Blood transfusion carries the risk of transmission of several infectious agents. The latest method for blood screening, nucleic acid testing is not affordable in developing countries.
The study was aimed to find response to post-donation counseling for reactive markers among the voluntary blood donors donating in blood donation camps.
Material and Methods:
This 1 year study was conducted in 2011. Transfusion transmitted infections testing was performed by routine enzyme linked immunosorbent assay method. The initial human immunodeficiency virus (HIV) reactive donors who returned back to the blood bank were confidentially counseled and referred to the Integrated Counseling Cum Testing Center (ICTC). The hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (HCV) reactive donors were referred to the gastroenterology department for confirmation by qualitative polymerase chain reaction (PCR, Roche Diagnostics, Germany) and followed-up.
Twenty seven thousand two hundred forty six 27,246 units were collected during the survey. One hundred twenty nine129 units were reactive for HIV 1 and 2, 99 were reactive for HCV, 206 for hepatitis B virus (HBV). Of these reactive donors, 138 could be personally communicated. Out of 47, 27 donors who returned for counseling were initially reactive for HIV 1 and 2, 8 for HBsAg and 12 for anti-HCV. Two were positive for HBV deoxyribonucleic acid and one was positive for HCV ribonucleic acid. The HIV positivity was detected in 1 of 27 donors at ICTC.
The response to the post-donation counseling appears in this study to be only 34% (47/138), which is still a challenge.
Integrated counseling and testing center; post-donation counseling; transfusion transmitted infections
The development of anti-red blood cell antibodies (both allo-and autoantibodies) remains a major problem in thalassemia major patients. We studied the frequency of red blood cell (RBC) alloimmunization and autoimmunization among thalassemia patients who received regular transfusions at our center and analyzed the factors, which may be responsible for development of these antibodies.
Materials and Methods:
The study was carried out on 319 multiply transfused patients with β-thalassemia major registered with thalassemia clinic at our institute. Clinical and transfusion records of all the patients were examined for age of patients, age at initiation of transfusion therapy, total number of blood units transfused, transfusion interval, status of splenectomy or other interventions. Alloantibody screening and identification was done using three cell and 11 cell panel (Diapanel, Bio-rad, Switzerland) respectively. To detect autoantibodies, autocontrol was carried out using polyspecific coombs (IgG + C3d) gel cards.
Eighteen patients out of total 319 patients (5.64%) developed alloantibodies and 90 (28.2%) developed autoantibodies. Nine out of 18 patients with alloantibodies also had autoantibodies. Age at first transfusion was significantly higher in alloimmunized than non-immunized patients (P = 0.042). Out of 23 alloantibodies, 52.17% belonged to Rh blood group system (Anti-E = 17%, Anti D = 13%, Anti-C = 13%, Anti-Cw = 9%), 35% belonged to Kell blood group system, 9% of Kidd and 4% of Xg blood group system.
Alloimmunization was detected in 5.64% of multitransfused thalassemia patients. Rh and Kell blood group system antibodies accounted for more than 80% of alloantibodies. This study re-emphasizes the need for RBC antigen typing before first transfusion and issue of antigen matched blood (at least for Rh and Kell antigen). Early institution of transfusion therapy after diagnosis is another means of decreasing alloimmunization.
Alloimmunization; autoimmunization; thalassemia major; transfusion
Random donor platelet (RDP) is not sufficient to improve the platelet count in most thrombocytopenic patients. Single donor platelet (SDP) or buffy coat pooled platelet (BCPP) are the two choices to provide a full therapeutic dose of platelets. However, there are constraints in the preparation of SDP due to stringent donor selection procedure, time required for procedure, and need of special expensive equipments and kits. BCPP is widely practiced, especially in the European countries, since 1995. In India, we decided to adopt the procedure of buffy coat pooling of platelets, especially for economically backward patients and for emergencies. This study was prospectively conducted from September 2009 to September 2010. A total of 129 units of BCPP [tested prior for viral markers by enzyme-linked immunosorbent assay (ELISA) and individual donor nucleic acid amplification test (ID-NAT)] were issued to 129 patients suffering from dengue and were included in this study. For comparison between efficacy of SDP and BCCP, patients were divided into two groups of 50 each. The post-transfusion platelet counts of the patients were noted after 2 hours of transfusion for each type of component. The platelet yield varied from 2.5 to 4.4 Χ 1011 in BCPP samples. The samples analyzed were sterile without any contamination. The different biochemical parameters were analyzed in detail. The observed post-transfusion platelet recovery and corrected count increment (CCI) at 1 hour and 24 hours after BCPP transfusion were similar to that after SDP transfusion. Hence, we concluded that BCPP can be a low cost alternative to SDP in the times of emergencies like dengue and non-affordability by the patient for SDP.
buffy coat; buffy coat pooling of platelets; random donor platelets; single donor platelets
A prospective study was undertaken to evaluate the use of 2% (w/v) alcoholic chlorhexidine gluconate (2% AlcCHG) in donor arm preparation, to monitor the contamination rate of blood products after the collection and to find incidence of transfusion associated bacteremia.
Settings and Design:
Optimal skin antisepsis of the phlebotomy site is essential to minimize the risk of contamination. Food and Drug Administration (FDA) in India has recommended antisepsis with three-step regimen of spirit-10% povidone iodine-spirit for donor arm antisepsis, but not with chlorhexidine, which is recommended by many other authors.
Material and Methods:
A total of 795 donors were studied from July 2011 to January 2012. Spirit-10% povidone iodine-spirit was used for 398 donors and 2% AlcCHG was used for 397 donors with the two-step method for arm antisepsis. Swabs were collected before and after use of antiseptic agents for all the donors. All the blood products collected from donors with growth in post-antisepsis swabs were cultured. A total of 123 various blood products were cultured irrespective of the method and result of antisepsis was observed. A total of seven patients had mild transfusion reaction. The transfused blood products, blood and urine specimen of the patients who had transfusion reaction were also cultured.
Seven donors out of 398 donors had growth in post-antisepsis swab with spirit-10% povidone iodine-spirit protocol and three donors out of 397 donors had growth in post-antisepsis swab with 2% AlcCHG protocol. All blood products collected from donors who had growth in post-antisepsis swabs when cultured had no growth. There was no contamination of blood products.
Two percent (w/v) alcoholic chlorhexidine gluconate with two-step protocol can be used as an antiseptic agent for donor arm preparation without considerable cost difference. It is at par with spirit 10% povidone iodine spirit protocol as suggested by FDA in India. There was no reported transfusion associated bacteremia in the study period.
Bacteremia; blood donor arm; chlorhexidine gluconate
The clinically significant antibodies are those active at 37°C and/or by the indirect antiglobulin test. Most of the published literature refers to antibodies of Lewis blood group system to be insignificant, whereas antibodies to M and N blood groups are associated with variable clinical significance.
The aim of this study is to find the frequency and clinical significance of antibodies to M, N and Lewis blood group systems.
Settings and Design:
The study was carried out retrospectively from January 2009 to December 2012.
Materials and Methods:
Antibody screening was performed by solid phase red cell adherence (SPRCA) technique using four cell screening panel on a fully automated platform GALILEO (Immucor Inc. USA). In case of a positive antibody screen, antibody identification was performed using SPRCA (GALILEO, Immucor Inc. USA).
A total of 49,077 red cell antibody screens were performed and a total of 427 identifications of red cell antibodies were carried out. A total of 304 specific antibodies were detected: 8.22% of antibodies were of anti-M specificity and 2.96% were of anti-N specificity. Majority (84%) of anti-M and 77.78% of anti-N were of Immunoglobulin G (IgG) class reacting at 37°C. 1.31% of the antibodies were directed against Lewis system antigens of which 0.65% were anti-Lea and 0.65% were anti-Leb. Half of the Lewis system antibodies, i.e., 1 each of anti-Lea and anti-Leb were of IgG class.
Our study highlights the importance of detecting the thermal amplitude of antibodies with variable clinical significance especially if both IgG and IgM types of antibodies are associated with it so as to establish their clinical significance.
Anti-M; anti-N; clinical significance; Lewis
In the last few decades through an awareness of transfusion transmitted infections (TTI), a majority of countries have mandated serology based blood screening assays for Human immunodeficiency virus (HIV), Hepatitis C virus (HCV), and Hepatitis B virus (HBV). However, despite improved serology assays, the transfusion transmission of HIV, HCV, and HBV continues, primarily due to release of serology negative units that are infectious because of the window period (WP) and occult HBV infections (OBI). Effective mode of nucleic acid technology (NAT) testing of the viruses can be used to minimize the risk of TTIs. This review compiles the examples of NAT testing failures for all three viruses; analyzes the causes for failure, and the suggestions from retrospective studies to minimize such failures. The results suggest the safest path to be individual donation testing (ID) format for highest sensitivity, and detection of multiple regions for rapidly mutating and recombining viruses. The role of blood screening in the context of the donation and transfusion practices in India, the donor population, and the epidemiology is also discussed. World wide, as the public awareness of TTIs increases, as the recipient rights for safe blood are legally upheld, as the possibility to manage diseases such as hepatitis through expensive and prolonged treatment becomes accessible, and the societal responsibility to shoulder the health costs as in the case for HIV becomes routine, there is much to gain by preventing infections than treating diseases.
Donor look back; individual donation nucleic acid technology testing; multi pool nucleic acid technology testing; recipient trace back; transfusion transmitted viral infections; window period and occult infections
An estimated 3% of the world population is infected with Hepatitis C virus (HCV), a hepatotropic RNA virus, transmitted primarily via the blood route. The major modes of transmission of the virus include injection drug use, unsafe injection practices, blood transfusion etc. HCV causes chronic hepatitis in about 80% of those infected by it. The mainstay in diagnosing infection with HCV is to initially screen high risk groups for antibodies to HCV (anti-HCV). The inclusion of serum to cut-off ratio (S/CO) in recent guidelines is helpful in deciding the supplemental assay to be used to confirm initially reactive screening results. Nucleic acid amplification tests (NAT) are used as confirmatory tools, and also to determine viral load prior to initiating treatment. Quantitative NAT has replaced qualitative assays. Genotyping is an important tool in clinical management to predict the likelihood of response and determine the optimal duration of therapy. The impact of this infection has begun to emerge in India. The problem of professional blood donation despite an existing law against it, and flourishing unsafe injection practices, are potential sources for the spread of hepatitis C in our country. All health care practitioners need to understand how to establish or exclude a diagnosis of HCV infection and to interpret the tests correctly. In the absence of a preventive or therapeutic vaccine, and also of post-exposure prophylaxis against the virus, it is imperative to diagnose infection by HCV so as to prevent hepatic insult and the ensuing complications that follow, including primary hepatocellular carcinoma (HCC). This review aims to help blood bank staff regarding options for diagnosis and management of donors positive for HCV.
Blood borne virus; hepatitis C virus diagnosis; nucleic acid test
For nucleic acid testing (NAT) of blood donations, either the blood samples can be pooled together in a batch of six or eight prior to testing (mini-pool-NAT [MP-NAT]), or the tests can be run on every individual sample (individual donor-NAT [ID-NAT]). It has been debated in various studies whether pooling of samples results in decreased sensitivity of detection as the volume of individual samples gets lesser in a pool. The objective of this study was to investigate the effect of dilution on the sensitivity of tests.
Materials and Methods:
The study was performesd on nine plasma samples which were hepatitis B reactive exclusively by Procleix Ultrio Plus and not by Procleix Ultrio or serology. These nine exclusive UltrioPlus ID-NAT yield samples were diluted in 1:2, 1:4. 1:6 and 1:8 dilutions using previously tested negative plasma and each dilution of every sample along with archived undiluted sample were retested in three replicates with Procleix Ultrio Plus Assay.
Among NAT yield samples, 88.88% of the samples were detected when retested in ID-NAT in undiluted form. Samples with higher viral load (sample 5 and 6) were detected by all dilutions. When samples with viral load below 20 IU/mL were tested in dilutions of 1:6 or 1:8, only 9 out of 27 replicates (33.33%) were detected. This means that more than 67% of low viral load samples were missed by MP-NAT of 1:6 or 1:8 dilution out of total NAT yield samples.
Individual Donor NAT is ideal methodology for NAT as dilution due to pooling may miss samples with low viral load as evident in this study.
Hepatitis B surface antigen; hepatitis B virus; nucleic acid testing; pooling of samples
Hepatitis E virus (HEV) is emerging as a potential threat to blood safety after several cases of transmission by transfusion or transplantation have been described. Currently, blood donors in India are not screened for HEV. The studies conducted on HEV in recent times in India have focused on epidemiology and future perspectives, but there is no published study on blood donors. To address possible issues surrounding blood safety and risk of HEV transmission within the Indian blood supply, HEV seroprevalence study was conducted in blood donors at our center.
Materials and Methods:
A total of 460 male voluntary blood donors were selected for the study and after taking their written consent. Serum anti-HEV IgM was detected by Dia.Pro HEV kit (Diagnostic Bioprobes Srl, Milano, Italy).
The study population was composed of 460 male voluntary blood donors and their age ranged from 18 to 60 years with a mean age of 30.48 years. Out of 460 donors, 22 (4.78%) donors were tested positive for IgM anti-HEV and the mean value alanine aminotransferase (ALT) was 26.06 IU/L, the highest being 93.5 IU/L. Normal reference value of ALT in our center was 40 IU/L. Out of 22 anti-HEV positive donors, 19 (86.36%) had ALT values above 40 IU/L.
HEV seroprevalence of 4.78% in our center. Though reports of HEV transmission through blood has been reported from various parts of the world, before making it as a mandatory screening test among blood donors in India, further studies with confirmatory assay of HEV need to be done.
Blood donors; hepatitis E virus; seroprevalence
Background and Aim:
Owing to the scarcity of data on hepatitis C virus (HCV) genotypes in Iraq and due to their epidemiological as well as therapy implications, this study was initiated aiming at determining these genotypes in Northern Iraq.
Materials and Methods:
A total of 70 HCV antibody positive multi transfused patients with hemoglobinopathies, who had detectable HCV ribonucleic acid, were recruited for genotyping using genotype-specific nested polymerase chain reaction.
The most frequent genotype detected was genotype 4 (52.9%) followed by 3a (17.1%), 1b (12.9%) and 1a (1.4%), while mixed genotypes (4 with either 3a or 1b) were detected in 7.1%.
The predominance of genotype 4 is similar to other studies from surrounding Eastern Mediterranean Arab countries and to the only earlier study from central Iraq, however the significant high proportion of 3a and scarcity of 1a, are in contrast to the latter study and may be explainable by the differing population interactions in this part of Iraq. This study complements previous studies from Eastern Mediterranean region and demonstrates relative heterogeneity of HCV genotype distribution within Iraq and should trigger further studies in other parts of the country.
Genotype 4; genotyping; hepatitis C virus; Iraq
Background and Objectives:
It is well established that Nucleic acid testing (NAT) reduces window phase of transfusion transmissible infections (TTI) and helps improve blood safety. NAT testing can be done individually or in pools. The objectives of this study were to determine the utility, feasibility and cost effectiveness of an in-house minipool-NAT(MP-NAT).
Materials and Methods:
Blood donors were screened by history, tested by ELISA and sero-negative samples were subjected to an in-house NAT by using reverse transcriptase-polymerase chain reaction (RT-PCR). Testing was done in mini-pools of size eight (8). Positive pools were repeated with individual samples.
During the study period of Oct 2005-Sept 2010 (5 years) all blood donors (n=53729) were screened by ELISA. Of which 469 (0.87%) were positive for HIV-1, HBV or HCV. Sero-negative samples (n=53260) were screened by in-house MP-NAT. HIV-NAT yield was 1/53260 (n=1) and HBV NAT yield (n=2) was 1/26630.
NAT yield was lower than other India studies possibly due to the lower sero-reactivity amongst our donors. Nevertheless it intercepted 9 lives including the components prepared. The in-house assay met our objective of improving blood safety at nominal cost and showed that it is feasible to set up small molecular biology units in medium-large sized blood banks and deliver blood within 24-48 hours. The utility of NAT (NAT yield) will vary based on the donor population, the type of serological test used, the nature of kit employed and the sensitivity of NAT test used. The limitations of our in-house MP-NAT consisted of stringent sample preparation requirements, with labor and time involved. The benefits of our MP-NAT were that it acted as a second level of check for ELISA tests, was relatively inexpensive compared to ID-NAT and did not need sophisticated equipment.
Blood donor testing; blood safety; in house assay; mini-pool nucleic acid testing; real-time-polymerase chain reaction
Young people, who tend to be healthy, idealistic, and motivated, are an excellent pool of potential voluntary unpaid blood donors. Recruiting and retaining young blood donors improves the long term safety and sufficiency of a country's blood supply. Knowledge, attitude, and beliefs about Human immunodeficiency virus (HIV) should play an important role in prevention of disease transmission.
Materials and Methods:
This study was a questionnaire based survey, conducted to explore the levels of knowledge, attitude, and beliefs about HIV in young college student blood donors.
The results showed that the proportion of participants with comprehensive knowledge of HIV prevention and transmission was lesser than expected. Increase in education level and male gender was found to be significantly associated with high HIV-related knowledge. The responses on the different aspects of HIV-related attitude were also varied and there is still stigma associated with Acquired Immunodeficiency Syndrome (AIDS) even in the educated groups.
There was a spectrum of myths and misperceptions emphasizing the need of education that recognizes the social context of attitude towards HIV. Results from this study may contribute to the development of appropriate educational and training material for this group of donors which in turn, may assist in achieving the elusive goal of safe blood supply in future.
Attitude; beliefs; blood donors; college students; HIV; knowledge
Vasovagal reactions (VVRs) in blood donors.
To find an association of age, sex, donation status, weight, total blood volume and volume of blood collected with occurrence of immediate VVR.
Settings and Design:
Retrospective single-centre study.
Materials and Methods:
The study was conducted from March 2000 to November 2010 at a tertiary care blood transfusion centre. All VVRs with or without syncope occurring during or at the end of donation were noted.
Statistical Analysis Used:
For qualitative association, c2-test was used. Unpaired ‘t’ test was used for assessing difference between two groups with respect to VVR status. Simultaneous impact of all risk factors was assessed using multivariate logistic regression analysis. The data entry software SPSS (version 17.0) was used for statistical analysis. A P-value <0.05 was considered statistically significant.
Overall 1085 VVRs were reported in relation to 88,201 donations, resulting in an overall VVR rate of 1.23%, that is, an incidence of 1 in every 81 donations. Donors with low blood volume, first-time donors, with low weight and female donors had higher absolute donation VVR rates than other donors.
Donation-related vasovagal syncopal reactions are a multifactorial process determined largely by weight, age, first-time donor status and total blood volume. Our study reinforces the fact that blood donation is a very safe procedure, which could be made even more event-free by following certain friendly, reassuring practices and by ensuring strict pre-donation screening procedures.
Blood donor; first-time donors; total blood volume; vasovagal reaction; volume of blood collected
Sickle cell disease (SCD) often leads to chronic hemolytic anemia of varying severity, and blood transfusion may be employed in the management of SCD complications.
The aim of the study was to evaluate the effect of blood transfusion on the activities of some antioxidant enzymes as well as lipid peroxide and to relate transfusion status to these enzymes and malondialdehyde (MDA) in SCD patients.
Materials and Methods:
Glutathione peroxidase (GPX), superoxide dismutase, catalase, MDA, and lipoproteins were assayed in 87 SCD and 20 age- and sex-matched subjects with normal hemoglobin. Of the 87 SCD patients, 30 had multiple transfusions, 21 had been transfused once while 36 had not been transfused within the last 3 months.
Statistically significant decrease in the mean levels of GPX (P = 0.045) and Cu/Zn SOD (P = 0.001) and increased (P = 0.001) MDA were observed in the transfused compared to non-transfused patients. Similarly, significant decrease (P = 0.001) in Cu/Zn SOD and increase (P = 0.01) in MDA were observed in multi transfused compared to those who had been transfused once. Transfusion status correlated (P <0.047) inversely with Cu/Zn SOD and positively with MDA.
Reduced activity levels of serum antioxidant enzymes and increased mean levels of MDA were observed in transfused compared to non-transfused SCD patients and these changes correlated with transfusion status.
Antioxidant enzymes; malondialdehyde; sickle cell disease; transfusion
Autoimmune hemolytic anemia (AIHA) is not an uncommon clinical disorder and requires advanced, efficient immunohematological and transfusion support. Many AIHA patients have underlying disorder and therefore, it is incumbent upon the clinician to investigate these patients in detail, as the underlying condition can be of a serious nature such as lymphoproliferative disorder or connective tissue disorder. Despite advances in transfusion medicine, simple immunohematological test such as direct antiglobulin test (DAT) still remains the diagnostic hallmark of AIHA. The sensitive gel technology has enabled the immunohematologist not only to diagnose serologically such patients, but also to characterize red cell bound autoantibodies with regard to their class, subclass and titer in a rapid and simplified way. Detailed characterization of autoantibodies is important, as there is a relationship between in vivo hemolysis and strength of DAT; red cell bound multiple immunoglobulins, immunoglobulin G subclass and titer. Transfusing AIHA patient is a challenge to the immunohematologist as it is encountered with difficulties in ABO grouping and cross matching requiring specialized serological tests such as alloadsorption or autoadsorption. At times, it may be almost impossible to find a fully matched unit to transfuse these patients. However, transfusion should not be withheld in a critically ill patient even in the absence of compatible blood. The “best match” or “least incompatible units” can be transfused to such patients under close supervision without any serious side-effects. All blood banks should have the facilities to perform the necessary investigations required to issue “best match” packed red blood cells in AIHA. Specialized techniques such as elution and adsorption, which at times are helpful in enhancing blood safety in AIHA should be established in all transfusion services.
Alloadsorption; alloantibody; autoadsorption; autoantibody; autoimmune hemolytic anemia; best match blood; flow cytometry; gel technology
This is the first study on phenotype frequencies of various blood group systems in blood donors of south Gujarat, India using conventional tube technique.
Material and Methods:
A total of 115 “O” blood group donors from three different blood banks of south Gujarat were typed for D, C, c, E, e, K, Jka, Lea, Leb, P1, M, and N antigens using monoclonal antisera and k, Kpa, Kpb, Fya,Fyb, Jkb, S,s, Lua, and Lub antigens were typed using polyclonal antisera employing Indirect Antiglobulin Test. Antigens and phenotype frequencies were expressed as percentages.
From the 115 blood donor samples used for extended antigen typing in the Rh system, e antigen was found in 100% donors, followed by D [84.35%], C [81.74%], c [56.32%], and E [21.74%] with DCe/DCe (R1 R1, 40.87%) as the most common phenotype. k was found to be positive in 100% of donors and no K+k- phenotype was found in Kell system. For Kidd and Duffy blood group system, Jk(a+b+) and Fy(a-b-) were the most common phenotypes with frequency of 52.17% and 48.69%, respectively. In the MNS system, 39.13% donors were typed as M+N+, 37.39% as M+N-, and 23.48% as M-N+. S+s+ was found in 24.35% of donors, S+s- in 8.69%, and S-s+ as the commonest amongst donors with 66.96%. No Lu(a+b+) or Lu(a+b-) phenotypes were detected in 115 donors typed for Lutheran antigens. A rare Lu(a-b-) phenotype was found in 2.61% donors.
Data base for antigen frequency of various blood group systems in local donors help provide antigen negative compatible blood units to patients with multiple antibodies in order to formulate in-house red cells for antibody detection and identification and for preparing donor registry for rare blood groups.
Blood donors; blood group systems; India; phenotype frequency; red cell antigens; south Gujarat
Immune hemolysis is one of the adverse effects that can occur following solid organ transplantation. Understanding the clinical settings and the various causes is necessary for prompt diagnosis and appropriate management. One such condition is passenger lymphocyte syndrome (PLS). This case report describes the case of a 27-year-old male renal allograft recipient of the B-positive blood group who received a kidney from an O-positive donor. Postoperatively, the patient showed declining hemoglobin (Hb) level and was transfused with B-group packed RBCs (PRBCs), following which there was steep fall in Hb level. A request for PRBCs was sent to the blood bank and this time cross-match with B-group PRBCs showed incompatibility. The patient's RBCs were found to be strongly DAT (direct anti-globulin test) positive and the eluate showed the presence of anti-B with a titer of 32. Thus, diagnosis of probable PLS was made. The patient was managed with methylprednisolone, plasmapheresis and O-group PRBCs. Gradually his condition improved and was discharged in stable condition.
Antibody titer; DAT; hemolysis; passenger lymphocyte syndrome; transplantation
Guillain-Barre syndromé (GBS) is an autoimmune disorder. It is rare in pregnancy as there is a decrease in cell-mediated immunity. A case of 28-year-old pregnant woman who presented with acute flaccid quadriplegia suffering from GBS is discussed in this study. She was treated with plasma exchange in her immediate post-partum period. The management of GBS in pregnancy has been discussed.
Guillain-Barré Syndrome in pregnancy; plasma exchange; therapeutic plasma exchange