ABO incompatibility

Last reviewed: June 5, 2012.

A, B, and O are the three major blood types. The types are based on small substances (molecules) on the surface of the blood cells. When people who have one blood type receive blood from someone with a different blood type, it may cause their immune system to react. This is called ABO incompatibility.

Causes, incidence, and risk factors

The different blood types are:

Type A Type B Type AB Type O

People who have one blood type may form proteins (antibodies) that cause their immune system to react against one or more of the other blood types. Being exposed to another type of blood can cause a reaction. This is important when a patient needs to receive blood (transfusion) or have an organ transplant. The blood types must be matched to avoid an ABO incompatibility reaction. For example:

A patient with type A blood will react against type B or type AB blood. A patient with type B blood will react against type A or type AB blood. A patient with type O blood will react against type A, type B, or type AB blood. A patient with type AB blood will NOT react against type A, type B, or type AB blood.

Type O blood does not cause an immune response when it is received by people with type A, type B, or type AB blood. This is why type O blood cells can be given to patients of any blood type. People with type O blood are called "universal donors." However, people with type O can only receive type O blood.

Both blood and plasma transfusions must be matched to avoid an immune reaction. Before anyone receives blood, both the blood and the person receiving it are tested carefully to avoid a reaction. Usually a reaction occurs because of a clerical error.

Symptoms
The following are symptoms of ABO incompatible transfusion reactions:

Back pain Blood in urine Chills Feeling of "impending doom" Fever Yellow skin (jaundice)

Signs and tests

The health care provider will perform a physical exam. Blood tests will usually show:

Bilirubin level is high Complete blood count (CBC) shows damage to red blood cells or anemia The patient's and donor's blood are not compatible

Urine tests show the presence of hemoglobin.

Treatment
Treatment may include:

Drugs used to treat allergic reactions (antihistamines) Drugs used to treat swelling and allergies (steroids) Fluids given through a vein (intravenously) Medicines to raise blood pressure if it drops too low

Expectations (prognosis)

ABO incompatibility can be a very serious problem that can even result in death. With the right treatment, a full recovery is likely.

Complications

Kidney failure Low blood pressure needing intensive care Death

Calling your health care provider

Call your health care provider if you have recently had a blood transfusion or transplant and you have symptoms of ABO incompatibility.

Prevention
Careful testing of donor and patient blood types before transfusion or transplant can prevent this problem.

References
1. Goodnough L. Transfusion medicine. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 180.

ABO Incompatibility in Newborns

By Jane Palmer

ABO incompatibility is a common and generally mild type of haemolytic disease in babies. The term haemolytic disease means that red blood cells are broken

down more quickly than usual which can cause jaundice, anaemia and in very severe cases can cause death. During pregnancy, this breakdown of red blood cells in the baby may occur if the mother and babys blood types are incompatible and if these different blood types come into direct contact with each other and antibodies are formed. Significant problems with ABO incompatibility occur mostly with babies whose mothers have O blood type and where the baby is either A or B blood type. Premature babies are much more likely to experience severe problems from ABO incompatibility, while healthy full term babies are generally only mildly affected. Unlike haemolytic disease that can result in subsequent babies when a mother has a negative blood group, ABO incompatibility can occur in first-born babies and does not become more severe in further pregnancies. To help you understand ABO incompatibility, it is helpful to review the different blood groups. The genes you inherit from your parents determine your blood group. There are four blood types; A, B, AB and O. Each blood type has its own individual collection of chemicals on the blood cell surface known as antigens, so type A has the A antigen, B has the B antigen, AB has both antigens and O contains no antigen. If different blood types mix, an immune response occurs and the person will produce antibodies to attack the foreign blood antigen.

Jaundice Baby
During pregnancy the mothers and babys blood generally do not mix. The mothers and babies circulation is kept separate by the placental membrane. Oxygen, carbon dioxide, nutrients, certain drugs and some viruses can pass through the placental membrane. However, some circumstances can cause the two blood types to mix, such as miscarriage, trauma and birth, and sometimes

they may mix for reasons unknown. Antibodies against the foreign blood types A and B may be formed. These antibodies could then pass across the placental membrane into the babys circulation and may result in the destruction of some of the babys red blood cells. This destruction of red cells causes an increase in the production of bilirubin a waste product. If too much bilirubin is produced, it can overwhelm the babys normal waste elimination processes and lead to jaundice. Jaundice is caused by bilirubin, a yellow pigment that gives the newborn's skin and whites of the eyes a yellow appearance. The babys colour is observed during regular newborn examinations by a midwife or doctor. The baby may need blood tests to check the level of bilirubin if the baby looks significantly jaundiced. Slight jaundice is very common in newborns and requires no follow up. Babies with high levels of bilirubin in their blood will require phototherapy and in severe cases they may need an exchange blood transfusion.

Baby having phototherapy

For babies affected by ABO incompatibility, anaemia may become an issue after a few weeks. The anaemia is caused by the faster than normal breakdown of the babys red blood cells caused by the mothers antibodies. These antibodies can linger in the babys circulation for weeks after birth. Because of this, some babies will need to have blood tests to check the level of anaemia. Routine blood screening tests in pregnancy do not screen for ABO incompatibility. Testing in pregnancy is not recommended as antibody levels do not correlate well to actual ABO haemolytic disease in the baby. There are no preventative measures that can be taken. After birth there are two options for testing for ABO incompatibility:

The cord blood of all babies whose mothers have an O blood group and the father either type A or B blood is tested The theory behind this approach is that if the baby is type A or B and they test positive in direct antiglobulin tests (DAT), the baby can then be followed closely for jaundice.

The alternate approach is to screen any baby who becomes significantly jaundiced (particularly within the first 24 hours).

What Is ABO Incompatibility? ABO Incompatibility is a fairly common and milder type of hemolytic disease of the newborn, and is caused by the result of an immune system reaction. Rh Incompatibility, another hemolytic disease of the newborn, is associated with poorer fetal outcomes. ABO incompatibility occurs when blood from two different - and incomparable - types of blood are mixed together. ABO incompatibility is a relatively common type of hemolytic disease of newborns, and may occur during blood transfusion reactions of older people. For purposes of this article, we will discuss ABO Incompatibility of the newborn. In contrast to an Rh Incompatibility of the newborn, ABO incompatibility of the newborn does not generally become more severe with subsequent pregnancies. Blood Types and ABO Incompatibility: To understand ABO Incompatibility, we must first touch upon the different blood types: A, B, AB, and O, differentiated by the collection of antibodies on the surface of the red blood cell.

Type A Blood has Type A Antigen Type B Blood has a Type B Antigen Type AB has both A and B Antigens Type O Blood contains no antibodies on the surface of the red blood cells

If maternal-fetal antibodies commingle, it can launch a maternal immune response, thus creating antibodies that attack the foreign (or fetal) red blood cells.

What Are The Risk Factors Associated With ABO Incompatibility? There are several risk factors associated with ABO incompatibility:

Maternal blood type is O, while fetal blood type is A, B, or AB. Fetal-maternal hemorrhaging, allowing the blood of the fetus to commingle with that of the mother. Trauma to the abdomen that may lead to hemorrhaging. What Causes ABO Incompatibility?

During a pregnancy, mixing of maternal and fetal blood doesn't occur very often - the blood circulation of both mother and fetus are separated by the placental barrier, which does not often allow blood to commingle. However, other things, such as oxygen, carbon dioxide, nutrients, drugs, and certain viruses can pass through the placental membrane. During pregnancy, maternal antibodies are transported via the placenta into the fetal circulation. This provides the newborn, who is born with an immature immune system, with invaluable maternal antibodies, which boosts the chance of fetal survival outside of the womb. The downside of this survival mechanism occurs when blood manages to cross the placental barrier and maternal antibodies target fetal red blood cells and can lead to ABO Incompatibility, a relatively mild form of hemolytic disease of the newborn. Sometimes, however, circumstances allow the two blood types to commingle. If maternal-fetal blood does manage to mingle in a mother who has one type of blood, pregnant with a fetus with a different type of blood, antibodies against the foreign blood are created. Unfortunately, these antibodies often pass through the placental barrier and into fetal circulation, where they can cause the destruction of some of the growing fetuses red blood cells. The destruction of fetal red blood cells by these antibodies leads to an increase of bilirubin - a waste product of red blood cells normally excreted by the liver - in fetal blood circulation. As a result, excess amounts of bilirubin can easily overwhelm the liver of a neonate, and lead to a condition called neonatal jaundice.

What is Newborn Jaundice? Newborn Jaundice is caused by the buildup of of excess bilirubin in the bloodstream of the newborn. Newborns are born with immature livers, and conditions like ABO Incompatibility, which causes excess bilirubin to build up in the bloodstream, can lead to newborn jaundice. While most cases of jaundice resolve on their own, newborn jaundice may require medical intervention to properly resolve. What Are The Complications of ABO Incompatibility? While ABO Incompatibility is not generally as dangerous as other types of hemolytic diseases of the newborn, there are complications that can be caused by this disorder. Complications of ABO Incompatibility may include: Newborn Jaundice: most babies who have ABO incompatibility are born with higher than normal levels of bilirubin which can lead to newborn jaundice. Newborn jaundice may or may not require medical intervention to resolve. Read more about newborn jaundice. Anemia: many newborns who are affected by ABO incompatibility may develop issues with anemia after several weeks. This anemia is due to the increased amounts of breakdown of the red blood cells in response to maternal antibodies. These antibodies may persist in the newborn's body for several weeks following delivery. This may necessitate laboratory blood studies to ascertain how anemic the newborn is. How Is ABO Incompatibility Diagnosed? Prenatal Testing: Normal prenatal blood screenings do not generally test for ABO incompatibility as during pregnancy, antibody levels do not often properly correlate with any type of ABO Incompatibility. Thus, there is no way to predict or prevent ABO Incompatibility. Antepartum Testing: There are two options pre-delivery, for determining whether a baby has developed ABO incompatibility during pregnancy:

1. Cord blood testing - mothers with type O blood with fathers who have blood types of A or B are often tested. If the baby is born with type A or type B blood, direct anti-globulin tests (DAT) are performed and the infant can be followed to see if he/she develops anemia or jaundice. 2. Screen any baby who appears significantly jaundiced - especially if the jaundice occurs within 24 hours of birth. Treatment of ABO Incompatibility: While ABO Incompatibility does not generally symptoms that require major medical treatment, treatment options can include the following: Phototherapy (anywhere from at-home to in the hospital for more severe cases of newborn jaundice) to treat any newborn jaundice. Antihistamines to treat allergic reactions (if they occur) Steroids to reduce swelling and inflammation. IV Fluids Exchange Transfusions, replacing fetal blood with donated blood, are only performed in extreme cases and in specialized medical centers. It's important to note that the anemia that may be caused by ABO Incompatibility of the newborn is often negligible, and requires no treatment.