Management of an Rh-Isoimmunized Pregnancy
Friday, February 23, 2007
Kenneth F. Trofatter, Jr., MD, PhD
We are caring for a young woman who is Rh-negative and became ‘sensitized’ during her first pregnancy. This probably occurred at the time of an emergency cesarean section for ‘fetal distress’ associated with ‘placental abruption’ (premature separation of the placenta) at which time she was probably exposed to a lot more of her baby’s blood than her provider’s realized. She had no Rh-antibodies found in her blood at the time of that admission and the baby had no complications related to anemia and ‘Rh-disease’ after the delivery. The woman was given Rh-immunoglobulin prior to discharge to help prevent sensitization, but only received the standard postpartum dose (sufficient to eliminate no more than about 15 cc of fetal blood from the maternal circulation) which was, as we shall see, probably, not enough in her case. When a larger than usual fetal-maternal hemorrhage is suspected, maternal blood can actually be screened for FETAL blood cells by a test (Kleihauer-Betke test), the amount of fetal blood in the maternal circulation can then be estimated, and sufficient Rh-immunoglobulin given to help prevent isoimmunization under these circumstances.
When she came in for her initial OB visit with her second pregnancy, she was found to have developed antibodies to TWO antigens of the Rh-system (I am not going into that discussion here, but things are never as straightforward as I might have led you to believe in an earlier post!). She had antibody to both the D and C antigens with ‘titers’ (see previous post for an explanation) of anti-D at 16 and anti-C at 32. The father of the baby (who was also the alleged father of her previous baby) was screened and his RBCs were found to have both the D and C antigens. If he did NOT have these, and he was indeed the father of this baby, then the baby could not have them either and our story could probably end here (even though Jerry Springer or Montel would then have an unhappy couple for their shows!). Because the father had the antigens, we now knew that the baby was at risk for having either or both as well, and was therefore at increased risk for ‘Rh-disease.’
The patient was given the option of having an amniocentesis done to find out for sure if the baby was D and/or C antigen positive, but she declined this test. She was followed with monthly antibody titers and at 22 weeks, the titers were found to have increased to 64 for anti-D and to 132 for anti-C. This rise in antibody titers increased the likelihood that the baby is D and C positive. Either of these antibody titers would be in a range that would increase our concern that the baby could develop complications related to Rh-disease, and the combination of two antibodies raised that concern even further.
In circumstances like this in the past, when we wanted to assess the degree of anemia in the baby of an Rh-sensitized woman, the standard approach was to perform an amniocentesis to determine levels of ‘bilirubin’ (see last post), a breakdown product of hemoglobin that is excreted in the fetal urine (amniotic fluid). We have standard curves for amniotic fluid bilirubin, based on years of experience when Rh-isoimmunization was a common problem, that tell us, fairly reliably, when the baby is at ‘low risk,’ intermediate risk,’ and very ‘high risk’ for being anemic. Based on the level of fetal risk, we could then plan when to check the bilirubin again (another amniocentesis), when to consider a ‘cordocentesis’ (a procedure in which fetal blood is sampled from the umbilical cord), when to consider a fetal transfusion (which can be coupled with a cordocentesis so the blood can be delivered directly into the fetal circulation through the umbilical vein if significant anemia is confirmed) or, even, when to just deliver the baby.
Nowadays, we have another alternative to these invasive diagnostic procedures for screening about which our needle-shy patient was delighted to hear. We have learned that by measuring the peak (systolic) blood flow velocity (PSV) in an artery in the baby’s brain (the middle cerebral artery, or MCA) using Doppler flow techniques (ultrasound), we can also identify, very reliably, the babies at increased risk for severe anemia before they have gone into heart failure. High PSV values correlate very well with fetal anemia, especially before 34 weeks, and this noninvasive technique has a very powerful ‘negative predictive value,’ so that when the baby’s PSV in the MCA is within the ‘normal’ range, it is extremely unlikely that the baby has life-threatening anemia.
We followed her weekly and the PSV steadily rose with advancing gestational age (in excess of the normal increase with advancing gestational age), suggesting some degree of fetal anemia, and then suddenly increased dramatically at 36 weeks. It should be noted that by 36 weeks the ‘positive predictive value’ of the PSV decreases significantly (i.e., higher values may NOT necessarily indicate severe fetal anemia), but the degree of the increase was still quite startling. There was no ultrasound evidence of fetal heart failure at this time. An amniocentesis was performed and the amniotic fluid was checked for bilirubin and also assessed for ‘fetal lung maturity’ (another post, another day). The bilirubin was only in the low-intermediate risk zone and the maturity studies were very “immature” suggesting that the baby could be at risk for respiratory problems if delivered at that time. Due to the immaturity of the lung studies, and not feeling pressed to deliver based on the amniotic fluid bilirubin, we gave the patient corticosteroids to help accelerate lung maturation (still controversial at this late gestational age, but proven effective below 34 weeks), and have continued to follow her with fetal heart rate testing and ultrasound. The patient’s due date was established by a first trimester ultrasound, and at this point we will probably simply deliver her by repeat cesarean section at 38-39 weeks.
I will admit up front that, even with four posts, I have left out a fair amount of information regarding Rh-isoimmunization and management during pregnancy. But, I also think I have given you a basic understanding of a very complicated condition and an appreciation for the steps we go through to help minimize risk and ensure a good outcome for both mother and baby. After our patient is delivered, I promise to give you some follow-up of the baby’s course. Thanks for reading....
26 Comments:
At Wed May 23, 06:29:00 AM 2007,
Jo said…
I have been extremely interested in your posts regarding treatment of the Rh-Isoimmunized patient.
I am a 34yr old woman with a similar history in that I am Rh Neg & developed antibodies to antigen C&D in my first pregnancy. Throughout both of my pregnancies titer levels remained low until the third trimester where they rose just above the 'danger' level & subsequently required early induction.
My husband & I would really like to have a third child but are worried about the potential risk. I visited my GP several weeks ago in relation to the matter but they were unable to advise me & I am currently awaiting a consultant referral instead. In the meantime, I wondered if you could help me with a little advice; is it possible to assess my current antibody levels to see how much of a potential risk a further pregnancy may be? Do the antibodies simply lie dormant in the body or do they decrease if there is nothing to stimulate them?
Having two children already & knowing the strains of Rh Isoimmunised pregnancy we are simply trying to assess if a third pregnancy would be viable or too great a risk. We would sincerely appreciate any advice you could give as it is extremely hard to find anyone with any great knowledge of this subject such as yourself
Kind Regards, Jo.
At Wed May 23, 10:54:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Lots of good questions! It is probably a good idea to get antibody titers to guide our counseling to you at this time; the higher the titers, the greater the risk you start off with in another pregnancy. Rh antibodies do not tend to fluctuate very widely. In other words, I doubt they will have decreased much since your previous pregnancy, and if they have, they will rebound and probably go even higher (an anamnestic response) with more antigen stimulation (i.e., if the next baby is Rh-positive as well). We can follow most Rh-sensitized pregnancies now simply with Doppler flow studies (not amniocentesis) of the middle cerebral artery to assess babies at risk for having significant anemia. This is done by ultrasound and is noninvasive. An invasive study can be reserved for babies that appear to be slipping into a 'high risk' range. As long as the peak systolic velocity of blood in the middle cerebral artery are within a 'normal' range, it is very unlikely the baby has a life-threatening anemia. In other words, the negative predictive value of the study is very good. If you see a GP for your pregnancies, I would suggest he/she refer you to a local specialist in Maternal-Fetal Medicine to discuss this in more detail before you embark on another pregnancy.
At Sun Oct 14, 06:33:00 AM 2007,
Anonymous said…
I have a complaint with this system of montioring with the doplar. I also devoleped antibodies with my first pregnancy, my son's health was monitored useing the doplar system. He was born at 34 weeks and 5 days weighing 3 lbs 7 ozs 17 inches long. He died 30 hours later. I was never told that doing an amnio would give actually numbers for the doctor's to monitor his growth, instead my primary physican who ordered me to the specialist the morning after this discovery was made with strict orders to do the amnio was vitoed by the specialist because the new technology is so much better. The new technology costed my family our son. So before going on and giving such high rateings to something I understand is still in experimental stages why don't you recomend something that is tride and true and will work? Women need to have all the information before they make life changing decisions, and I did what I had to do with the only information given to me by the people I trusted with my child's life, now he sleeps in a little white box for the rest of mine.
At Tue Oct 30, 03:05:00 PM 2007,
jo said…
Thankyou both for your comments, I apologise at taking such a long time to respond back from my first post. I've had a lot of thoughts & conversations since then.
Firstly, I am so sorry to hear of the last contributors situation, I truly appreciate your comments & cannot imagine how hard it must be to deal with such a tragedy. I froze when I read your words,it is my worst fear & it is exactly why I have been trying to do all I can to prepare myself before embarking on another pregnacy.
I have since had my consultant referral which echoed many of the comments from Kenneth F. Trofatter, I was informed that with the techniques explained & close monitoring, pregnancy should be successful. However, my consultant was adamant that ultimately there is no way of predicting the potential risk of another pregnancy.
The promise of being closely monitored & taken 'special care of' is all great in theory - However, from my past pregnancies I am only too aware that in reality it is a very different matter. The UK NHS maternity situation is stretched to the limits & subsequently mistakes are made, promises broken & untrained staff stand in all too regularly for trained specailists & consultants. I am left with the feeling that you always have to be one step ahead of the medical providers (& extremally pushy!) to simply ensure that your health & that of your baby is handled efficently. One slip & the consequences can be devastating. Due to legalities private maternity care in the UK is virtually non-existent & knowledge of Rh sensitive pregnancies is scarce.
To be honest, my overwhelming feeling now is not to go ahead with another pregnancy, despite my husband & I desperately wanting another child. I simply feel that we would be playing yet another game of Russian Roulette, & the stakes (as so tragically illustrated by the previous post) are simply too high. We are lucky enough to have two healthy children already & do not wish to do anything to jepordise that situation.
But thank you all for your comments, they really did contribute to this decision.
Thanks Again, Jo.
At Mon Nov 05, 04:57:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jo Oct 30: You are welcome Jo. Glad this blog could be of help to you. Wish I could guarantee you a healthy pregnancy that you so desperately want but as Oct 14 pointed out, sometimes things do not turn out well despite best intentions. I do wonder though if there might not have been something else wrong with her baby because it was VERY small for 34 weeks...Dr T
At Thu Nov 15, 12:47:00 PM 2007,
Emma said…
Hello! This is very interesting..I've been concern with my pregnancy (I'm 28 weeks pregnant) This is my second pregnancy and with my first pregnancy my baies blood got mixed with mine and now I'm positive with Anti-Jka. We now found out that it's from my husband who is positive too. My titer level was 1:1 then when down that they could not even know how much it was( wich is very good) Then at 24 weeks went back to 1:1. I was wondering if there is any danger that it goes higher ( high risk)?
Today I got another blood test to see if it went up..I'm nervous that it went up..
So please just let me know if there is any chance of affecting my baby in my last trimester.
Thanks very much
At Fri Nov 23, 06:23:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Emma Nov 15: Antibodies to Jka are a very RARE cause of severe hemolytic disease of the newborn, and with your very low antibody titers, your baby is probably at very low risk for complications. Ultrasound can be used to assess fetal anemia noninvasively and indirectly by doing Doppler flow studies on the baby's middle cerebral artery. If you are really worried about it and want more advice, have your doctor send you to a specialist in Maternal-Fetal Medicine, but I doubt you will have any problems with the pregnancy related to this. Good luck and let us know how things turn out. Dr T
At Mon Dec 17, 03:23:00 PM 2007,
Denise in NY said…
At 23 I became rh sensitized (without knowing) during a termination of a 10wk pregnancy.
I am now 33, and became pregnant w/out knowing that I was sensitized in the past.
I am 16wks pregnant right now, and am being transferred to a high risk pregnancy OB, so that my risk and situation can be monitored.
Should I be OVERLY concerned considering this is the 1st pregnancy after I was sensitized? I've read that each additional pregancy contributes to a higher risk of fetal harm, but I am wondering the likelyhood of danger for THIS BABY.
Lastly, will my sensitization affect a RH neg baby? And, will I have an RH pos baby (no matter what) if my husband is RH pos?
I would appreciate any information.
Thanks in advance.
At Tue Dec 18, 09:43:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Denise Dec 17: Your lowest risk is if you actually get sensitized during a pregnancy. Since you became sensitized before your current pregnany, your risk will depend on the titer of the antibody, whether or not the titer rises during the pregnancy, and whether or not your baby is Rh-D- positive (I am assuming you are sensitized to the Rh-D antigen). Your sensitization will NOT affect an Rh-D-negative baby. If your husband is Rh-positive and is HOMOZYGOUS (has two doses of the Rh-D gene), then ALL your children together will be Rh-positive and at risk for complications related to your anti-D antibodies. It only takes ONE dose of the Rh-D gene for someone to be Rh-positive. If your husband is Rh-positive but is HETEROZYGOUS (has only one dose of the Rh-D gene), then, statistically, half of your children (girls or boys) will be Rh-positive (and 'at risk') and half will be Rh-negative (and not at risk). If you want, you can get your husband tested to find out if he is homozygous or heterozygous because if he is the latter, you might consider having the baby evaluated to find out if he/she is Rh-negative or positive. Hope this helped and be sure to ask your 'high risk doctor' the same questions. Thanks for reading and let us know how things turn out! Dr T
At Thu Jan 10, 07:35:00 PM 2008,
Amy & Damon said…
I am a 26 year old and I developed antibodies in my first pregnancy. The baby had to be induced but was full term. She had phototherapy for 5 days before being discharged.
My second child was monitored using the Doppler flow every 2 weeks. Then had his first fetal transfusion at 23 weeks and had to have one every 3 weeks. He was induced at 36 weeks weighing 3.35kg so in total he had 4 fetal transfusions. After he was born he had phototherapy for 5 days. Then needed another transfusion, at 2 weeks of age.
Now is 7 half months old and very healthy, normal and happy boy.
Now I am pregnant with my 3rd child (not planned but we are both happy) and scared what's going to happen? As I understand with each pregnancy it gets worse!
I do have an appointment with a specialist in Maternal-Fetal Medicine in a few days but would love to know your opinion.
Yours sincerely
Amy
P.S I have no complaints about the Doppler method. Their was a very close call at 23 weeks as the doctors didn’t think the levels would rise so fast, but it all worked out I am just very greatful, we have such great technology and doctors!
I Am very sad to hear bout your baby passing away its heart breaking and my biggest fear.
At Tue Feb 12, 11:10:00 AM 2008,
Sarah said…
I am a 30 year old. I have a daughter (2), during my pregnancy with her I discovered I was sensitized from a previous termination (12 weeks). My husband and I have been doing IVF for a year now (2 fresh cycles and 1 frozen). The embryos were tested with PGD and only implanted the neg. Unfortunately, none of the embryos took. I just found out last week that I'm pregnant (6 weeks along). I have a few questions:
A) when I had the termination, I didn't know my blood type (didn't know it was so improtant) and left that box on the form blank. When I called the dr. after I found out I was sensitized he told me I was tested and my blood came back "false positive", and that's why he didn't give the rogam. Is that possible?
B) I just had my titers checked Friday (1 year since they were last checked) and my doctor called and said that they showed I wasn't sensitized, at all. I'm guessing that there was a problem with the lab and I'm having the test done again today. Is it possible that my titers went down that much? (A girl can dream right)
Sarah
At Fri Feb 15, 10:36:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Sarah: If your titers are very low, there is a reasonable chance of doing well even with an Rh-positive baby if you are followed carefully. Gues my suggestion would be to forget the PGD and go for it with the IVF. There is a chance the baby will be Rh-negative anyway and even if you rebound your antibody titers (an anamnestic response), like I said, in this day and age, we should be able to get you to good fetal viability! Good luck. Dr T
At Mon Feb 25, 09:11:00 PM 2008,
michele said…
I am 29 weeks pregnantRH negative with a d titer of 1:32, 4weeks ago it was only 1:1. First of all can it jump so high in 4 weeks? I also had a Delta OD sonogram today and they did measure the blood flow to the babies heart and brain,and the said everything looked good, but didn't say anything about the method you descibe. I was supposed to have the amnio but didn't because of the chances of contractions and my drive was far. This is my 6 th preg, my 5th had a d titer of 1:16 and all other pregnancies were normal. I am worried to have the amnio but I guess my question is can the titer increase so rapidly? And any other advice ofr information for a case like mine. Thank you.
At Wed Feb 27, 05:25:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Michele Feb 25: With that increase in titer, the baby is almost certainly Rh-positive and therefore at risk for hemolytic anemia. If the doctors did measurements of "blood flow to the brain", they probably did perform an assessment of the peak systolic velocity (PSV) in the middle cerebral artery (MCA). High PSVs are correlated with increased risk that the baby has significant anemia. Normal PSVs are very reassuring (strong 'negative predictive value' of the test) that the baby does not. This technology has replaced amniocentesis as the primary mode of screening Rh-isoimmunized women, but the measurement has to be taken correctly with the ultrasound transducer as close to 'head on' to the MCA as possible or the result is of little use. Best of luck and let us know how things turn out! Dr T
At Tue Mar 25, 04:59:00 PM 2008,
Julia Mangan said…
How important is it to get a blood test before getting pregnant to check for Rh-sensitization? I had a miscarriage last year and 2 subsequent D&C's but I bled for 6 weeks total. I received the RH shot 3 times but was told before the first time I may not have received it in time.
At Wed Mar 26, 06:00:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Julia Mar 25: It is probably unnecessary to do an antibody screen before you get pregnant again. That is part of the 'routine' new OB labs that get sent after you get pregnant anyway and it sounds like you got more than enough Rh-immune globulin to cover you with that previous pregnancy. good luck and thanks for reading. Dr T
At Mon May 05, 02:19:00 PM 2008,
Carrie in Atlanta said…
Hello, I have recently had a positive antibody screen at 28 weeks gestation. I believe it was 1:1 Anti-D. (I am RH-) I had a previous pregnancy in which I received Rhogam at 29 and after delivery, I delivered a RH+ baby. My next pregnancy ended in miscarriage with D&C at 12 weeks. I received Rhogam twice during that pregnancy, at 6 weeks for spotting, and right after the D&C. This pregnancy I received Rhogam at 18 weeks for spotting as well. I am not sure of the results of any previous antibody screens I had done, though I would hope that if any previous ones were positive I would have been notified. I know for sure that they did one before my Rhogam at 18 weeks during this pregnancy. So, what are the implications of my now positive antibody screen? Could I have become sensitized in one of my previous pregnancies or would it be from this one? After 18 weeks when I'm assuming my antibody screen was negative? My OB said that she will draw my blood for another screen/titer at my next visit. Thanks for any help,
Carrie
At Tue May 06, 03:42:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Carrie May 5: It is unlikely you became sensitized during your previous pregnancies with that low titer. The real question is are you sensitized at all or is this simply leftover antibody from the last Rhogam shot you were given at 18 weeks?!? Rhogam is anti-D antibody. Even if you have become sensitized, it is highly unlikely this baby will have any major problems with the titer so low now and the pregnancy so far along. It will be the next Rh-positive baby you carry that will be at greater risk. See what the next antibody titer shows and let me know. Best wishes and thanks for reading! Dr T
At Sun May 18, 07:57:00 AM 2008,
Anonymous said…
I had a drop in titer from 1:64 to 1:16 (performed by the same lab - tests were taken 6 months apart - I am not pregnant). Is this considered significant? I heard that the newer gel method of determining titer is 3-4 times more sensitive than the older tube method. Does this mean that the "critical" titers are different for the gel method? One more question - Are antibodies being constantly reproduced as old ones terminate in the absence of further antigen stimulus? Thanks
At Wed May 21, 07:50:00 AM 2008,
Anonymous said…
I am trying to wrap my brain around what is currently happening to us. I am O negative and my husband is O positive. We have two beautiful girls, I receievd the Rho (D) immune globulin with both girls at around 28 weeks and I am honestly unsure about their blood types and whether or not I received at afterwards (yes, I feel ignorant).
I am now 29 weeks pregnant with my third baby. At 10 weeks, I tested RH negative and was told about taking RhoGAM again at 28 weeks. I just took the antibody screen blood test and it came back positive now. I am sitting here just waiting, trying to figure out how or why and what comes next.
I didn't have any accidents or bleeding with this pregnancy, but I did have a mild placental abruption with my second pregancy at around 30 weeks. The bleeding put me into preterm labor, but with magnesium the labor was managed and the bleeding eventually started to clot. The baby was born at 36 weeks 3 days....totally healthy, natural birth. Being under magnesium, I don't remember much, but they gave the baby steroids to mature her lungs. I don't remmeber receiving an additional shot of RhoGAM, but I had just recieved the regular dose 2 weeks prior. My question is 1) Is this possibly how I became sensitized? 2)If so, how come I tested negative at 10 weeks with this pregnancy?
Also, I had a c-section with my first child.
Thanks for helping me understand why and how this happened. Shawn
At Thu May 22, 12:38:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 18: Your Rh antibody titers may fluctuate (and if the lab has changed their assay, the difference in titers may be meaningless). Once you are immune to Rh, you will continue to make Rh antibodies. The antibody-producing cells will probably NOT go away, even if your titers get very low, and when you are reexposed to Rh-antigen, the titers will again rise, usually quite quickly as the result of an 'anamnestic' (secondary)immune response. That's why women who are Rh-isoimmunized are at greater risk with each Rh-positive baby they carry. Hope this answers some of your questions. Best wishes and thanks for reading. Dr T
At Sun May 25, 05:25:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Shawn May 21: First, how high was your antibody titer? You could have become sensitized with the placental abruption, the cesarean delivery, or even sometime during the current pregnancy. Since your antibody screen was negative early on, the isoimmunization probably did occur more recently. Fortunately, this baby is also probably at very low risk for complications because this is a first affected pregnancy. By the way, stop kicking yourself over this. There is nothing else you could have done to prevent it. "What comes next" depends on the antibody titer. If it is less than 16, most folks will just follow you with serial titers. If it is > 16, you will probably need to be followed by a maternal-fetal medicine specialist who is experienced in obtaining accurate peak systolic velocity (PSV) measurements by ultrasound on the baby's middle cerebral artery. If these remain < 1.5 MoM, it is usually safe to continue following you that way until the baby is mature enough to deliver. If they become > 1.5 MoM, the MFM can discuss your options that will depend to some extent on the gestational age of the baby. Relax, things will turn out fine! The important thing is that your doctors found out before anything seriously wrong happened to you or the baby. Thanks for reading and let us know how things turn out. Dr T
At Mon Jul 21, 07:42:00 PM 2008,
Anonymous said…
I am rh- and with my first pregnancy I had a placental abruption at 32 weeks. My son was born via emergency c-section. After the birth I received the rhogam shot. Approx. 4 months later I became pregnant and had an early miscarriage.(5-6 weeks preg.) When I ask for the rhogam shot I was told that it was past the 72 hour window. When I became pregnant with my second child in August of 2007 I was informed I was sensitized. I opted to do the MCA twice weekly. My numbers started to rise then leveled off or so I thought. My specialist left his firm and I began seeing a new doctor. I was going to my regular doctor twice weekly for NST and at the end once weekly to a specialist. I also was doing fetal kick counts which had be in the hospital a few times for additional monitoring. On a Sunday I noted decrease fetal movement and went to the hospital for another NST. The strip was not the best so they sent me for a Biophysical Profile. Which was fine. That Monday I went to the specialist and was told the MCA levels were good (less that 1.5) and the baby looked great. That Tuesday I had my regular weekly NST and the fetal heartrate was dropping. I was sent to the hospital for another emergency c-section. My placenta had abruption again. In addition, despite the MCA doppler results my daughter was affected by the rh- factor. She required 1 regular transfusion, 1 double exchange transfusion and recieved platelets. She also was under the lights for almost a week. My questions are:
1. Could I have been sensitized with an early miscarriage?
2.Why did the MCA not show my daughter was not coping?
3. Why didn't the sonogram the prior day not show the abruption?
Thanks,
Nora
At Wed Jul 23, 01:19:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Nora: When you had the miscarriage, did they perform an antbody screen on you at that time. The reason I asked is that it is more likely that you got sensitized by the pregnancy with the abruption (even though you received Rh-immune globulin) than by the miscarriage - although the latter does occur as well. With regard to the MCA Dopplers, in all honesty it is a very good test, but sometimes the results depend on who is performing the study. Some sonographers and physicians have more experience than others and even though I have wonderful sonographers with whom I am blessed to work, when it comes to measuring the peak systolic velocities in the MCA for purposes of assessing risk for fetal aneemia, that is one study I always repeat myself. With regard to the abruption, they can be hard to see unless they are large and even less likely to be picked up if they are unsuspected late in pregnancy. Regards, Dr T
At Thu Jul 24, 02:03:00 PM 2008,
Anonymous said…
When I had the miscarriage they did run blood work because as a result of it I had to see a hematologist because something weird showed up in my blood work. It turns out I had tested positive for antibodies for hemolytic anemia, although I do not show any symptoms as of yet. Never during any of this time was I told I was sensitized. Actually once I got pregnant with my daughter and was told I was sensitized I spoke to my hematologist who told me that is not what he was treating me for. My OBGYN never mentioned it either and they knew I was trying to get pregnant again. I thought that prior to my shot of rhogam they tested by blood to see how much to give me. In all honesty, I do not think that my OBGYN knows when I was sensitized or did they realize the implications that it has on a pregnancy. As to the MCA testing. I was seeing one specialist up until about 29 weeks then he abruptly left his position to head up a new position to far from my house. I was referred to another doctor who did perform the MCA himself as well as the sonographer. Wouldn't my daughter's organs have showed something if she was being severly affected? After all this happened my OBGYN spoke to the specialist being that I was just there the day before and they concurred that she was holding her own until the placenta abrupted. However, her symtpoms at birth clearly indicated that she was being affected. (double exchange transussion, platelets, light therapy) Any input you have would be greatly appreciated.
Nora
At Fri Jul 25, 07:19:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Nora: Sometimes things are not as straightforward as they seem. It can be difficult to perform the Doppler flow studies properly and sometimes, even when done correctly, they might not reveal the true status of the baby. You are VERY high risk for complications if you ever get pregnant again. So please look for the best doctor on town for managing your pregnancy. Thanks for writing back. Dr T
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