Timed and targeted transfusion in Rh isoimmunization: A case report on early detection and neonatal outcomes.

Abstract

Background: Rhesus (Rh) alloimmunization remains an important cause of fetal anaemia and perinatal morbidity despite the widespread use of anti-D immunoglobulin, particularly in regions with inadequate antenatal surveillance. Early detection of fetal anaemia using middle cerebral artery (MCA) Doppler ultrasonography and timely intervention are essential for improving neonatal outcomes.

Case presentation: We report the case of a 35-year-old multigravida (G3P2L1) with Rh-negative blood group, managed at a tertiary-care referral centre in India. She had a previous history of neonatal death attributed to complications of Rh-isoimmunisation. During her current pregnancy, high antibody titres were detected at 32 weeks of gestation. MCA Doppler revealed severe fetal anaemia, following which a single intrauterine transfusion was performed at 33 weeks. Delivery was performed by caesarean section at 35 weeks and 4 days of gestation. The neonate required two double-volume exchange transfusions and intensive phototherapy in the immediate postnatal period. At 45 days of life, the infant developed late-onset normocytic normochromic anaemia, which was successfully managed with packed red blood cell transfusion.

Discussion: This case highlights the importance of late third-trimester detection of severe fetal anaemia using MCA-peak systolic velocity (PSV) Doppler assessment, enabling timely intrauterine correction with a single transfusion and reducing the need for repeated invasive procedures. Despite antenatal optimization, the neonate required intensive postnatal management, including double-volume exchange transfusions, intravenous immunoglobulin (IVIG), and phototherapy, highlighting the continued impact of circulating maternal antibodies. Long-term haematological follow-up remained necessary.

Conclusion: Early Doppler-based diagnosis, timely single intrauterine transfusion, structured neonatal intensive care, and long-term hematologic follow-up resulted in favourable survival with normal developmental progression at 15 months of age.