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

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.

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.

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.

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.