Navigating Dual Obstetric Risks: Intrauterine Transfusion for Rh D Alloimmunization in the Setting of PPROM

Purpose: To describe the successful use of percutaneous umbilical blood sampling (PUBS) and intrauterine transfusion (IUT) for fetal anemia in a Rh D-alloimmunized pregnancy complicated by preterm premature rupture of membranes (PPROM), highlighting a rare but feasible therapeutic intervention in a high-risk obstetric setting. Introduction: Hemolytic disease of the fetus and newborn, primarily due to Rh D alloimmunization, remains a significant cause of fetal anemia and perinatal morbidity. Management typically includes close fetal surveillance with middle cerebral artery peak systolic velocity (MCA-PSV) Doppler measurements, and, when indicated, intrauterine transfusion. While IUT is well-established, its use in pregnancies complicated by PPROM is exceedingly rare due to increased risks of infection, preterm labor, and procedural complications. This case represents the only known reported instance of successful PUBS and IUT in a pregnancy affected by both Rh alloimmunization and PPROM, allowing for safe prolongation of gestation. Methods: Case Report. Results: A 38-year-old G10P2162 woman presented at 29 3/7 weeks gestation with confirmed PPROM. Her pregnancy was complicated by Rh D alloimmunization, with an Anti-D antibody titer of 1:64 and serial MCA-PSV Dopplers demonstrating progressive elevation, reaching 1.7 MoM. A diagnosis of fetal anemia was suspected. The patient was counseled extensively by the Maternal-Fetal Medicine team regarding the risks and benefits of intervention and consented to undergo PUBS and IUT at 30 5/7 weeks. Under spinal anesthesia and continuous ultrasonographic guidance, a 20-gauge needle was inserted into an accessible portion of the umbilical vein. Fetal blood sampling confirmed anemia (hematocrit 30%, macrocytic indices). A total of 30 mL of O Rh-negative, CMV-negative, Kell-negative, buffy coat-poor packed red blood cells was transfused without complication. Streaming of transfused blood into the umbilical circulation was confirmed via color Doppler. Postprocedural evaluation was reassuring and a normalization of the MCA doppler value was encountered within the week at 1.02 MOM. Throughout the rest of her pregnancy course, the patient was monitored daily and received frequent fetal assessments. The MCA doppler values never exceeded critical values (1.55 MoM) prior to the spontaneous onset of labor. The patient subsequently delivered at 33 2/7 weeks via repeat cesarean section with bilateral tubal ligation due to preterm labor and malpresentation. Neonatal Apgar scores were 4 at 1 minute, 6 at 5 minutes, and 8 at 10 minutes with initial neonatal hemoglobin/hematocrit of 12.7/39.2. The patient’s surgery was uncomplicated, and neonate subsequently was admitted to the Neonatal Intensive Care Unit (NICU). The neonate remained in the NICU for 12 days prior to discharge during which time her total bilirubin was frequently trended. Total bilirubin peaked at 16.4 on postpartum day 5, but was adequately treated with phototherapy. The neonate did not require transfusion but did receive a single dose of IVIG. She was discharged from the NICU 12 days after delivery with no significant sequelae. Postoperatively, the patient remained stable and received routine postpartum care throughout her admission prior to being discharged on postpartum day 4. Conclusion: This case demonstrates that intrauterine transfusion via PUBS is technically feasible and clinically effective even in the setting of PPROM. It reinforces the importance of vigilant fetal surveillance in alloimmunized pregnancies and the value of timely intervention to mitigate the risks of severe anemia. The decision to proceed with transfusion must be individualized, balancing the risk of preterm labor or infection against the morbidity and mortality of untreated fetal anemia. A multidisciplinary approach, including MFM, neonatology, anesthesiology, and transfusion services, is essential for optimizing maternal and fetal outcomes in such complex scenarios. This case also provides novel clinical insights into a scarcely reported situation and supports the role of PUBS/IUT in prolonging gestation and improving neonatal outcomes, even under compromised membrane conditions.