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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 12  |  Page : 1759-1766

Prevalence of Rhesus C and D Alloantibodies among Rhesus-Negative Women of Child Bearing Age at a Tertiary Hospital in South-West Nigeria


1 Department of Haematology and Blood Transfusion, College of Medicine University of Lagos, Idi-Araba, Lagos State, Nigeria
2 Department of Obstetrics and Gynaecology, College of Medicine University of Lagos, Idi-Araba, Lagos State, Nigeria
3 Division of Epidemiology and Biostatistics, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
4 Department of Clinical Pathology, College of Medicine University of Lagos, Idi-Araba, Lagos State, Nigeria

Date of Submission05-Mar-2019
Date of Acceptance28-Aug-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. S John-Olabode
Department of Haematology and Blood Transfusion, CMUL, Lagos State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_114_20

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   Abstract 


Background: A major cause of hemolytic disease of the fetus and newborn (HDFN) is an incompatibility of the Rhesus (Rh) blood group between the mother and fetus. Aim: To determine the prevalence of Rh c and D alloantibodies among Rh-negative women of childbearing age (18–49 years). We conducted a cross-sectional study among women who attended the antenatal, gynecology and blood donor clinics at a Tertiary Hospital in South-West Nigeria from January to August 2019. Serological typing of Rh c and D was done manually with the tube test using anti-c and anti-D antisera, while indirect antiglobulin test was then performed to screen for Rh antibodies. Subjects and Methods: Data was analyzed using Stata 16.1 software; Categorical data was summarized using frequency and percentages while continuous variables were described using the mean and standard deviation or median and interquartile range. Pearson's Chi-square (or Fisher's exact) test was used to test for association between categorical variables and Rh status. P values of ≤0.05 were assumed to be statistically significant. Results: A total of 700 consenting women, comprising 505 pregnant (72.1%) and 195 non-pregnant (27.9%) women were recruited into this study. The mean age was 30.7 ± 4.9 years. All (100%) participants were Rhc positive while 641 (91.6%) were RhD positive and 59 (8.4%) were RhD negative. All 59 RhD negative subjects tested negative for anti-D. There was no statistically significant difference between proportion of RhD-negative women who had a jaundiced baby and the proportion of RhD-positive women who had a jaundiced baby (15.6% vs. 18.6%, P = 0.540). Conclusions: This study did not identify any Rhc and D alloantibodies in the study population suggesting there is a low risk of alloimmunization and HDFN due to anti-Rhc and D in this population.

Keywords: Hemolytic disease of the foetus and new born, Rhesus phenotype


How to cite this article:
Otomewo L, John-Olabode S, Okunade K, Olorunfemi G, Ajie I. Prevalence of Rhesus C and D Alloantibodies among Rhesus-Negative Women of Child Bearing Age at a Tertiary Hospital in South-West Nigeria. Niger J Clin Pract 2020;23:1759-66

How to cite this URL:
Otomewo L, John-Olabode S, Okunade K, Olorunfemi G, Ajie I. Prevalence of Rhesus C and D Alloantibodies among Rhesus-Negative Women of Child Bearing Age at a Tertiary Hospital in South-West Nigeria. Niger J Clin Pract [serial online] 2020 [cited 2022 Nov 30];23:1759-66. Available from: https://www.njcponline.com/text.asp?2020/23/12/1759/304416




   Introduction Top


Hemolytic disease of the fetus and newborn (HDFN) is still a serious complication in pregnancy.[1] It is triggered by red blood cell (RBC) antibodies that can cross the placental barrier and attack fetal RBCs. In particular, maternal alloimmunization to Rhesus-D antigen is recognized as a major contributor to fetal morbidity and mortality.[2] To date, the focus of antibody screening has been on determining the presence of anti-D antibody, with over 50 RBC antigens other antibodies including anti-c have been implicated in HDFN.[3],[4],[5],[6]

In severe cases, HDFN can manifest as fresh stillbirth or as hydrops fetalis,[4],[5] and despite adequate anti-D prophylaxis, 1.8% of RhD-negative women still go ahead to produce anti-D due to small transplacental hemorrhages during pregnancy.[7],[8],[9],[10]

In Nigeria, the prevalence of HDFN due to RhD is between 2.5% and 11.3%,[11],[12],[13],[14] but there is paucity of data on the prevalence of HDFN due to Rhc. This study was aimed at determining the prevalence of anti-c and anti-D and their contribution to risks of HDFN, to provide epidemiological and clinical data that will be useful in reducing HDFN in our environment.


   Methods Top


This was a cross-sectional study to determine the prevalence of Rhc antigen, anti-c, RhD antigen, and anti-D among women who attended the antenatal, gynecology, and blood donor clinics in Lagos University Teaching Hospital (LUTH) from January to August 2019. Study participants were selected using convenience sampling. Ethical approval was granted by the LUTH HREC (ADM/DCST/HREC/APP/2612).

This study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Sociodemographic characteristics, awareness of risks of Rhesus antigen, blood transfusion history, and previous Rhogam administration was elicited from the participants using an interviewer administered structured proforma.

Rhesus typing

Three milliliters of venous blood was carefully collected from the antecubital vein using 5 ml syringes and dispensed into a plain bottle. Serological typing of Rhc and D was carried out manually in tubes using anti-c and anti-D antisera (Lorne laboratories, Berkshire, United Kingdom), Rhesus controls were added in all tests and all negative results were confirmed using indirect agglutination test method with 20% bovine albumin and anti-human globulin (AHG) tests at 37°C. The RBC was then spun for 20 s at 100 rpm and was gently resuspended and immediately observed macroscopically and confirmed microscopically before recording the result as positive or negative. RhD-negative samples were centrifuged within an hour after sample collection and the sera were separated and stored in anti-coagulant free eppendorf tubes and stored at -20°c until time for analysis.

Antibody screening

Indirect antiglobulin test was used to screen for alloantibodies by tube method in low ionic strength solution, albumin, and AHG phase according to the manufacturer's instructions. All the different laboratory procedures were assayed at the blood bank of Lagos University Teaching Hospital, Lagos with the appropriate reagents in line with the manufacturer's instructions.

Data was analyzed using Stata version 16.1 statistical software and presented in Tables. Categorical data was summarized using frequency and percentages while continuous variables were described using the mean and standard deviation or median and interquartile range. Prevalence (and 95% confidence interval) of each of the studied Rhesus antigens and antibodies were calculated. Prevalence of Rhesus antigen D-positive and negative status was further calculated by ethnicity, age-group, and pregnancy status. Pearson's Chi-square (or Fisher's exact) test was used to test for association between categorical variables and Rhesus status. Student's t-test and Mann–Whitney U test was respectively used to test for association between normally distributed continuous variable, non-normally distributed continuous variables, and the Rhesus antigen status. Sub-analysis of the association between Rhogam administration and pregnancy and clinical outcomes among Rh D-negative women was also conducted. Two tailed test of hypothesis was assumed and P values of < 0.05 were assumed to be statistically significant.


   Result Top


Sociodemographic and clinical characteristics of the participants

A total of 700 women were enrolled in this study. Mean age was 30.7 ± 4.9 years.

Demographic characteristics are shown in [Table 1].
Table 1: Socio-demographic and clinical characteristics of participants

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Prevalence of Rhesus D and c antigen and antibodies with test for association between categorical variables and Rhesus status.

Out of 700 subjects tested for their Rhc and D phenotype, all (n = 700/700, 100%) were Rhc positive and none (0%) was Rhc negative, while 641 [91.6% (95% CI: 89.3–93.4%)] participants were RhD positive and 59 [8.4%, (95% CI: 6.6–10.7%)] were RhD negative. [Table 2]A The prevalence of Rhesus D negative status among pregnant women was 8.9% (95% –CI: 6.7–11.7%) [Table 2]B. The prevalence of RhD-negative phenotype was highest among the Hausa ethnic group [2/16, 12.5% (95% CI: 2.6–43.0%)]. and followed by the Yoruba ethnic group [(34/394, 8.6% (95% CI: 6.2–11.9%)], P value = 0.88). [Table 2]B.


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The 59 RhD-negative subjects were further screened for antibodies to the RhD antigen (anti-D). All tested negative for anti-D. Since all the participants were positive for Rhesus c antigen, antibody screening test for anti-c was not done.

Association between socio-demographic characteristics, pregnancy outcome and Rhesus status.

[Table 3] shows the association between sociodemographic characteristics and Rhesus D status. Of the 59 RhD-negative women, more than half were of the Yoruba ethnic group (n = 34/59, 57.6%). There was no statistically significant association between ethnicity, age marital status, and educational status in relation to Rh D status of the participants.
Table 3: Association between Socio demographic characteristics and Rhesus D antigens

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[Table 4] shows the association between pregnancy outcome, history of blood transfusion, and Rh D antigens. There was no statistically significant difference between proportion of RhD-negative women who had a jaundiced baby as compared to the proportion of RhD-positive women who had a jaundiced baby (15.6% vs. 18.6%, P value = 0.540). RhD-negative women had higher median live births as compared to the RhD positive women [0.98 (0–5), P = 0.0007)]. The prevalence of ectopic pregnancy [(20.3% vs. 11.5%, P value = 0.049), cesarean section [(11.9% vs. 1.3%, P value < 0.001)], blood transfusion [(25.4% vs. 8.1%, P value < 0.001), and blood transfusion reaction [(5.1% vs. 1.4%, P = 0.037)] was higher among Rh-negative participants than the prevalence among Rh-positive participants (P-value < 0.05). The level of awareness of Rhesus type among participants who had Rh-negative phenotype were about four-fold as compared to the Rhesus type awareness among participants who had Rh-positive phenotype. (81.4% vs. 21.1%, P value < 0.0001)
Table 4: Association between Pregnancy outcome, history of blood transfusion and Rhesus D antigens

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History of Rhogam administration and potentially sensitizing events

Of the 59 women who were RhD negative, Rhogam was previously administered to 22 of them giving a prevalence rate of Rhogam administration of 37.3% (95% CI: 25.7% - 50.6%). Nearly all or all the women who had Rhogam were previously pregnant (100%) or currently pregnant (99.9%). All the women who had history of neonatal jaundice (NNJ) (n = 11,100%) or cesarean section (n = 12, 100%) had Rhogam administration. In contrast, about 25% (n = 1/4), 57.1% (n = 4/7), and 100% (n = 3/3) of women who respectively had prenatal diagnosis procedure, ectopic pregnancy and blood transfusion reaction did not have Rhogam injection [Table 5].
Table 5: Association between history of blood transfusion and pregnancy and clinical outcome among Rhesus negative women

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   Discussion Top


The Rh immune response in Rh-negative women is the primary etiology for hemolytic disease of the fetus and newborn.[15] The distribution of RhD antigen significantly varies with race,[16],[17] with the prevalence of RhD antigen higher in Africans than Asians.[18] The prevalence of RhD and Rhesus c phenotypes in this study were 91.6% and 100%, respectively, which is in keeping with findings in previous studies done in Northern and Eastern parts of Nigeria.[19],[20],[21],[22] As expected these are higher than what has been reported in the Caucasian population.[23]

In this study, we found the RhD-negative prevalence of 8.4% (95% CI 6.6–10.7%) which is consistent with some reports from various parts of the country[22],[24],[25] but slightly higher than prevalence studies carried out in the Northern region of the country.[26],[27],[28],[29],[30],[31],[32] The Yoruba ethnic group from the South western part of the country has been known to have the highest proportion of RhD-negative population.[31] Therefore, it was not surprising that a prevalence of 8.4% was obtained in this study whose population is predominantly of Yoruba ethnic group. This rate shows a slightly higher frequency in this environment which implies an increased risk of alloimmunization to the RhD antigen.

In this study, neither Rhc nor D alloantibodies were detected suggesting that Rhc and D alloimmunization are rare causes of NNJ among neonates in Lagos. This finding is in line with other previous studies which puts RhD alloimmunization rate to between 0% and 1.6%.[11],[33],[34] It has been postulated that RhD-negative Nigerians have a low isoimmunization potential, probably due to some genetic predisposition. Interestingly, as reported by previous studies the commonest causes of NNJ in our environment are sepsis and preterm delivery.[35],[36],[37] This hypothesis has been corroborated by our study which reported no statistically significant difference between RhD-negative women and RhD-positive women who have had a baby with NNJ.

As revealed in this study, RhD-negative women had higher median live births as compared to the RhD-positive women despite the fact that there is still a challenge to Rhogam administration in the antenatal period, after a sensitizing episode or after delivery. We report a prevalence rate of Rhogam administration of 37.3% and only a quarter of the RhD-negative participants received Rhogam after a sensitizing episode. The major obstacle to Rhogam is cost and this finding underscores the need for government to subsidize the cost of Rhogam to reduce fetal morbidity and mortality.


   Conclusion Top


Our study shows that whereas the risk of HDFN due to Rh c alloantibodies is negligible in this population, RhD alloimmunization still poses a risk of adverse pregnancy outcome especially without the use of anti-D prophylaxis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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