Authors: Russo C M et al.
Cureus 17(2): e79346.
Summary
This case report describes a high-risk obstetric anesthetic scenario where standard transfusion “backup” essentially didn’t exist. A 37-year-old gravida 2 para 1 scheduled for repeat cesarean delivery was found on preoperative testing to be Jr(a−) (Junior-negative) with anti-Jr(a) antibodies — a situation the team characterized as incompatible with nearly all available donor red blood cells. That single laboratory reality changed the entire perioperative plan because cesarean delivery always carries a hemorrhage risk, and this patient also had multiple fibroids, increasing the chance of brisk bleeding.
The team’s core problem was simple: if major bleeding happened, giving “emergency release” blood could trigger clinically significant hemolysis because the patient’s antibody targets a high-frequency antigen. Since there was no practical way to source compatible donor units on short notice, they built a plan around avoiding transfusion and substituting autologous strategies.
Their approach included:
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Choosing a combined spinal-epidural to maintain flexibility for surgical duration and physiologic stability.
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Pre-positioning and relying heavily on intraoperative cell salvage (cell saver) as the primary “transfusion” contingency.
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Using hemorrhage-mitigation tactics early, including tranexamic acid at incision and having uterotonics immediately available (with methergine avoided because of chronic hypertension).
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Coordinating closely with hematology and the blood bank preoperatively so everyone understood the true limitations before incision.
Intraoperatively, brisk bleeding occurred at uterine incision in the setting of fibroids and poor uterine tone. The team used oxytocin boluses followed by infusion, gave carboprost, supported blood pressure briefly with phenylephrine, and used albumin for temporary volume expansion while surgical hemostasis was achieved. Cell saver collected 387 mL, which was washed and transfused back without adverse reaction, allowing the case to finish without incompatible donor blood. The patient recovered hemodynamically stable.
Key Points
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Jr(a−) with anti-Jr(a) can make compatible donor RBCs effectively unavailable, even when routine type-and-screen/crossmatch workflows are followed correctly.
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For hemorrhage-capable surgery (especially cesarean), the anesthetic plan should assume “no rescue blood” and build layered alternatives.
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Intraoperative cell salvage can be the most practical bridge when allogeneic transfusion is unsafe or unobtainable.
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Early hemostasis strategy matters: slow, methodical surgical technique, early TXA, and uterotonic readiness can meaningfully reduce exposure to a no-win transfusion scenario.
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The case is a good reminder that “rare blood type” risk isn’t ABO/Rh — it’s the unexpected antibody to a high-frequency antigen.
What You Should Know
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If a patient’s antibody targets a high-frequency antigen, “compatible units” may be essentially nonexistent locally, regionally, or even nationally in real time.
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The most valuable move is early coordination (anesthesia, OB, blood bank, hematology) before the patient reaches the OR.
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Build a hemorrhage plan that does not depend on donor RBCs: cell saver, TXA, uterotonics, strict surgical hemostasis, and clear thresholds for escalation.
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If transfusion becomes unavoidable, the team may be forced into incompatible blood with significant risk — so the whole goal is to never get there.
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