A suspected case of fetal and neonatal alloimmune thrombocytopenia (FNAIT) has been reported in Nigeria that resulted in an infant’s death, according to findings from a study published recently in the Journal of Case Reports in Medical Science.
Among those with the rare disorder FNAIT, a considerable risk for severe neonatal morbidity exists. In fact, FNAIT has been recognized as “the major cause of primary hematologic morbidity and mortality in neonates.”
Pregnancy and delivery
The mother is a 33-year-old woman who delivered a male baby via an emergency lower segment cesarean section (CS) because of premature rupture of the membranes (PROM) with oligohydramnios at 29 weeks, 3 days’ gestational age (GA).
The mother’s blood group is O Rhesus (Rh) D-positive; her genotype is HbAA. No history of preeclampsia, hypertension, or diabetes was reported.
Her first pregnancy resulted in the birth of a healthy male child. In her second pregnancy, in which a male child was delivered via CS, the baby died within 12 hours after birth. Although the cause of death was inconclusive, it was reported that the child exhibited some petechial hemorrhages distributed throughout his body.
Read more about FNAIT causes and risk factors
In her current pregnancy, the mother began to consult with the appropriate clinicians at a private hospital when the baby’s estimated GA was four weeks. She had regular antenatal visits and took routine medications, as prescribed.
She was treated for malaria with oral medications at an estimated GA of 21 weeks. At one week prior to delivery, she noticed some drainage of fluid from her vagina and was admitted to the private hospital. About 24 hours later, she began to experience vaginal bleeding. Dexamethasone, magnesium sulfate, and antibiotics were prescribed, with no significant improvement noted.
Following one week at the private hospital, she was transferred to the Ladoke Akintola University of Technology Teaching Hospital Ogbomoso, located in Oyo, Nigeria.
The infant male was born preterm with a very low birthweight. The infant experienced bleeding from his mouth and anus after only a few minutes of life. He then had an episode of apnea, for which he received resuscitation via airway suctioning and artificial manual breathing unit (AMBU) bagging for approximately 30 minutes, until he regained spontaneous respiration.
The baby was diagnosed with severe sepsis that was complicated by disseminated intravascular coagulopathy and vitamin K–dependent bleeding. Numerous medications were administered.
At 42 hours of life, recurrent episodes of apnea were observed in the newborn. Cardiopulmonary resuscitation, AMBU bagging and chest compressions were performed. The final resuscitation attempt lasted for one hour, 30 minutes. The baby did not regain consciousness and was then declared to be dead.
Autopsy findings
Areas of petechial hemorrhage were noted in the pleural and epicardial surfaces. The lungs showed congestion of the alveolar capillaries, interstitial edema, areas of hemorrhage, and infiltration by neutrophils.
Kidney analysis revealed features that are indicative of tubular necrosis. Areas of hemorrhage and congested blood vessels were seen on the liver. Features that align with placental vasculopathy were noted as well.
A summary of the autopsy findings showed anemia, central cyanosis, petechial hemorrhage, diffuse alveolar damage, cerebral edema, and acute tubular necrosis.
Death of an unknown cause
Because the cause of the mother’s placental vasculopathy could not be established, it was suggested that she undergo screening for cytomegalovirus and thrombophilia as possible causes of the baby’s death.
“The key findings from this case included a recurrent neonatal death of unknown cause, small for gestational age, PROM, significant [anhydramnios], uncontrolled hemorrhage, thrombocytopenia, persistent anemia, recurrent apnea and seizures.”
The recurrence of early neonatal death with similar circumstances of neonatal bleeding and thrombocytopenia experienced by the mother this time as in her prior pregnancy, along with thrombocytopenia within 72 hours of life, raise the suspicion of FNAIT.
Recognized as a rare condition, FNAIT “poses a challenging diagnosis and treatment plan in resource-limited [centers, particularly] in developing countries,” the authors concluded.
