CASE REPORT

Emergency Dilatation and Curettage in a Patient

with Bombay Blood Group
Muhammad Asghar Ali and Muhammad Sohaib

ABSTRACT
Bombay blood group is a rare autosomal recessive phenotype within the ABO blood group. It represents genetically
suppressed A, B and H genes. When considering such patients for transfusion, only blood of identical Bombay type can
be safely transfused. We are reporting a patient having Bombay phenotypic blood, underwent emergency dilatation and
curettage with active per vaginal bleeding due to retained products of placenta. There are numerous anaesthetic
considerations, including emergency surgery with hemodynamic instability due to ongoing blood loss, dilutional
coagulopathy as well as presence of Bombay phenotype that severely limit the possibility of red blood cell transfusion.
Only four donors were registered with the blood bank of the institution and none was traceable. It becomes a real
challenge for the anesthesiologist to manage such type of patients without having units of red packed cell which
management is described hereby.

Key Words: Bombay phenotype. Hemodynamic instability. Dilatation and curettage. Blood group.

INTRODUCTION vaginally and was referred to our hospital for further

The Bombay group is a rare autosomal recessive
phenotype within the ABO blood group.1 It's prevalence
is higher in India; as it was first discovered in Bombay
hence, the name Bombay blood. The estimated
prevalence is 1:10,000 in India and 1: 1,000,000
individuals outside of India.2
It is genetically suppressed A, B and H genes. The
Bombay type is very peculiar because in routine tests for
blood grouping it is an O type, but during cross matching
procedure donor's O-type cells get clumped with the
serum of Bombay type recipient, as Bombay type
possesses suppressed H-gene. When considering such
patients for transfusion, only blood of identical Bombay
type can be safely transfused.1 Therefore, it becomes a
real challenge for the anesthesiologist to manage such
type patients without having units of red packed cell.
We are reporting a patient having Bombay phenotypic
blood, underwent emergency dilatation and curettage
with active per vaginal bleeding.
CASE REPORT
A 22 years old female weighing 53 kg with no known
comorbids presented in emergency department (ER)
with heavy per vaginal bleeding due to retained pieces
of placenta. She delivered a baby 4 hours ago per
Department of Anaesthesia, The Aga Khan University Hospital,
Karachi.
Correspondence: Dr. Muhammad Asghar Ali, R-27, Block 15,
Dastagir Society, F.B Area, Karachi.
E-mail: asghar.ashraf@aku.edu
Received: February 21, 2013; Accepted: July 09, 2013.
management. At the time of presentation in ER, the
patient was hemodynamically unstable with heart rate of
130 beats per minute and blood pressure of 80/45
mmHg. Her respiratory rate was 24 breaths per minute
and oxygen saturation was 96% on room air. She was
immediately shifted to theatre for dilatation and
curettage, in the meanwhile her blood was sent for
laboratory investigations as well as for cross match. At
the time of induction we just came to know that patient's
blood group is Bombay phenotype, so the option of red
blood cells transfusion was not there. Only 4 donors with
Bombay phenotype were registered with the Blood Bank
of the Aga Khan University Hospital. We tried to contact
the donors but none of them was available. Other
laboratory investigations were within normal limit except
hemoglobin, which was 9.3 gm/dl.
After taking the patient in operating room, standard ASA
monitoring (ECG, NIBP and SpO2), was applied along
with arterial line, which was inserted in right radial artery,
bispectral index (BIS) electrode was applied on forehead
and Foleys catheter was inserted to monitor urine
output. Two large 16 gauge intravenous cannula were
also inserted. She was still hemodynamically unstable
with heart rate 137/minute and blood pressure 97/37
mmHg, so 1000 ml colloid was given intravenously
through pressure bag. After fluid resuscitation, her heart
rate became 103/minute and blood pressure was raised
to 108/65 mmHg.
Because her fasting was incomplete, rapid sequence
induction with cricoids pressure was planned. Patient
was induced with midazolam 2 mg, ketamine 75 mg and
suxamethonium chloride 80 mg. Intravenous pethedine
50 mg was given after intubation for analgesia.
Anaesthesia was maintained with 40:60 oxygen and

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (8): 603-605 603
Muhammad Asghar Ali and Muhammad Sohaib
nitrous oxide along with intravenous infusion of
midazolam at 2 mg/hour along with intermittent boluses
of atracurium. BIS value was maintained between
46 - 54 throughout the procedure.
Duration of surgery was 2 hours. The blood loss was
approximately 1200 ml, which was replaced by
crystalloid and colloid. We maintained her hemo-
dynamics with heart rate between 90 - 105 beats per
minute and mean arterial pressure between 60 - 65
mmHg to minimize blood loss. Placenta was removed
with dilatation and curettage and there was no active
bleeding.
At the end of surgery, oropharyngeal suctioning was
done and residual neuromuscular blockade was
reversed with neostigmine 2.5 mg and 0.4 mg
glycopyrolate. She was allowed to regain complete
consciousness and reflexes, after then she was
extubated. She was shifted to recovery room and her
postoperative vitals were within normal limits except her
heart rate 100 - 110 / minute.
In the recovery room we sent her blood for laboratory
investigation in which all labs were within normal range
except hemoglobin level of 7.2 gm/dl and international
normalization ratio (INR) of 1.75. So six units of FFPs
were transfused to patient. Patient remained stable in
the recovery room and shifted to the ward next day.
DISCUSSION
Bombay red blood cell phenotype (Oh or hh) was first
described by Bhende et al. in 1952 who documented the
incompatibility of a patient with group O blood with
multiple group O donors.3 The Bombay phenotype has
since been determined to be a rare autosomal recessive
phenotype confined mostly to the Southeast Asian
countries.4
According to the International Society for Blood
Transfusions, there are over 700 documented
erythrocyte antigens and twenty-nine blood grouping
systems. Landsteiner's ABO blood typing system
remains the single most important group for blood
transfusions. Briefly, the A, B, AB, and O blood types
refer to specific antigenic sugar moieties attached by an
alpha 1-2 linkage to short oligosaccharide chains that
exist as the carbohydrate moiety of glycolipid and
glycoprotein molecules located on red blood cells.5 This
linkage is controlled by the action of glycosyltransferase
enzymes that specifically select for N-acetyl-D-
galactosamine (Ga1NAc) for type A and for D-galactose
(Gal) for type B. The glycosyltransferase enzyme for
type O blood cross-reacts immunologically with the A
and B transferase enzymes but is functionally silent.
These transferase enzymes are the product of four
major alleles located on the long arm of chromosome 9.6
In addition, there is another glucose antigenic moiety,
fucose, the H antigen, which serves as the precursor of
604 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (8): 603-605
the A, B, and O antigens.7 The responsible transferase
for fucose is the product of a very common H gene that
is lacking in the Bombay phenotype. Since the fucose
moiety is a necessary precursor for the A and B
antigens, Bombay blood will type as O, but will have
hemolytic auto-antibodies to the H antigen.8
The Bombay type is very peculiar because in routine
tests for blood grouping it is a O type, but during cross-
matching procedure donor's O-type cells get clumped
with the serum of Bombay type recipient, as Bombay
type possesses suppressed H-gene. The serum
contains anti-H antibody as an A or B-type serum does
anti-B or anti-A respectively as a natural protector.1
When considering such patients for transfusion, only
blood of identical Bombay type can be safely
transfused.1
Thus, perioperative management of transfusion with
autologous red blood cells is challenging given the
conflicting concerns of a limited supply of available
blood. It is fortunate that patients with Bombay
phenotype can receive any fresh frozen plasma,
platelets and cryoprecipitate for the treatment of
coagulopathies.9 There is no well-documented disease
association with Bombay phenotype. However, all
patients with type O blood, including Bombay
phenotype, have been described with higher rates of
bleeding complications.10
There are numerous anaesthetic considerations for this
particular case including emergency surgery with
ongoing bleeding along with hemodynamic instability,
dilutional coagulopathy and presence of Bombay
phenotype that severely limits the possibility of red blood
cell transfusion.
In elective surgeries, the approach of pre-donating and
deep freezing autologous red blood cells has been used
successfully. Patients with Bombay phenotype red blood
cells present as type O, but they are unable to receive
red blood cells from any phenotype other than Bombay
phenotype. Fortunately, they are able to receive all
other blood products, including fresh frozen plasma,
cryoprecipitate, platelets, prothrombin complex concen-
trate, and recombinant activated factor VIIa. Co-
ordination among blood bank service, surgery, and
anaesthesia is important in managing these patients.
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