Exeley Inc.

Tan, Yuxing

Yao, Hongge

Deep Capsule Network Handwritten Digit Recognition

Wu, Aiqun

Gao, Zhangxing

Imperative to Build Network Security System and Speed Up the Future Network Construction

Wu, Xudong

Review of Anomaly Detection Based on Log Analysis

Xu, Wang

Baolong, Liu

A Review of Segmentation Technology Based on 3D Point Cloud

Falsetti, Paolo

Conticini, Edoardo

Baldi, Caterina

Bardelli, Marco

Al Khayyat, Suhel Gabriele

D’Alessandro, Roberto

Cantarini, Luca

Frediani, Bruno

Ultrasound evaluation of the scapholunate ligament and scapholunate joint space in patients with wrist complaints in a rheumatologic setting

Klontzas, Michail E.

Koltsakis, Emmanouil

Kakkos, George A.

Karantanas, Apostolos H.

Ultrasound-guided treatment of Morton’s neuroma

Patale, D.S.

Lokhande, T.L.

Chaudhary, R.K.

64 IMMUNOHEMATOLOGY, Volume 37, Number 2, 2021
ABO incompatibility is the most common cause of immune 
hemolytic disease of the fetus and newborn (HDFN). The 
American Academy of Pediatrics lists blood group incompatibility 
as one of the major risk factors for severe hyperbilirubinemia in 
newborns. We have estimated the risk of ABO HDFN to determine 
the need for its routine screening. Blood group data from all 
blood donors who donated in the last 10 years were collected 
and analyzed. The population prevalence of ABO blood group 
genes using the phenotype data of blood donors was estimated. 
This information was further used to calculate an incidence of 
ABO HDFN requiring intervention in the population. ABO blood 
group typing was analyzed in 425,743 blood donors. The ABO 
phenotypes of A, B, O, and AB were 22.48, 36.73, 31.59, and 9.2 
percent, respectively. The gene frequencies were 0.1733, 0.2647, 
and 0.5620 for A, B, and O, respectively. It was estimated that 
13.84 percent of group O women would give birth to a non–group 
O baby and that approximately 2.77 percent of deliveries would 
likely have ABO HDFN in the study population. In India, the 
estimated risk of ABO HDFN is 2.9 percent, with a daily 2196 
babies at risk of ABO HDFN requiring intervention. This analysis 
estimates the overall burden of ABO HDFN in the population, 
which could aid in the decision-making of policymakers, 
physicians, and community health practitioners to improve 
neonatal care. Immunohematology 2021;37:64–68. 
DOI:10.21307/immunohematology-2021-009.
Key Words: ABO HDFN, ABO gene frequency, risk 
estimation
In recent years, clinical and public health efforts, such as 
red blood cell antibody screening of all pregnant women and 
administration of Rh immune globulin (RhIG) in developed 
countries, have reduced the burden of Rh hemolytic disease 
of the fetus and newborn (HDFN), ultimately resulting in 
ABO HDFN as the most common cause of immune HDFN. 
Approximately 15–25 percent of feto-maternal pairs are 
ABO incompatible (blood group O mother with non–group 
O neonate), of which 10–15 percent of neonates develop ABO 
HDFN.1,2 ABO HDFN is usually managed successfully with 
phototherapy, although it is not always a benign condition. 
Severe cases having bilirubin-induced neurologic dysfunction 
and, rarely, antenatal hydrops fetalis have been described.3 
Ethnicity plays a critical role in the prevalence and severity 
of ABO HDFN. Toy et al.4 highlighted that the prevalence of 
direct antiglobulin test positivity in a group A infant born to 
a group O mother was highest (50%) in Asians and lowest 
(31%) in Europeans.4 The current scenario of ABO HDFN 
in India is unknown; unusually severe cases requiring active 
intervention such as exchange transfusions have been reported 
from India.5,6 ABO blood group gene frequencies are useful 
to predict the risk of ABO HDFN in the population. Careful 
surveillance and early detection of infants at risk of bilirubin-
related brain injury begins with recognition of an infant’s risk 
for severe hyperbilirubinemia. It requires a systemic approach 
and awareness regarding significant risk factors for severe 
hyperbilirubinemia. This study was therefore planned to 
estimate the risk of ABO HDFN in our North Indian population 
and to assess the need for routine ABO HDFN screening.
Material and Methods
Blood group data from all blood donors who donated 
blood at a tertiary care hospital in Lucknow in the last 10 years 
(2010–2019) were collected from the hospital information 
system and analyzed. The prevalence of ABO blood group 
genes in our population using phenotype data of blood 
donors was estimated. It is assumed that gender does not 
influence ABO gene inheritance and blood group distribution; 
therefore, calculated gene frequencies can be applied to the 
female population. The data were further used to estimate the 
probability of feto-maternal ABO incompatibility and ABO 
HDFN requiring intervention.
Statistical Analysis
The frequency and percentage of each blood group (A, B, 
AB, and O) were calculated using descriptive statistics. Blood 
group allelic frequencies were calculated with the assumption 
of the Hardy-Weinberg equilibrium with Ceppellini 
oRiginal RepoRt
Statistical model for prediction of ABO 
hemolytic disease of the fetus and newborn 
in India
D.S. Patale, T.L. Lokhande, and R.K. Chaudhary
IMMUNOHEMATOLOGY, Volume 37, Number 2, 2021 65
correction.7 This iterative method yields maximum likeli-
hood estimates. It was assumed that:
• ABO blood group system is determined by three alleles 
of a single gene: A, B, and O.
• A and B are co-dominant, and they are dominant over 
O.
• In the population, genes follow the Hardy-Weinberg 
principle.
• A random sample of blood donors from the population 
was studied.
• Static allele frequencies across generations assume that 
there is no mutation and migration, population size is 
infinite, and there is no selective pressure for or against 
any genotypes.
The probability of a group O woman giving birth to a child 
with a non–group O phenotype was calculated. Maternal 
immunoglobulin (Ig)G anti-A and/or anti-B titer ≥512 
predicts the risk of ABO HDFN and the need for invasive 
treatment.8 Almost 20 percent of group O donors have 
IgG anti-A and/or anti-B titer ≥512.9 Accordingly, we have 
estimated the risk of ABO HDFN in the population.
Results
ABO blood group data of 425,743 blood donors were 
analyzed, in which 17,881 (4.2%) were female and 407,862 
(95.8%) were male. The details are summarized in Table 1. 
The study revealed that blood group B was the most prevalent 
(36.73%), closely followed by O at 31.59 percent, then A at 
22.48, percent, and AB as the least frequent group, at 9.2 
percent. The observed and expected phenotype frequencies 
are shown in Table 2. The χ2 test between the observed and 
expected phenotype frequencies in case of ABO group was not 
statistically significant (p > 0.0001).
CalCulation for gene frequenCy: 
A, B, and O were represented by letters p, q, and r.
CalCulation of O allele frequenCy (r):
The frequency of allele O is equal to the frequency of the 
recessive genotype (r2).
r2 = frequency of O phenotype ([number of group O 
individuals]/[total number of individuals])
r2 = (O/N)
r = √(O/N)
r = 0.5620
CalCulation of A allele frequenCy (p):
p = frequency of the group A phenotype + frequency of the 
group O phenotype.
The frequency of A + O = p2 + 2pr + r2 = (p + r)2
p + r = √ (A + O)
p = √(A + O) – (r) 
p = √(0.2248 + 0.3159) – 0.5620
p = 0.1733
CalCulation of B allele frequenCy (q):
Because p + q + r = 1
q = 1 – (p + r)
q = 1 – (0.1733 + 0.5620)
q = 0.2647
Thus, the calculated gene frequencies were 0.1733, 0.2647, and 
0.5620 for the A, B, and O genes, respectively.
the CalCulation for the probability of non–group o Child to 
group o mother:
The probability of a non–group O child to group O mother 
will be the probability of a group OO genotype woman mating 
with a genotype AA, BB, AO, BO, or AB man, resulting in an 
offspring with the non–group O gene. Using gene frequencies 
calculated above, the probability that an OO genotype woman 
mating with an AA genotype man is the product of frequency 
of AA genotype and frequency of OO genotype:
AA = r2 × p2 = 0.00948
HDFN prediction model
Table 1. Distribution of blood groups in the study population
Blood group A B O AB
Rh(D) type Pos Neg Pos Neg Pos Neg Pos Neg Total
Number of donors (%) 91,027
(21.38)
4663
(1.10)
148,941
(34.98)
7454
(1.75)
127,680
(29.99)
6805
(1.60)
37,315
(8.76)
1858
(0.44)
Total number (%) 95,690 (22.48) 156,395 (36.73) 134,485 (31.59) 39,173 (9.20) 425,743 (100)
Pos = positive; Neg = negative.
66 IMMUNOHEMATOLOGY, Volume 37, Number 2, 2021
D.S. Patale et al.
Similarly,
BB = r2 × q2 = 0.02214
The probability of an OO genotype woman mating with an AO 
genotype man is:
AO = r2 × 2pr
The probability of inheriting the A gene from the father is 50 
percent. Therefore, the probability of an AO man and an OO 
woman having an AO child is:
AO = (r2 × 2pr)/2 = r2 × pr
AO = 0.03076
Similarly,
BO = 0.04700
The probability of an OO genotype woman mating with an AB 
genotype man and having a child with either the A or B gene is:
AB = r2 × 2pr
AB = 0.02897
The sum of all probabilities is 0.13837.
Therefore, 13.84 percent of deliveries will result in a 
non–group O child to group O mother. Because 20 percent of 
group O mothers will have IgG anti-A and/or anti-B titer ≥512, 
ultimately 2.77 percent of deliveries in our study population 
are at risk of ABO HDFN, requiring intervention.
Discussion
In India, diversity has been observed in the geographical 
distribution of blood groups. In the present study, group B was 
the most prevalent blood group, followed by group O, in a north 
Indian population; this observation is similar to that found in 
the study by Arora et al.,10 although a multicentric study shows 
group O as the most common blood group, followed by group 
B, in India.10,11
Using ABO gene frequency, we calculated the probabilities 
of ABO incompatibility as 13.8 percent. Bhat and Kumar12 
found 17.3 percent ABO incompatibility, similar to our 
estimate. Akanmu et al.13 did a similar study in Nigeria in 
which they estimated that 14.3 percent of deliveries would 
result in feto-maternal ABO incompatibility, again similar 
to our findings. They estimated that 4.3 percent of deliveries 
are likely to suffer ABO HDFN, which is quite high compared 
with our estimation. This finding is consistent with previous 
reports stating that the incidence of ABO HDFN is higher in 
individuals of African descent. This difference can be due to 
the very high cutoff value (≥512) for antibody titer used in the 
present study.14,15
The burden of neonatal jaundice is highest in South Asia, 
where it is the seventh leading cause of neonatal mortality.16 
Various studies from India reported neonatal jaundice as the 
most common cause of neonatal morbidity, varying from 7 to 
16.7 percent.17,18 Statistical estimates allow us to project the 
overall burden of ABO HDFN in the population. Therefore, 
we extended this observation to national data and found that 
2.9 percent of neonates are at risk of ABO HDFN in India 
(Table 3). The birth rate in India is 20 per 1000 population, 
and currently the total population is 1,381,625,777.19,20 Thus, 
approximately 2196 babies are born per day who are at risk 
of ABO HDFN, requiring intervention. Barring the limitations 
associated with statistical modeling of disease burden, our 
data suggest that neonatal jaundice due to ABO HDFN is an 
important cause of neonatal morbidity.
Phototherapy and exchange transfusions are the 
mainstay treatments for severe hyperbilirubinemia, but 
these therapies require adequate infrastructure. The need for 
exchange transfusion has been reduced with the introduction 
Table 2. Distribution of ABO allele frequencies
Blood group 
(phenotype)
Observed 
frequency Genotype Expected frequency
A 0.2248 AA p2 0.0300 0.2247
AO 2pr 0.1947
B 0.3673 BB q2 0.0701 0.3677
BO 2qr 0.2976
O 0.3159 OO r2 0.3159 0.3159
AB 0.0920 AB 2pq 0.0917 0.0917
Total 1 1 1
p = A allele frequency; r = O allele frequency; q = B allele frequency.
Table 3. Comparison between Indian population and study 
population
Allele frequency Our data Indian data11
A 0.1733 0.1653
B 0.2647 0.2254
O 0.5620 0.6093
Probability
Non–group O child to group O 
mother 
0.13835 0.1450
ABO HDFN requiring intervention 2.77% 2.90%
HDFN = hemolytic disease of the fetus and newborn.
IMMUNOHEMATOLOGY, Volume 37, Number 2, 2021 67
HDFN prediction model
of phototherapy and intravenous immunoglobulin (IVIG) 
therapy. However, availability and cost of IVIG therapy 
are major limitations for its routine use in resource-poor 
nations. Immediate exchange transfusion is required when 
phototherapy fails to curtail the rate of bilirubin rise and 
the total serum bilirubin. Provision of exchange transfusion 
requires centers with fully equipped blood banks with 
component separation, such as a sterilized connecting device, 
leukocyte filtration, gamma irradiation, a dielectric tube sealer, 
laminar air-flow, and trained personnel. In a developing and 
resource-constrained nation such as India, infrastructure with 
facilities for special care, including monitoring and resuscita- 
tion capabilities, is most likely available at tertiary care 
hospitals. Findings of this study should help administrators 
plan for the provision of exchange transfusion when consider-
ing improvements in the Indian medical care infrastructure.
As per routine antenatal care, the blood group and Rh(D) 
type of the mother (ABO and Rh) is determined by a blood test. 
In resource-constrained areas, group O mothers should be 
tested for ABO antibody titers, and ABO-incompatible babies 
of high-risk group O mothers should be kept under vigilance. 
At present, D incompatibility is the only cause of HDFN for 
which screening is routinely done.21 Routine screening for 
ABO HDFN may be considered as an additional step in risk 
assessment of HDFN. Timely diagnosis with the appropriate 
intervention will result in a better outcome in babies at risk.
A limitation of the study is that the numbers used to 
calculate the risk of severe ABO HDFN are from a donor base 
that is likely all male, although gender does not influence ABO 
blood group distribution.
Conclusions
The estimated risk of ABO HDFN is 2.77 percent of all 
deliveries in our study population. In India, the calculated risk 
is 2.9 percent, with a daily number of 2196 babies at risk of 
ABO HDFN. A policy for routine screening of these neonates 
is needed.
Acknowledgments
The authors express their thanks and gratitude to all the 
blood bank staff working in the phlebotomy room and blood 
processing laboratory.
References
 1. Usha KK, Sulochana PV. Detection of high risk pregnancies 
with relation to ABO hemolytic disease of newborn. Indian J 
Pediatr 1998;65:863–5.
 2. Singhal PK, Singh M, Paul VK, Deorari AK, Ghorpade MG. 
Spectrum of neonatal hyperbilirubinemia: an analysis of 454 
cases. Indian Pediatr 1992;29:319–25.
 3. Ziprin JH, Payne E, Hamidi L, et al. ABO incompatibility 
due to immunoglobulin G anti–B antibodies presenting with 
severe fetal anaemia. Transfus Med 2005;1557–60.
 4. Toy PT, Reid ME, Papenfus L, et al. Prevalence of ABO 
maternal-infant incompatibility in Asians, Blacks, Hispanics, 
and Caucasians. Vox Sang 1988;54:181–3.
 5. Marwaha N, Dhawan HK, Thakral B, Kaur R, Basu S, Parmar 
V. Severe ABO hemolytic disease of the newborn with a 
positive direct antiglobulin test. Indian J Pathol Microbiol 
2009;52:292.
 6. Goraya J, Basu S, Sodhi P, Mehta S. Unusually severe 
ABO haemolytic disease of the newborn. Indian J Pediatr 
2001;68:285–6.
 7. Ceppellini R, Siniscalco M, Smith CAB. The estimation of gene 
frequencies in a random-mating population. Ann Hum Genet 
1955;20:97–115.
 8. Li P, Pang LH, Liang HF, Chen HY, Fan XJ. Maternal IgG anti-A 
and anti-B titer levels screening in predicting ABO hemolytic 
disease of the newborn: a meta-analysis. Fetal Pediatr Pathol 
2015;34:341–50.
 9. Sood R, Neelima, Kumar D, et al. Antibody titers study in group 
O blood donors: tube and column agglutination techniques. J 
Thrombo Cir 2016;2:104.
 10. Arora D, Kaushik A, Rawat DS, Mandal AK. ABO blood group 
phenotype in and around Delhi: a study from tertiary care 
hospital. Ann Pathol Lab Med 2015;2:A26–9.
 11. Agrawal A, Tiwari AK, Mehta N, et al. ABO and Rh (D) group 
distribution and gene frequency; the first multicentric study in 
India. Asian J Transfus Sci 2014;8:121–5.
 12. Bhat YR, Kumar CG. Morbidity of ABO haemolytic disease in 
the newborn. Paediatr Int Child Health 2012;32:93–6.
 13. Akanmu AS, Oyedeji OA, Adeyemo TA, Ogbenna AA. 
Estimating the risk of ABO hemolytic disease of the newborn 
in Lagos. J Blood Transfus 2015;2015:560738.
 14. Peevy KJ, Wiseman HJ. ABO hemolytic disease of the 
newborn: evaluation of management and identification of 
racial and antigenic factors. Pediatrics 1978;61:475–8.
 15. Kirkman HN Jr. Further evidence for a racial difference in 
frequency of ABO hemolytic disease. J Pediatr 1977;90: 
717–21.
 16. Olusanya BO, Kaplan M, Hansen TW. Neonatal 
hyperbilirubinaemia: a global perspective. Lancet Child 
Adolesc Health 2018;2:610–20.
 17. Saini N, Chhabra S, Chhabra S, Garg L, Garg N. Pattern of 
neonatal morbidity and mortality: a prospective study in a 
district hospital in urban India. J Clin Neonatol 2016;5:183–8.
 18. Modi R, Modi B, Patel JK, Punitha KM. Study of the morbidity 
and the mortality pattern in the neonatal intensive care unit 
at a tertiary care teaching hospital in Gandhinagar District, 
Gujarat, India. J Res Med Den Sci 2015;3:208–12.
68 IMMUNOHEMATOLOGY, Volume 37, Number 2, 2021
D.S. Patale et al.
 19. Office of the Registrar General & Census Commissioner, 
India Ministry of Home Affairs, Government of India. Sample 
Registration System (SRS) Bulletins. Available from https://
censusindia.gov.in/vital_statistics/SRS_Bulletins/SRS%20
Bulletin_2018.pdf. Accessed 12 August 2020.
 20. Worldometer. India Population (LIVE). Available from https://
www.worldometers.info/world-population/india-population/. 
Accessed 12 August 2020.
 21. Dean L. Hemolytic disease of the newborn. In: Blood groups 
and red cell antigens. Bethesda, MD: National Center for 
Biotechnology Information (US), 2005:25–30.
The editorial staff of Immunohematology welcomes manuscripts 
pertaining to blood group serology and molecular genetics 
for consideration for publication. We are especially interested 
in review articles, case reports, papers on platelet and white 
cell serology, scientific articles covering original investigations 
or new blood group alleles, papers on molecular testing, and 
papers on new methods for use in the blood bank. To obtain 
instructions for submitting scientific articles, case reports, and 
review articles, see Instructions for Authors in every issue of 
Immunohematology, at our Web site: https://www.exeley.com/
journal/immunohematology, or e-mail a request to immuno@
redcross.org. Include phone number and e-mail address with 
all manuscripts and correspondence. E-mail all manuscripts to 
immuno@redcross.org.
Manuscripts
Notice to Readers
Immunohematology is printed on acid-free paper.
For information concerning Immunohematology 
contact us by e-mail at immuno@redcross.org.
Dnyaneshwar S. Patale, MD (corresponding author), Senior 
Resident, Department of Transfusion Medicine, Sanjay Gandhi 
Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 
India 226014, dnyaneshwar.patale@gmail.com; Trupti L. Lokhande, 
MD, Senior Resident, Department of Transfusion Medicine, Sanjay 
Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India; 
and Rajendra K. Chaudhary, MD, Professor and Head, Department 
of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of 
Medical Sciences, Lucknow, India.


Statistical model for prediction of ABO hemolytic disease of the fetus and newborn in India

MILOŠEVIĆ, Predrag

MILOŠEVIĆ, Vladimir

MILOŠEVIĆ, Grigor

OFFICE BUILDINGS THROUGHOUT CENTURIES VS NOW, IN THE 21ST CENTURY – DEVELOPING INNOVATIVE SPACE CONCEPTS

Jiao, Yan

Zhao, Li

Xu, Hexin

Research on Capsule Network Based on Attention Mechanism

Fiskum, Charlotte

Andersen, Tonje Grønning

Johns, Unni Tanum

Jacobsen, Karl

Differences in affect integration in children with and without internalizing difficulties

Not a member yet