Alloimmune Disorders of Pregnancy: Anaemia, Thrombocytopenia and Neutropenia in the Fetus and Newborn (Paperback)

by Andrew Hadley (Editor), Peter Soothill (Editor) "A comprehensive review of humoral immune responses is outside the scope of this chapter..." (more)
Key Phrases: Vox Sanguinis, British Journal of Haematology, New England Journal of Medicine (more...)

Editorial Reviews

From the New England Journal of Medicine, February 27, 2003
The permissiveness of the maternal immune system toward the fetus as an allogeneic "graft" is governed by complex immunologic interactions that ultimately allow successful pregnancy in most cases. Contributing to these processes are fetal and maternal factors that define immunogenicity and immunoreactivity in the bidirectional maternal-fetal relationship. A breakdown of maternal immune permissiveness (rejection of the fetal allograft) can have devastating consequences for the fetus and result in pregnancy loss. Some fetal elements do not become immunogenic to the mother or vulnerable to maternal immune responses until pregnancy progresses. This may occur concomitantly with developmentally regulated changes in fetal antigen expression or may be due to a breakdown of barriers that normally separate the fetal and maternal circulations. Certain maternal immune responses elicited by fetal antigens, such as RhD antigens, do not become clinically significant until subsequent pregnancies, whereas others cause disease in the first pregnancy. Although the consequences of maternal immune responses against fetal lymphohematopoietic cells have been recognized since the 1930s, the clinical sequelae were described centuries ago. Historical notes suggest that of six children born to the first wife of England's King Henry VIII in the early 16th century, five were stillborn or died during early infancy with features consistent with hemolytic disease of the newborn, leaving only a daughter -- a situation that had enormous political ramifications. A report from the early 17th century documenting the outcome of a twin pregnancy describes the clinical features of kernicterus and hydrops that were later linked by Louis Diamond to the effects of intrauterine hemolysis and termed "erythroblastosis fetalis." Before the development of adequate treatment, it was estimated that 1000 neonates died each year in the United Kingdom from hemolytic disease; in North America, the estimated rate of death among affected newborns was 50 percent. Fetal death added considerably to the impact of erythroblastosis fetalis. In the 1940s, in a fascinating sequence of astute observations and applied thinking, there was rapid advancement in the understanding of the immunologic basis and pathophysiology of these conditions, particularly fetal hemolysis caused by maternal RhD sensitization. This led to the development of treatment of the affected newborn by means of exchange transfusions and progressed within a few years to intrauterine intervention for the purpose of providing direct fetal transfusions. Despite these advances, however, the resounding success came not with treatment of the affected fetus or infant but with prevention. Strategies developed in the 1960s by Finn, Freda, and others demonstrated that sensitization of the RhD-negative mother by her RhD-positive fetus could be prevented by the administration of anti-D antibody. By the 1980s, this approach had resulted in a reduction in perinatal deaths due to RhD hemolytic disease by a factor of more than 20 and the prevention of intrauterine deaths. The decline in mortality and morbidity continues as obstetrical and fetal techniques improve and as molecular methods are integrated into diagnostic and treatment approaches. The remarkable success story of RhD illustrates the power of an integrated approach to clinical medicine for a disease process that, like many others, lies at the interface of several fields of applied science and medicine. In Alloimmune Disorders of Pregnancy, editors Andrew Hadley and Peter Soothill acknowledge the need for an integrated multidisciplinary effort to ensure that advances in this field continue to have practical applicability. They bring together their individual expertise in transfusion science and maternal-fetal medicine toward this end. They have assembled the contributions of experts in various research and clinical aspects of the field into a concise overview that includes epidemiology, pathophysiology, prevention, diagnosis, and management, ranging from the molecular level to the population level. The book begins with a preface that includes a helpful explanation of historical terms and a clarification of terminology used in the book. This section would have been enhanced by inclusion of historical notes to provide a perspective on progress in the field. An introductory chapter on the pathophysiology of the alloimmune cytopenias of pregnancy as a group of diseases provides a clear overview of the various threads and biologic complexities of the disease entities. Nine of the 13 subsequent chapters are related to hemolytic disease of the fetus and newborn, 3 are concerned with alloimmune thrombocytopenia, and 1 discusses alloimmune neutropenia. The flow of information is somewhat interrupted because of the curious organization of the chapters. A better arrangement would have been an initial grouping of the chapters dealing with hemolytic disease, but this is a minor criticism. Chapter 2, which addresses the specific antigen systems and antibodies involved in hemolytic disease of the fetus and newborn, is particularly clearly written and serves as an excellent basis for the complexities of screening techniques and fetal genotyping presented in later chapters. Likewise, Chapter 5, on the principles of antibody-mediated immune suppression, gives a clear explanation of the theoretical and historical basis of strategies to prevent maternal alloimmunization through the administration of anti-D antibody. The other chapters on hemolytic disease provide much practical and detailed information on diagnosis and treatment in the individual patient, as well as screening approaches and treatment guidelines for various populations at risk. Laboratory assays used for clinical management are explained clearly. Problems and failures are also noted, as well as potential risks to the fetus in maternal treatments. Future directions are discussed in most chapters. Overall, the chapters dealing with alloimmune hemolytic disease are highly informative and well written. Although some approaches are biased toward a U.K. perspective, practices in other countries are usually noted. The other sections are rather brief, particularly the single chapter on alloimmune neutropenia, and would have benefited from expansion, with the acknowledgment that these areas have been less well explored than alloimmune hemolytic disease. This book will serve as a useful resource for the many participants in multidisciplinary teams that manage alloimmune disorders in pregnancy. It should serve to enhance communication and coordination among investigators and clinical specialists in each of the contributing fields, thus achieving the editors' goals. Lori J. West, M.D., D.Phil.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.

Review
"This book serves as an excellent update on the comprehensive management of alloimmune disorders of pregnancy. It is an excellent source..." Canadian Journal of Medical Laboratory Science

"[V]ery useful in understanding the mechanisms of the alloimmune response...I do not know of any other book that covers this topic." Doody's Review Service G

"This book will serve as a useful resource for the many participants in multidisciplinary teams that manage alloimmune disorders in pregnancy. It should serve to enhance communication and coordination among investigators and clinical specialists in each of the contributing fields, thus achieving the editors' goals." The New England Journal of Medicine

See all Editorial Reviews

• Paperback: 304 pages
• Publisher: Cambridge University Press; 1 edition (August 22, 2005)
• Language: English
• ISBN-10: 0521018048
• ISBN-13: 978-0521018043
• Product Dimensions: 9.4 x 6.8 x 0.9 inches
• Shipping Weight: 1.1 pounds (View shipping rates and policies)
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