Taiwanese Journal of Obstetrics & Gynecology 61 (2022) 722e725

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Case Report

Polyhydramnios as a sole ultrasonographic finding for detecting fetal

hemolytic anemia caused by anti-c alloimmunization
Shih-Chung Wang a, 1, Yun-Chia Wu b, 1, Wan-Ju Wu b, Mei-Hui Lee c, Wen-Hsiang Lin d,
Gwo-Chin Ma c, Ming Chen b, c, e, f, g, h, i, *
a
Division of Pediatric Hematology and Oncology, Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
b
Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
c
Department of Genomic Medicine, Changhua Christian Hospital, Changhua, Taiwan
d
Welgene Biotechnology Company, Nangang Business Park, Taipei, Taiwan
e
Department of Obstetrics and Gynecology, College of Medicine, and Hospital, National Taiwan University, Taipei, Taiwan
f
Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
g
Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
h
Department of Medical Science, National Tsing Hua University, Hsinchu, Taiwan
i
Department of Biomedical Science, Dayeh University, Changhua, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The prenatal course of a rare case with fetal anemia caused by maternal anti-c alloimmuni-
Accepted 29 April 2022 zation was reported.
Case report: A 39-year-old female with anti-c and anti-E antibodies against red cells had previously
Keywords: experienced a stillbirth. At her present pregnancy, titers of maternal antibodies and fetal middle cerebral
Maternal anti-c alloimmunization artery peak systolic velocity (MCA-PSV) were frequently monitored to investigate the severity of fetal
Hemolytic disease of the fetus and newborn
hemolytic anemia. Rather than manifesting as an increase in MCA-PSV, the anemic fetus was delivered at
(HDFN)
32 weeks and one day of gestation with a sole presentation: polyhydramnios. Neonatal hospitalization
Fetal anemia
Polyhydramnios
course were compatible with hemolytic anemia. The baby was discharged at 48 days of age.
Middle cerebral artery peak systolic velocity Conclusion: This case illustrated the complexities of dealing with maternal red cell alloimmunization
(MCA-PSV) during pregnancy and the limitations of noninvasive diagnostic modalities for detecting fetal anemia,
and highlighted that obstetricians should refer all available clinical parameters in order to offer appro-
priate perinatal care.
© 2022 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction
Maternal alloimmunization against red blood cells (RBC) is a
major concern in obstetric care because its relationship with he-
molytic disease of the fetus and newborn (HDFN), especially in the
Western populations where Rhesus D alloimmunization is preva-
lent. Over the past several decades, a variety of prenatal diagnostic
modalities have been tested in order to minimize complications,
including parental screening for blood type and antigen status,
prophylactic anti-D immune globulin treatment (RhIG or
* Corresponding author. Department of Obstetrics and Gynecology, Changhua
Christian Hospital, Changhua, Taiwan.
E-mail addresses: mingchenmd@gmail.com, mchen_cch@yahoo.com, 104060@
cch.org.tw (M. Chen).
1
These authors contributed equally to this study.
RhoGAM®) if at-risk, and even circulating cell free fetal DNA testing
(cffDNA) to elucidate the fetal antigen status [1].
The most frequently non-invasive method used for monitoring
the risk of fetal anemia is Doppler ultrasonography of the fetal
middle cerebral artery peak systolic velocity (MCA-PSV). If the MCA-
PSV value is greater than 1.5 multiples of median (MoM), it is
considered a predictor of moderate-to-severe fetal anemia, with
subsequent interventions including diagnostic cordocentesis to
confirm fetal anemia followed by intrauterine transfusion if neces-
sary is the gold standard of care, especially when fetal viability is yet
achieved. Meanwhile, treating the pregnant women with intrave-
nous immunoglobulin (IVIG) or plasmapheresis is also helpful to
reduce the transplacental passage of these antibodies from maternal
circulation to result in the fetal hemolytic disorders [1].
Herein, we present a case that underwent close monitoring of
maternal alloantibodies titers and prenatal MCA- PSV since the

https://doi.org/10.1016/j.tjog.2022.04.006
1028-4559/© 2022 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
S.-C. Wang, Y.-C. Wu, W.-J. Wu et al.
fetus was at-risk for hemolytic anemia. Instead of marked elevation
of MCA-PSV, the fetus demonstrated no other ultrasonographic
abnormalities except progressive polyhydramnios at the 3rd
trimester without worsening of titers of anti-c and anti-platelet
antibodies was noted. The pregnancy was delivered at 32 weeks
of gestational age (GA). The neonate was born with a rapidly pro-
gressive severe hemolytic anemia (despite the anemia was not
evident immediately after birth) treated with multiple transfusions
and eventually cured.
Case Report
A 39-year-old female, G4P3, with no history of blood transfusion
herself, had an uneventful obstetric history during her first and
second pregnancies with her first partner and ex-husband. At her
third gravidity, the first child with her now-husband, she experi-
enced emergent cesarean section due to fetal distress at GA ¼ 38
weeks. The infant expired immediately after birth with the pres-
ence of atypical HLA class I, anti-E and anti-c antibodies at another
referral hospital. Neonatal death resulted from alloimmunization to
platelets and red cells was highly suspected. At the fourth (the
present) pregnancy, she was referred to our medical center to
receive multidisciplinary antenatal care in our obstetric and pedi-
atric hematology departments. In addition to routine antenatal
testing, the mother was tested for alloantibodies every two weeks,
the anti-E antibody titer was stabilized at 1:1, the anti-c antibody
titers fluctuated between 1:16e1:64, and the anti-platelet antibody
titers fluctuated between 1:16e1:32.
We further determined the RBC antigen status and phenotyping
of the couple. Along with RhD antigen on the couple, the women
exhibited Rhe and C antigens, whereas her spouse carried E,c,e and
C antigens on the red cells. Given the history of HDFN and the fact
that her spouse is heterozygous for Rhc, E antigens, we inferred that
the fetus had a 50% chance of autoimmune hemolytic anemia.
However, since the limitation of PCR-based method on Rhc/E typing
and the possibility of immune thrombocytopenia, we chose
expectant management with serial ultrasonographic and serolog-
ical follow-ups for markers indicative of worsening fetal anemia
prior to more aggressive interventions with cordocentesis and in-
trauterine fetal transfusion as the spare options after counseling
Fig. 1. Fetal ultrasound performed at 31 weeks and 6 days of gestational age. (a) The maximal amniotic pouch reached 11.06 cm. (b) The middle cerebral artery peak systolic velocity
(MCA-PSV) was 47.35 cm/s, corresponding to 1.071 of multiple of medium (MoM).
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Taiwanese Journal of Obstetrics & Gynecology 61 (2022) 722e725
and informed consent. The woman was a bit hesitated for invasive
procedures because of the presence of anti-platelet antibody, the
risk of inciting thrombocytopenia and therefore ensuing hemor-
rhage. Nevertheless, she understood the necessity of those invasive
procedures once they are strongly indicated.
Initially, we advised the women to receive weekly IVIG injection
based on her antibody statuses due to her previous poor obstetric
history but she declined due to financial constriction since it is not
reimbursed by our National Health Service because of its rarity.
Instead, the prenatal care strategy was therefore shifted to fort-
nightly monitoring of maternal anti-E, anti-c, and anti-platelet ti-
ters, as well as fetal sonographic surveillance. If signs implying
hydrops occurred during pregnancy, prenatal interventions to both
the fetus and the mother, consisted of in utero blood transfusion or
therapeutic plasmapheresis would be indicated. The fetal HLA
genotyping and antibodies would be identified in the third
trimester if platelet transfusion was necessary. Routine antenatal
tests were all normal (e.g., 46,XX in karyotyping). Elevation of MCA-
PSV or other fetal hydropic signs was hypothesized to be a marker
for fetal anemia, indicating the need for in utero transfusion. At
GA ¼ 28 weeks, the women received prophylactic steroid injection
to promote fetal lung maturation, as iatrogenic preterm delivery
would be scheduled at GA ¼ 34 weeks. However, polyhydramnios
developed gradually while the patient was neither at risk for
gestational diabetes nor fetal anomalies. At GA ¼ 30 weeks and 6
days, the ultrasound showed a 9.33 cm-deep in the largest amniotic
fluid pocket with an MCA-PSV value of approximately 0.735 MoM.
At GA ¼ 31 weeks and 6 days, the largest amniotic fluid pocket
reached 11.06 cm in depth while the MCA-PSV value was 1.071
MoM value (Fig. 1) without any significant rise of titers of maternal
serum anti-c (1:16), anti-E (1:1), and anti-platelet (1:32) anti-
bodies. After excluding other causes of polyhydramnios such as
congenital infections (Toxoplasma gondii, cytomegalovirus, rubella,
herpes simplex viruses, and others), fetal CNS anomalies, GI
obstruction, or gestational diabetes, we suspected that idiopathic
polyhydramnios was the onset of fetal anemia resulted from
increasing cardiac output, even though MCA-PSV was less than
1.5MoM. The titers of maternal alloantibodies and the corre-
sponding fetal MCA-PSV during pregnancy were summarized in
Fig. 2.
S.-C. Wang, Y.-C. Wu, W.-J. Wu et al.
Fig. 2. The maternal antibodies (anti-E and anti-c) titers and corresponding fetal MCA-PSV (MoM) investigated throughout the pregnancy.
The patient hospitalized for fetal surveillance in order to prevent
the recurrence of her previous pregnancy ended up with neonatal
death. After second course of antenatal steroid administration,
emergent cesarean section was arranged at of GA ¼ 32 weeks and
one day due to non-reassuring fetal heart beats (loss of fetal heart
rate variabilities). A 1654-gram-weight female infant was born with
APGAR score 80 and 90 , at 1 and 5 min respectively. She was then
admitted to neonatal intensive care unit. The series of examinations
revealed blood type Bþ, thrombocytosis (550  103/mL), mild
anemia (Hb: 12.7 g/dL), hypohaptoglobinemia (<30 mg/dL), posi-
tive direct and indirect Coombs test, presence of reticulocyte (6.7%)
and anti-c antibody, which indicated neonatal hemolytic anemia
caused by anti-c alloimmunization. Antigen identification referred
that the neonate carried Rh E,c,e, and C anti-gens on the red cells.
She experienced phototherapy on 3rd day for hyperbilirubinemia,
and packed red blood cells transfusion for progressive anemia (the
lowest Hb level: 6.7 g/dL) was repeatedly given. The infant was
discharged from our neonatal unit on 48-day-old in stable condi-
tion and continues to receive regular routine OPD follow-up
vigorously. The baby is healthy at age 2Y when submission.
Discussion
Red cell alloimmunization is an important issue in immune fetal
anemia. In contrast to RhD incompatibility, that predominantly
occur in Caucasian race, anti-c antibodies are presented in approx-
imate 18% of Caucasians, 50% of Chinese, and are rare in Africans
regarding HDFN [2,3]. Meanwhile, approximately 40% of the serum
samples with anti-c also contain anti-E [4]. Those Rh IgG antibodies
were frequently associated with previous transfusion history, feto-
maternal hemorrhage, or fetal antigen transmitted from paternal
inheritance. Similar to RhD alloimmunization, RhE and Rhc alloim-
munization also implicate in HDFN, that in those severe cases may
clinically present as fetal anemia, hydrops fetalis, even intrauterine
or neonatal death. Thus, appropriate testing and assessing the risk of
HDFN are of paramount importance to obstetric care.
Maternal antibody titer can reflect the antibody concentration
in maternal blood. A critical titer, often 1:8e1:32, refers to associate
with a significant risk for severe erythroblastosis fetalis and
hydrops. However, an increasing titer does not linearly correlate
with the risk of HDFN or the severity of hemolysis, particularly in
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Taiwanese Journal of Obstetrics & Gynecology 61 (2022) 722e725
women who have had an affected fetus with the same partner.
Instead, if the titer exceeds the critical threshold, it provides the
rationale for additional testing [1].
A variety of noninvasive sonographic parameters had been used
to detect fetal anemia, including polyhydramnios, placentomegaly,
hydrops, enlargement of umbilical vein/head circumference/
abdominal circumference/fetal liver/fetal spleen. However, there
were no reliable parameters to distinguish between mild and se-
vere fetal anemia [5].
In 2000, Mari et al. demonstrated a landmark sonographic in-
dicator, MCA-PSV by Doppler ultrasound more than 1.5MoM value,
to predict moderate-to-severe fetal anemia with a sensitivity of
100% and false positive rate of 12% [6]. Current guidelines recom-
mended that at-risk fetal assessment should be initiated since
GA ¼ 16e24 weeks. The false negative of MCA-PSV may exist in
observers with insufficient training or in mildly anemic fetuses
whose velocities do not necessarily change. Table 1 summarizes the
performance of using MCV-PSV to detect fetal anemia from a few
featured series [6e9].
In our case, throughout the pregnancy, the MCA-PSV never
reached the cut-off value of 1.5 MoM therefore we expected the
fetus may at most suffered from mild anemia. However, progressive
polyhydramnios was noted at third trimester, which reflected the
high-cardiac-output scenario possibly due to physiologic
compensation of fetal anemia. Moreover, since the overall neonatal
survival rate after GA ¼ 32 weeks in most neonatal intensive care
nurseries is greater than 95%, delivery was chosen rather than
conventional prenatal intervention. Notably, the hemoglobin level
immediately after birth (12.7 g/dL) could explain the reason why a
normal MCV-PSV was found in this case at prenatal stage. The usual
cut-off point of neonatal anemia is 12 g/dL but according to a
comprehensive study the level of 12.7 g/dL is still below the 5th
percentage in premature neonates delivered at GA ¼ 32 weeks [10].
It is noteworthy that despite RhD alloimmunization is rare in the
Chinese population whereas a recent study regarding a cohort of a
subset of HDFN, the hemolytic disease of fetus (HDF) from China,
revealed that anti-D is still the most common etiology (82/122,
67.2%) despite HDF is very rare and anti-Ec HDF was exceedingly
rare (2/122, 1.64%), indicating most anti-Ec alloimmunization may
not manifest at the fetal stage and hence to some extent justified
the noninvasive strategy we initially adopted in this case [11]. We
S.-C. Wang, Y.-C. Wu, W.-J. Wu et al. Taiwanese Journal of Obstetrics & Gynecology 61 (2022) 722e725

Table 1
The reported sensitivity and specificity using MCA-PSV 1.5 MoM value for prediction of fetal anemia.

Published report Study Target Sensitivity Specificity Nature of Study

Mari et al. 2000 Moderate-to-severe fetal anemia 100% 88% Prospective study
Oepkes et al. 2006 Severe fetal anemia 88% 82% Prospective study
Martinez-Portilla et al. 2019 Moderate-to-severe fetal anemia 83% 79% Systematic review/Meta-analysis
Untransfused fetuses with moderate-to-severed anemia 86% 71%
Abdelshafi et al. 2021 Severe fetal anemia before 1st IUT 96.8% 32.4% Retrospective study
Severe fetal anemia before 2nd IUT 89.8% 55.5%
Severe fetal anemia before 3rd IUT 92.5% 55.8%

IUT ¼ intrauterine transfusion.

admit it is a pity that prenatal ultrasound assessment of fetal he- References

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Conclusion
In conclusion, prenatal management on red cell alloimmuniza-
tion is a challenging issue. Although maternal antibody titers and
fetal MCA-PSV by Doppler ultrasound are long been regarded as the
best noninvasive method for predicting fetal anemia, they remain
limited in diagnostic accuracy. Clinicians should notice all the
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(including intrauterine transfusion, maternal plasmapheresis,
maternal IVIG treatment, or prompt delivery) to improve the
neonatal outcome, since false negative does occur in all kinds of
medical tests [15].
Declaration of competing interest
The authors have no conflicts of interest relevant to this article.
Acknowledgements
We are sincerely thankful to the Chief Technologist Su-Feng Kuo
of the Dept. Laboratory Medicine, CCH for RBC antigen detection,
and Dr. Pei-Yin Yang, the Chief Obstetrician of the Dept. Ob/Gyn,
CCH for providing critical comments during manuscript
preparation.
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