Intensive Plasma Exchange in the Management of Severe Rh Disease

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Abstract
Fourteen high-risk cases of Rh alloimmunized women were treated by intensive plasma exchange on the cell separator throughout their pregnancies. The mean volume of plasma exchanged per week was 3.21 with a total volume of 10-123 1. The replacement fluid was plasma protein fraction (PPF) supplemented with fresh frozen plasma (FFP). The mean duration of treatment was 13 1/2 wk, ranging from 2-22 wk and commencing at 12-30 wk gestation. The complications encountered and the selection of the optimal time for delivery are discussed. The expected stillbirth rate in this series as determined by past obstetric histories and anti-D levels was 62%. Intrauterine transfusion was given to only 2 of the infants and both were later stillborn. It was possible to reduce and maintain a lower level of anti-D in the serum of most of the patients; a successful outcome was achieved in 9 of the 12 cases included for analysis (75%). Plasma exchange commenced early in pregnancy is recommended as a non-hazardous form of treatment in the management of severe Rh hemolytic disease. If the mean level of anti-D cannot be maintained at < 35 IU/ml, then the outcome is more likely to be fatal. Amniocentesis should be delayed where possible until 28 wk gestation and intrauterine transfusion reserved for those cases where the anti-D level becomes uncontrollably high and fetal death is imminent.