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Erythroblastosis Fetalis
Disease when maternal antibodies destroy fetal RBCs, either in-utero or ex-utero (postpartum); fetal RBCs have antigens foreign to the mother that results in teh stimulation of maternal antibody production
Hydrops Fetalis
The effect of erythroblastosis fetalis on the fetus that includes general anemia, possible edema, possible cardiac failure, and up to fetal death
anti-E
anti-c
anti-K
anti-Jk
anti-Fy
Immune allo (“other”) Abs that cause HDFN are usually due to which antibodies? (5)
Anti-K
Second most common form of severe HDFN; disease ranges from mild to severe; over half of the maternal cases that develop this antibody are caused by previous multiple blood transfusions
Fetal severe anemia
Fetal heart failure
Fetal death
Dangers of HDFN in-utero (pre-partum)
Unconjugated (indirect) bilirubin
As a result of the destroyed RBCs in HDFN, (——) is released into the fetal body
Unconjugated bilirubin is sequestered out via the mother’s liver
Why is unconjugated bilirubin not as harmful in in-utero HDFN, as opposed to post-partum HDFN?
ABO, Rh, ABS tests performed on first obstetrical visit
ABS (-) → repeat 24 weeks
ABS (+) → AB ID, if IgG → AB titer
Maternal prenatal care/testing (3)
>1:32
Ab titer significant for HDFN maternal prenatal testing
Last previous titer sample
(Maternal prenatal testing) When performing the current titer, mist run (——) in parallel with current titer sample
amniocentesis at 18-20 weeks gestation
Based on maternal Ab titer results, if HDFN is suspected then a (——) is performed
Amniotic fluid bilirubin
(——) is a direct indicator of the severity of HDFN
ΔOD at 450 nm
What is observed when testing for bilirubin (risk of HDFN) in amniotic fluid through a spectrophotometer?
Liley’s graph
Queenan curve
What is used to help interpret the data from spectrophotometric analysis of bilirubin in amniotic fluid (2 charts)
Fetal hydrops detected on ultrasound
Fetal Hb <10 g/dL (severe anemia)
ΔOD 450 is high on Liley’s graph or Queenan curve (hyperbilirubinemia)
Intrauterine transfusion is necessary when one or more of the collowing conditions are met (3)
<5 days old
CPDA-1 or AS-3 additive only
Ag negative to maternal allo Ab
O neg
CMV neg
Hb S neg
Irradiated
Intrauterine blood requirements (7)
Anemia
Hepatomegaly
Splenomegaly
Jaundice
Kernicterus
Maternal Ab(s) continue to destroy fetal RBCS postpartum during HDFN. What are the signs and symptoms that occur? (5)
Phototherapy (at 460-490 nm)
Exchange transfusions
Choices of treatment for neonatal hyperbilirybinemia are… (2)
Lipophilic
Toxic to the brain
Phototherapy is used to change unconjugated bilirubin to an isomer which is less (——) and less (——)
ABO HDFN
Most common form of HDFN; can occur at the 1st delivery and subsequent pregnancies; no prior exposure needed
O type mother with Anti-A,B IgG, delivering A neonate (B less common)
How is ABO HDFN commonly caused?
Less
ABO HDFN is usually (more/less/equal to) Rh HDFN
It is not predictive of HDFN (not significant, no titers done)
What is the significance of maternal prenatal testing in predicting ABO HDFN?
Repeat ABO/Rh and ABS (mother)
Determine ABO/Rh, including weak D (baby)
Perform DAT (baby)
if IgG DAT positive → elution procedure against A1 and B cells
Postpartum lab testing (cord blood workup) for ABO HDFN (cord blood work-up) (3)
heat/chemicals dissociate Ab from baby RBCs, and supernatant used for Ab ID (Ab found is of maternal origin)
What is the elution procedure during postpartum testing of ABO HDFN?
Not preventable
Commonly treatable by phototherapy only
≥20 mg/dL serum bilirubin (rare) requires exchange transfusion
ABO HDFN prevention and treatment (3)
anti-D
C, c, E, e
Most common cause of Rh HDFN is (——), but Abs against (—4—) antigens are known to cause it as well
Rh HDFN
Most severe form of HDFN; severe anemia may occur resulting in severe hyperbilirubinemia and jaundice; kernicterus could result
2nd or subsequent pregnancies
Must consider miscarriage, abortion, prenatal fetal/maternal bleed
When does Rh HDFN typically manifest
Anti-C = rare
Anti-c = mild to severe
Anti-E = mild
Anti-e = rare
Ab combinations can be severe
Severity of Rh HDFN due to anti- C, c, E, and e
ABO, Rh (Du), ABS
if ABS (+)
AB ID and titer (repeat titer every 4 weeks)
Ag status of father (optional)
Ig subclass of maternal Ab
Rh HDFN prenatal testing (4)
Middle Cerebral Artery-Peak Systolic Velocity (MCA-PSV)
Amniocentesis
If anti-d (or anoy other Rh AB) titer reaches >1:32, consider further testing… (2)
Middle Cerebral Artery-Peak Systolic Velocity (MCA-PSV)
(Rh HDFN testing) color doppler/ultrasound transducer that is a reliable predictor of fetal anemia; favored over amniocentesis because it is noninvasive and gives tehe same information
Repeat ABO/Rh and ABS
If ABS positive, must do Ab ID
weak anti-D may be due to Rh Immune Globulin shot (Rhogam) = “passive” anti-D
Enumerate # fetal cells in mother’s blood
Postpartum testing for Rh HDFN in mother (3)
Determine ABO/Rh (including weak D)
Perform DAT
DAT + → elution test against Ab ID panel cells
Postpartum lab testing (cord blood work-up) on the baby for Rh HDFN (2)
Iatrogenic anemia
Some hospitals may not perform an elution test on baby RBCs for allo Ab ID because it can cause…
Fetal Hgb Screen Test/Rosette Test
Qualitative test that demonstrates small number of D positive cells in mother’s D negative cell suspension
Kleihauer-Betke test
Quantitative test where the blood sample from the mother is treated with acid and stained to show any present fetal red cells (resistant to acid); determine # of fetal cells in first 2,000 maternal cells counted
Volume fetal cells = # fetal cells * maternal blood volume / 2,000
Equation used for the Kleihauer-Betke test
Hb < 10 g/dL
Bilirubin ≥20 mg/dL
Exchange transfusion can occur when either conditions exist… (2)
Type AB
Rh can be disregarded
No irradiation
Requirements of plasma transfusion for neonate (3)
Removes 50% bilirubin
Removes 80-90% infant’s sensitized RBCs
Removes 80-90% maternal incompatible Ab
Replacement of incompatible RBC with compatible RBC
Beneficial effects of a 2-volume exchange transfusion in an HDFN neonate (4)
Avoid clinically significant hemodynamic shifts
Avoid any metabolic abnormalities
The neonatal exchange transfusion process is very slow in order to…
Donor blood → venous catheter
Arterial catheter → drainage/waste container
Direction of blood entering/exiting the baby during exchange transfusion