainstem response) was normal before discharge. On follow-up, sickle cell trait was established in the baby at 3 months postnatal age. During the same visit, iron and folic acid supplementation were initiated (hematocrit 30%). Growth and development at 4 months postnatal age are satisfactory.

  Discussion with Review of Literature Top

This case report depicts a severe presentation of HDN due to a combination of minor blood group alloimmunization. Most reports of hemolysis following anti-S alloimmunization show a mild presentation, with only a few cases reported with severe HDN.[1] Maternal antibodies may form against three types of RBC antigens: RhD, ABO antigens, or the minor blood group antigens (Kell, Duffy, MNS, P, and Diego systems).[1] The estimated global prevalence of HDFN due to Rh iso-immunization has been reported from 3 to 8/100,000 live births, per year in developed nations, to 252–529/100,000 live births per year in developing nations.[1] The incidence of RhD alloimmunization has decreased from 13%–19% to 0.9%–1.8% with postpartum immunoprophylaxis and further down to 0.1%–0.3% with antenatal prophylaxis.[2],[3] The incidence of non-RhD, non-ABO minor blood group alloimmunization is reported to be around 3%–5%. The most commonly implicated minor blood group antigens are the c, K, C, E, e, Duffy, Kell, Kidd, and MNS antigens.[4]

There are two mechanisms by which a mother may harbor antibodies that can potentially cause HDFN. First, she may be carrying naturally occurring ABO/Rh antibodies as per her own blood group, and second, she may develop antibodies following exposure to foreign RBCs (alloantibodies) due to fetomaternal hemorrhage or past blood transfusion or prior surgery or transplant.[5] Transplacental fetomaternal hemorrhage noted in almost 75% of all pregnancies rises with advancing gestation, from 3% in the first trimester, 12% in the second trimester, to 45% and 64% during the third trimester and delivery, respectively.[6]

The alloantibodies may be IgG or IgM subtypes; however, only the IgG subtype is able to cross the placenta and cause HDFN. Anti-C antibodies are IgG type of antibodies, produced against the “c” antigen of Rh system. The isolation of IgG anti-S antibodies, against the S antigen of the MNS group, is relatively rare. In a large retrospective cohort study of pregnant women, the incidence of anti-C and anti-S antibodies was 10% and 2%, respectively.[7] A summary of the case studies reporting anti-C and anti-S alloimmunization leading to HDFN is shown in [Table 1].
Table 1: Cases reported in the literature of hemolytic disease of the fetus and newborn due to anti-S and/or anti-C antibodies

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The risk and severity of HDFN due to alloimmunization differ with different minor blood group antigens. This may be due to poor expression of the respective antigens on the RBC surface or because they are IgM antibodies, which do not cross the placental barriers, like anti-N. The most common clinically significant minor blood group alloantibodies causing HDFN include anti-E, anti-C, and anti-K.[18] The anti-Kell HDN can be severe and may require intrauterine intervention. Others, such as anti-c, e, Kidd, Duffy, and MNS blood group antibodies, including the anti-S antibodies, can lead to fetal disease, usually with favorable outcomes.[19] The clinical spectrum of anti-C and anti-S sensitization is broad, ranging from fetal hydrops with congestive cardiac failure to significant hyperbilirubinemia and anemia in the neonatal period.[1],[10],[14],[15] The severity of HDN and hyperbilirubinemia seen in our case could be explained by the combined presence of anti-C and anti-S alloimmunization.

It has been reported that the risk of alloimmunization may be as high as 60% in chronically transfused mothers,[18] probably explaining the alloimmunization in the mother of the case reported by us.

In an alloimmunized mother, extended blood group typing is essential in the first trimester, and subsequently, titers are to be monitored throughout pregnancy. Critical titers can be detected with regular Indirect coomb's test (ICT) monitoring, and the severity of fetal anemia can be assessed by Doppler velocimetry of the middle cerebral artery peak systolic velocity (MCA PSV).[6] When MCA PSV is more than 1.5 multiples of the median according to gestation, intrauterine transfusions are planned, preferably between 18 and 35 weeks of gestation.[6] The blood used for this purpose should be fresh, leukoreduced, and irradiated with the baby's blood group/O negative, cross-matched with maternal plasma, washed, and devoid of the implicated antigens. In the postnatal period, isoimmune hemolysis and hyperbilirubinemia require intensive phototherapy and exchange transfusion. Intravenous Ig is recommended in isoimmune hemolytic disease and positive direct antiglobulin test with total bilirubin approaching escalation of care levels before exchange transfusion.[20]

In our case, the mother was likely to have developed multiple antibodies to non-RhD antigens antenatally following allosensitization due to recurrent blood transfusions, but had not been screened during pregnancy. Only after the baby developed jaundice on the 1st day of life, the possibility of early HDFN was considered. Detection of the antibody immunophenotypes helped in the early arrangement of cross-matched, compatible blood products for exchange transfusion, thereby preventing the newborn from the harmful effects of prolonged hyperbilirubinemia. The summative impact of anti-C and anti-S antibodies may have been instrumental in aggravating jaundice. Previous studies have shown similar findings with the combination of anti-C and anti-S antibodies.[15] Anti-S antibodies in association with other antibodies have also been reported to cause severe HDFN in cases of previously sensitized mothers.[7]

Regular follow-up for neurodevelopmental monitoring and hearing evaluation till 5 years of age is advised.[6] Hemoglobin levels should also be assessed in follow-up to rule out late-onset anemia, another known complication in isoimmune HDFN cases receiving intrauterine/double-volume exchange/blood transfusions. The antibody response in subsequent pregnancies is amplified, thereby increasing the risk of fetal anemia and hydrops. Early initiation of MCA PSV by Doppler velocimetry is warranted to recognize and manage fetal anemia.

  Conclusion Top

To conclude, non-RhD alloimmunization may cause HDN with rapid-onset hyperbilirubinemia in the newborn; the clinical severity of which depends on the immunophenotype and the antibody titers. Pregnant women with a history of multiple blood transfusions are prone to alloimmunization, and antenatal screening for minor blood group antibodies can ensure the timely availability of cross-matched, compatible blood as soon as HDFN is detected.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for images and other clinical information to be reported in the journal. The parents understand that names and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Pitan C, Syed A, Murphy W, et al. Anti-S antibodies: An unusual cause of haemolytic disease of the fetus and newborn (HDFN). BMJ Case Rep 2013;2013:bcr2012006547.  Back to cited text no. 1
Zipursky A, Paul VK. The global burden of Rh disease. Arch Dis Child Fetal Neonatal Ed 2011;96:F84-5.  Back to cited text no. 2
de Haas M, Thurik FF, van der Ploeg CP, et al. Sensitivity of fetal RHD screening for safe guidance of targeted anti-D immunoglobulin prophylaxis: Prospective cohort study of a nationwide programme in the Netherlands. BMJ 2016;355:i5789.  Back to cited text no. 3
Koelewijn JM, Vrijkotte TG, de Haas M, et al. Risk factors for the presence of non-rhesus D red blood cell antibodies in pregnancy. BJOG 2009;116:655-64.  Back to cited text no. 4
Dean L. Hemolytic disease of the newborn. In: Blood Groups and Red Cell Antigens. Ch. 4. Bethesda (MD): NCBI, National Library of Medicine (US); 2005.  Back to cited text no. 5
Sahoo T, Sahoo M, Gulla KM, et al. Rh alloimmunisation: Current updates in antenatal and postnatal management. Indian J Pediatr 2020;87:1018-28.  Back to cited text no. 6
Dajak S, Roje D, Hašpl ŽH, et al. The importance of antenatal prevention of RhD immunisation in the first pregnancy. Blood Transfus 2014;12:410-5.  Back to cited text no. 7
Liyan Y, Yongmei J, Jing F. A Rare Case of Hemolytic Disease of the Fetus and Newborn Caused by Anti-s Antibody in a Chinese Patient. Clinical Laboratory. 2023;69.  Back to cited text no. 8
Vani DN, Mangaiyarkarasi DA. Hemolytic Disease of Newborn due to Anti-c Antibodies - A Case Report. 2019;10.  Back to cited text no. 9
Bakht A, Turner B, Warren CS, et al. Anti-S antibody: A rare cause of fetal hydrops in a previously sensitized mother. Lab Med 2021;52:609-13.  Back to cited text no. 10
Odabasi IO, Uslu S, Bas EK, et al. Hemolytic anemia due to anti-c incompatibility in the newborn period: A case report. Sisli Etfal Hastan Tip Bul 2020;54:502-4.  Back to cited text no. 11
Pramod T, Rajan N, Kingsley S, et al. Case series of severe fetal hemolysis in Rh-C-negative mother. Glob J Transfus Med 2020;5:90.  Back to cited text no. 12
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Bilgin H, Eren A, Kara S. Hemolytic anemia and heart failure caused by anti-c and anti-e immunization. J Coll Physicians Surg Pak 2016;26:539-40.  Back to cited text no. 13
Sheeladevi CS, Suchitha S, Manjunath GV, et al. Hemolytic disease of the newborn due to anti-c isoimmunization: A case report. Indian J Hematol Blood Transfus 2013;29:155-7.  Back to cited text no. 14
Thakral B, Agrawal SK, Dhawan HK, et al. First report from India of haemolytic disease of newborn by anti-c and anti-E in Rh (D) positive mothers. Hematology 2007;12:377-80.  Back to cited text no. 15
Abourazzak S, Hajjaj S, Hakima C, et al. Haemolytic disease of the newborn due to anti-c. Case Reports. 2009;2009:bcr0920080987.  Back to cited text no. 16
Babinszki A, Berkowitz RL. Haemolytic disease of the newborn caused by anti-c, anti-E and anti-Fya antibodies: Report of five cases. Prenat Diagn 1999;19:533-6.  Back to cited text no. 17
Webb J, Delaney M. Red blood cell alloimmunization in the pregnant patient. Transfus Med Rev 2018;32:213-9.  Back to cited text no. 18
Duete ÚR, Brunetta DM, Araujo Júnior E, et al. Maternal-fetal alloimmunization: Perinatal outcomes in a reference hospital in Northeastern Brazil. Rev Assoc Med Bras (1992) 2022;68:670-4.  Back to cited text no. 19
Kemper AR, Newman TB, Slaughter JL, et al. Clinical practice guideline revision: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2022;150:e2022058859.  Back to cited text no. 20


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