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....
81 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
At Wed Sep 03, 02:26:00 AM 2008,
Anonymous said…
Dear dott.
my name is Monica and i’m an italian girl.
I hope will excuse me for the disturbance and my not corrected english but I have a a serious problem.
Some years ago I have had an abortion to the 11 week with review cavity uterina
I have rh- and my husband rh+.
They have NOT made Rh-immune globulin.
I have made the "test of coombs" and this is negative (i have not developed antibodies) but... I have much fear.
I can have sons?
I do not succeed to sleep and I do not know if there are hopes for me. In the worse one of the hypotheses that Rh antibodies in another pregnancy became positive what i can do?
Thank you for your time for me.
At Tue Sep 30, 12:40:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Monica: If uo do not have Rh antibodies now, there is a very good chance that you were not sensitized by the abortion. You will be checked for antibodies in any other pregnancies you might have and even if you do become sensitized, there is still a very good chance you will get through pregnancy successfully. This should not affect your ability to have sons (or daughters). There is NO REASON to lose sleep over this now! Take care of yourself and thank you for reading. Ciao. Dr T
At Sun Oct 05, 01:51:00 PM 2008,
Anonymous said…
I am RH Neg and my husband is RH pos. We have two healthy daughters. First pregnancy, I knew I had the RH factor but wasn't aware it would affect my daughter until she had severe jaundice at birth (bilirubin level at highest was 20) even though she had negative blood (a-). My second pregnancy was NOT monitored for sensitivity or anything regarding RH factor besides the normal Rhogam shot at 28 weeks. My daughter was born and within 24 hours developed jaundice and had to have an anti-body tranfusion (she had a+ bloodtype). Our girls are now 4 and 5 and we are considering a third child. But, I'm afraid of the risks and would like more information on the risks of having another child.
Thank u,
Mollie J.
At Tue Oct 07, 05:34:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Mollie Oct 5: I am a little confused. Exactly what type of antibody do you have? Please ask you doctors and let me know. Dr T
At Thu Oct 16, 04:24:00 AM 2008,
Anonymous said…
I have a concern. I am O-neg and my husband is o-positive. Approx. 1 1/2 years ago my husband and I suffered a miscarriage - this was my first pregnancy. I was approx. 10 weeks at the time, however upon examination the fetus was determined to be only 5 or 6 wks. I was out of town when the miscarriage happened, so I didn't have a chance to see my normal OB until later. I also had some mild spotting during that time. I never was offered a Rhogam shot. I am now 26 weeks pregnant - with my second pregnancy- and awaiting my rhogam shot at 28 weeks. I believe that my first blood screenings at 7weeks indicated that sensitization hadn't occured, but I'm still a bit nervous. Prior to the rhogam shot I will have more blood drawn to check for senstization. What are the chances that I was sensitized during my first pregnancy? If I am sensitized what happens next? What are the risks to my baby?
At Thu Oct 16, 12:38:00 PM 2008,
Anonymous said…
I was sensitized (anti-D) during my first pregnancy 11 years ago and delivered my daughter at 34 weeks when titers were over 1,000 and ultrasound showed liver enlargement. She required one transfusion after birth and 10 days of phototheraphy. During my second pregnancy I was monitoried using MCA doppler (titers never rose above 1:16) up to 35 weeks when the MoM was 1.44. I delivered my daughter at 36.4 weeks 15 months ago. She required 8 days of phototherapy and 2 transfusions.
I am thinking of having a third child, but am concerned that each pregnancy is more affected. Is this true? I know it is impossible to pedict, but would you expect my outcome to be significantly different than with my previous pregnancies. Does the time gap between pregnancies make any difference?
What if any positive results are there of using IVIG treatment during pregnancy and how does it work?
Jenn
At Thu Oct 16, 03:03:00 PM 2008,
Anonymous said…
When you test positive for titers due to being rh sensitized, can the levels continue to increase even if your child is a negative blood type like the mother? Also can test positive for rh sensitization if your children are close together from the previous rhogam shot you received at the end of the last birth?
At Sat Oct 18, 07:26:00 AM 2008,
Anonymous said…
If I received a rhogam shot and had my children close together is it possible for the rhogam shot to show as I am sensitized in my first trimester blood work? How long does the rhogam shot stay on your blood work? If I am sensitized from my first pregnancy and my second pregnancy my child was A- as I am does the risk increase with the third child since the second was my blood type. I heard that each pregnancy following becomes a higher risk when you are sensitized.
At Sun Oct 19, 02:16:00 AM 2008,
Anonymous said…
I'm 33 weeks pregnant with my 3rd child. At my routine 28 week blood tests in my 2nd pregnancy it was discovered that I was RhD positive with anti c+Cw. From then on I had fortnightly blood tests and obstetric appointments. The antibody levels steadily rose and eventually I was induced at 38 weeks and my daughter was given daily blood tests until 6 days old when she required phototherapy and was borderline for a blood transfusion for a number of weeks.
At my booking appointment for this pregnancy (at 10 weeks)the anti c+ level was 5.7iu. Again I'm having regular blood and ob appointments. It has been predicted by a that my baby is Rh c positive. I am therefore a little confused as to why my antibody level has been going down as well as up, ranging from 5.2iu to 6.4iu (at 28 weeks), my most recent level was 5.3iu (30 weeks)is this normal? Could this be because I was anemic, but now that i am taking iron tablets it will rise? I will not be sent for a doppler scan until the levels reach 7.5iu/ml. I have been given seriod injections just incase an early induction is necessary. In the UK information regarding these antibodies is very limited and both my husband and I would appreciate any further information you could provide. Also are the levels likely to increase in the weeks to come?
At Tue Oct 21, 06:50:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 18: The Rhogam is usually gone by about 3 months. What antibody titere did you have? If your current pregnancy is Rh-negative, the baby should be at no risk (unless you have become isoimmunized to a red cell antigen other that D) and that should not increase your baseline risk even further for a subsequent Rh-positive baby having complications. Good luck and let us know how things turn out. Dr T
At Tue Oct 21, 06:55:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 19: The antibody levels have NOTHING to do with your anemia. Although it is "predicted" this baby is at high risk for carrying the c-antigen, perhaps it does not and that's why your antibody levels haven't risen. That would be great! Anyway, it sounds like you are doing well, so I wish you the best for the rest of the pregnancy. Let us know how things turn out. Dr T
At Wed Oct 22, 07:29:00 AM 2008,
Anonymous said…
I was sensitized (anti-D) after some early bleeding in my first pregnancy 11 years ago. My daughter was delivered at 34 weeks after my titer level rose to 1:1024 and an enlarged liver and edema were found via ultrasound. She was in the NICU for 15 days and under bili lights for 10 days and required 1 transfusion after birth. My second daughter was delivered 15 months agoat 37 weeks. My titer levels went from 1:2 at 4 weeks to 1:16 at 28 weeks when they stopped checking them. My highest doppler at 35 weeks was 1.4. She required bili lights for 9 days and 2 transfusions after birth. I understand that in theory each subsequent pregnancy is more affected than the previous one. Is this always true? Does the time gap between pregnancies make any difference? Has IVIG treatment shown any positive results with isoimmunized pregnancies?
Jenn
At Sat Oct 25, 08:58:00 AM 2008,
Anonymous said…
On my second pregnancy being rh sensitized, why did my titers increase to 1:64 with a A(-) baby, she was my blood type but my titers increased to high levels? Will such high titers increase with a 3rd pregnancy to the same levels? The doctors did say on the last pregnancy we have a 50% chance of having a positive or negative blood type for each pregnancy due to our antigens types.
At Tue Oct 28, 07:21:00 AM 2008,
Klahn Family said…
Hello,
I am a 39 yr old woman and am currently 17 weeks in my 12th pregnancy (1st was premature and died of group B strep, 2nd was early miscarriage).
Near the end of pg #9 and all through pg #10 they did rh screens and found a "trace" of antibodies. In the beginning of pg #11 I had a 1:2 number and then 8 wks later a 1:4 number. This remained the number throughout the pregnancy.
During this pregnancy my first two titers were 1:4, then at 16 weeks they said my number was 1:2. Can you tell me why my number may have gone down and could this indicate that it may "rebound" as you mentioned in another comment?
Thank you for any information you can give.
Gina
At Thu Oct 30, 03:52:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jenn: No it is NOT always true that subsequent pregnancies are more complicated, but it is generally the case because the antibody titers tend to rise more quickly following each "immunization" by another Rh-positive baby. I am curius though, do you know each of your babies actual blood types (not just their Rh status)? And what is your blood type. For example, if you are O, you would have anti-A and anti-B antibodies, and if your second baby was A+ or B+, you might clear any of the baby's red blood cells that got into your system before you stimulated your anti-Rh antibodies. that's one mechanism by which a subsequent pregnancy might not be as severely affected. IVIg has had variable response in Rh-isoimmunization and it is very expensive. If you have an MFM doctor, ask her/him that question directly. There may be some ongoing research protocols you could become part of. Best wishes and thanks for the great questions. Dr T
At Fri Oct 31, 01:05:00 PM 2008,
Anonymous said…
I had a blood test to check my titer levels without being pregnant. They are 1:32 D and 1:16 C. My blood is A negative and my husband A positive. He is D with a recessive d since we have a 50% chance of having either of our blood types. With such high titers without being pregnant, does that mean they will increase quicker since they sustain such a high level without being pregnant? Can your titers elevate to high levels without actually doing damage to the fetus?
At Fri Oct 31, 02:19:00 PM 2008,
Anonymous said…
Both my daughters are O+ and my husband is O+. I am O-. They actually phenotyped all of us (other than my youngest) becuase my indirect Coombs test before my second pregnancy came back negative and they had no explanation for it. They chalked it up to the time gap between the pregnancies.
Jenn
At Sat Nov 01, 09:41:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 16: You probably were NOT sensitized by that other pregnancy or there is a very good chance it would have been detected with you first round of laboratory studies. Why don't we cross the bridge of all your questions if it actually becomes a problem. Relax a little, Girl! Best wishes for the rest of the pregnancy and we will be here if you need us! Dr T
At Tue Nov 04, 06:25:00 AM 2008,
corinne said…
Hi Dr T. On the facebook group of rhesus we are so confused and I knew you would have the right answer! It seems some of them who are sensitised are being given anti D shots in their pregnancies? We are confused as we thought anti D is of no use once sensitised and wondered why the docs are doing this in the Uk? One ladies levels even rose after getting the shot?Is it dangerous to do this or just a waste of time or is there something I have missed? I have tried reading through all your posts for the info but might have missed it. Thank you Corinne S. Africa
At Fri Nov 07, 07:31:00 AM 2008,
Anonymous said…
I am Rh- with type A blood. My husband is O+. I became sensitized during my first pregnancy, but the titer did not go up till the end of the pregnancy at 36 weeks. My first daughter was born uneffected by antibodies. However during my second pregnancy I started off with 1:16 titer and it rose to 1:64 twords the end my pregnancy. Throughout this pregnancy my doctor was using the monitoring method and my second baby was delivered at 35 weeks and needed 8 days of phototherapy. Now I am pregnant for the third time. I am currently 16 weeks and my titer is 1:32. My doctor wants me to go for a plasmaphoresis and IVig. Can you give me some light on plasmophoresis, please. Its success and complications. Id addition, my doctor wants to preform amnio to determine baby's blood. I am affraid that I will end up having a miscarage because of the amnio. What are my other options. My last question is eventhough I am already senitized should I get RO-Gam after each delivery? Thank you very much. Irina
At Tue Nov 18, 11:58:00 AM 2008,
hamid said…
Dear doc
My wife has a O negative blood group and I have B positive. my wife had a pregnancy (8 weeks) terminated 7 months ago through vacuum, but unfortunately no anti D was given after the abortion and we were not also aware of the negative rhesus at that time. Now my wife is pregnant again for 6 weeks and this time we want to have our baby, the problem is we did not inform the GP about the abortion and (we dont want to disclose due to the social problems here)GP assumes that this is her first pregnancy. we are desperately worried someone will be able to tell us that is there any special care required if you had not given the anti d in first pregnancy(after abortion) and will our baby a healthy one and what treatment we need to go through for a healthy baby?
thanking you in advance.
hamid
At Sat Nov 22, 07:12:00 AM 2008,
Encian said…
Hello,
we are trying to get pregnant and I am a bit worried that I am just experiencing my first miscarriage. If so, my pregnancy would be just two weeks old. My husband is A+ and I am A-. I wonder if it is possible to be RH sensitized this early into pregnancy.
Thank you very much for your time.
Sincerely
Encian
At Sat Nov 22, 04:47:00 PM 2008,
CC said…
I'm 36 yrs old and 12 weeks pregnant with my second child. I found out I became sensitized after my daughter's birth. I was told by my regular OBGYN that my titer level was 1:13 from my visit during my 10th week. I have an appt next week to see a peri dr, but my questions are what are the titer ranges that are considered "safe", "moderate" and "high risk"? I'd like to have an idea of what to expect as far as treatment, etc. I delivered my daughter at 35 weeks and suffered from preeclampsia and PUPPP - so I already have concerns about complications with this pregnancy.
Thank you,
CC
At Sat Nov 22, 06:25:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 25: Your titers may go up simply due to repeated exposure to the Rh-antigen form other sources in your environment - particularly your husband. Once you have developed an immune response to something, it does not take much more exposure ti 'boost' your antibodies. This is called an anamnestic response and is the principle by which vaccines are so effective in protecting us. By the way, if your next baby is Rh-positive, the titers may go MUCH higher than they already are. Thanks for writing. Dr T
At Mon Nov 24, 04:00:00 PM 2008,
Erika said…
Hi Dr T, I just found your blog after researching RH-immunization. I'm currently 10 weeks pregnant with our 3rd baby. I had the Rhogam shots with my previous pregnancies and never had any sensitization. I have O- blood, my husband has O+ blood, and my son and daughter both have O+ blood.
I had an early miscarriage in September (08) at 5 weeks. I went in the day I started miscarrying and received a Rhogam shot. Bloodwork taken that day prior to the shot showed that I was NOT sensitized.
With this current pregnancy, I had bloodwork done 3 weeks ago. The nurse just called me today to let me know my doctor was very concerned because my titer came back at less than 1:1. Very low, but they are apparently concerned and want me to rush back for more bloodwork. I asked the nurse if the doctors took into account that I JUST had a Rhogam shot in Sept - just 8 weeks prior to the blood draw showing the slight sensitization. She said no, they didn't know that. But the dr still wanted me to come in soon for repeat bloodwork. I live an hour away from the dr and asked if I could just get the bloodwork done when I come in for my next appointment in 3 weeks. Nurse said the doctor was very worried and insistent that I come in NEXT week at the latest. I don't think it's necessary. I'm happy to get bloodwork done with my next appointment (3 weeks) but I don't think I need to rush down there ASAP because my doctor didn't bother to read my chart fully.
I've done a lot of research and I'm pretty confident that the slight sensitization my blood is showing is just from my recent Rhogam shot. However, I wanted to get your opinion... Thank you! -Erika
At Wed Nov 26, 06:05:00 AM 2008,
Anonymous said…
Hi Dr T,
Should you be given Rhogam shots if you are already producing anti bodies? Doctors in the UK seem to be doing this?
At Fri Nov 28, 09:20:00 PM 2008,
sad said…
I really need help because I am not sure where I stand. I received a RhoGam shot in my 28th week of pregnancy. I am o- and my husband is b+ - my some was born with jaundice two weeks late (the RhoGam shot had expired 2 days before delivery) and there is no record of another RhoGam shot.
What are the chances I was sensitized? Are there blood tests I can take before another pregnancy? and wasn't this medically negligent?
My main concern is having a healthy second baby. I am 38 and don't want to deliberately inflict suffering on a second baby.
Thank you!
At Tue Dec 16, 09:42:00 AM 2008,
Lou said…
Hello Dr T,
I too have found your blog invaluable, thank you so much for making clear, balanced information available online.
This is a similar question to that raised by Erika on 24th Nov.
I am Rh- while my husband is positive, this is our first baby, and I have been tested regularly for antibodies through out the pregnancy. Each test has, until today, come back negative.
My husband is Norwegian and so we have taken the decision to return to his home country and spend time with family with a temporary residence permit. He is working and setting himself up, and I in the meantime have been introduced to the maternity system here in Norway, which is offered to temporary residents married to nationals.
However, I received a call today from my new doctor, advising me that Anti bodies are present in my blood and that I must go to a clinic in Bergen for an ultrasound.
As I have had no prior pregnancies or miscarriages, at least of course not to my knowledge, is it possible that the anti bodies that have been detected are due to my Anti D injection? The blood which has shown anti bodies was taken on the 7th December here in Norway, while my Anti D injection was administered by the NHS on the 13th November.
There is much which is understandably lost in translation in our transition to a new country, and that combined with a different medical system for pregnancies (in Norway mothers are typically only offered one scan at 17 weeks) means that issues such as my Rh- blood type and November Anti D injection have not been noted by the new doctor, despite having full access to my UK notes. They have not been able to give me any detail with regards to the level of anti bodies detected in my blood, or whether I can be seen for the ultrasound before Christmas.
Any advice you can give regarding whether this is possible sensitisation, or just a trace of the Anti D injection administered 4weeks ago, would be hugely appreciated.
Many thanks again for your blog, the information, no nonsense approach and tone are absolutely spot on.
Kind regards,
Louise Martens
At Wed Dec 17, 05:47:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Klahn Family Oct 28: Slight increases and decreases in your antibody titers are usually insignificant and can occur as the result of your own body making more or less antibody or as the result of normal variation in the laboratory assay. At your levels, the baby is at very low risk for complications related to Rh sensitization even if it is Rh-positive. With titers greater than 16 we become more concerned, especially if you started low as you have. That usually implies the baby IS Rh-positive and may be at risk. I hope everything turns out fine and thank you for reading! Dr T
At Wed Dec 17, 05:50:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Hamid Nov 18: You should tell the doctor, but if you do not, routine screening for Rh antibodies is the 'standard of care' in all pregnancies, so you will probably find out if your wife did became sensitized because of the other pregnancy. Most likely she did not. Best wishes and I hope things go well for both of you. Dr T
At Wed Dec 17, 05:53:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Encian: You can BECOME sensitized as the result of an early pregnancy loss, but it would be very rare that Rh-sensitization would actually CAUSE an early loss. I hope things turn out okay. Kind regards, Dr T
At Wed Dec 17, 06:01:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To CC Nov 22: Sorry for the delay in my response, but I just received your comment in my mailbox this week. Under most circumstances, it is unusual for babies to develop signifivant complications related to Rh-isoimmunization before 34-36 weeks with titers < 16. Once the titers become > 32, the prediction of outcome based on the titers alone becomes much less practical. Using Doppler flow velocimetry to measure the peak systolic velocity (PSV) of blood in the baby's middle cerebral artery has become a very acceptable approach as the preferred alternative to amniocentesis in the assessment of fetal risk for significant anemia. Once the PSV results exceed 1.5 multiples of the median (MoM) for a given gestational age, then percutaneous umbilical blood sampling and transfusion as needed is the next step. So, that is what to expect in the hands of most specialists in Maternal-Fetal Medicine. I hope things go well with the pregnancy and please let us know how you and the baby do! Dr T
At Wed Dec 17, 06:04:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Erika: Sorry for the delay in my response but I just got your comment delivered to my mailbox this week. You are correct. At that titer (even if it is real, and it probably is not) and this early in a pregnancy, your baby should not be at risk for complications related to that low level of Rh-antibody. Hope things turn out great! Thanks for writing. Dr T
At Tue Dec 23, 02:11:00 PM 2008,
Anonymous said…
Hi,
I am 25 weeks pregnant and tested RH Pos during my first prenatal visit. My doctor tested for IGG and IGM but they were too low for her to know exactly which one i had. My husband was tested for the presence of anitgen M and N and it came out positive. I am testing every month now and my first test my titer was 1:1. Should i be worried about anything? what conversations do i need to have with my doctor? Should we be increasing the frequency of this test?
Thank you
Lo
At Sat Dec 27, 08:42:00 AM 2008,
Anonymous said…
Can you advise if there is a reason to be checked medically in the first 12 weeks of pregnancy? I became sensitised in my last pregnancy - developed antibody D - just want to know if titer levels are high, is there anything that can be done at such an early stage of shall I wait for 12 weeks?
Thanks in advance.
At Mon Jan 05, 10:55:00 AM 2009,
jo said…
Dear Dr T,
Hi again. You may remember that I posted to you in '07 regards my Rh sensitization following two earlier pregnancies. Despite my husband & I deciding not to risk a further pregnancy nature had other ideas & I am now currently expecting our third child.
I am now 35 weeks pregnant & under the care of a hospital consultant. I currently have bloods taken every 2 weeks & an MCA Doppler every week. Things had been progressing as well as could be expected; the scans have been normal & my Anti D levels have been slowly rising within reasonable levels to a previous maximum of 8 iu/ml. However, today my blood results (taken last week) returned a reading of 29 IU/ml. This seems such a huge, unexpected surge and I am perplexed by the situation. My consultant has been excellent throughout but even he now seems puzzled by the situation as the results of the doppler & blood results seem to be contradictory. I would really appreciate any comments on the situation & ideas on what may have caused such an increase in antibodies (I have had no signs such as bleeds etc). I am scheduled for a CRT later this week followed by another doppler & possible induction next week. Any information in the meantime would be greatly appreciated.
Many Thanks, Jo.
At Fri Jan 09, 04:47:00 PM 2009,
Erika said…
Hi Dr T-
Thank you for your response. Further blood tests showed that the slight sensitization is now gone, just as you & I both thought. Thank you again very much! -Erika
At Fri Jan 23, 02:25:00 PM 2009,
J.R. Silverthorne said…
I'm sensitized to little c and big D. During my previous pregnancy I received RhoGam per protocol; no antigen/antibody testing was done, so we have no idea when or how I became sensitized. I've never had a miscarriage or abortion. The first baby was born with obvious jaundice, positive (surprise!) Coombs test, and underwent phototherapy. He's fine now.
Now in my second pregnancy my titers recently jumped from 1:1 c and 1:16 D, up to 1:16 c and 1:132 D over a four-week span. I had an amnio that shows the fetus is Rh positive. The perinatologist told me her training doc said not to transfuse until the titers go into the "thousands" range.
First question: why are my titers rising and the perinatologist is still telling me "maybe the baby isn't affected, maybe the baby is Rh negative, maybe the titers don't matter," yet they keep being tested?
Secondly, I am a bit frustrated because the perinatalogist keeps ordering the same bloodwork repeatedly, saying "oops, last time your husband wasn't checked for the E/e antigen," and so on. This results in an obvious financial issue for us and I'd like to avoid future duplicate charges. I don't understand why my husband needed to be tested for E/e since I'm not sensitized to E/e (this has just now occurred to me). Is there some information you can give me about whether or not it appears that I and my husband need further antigen testing? I understand that my antibody titers may continue to be assessed, although what for, I don't know, since it appears that my perinatologist has a standing order for serial ultrasounds every 4 weeks. At this point I have received no information about my husband's zygosity for the antigens.
My 16-week MCA ultrasound showed the PSV to be 1.19 of the mean, so clearly not to the point where the fetus is in danger (yet). Is this very early for such titer levels, does the PSV of 1.19 times the mean indicate a rising risk, and what can I expect in the future regarding odds of the baby experiencing brain damage/heart defects, being injured or killed by the intra-uterine transfusions, and so on? Thank you kindly for your answers; I know this is a lot.
At Mon Jan 26, 02:08:00 AM 2009,
Kamie said…
i am 35 wks along in my second pregnancy (first was an abortion) with an anti-d titer level of 1:32 and an MoM level of 1.04. My specialist plans to contiue monitoring the risk to fetus for anemia via the doppler method. However, I'm concerned as my titer levels rose from 1:16 to 1:32 within 2 wks which seems dramatic. Is the rate of this rise something to be concerned about? I currently have the doppler done every 10 days. With the quick rising level of my anti-bodies should i be seeing him more often? Also in reading previous postings I see that mothers in similar situations have given birth to babies whom required tranfusions and phototherpy. What is the likely hood of a transfusion being nessecery and how is this determined? Thank you for your time and consideration!
At Thu Jan 29, 01:50:00 PM 2009,
Susan H said…
Does the risk of fetal anemia increase as pregnancy progresses? Is there more maternal/fetal blood exchange as pregnancy progresses? During my last 2 sensitized pregnancies, severe anemia was detected just at around 38 weeks which led to induction so I'm wondering if it has something to do with the progression of pregnancy.
At Mon Mar 09, 08:29:00 PM 2009,
Anonymous said…
I am confused here.
I was guided by a specialist in Boston to receive IVIG shots when I decide to have my 2nd pregnancy. I am RH- and became sensitized even after receiving both routine Rhogam shots with my first baby. I am 28.
WHY is no one mentioning this on this forum/thread??? I was told thid was extrememly successful and no one has even brought it up. Any answers regarding using IVIG to prevent still born, post-partum death or Miscarriage??????
At Fri Apr 03, 05:22:00 PM 2009,
Anonymous said…
I'm 28 weeks pregnant, A negative blood type. My second husband has O positive blood. My first baby had A positive blood and positive Coombs test, so now I'm being followed with serial Dopplers, which are all completely normal. My second husband is homozygous for his blood type.
So, my two questions are: why isn't this baby being affected? (we are grateful) Does this mean we're safe for future pregnancies? and...
At what point (weeks gestation), if the PSV is greater than 1.5 MoM, do we decide to induce labor/C-section instead of an intrauterine transfusion?
At Thu Apr 09, 05:50:00 PM 2009,
Stephanie said…
I am pregnant with my third child and have been told with this one that I have tested positive for antibody c. I have a two year old and a 12 year old and did not have this with them. My titers at 12 and 17 weeks were 1:1. I am now almost 19 weeks and will be tested every 4 weeks to check the titers. The specialist said he does not foresee any problems this time around and thinks things will be fine. How much should I worry about this????
At Sat Apr 18, 05:54:00 AM 2009,
Anonymous said…
Would you address importance of seeing if you are RH sensitized before you become pregnant for my daughter. My husband and I are both O+ (My father 0- Mother A+)She was in NICU for 6 weeks in 1983 w/ major surgery at 5 days and 1 yr. Upon checkout transfusion information for 5 day surgery missing...........She is O- and married to RH positive spouse. I have read your articles and feel it is imperative to find out before hand if already sensitized. I don't want to be an obnoxious mother-in-law so can you tell if I or they should be concerned.
At Sun May 03, 05:06:00 AM 2009,
Anonymous said…
I am RH negative. I had a successful pregnancy, and two subsequent miscarriages and was given Rhogam through all. I am currently 16 wks pregnant and was not sensitized at the beginning of this pregnancy. I had spotting in wk 4 of pregnancy and was given Rhogam. I had a huge bleeding episode in wk 12. Ultrasound did not show where bleeding was coming from. I was not given Rhogam again as it was still in my system determined by blood test. I was bleeding brown blood for the past 3 wks and asked my OB if I should have Rhogam again. Bloodwork was taken on 4/24/09 along with the Kleihauer-Betke test. This test showed that I had fetal blood cells in my system and there were still antibodies from Rhogam. On 04/30 I was given another blood test and the Rhogam shot. Blood test showed negative antibodies before I took Rhogam. I am paranoid that when the 1st Rhogam shot was wearing off that maybe my body was starting to develop the antibodies and that I didn’t get the second Rhogam shot in time?? Is there any possibility however small that I could become sensitized? If so, can it affect this pregnancy since I am only 16 weeks? Since my two miscarriages I have become very paranoid about everything. Please advise. Thank you.
At Mon Jun 29, 02:42:00 AM 2009,
Paolita said…
Dear Doctor, I am 32 years old an I´m O negative. On may 19 th I gave birth to my first daughter who is O positive (A c_ section at week 35 due to cholestasis) I received the Rh shot when I was 28 weeks pregnant. The thing is that I received a second shot 5 days after my daughter was born. I read I should have received this shot anytime during the first 72 hs post surgery. The obstetrician told me that I should not worry because the dose is equally effective even though I received it 5 days later. Is that so? Is there any lab test that can tell me if I got sensitzed? I apologize for any grammatical mistake, I am from Buenos Aires Argentina. I´m a gynecologist, I tried to look for this information in many journals (this is by far not my area of expertise, I work mainly in gynecologic oncology) but I really could not find any article that could backup what my doctor told me. I really appreciate any information that you could provide me with. Regards, Paola
At Thu Jul 02, 07:33:00 AM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Paola June 29: There is a good chance you will not become sensitized having gotten the Rh-immune globulin at 28 weeks, delivering early, and then receiving more after delivery. However, if you need to know before another pregnancy, I would suggest waiting 4-6 months (to allow any of the Rh-immune globulin you received to be lost) and then simply ask for an "antibody screen" at you hospital laboratory or blood bank. You will also be screened again as part of the routine early in any subsequent pregnancy. Best wishes and thanks for writing.
Dr T
At Wed Jul 22, 02:40:00 PM 2009,
Christine said…
Dear Dr.T, My husband and I recently had our second child, Luke Thomas, on June 18. I was under the impression that Baby Luke was a healthy, viable little boy in utero. However, on the morning of June 18 as I went in to be induced, a fetal-maternal specialist was called in to look at the ultrasound that my OB had ordered (due to low heart rate). She advised that my baby was "very sick" and needed to come out immediately! So after an emergency section, she said he could not have been more dead and still had a heartbeat. They did chest compressions and all kind of heroics....all to sustain his life for three weeks. It was determined that Luke was Kell positive and I am Kell negative. He had severe HDN and fetal hydrops, along with severe anemia, swelling, and bleeding in his brain. We were all blindsided, including my wonderful OB. Luke was taken off of life support on July 9 and died very quickly. On the outside, he was a beautiful little boy. But his body was hiding a huge mess on the inside. I guess I am writing to you (an Rh guru) in hopes that you can maybe shed some light onto the Kell Factor and where Luke got this from. The hematologist told us that my first born is Kell positive and his blood got in my circulation during delivery two years ago, so then my body made antibodies to fight them because I am Kell negative. But I never have had a blood transfusion, so how did my first born become Kell positive? Does my husband carry the gene and does he have to be homozygous? We are confused and don't know what to think. I have had 4 doctors tell me not to get pregnant again for the third time because it would be even worse next time. Are we capable of having a Kell negative child? Please let me know what you think and if you know of any Kell specialist that my husband and I could contact. We are set to see the fetal-maternal medecine doctor on August 10, so hopefully we can get some answers. I'll check back to see if you have posted anything in reference to my blog. Thanks for your time. Christine from Louisiana
At Fri Jul 24, 02:21:00 AM 2009,
Woollyknickers said…
Christine from Louisiana, my heart goes out to you. I hope you get accurate information and support from your local medical community, and if required find a suitable specialist. You sound extremely brave following such a painful, tragic event - I can only imagine what you and your family have been through. Just remember that life changes, for the better, so unexpectedly sometimes. You are an admirable lady indeed. Wishing you and your family all the very best for the future, Louise
At Tue Oct 20, 03:31:00 PM 2009,
Anonymous said…
I just found out that i am 4wks and 4days pregnant with my 3rd child. My first pregnancy ended in miscarriage early so i was unaware if what had happened. I did not receive a Rhogam shot. #months later i became pregnant with my son and at about 6 and a half months was told that I had antibodies showing up in my blood. I went in and had an amnio done and they decided to deliver him by c-section at 7 and a half months. He was born with the rh disease and jaundice but pulled through wonderfully and is a perfectly healthy 4 year old.
I am currently 4weeks and 4 days pregnant with my 3 rd child and am alittle worried about how this is going to turn out. I'm trying to be positive but reality that there is a risk is there. When i was pregnant with my second my doctor actually advised me to get tied but i was only 19 and didn't think i was ready for that. Now I'm 24 and am very excited.
I really want to know what your opinion is. Thank you, Stacey
At Tue Oct 20, 05:35:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Christine July 22: Sorry but I had never seen your comment until today. Yes, if your husband was the father of the other baby, he must be Kell positive. That means he carries the Kell anitigen on his red blood cells. You became sensitized (make anti-Kell antibodies)as the result of exposure to your previous baby's blood. Our immune systems react to things that are foreign to our bodies - in your case Kell antigen. Your husband can be tested to see if he is Kell homozygous (in which case all of your children together will be Kell antigen positive) or heterozygous (half your children will be Kell antigen positive. If he is heterozygous, another baby could be checked to determine if he/she carried Kell and if not, that baby would not be at risk for hydrops. You can be followed during another pregnancy by Doppler flow velocimetry studies of the baby's middle cerebral artery to screen to determine if the baby is developing significant anemia. If it appears to be, then a series of intrauterine transfusions can be done to help avoid serious complications. Best wishes and hope you find this response some time!
Dr T
At Tue Oct 20, 05:38:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Stacey Oct 20: The baby will be at risk only if it is Rh-positive. If it is, you will be at increased risk for another affected baby having had one. Otherwise, see my comments to the reader immediately beneath your post. They apply to you as well as to her even though you have a different antibody problem. Best wishes and let us know how things turn out!
Dr T
At Tue Oct 20, 06:56:00 PM 2009,
Anonymous said…
Hi Dr T, thanks for your commitment to this blog and the women reading it. I have a couple of questions. How long does Anti-D injection cover me for? If I have several bleeds within weeks in early pregnancy, do I need Anti -D each time? I heard that Anti-D injection may still be effective even if not given within the first 72 hours. I heard that the amount of fetal blood in mother's blood at miscarraige around 8 weeks is very small and unlikely to create isoimmunisation, (I missed the 72 hour mark so I'm a bit worried, although they gave me Anti-D about a week after the bleed)
At Wed Oct 21, 05:15:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 20: Fortunately most (but NOT all) women do not become sensitized with early miscarriages. The anti-D hangs around for 12 weeks or longer unless it is used up by exposure to Rh-positive fetal blood. Each regular vial of Rh-immune globulin can neutralize about 30 cc (1 ounce) of fetal blood. Most women will NOT become sensitized if the receive Rh-immune globulin within 72-96 hours after exposure to Rh-positive red blood cells unless there are more red cells present than expected. "Excessive fetal-maternal hemorrhage" is usually screened for in many hospitals following delivery of an Rh-positive baby to an Rh-negative mother and then additional Rh-immune globulin is given as needed. Thanks for asking!
Dr T
At Tue Oct 27, 01:47:00 PM 2009,
Anonymous said…
I am rh negative and 12 weeks pregnant with my second baby. I received rhogam throughout my first pregnancy in 2007: after my amnio, at 28 weeks and again at delivery (which was natural and not difficult). I had a miscarriage in early July after which I received a rhogam shot. I recently tested positive for anti-d with titers 1:<1. The MFM speculates that this is either residual rhogam from my miscarriage, or I didn't receive enough rhogam during my first pregnancy. Either way, he doesn't think my levels are high enough to create any problems with this pregnancy. My questions are: what is the likelihood that this is leftover rhogam from the m/c (the shot was given 16 weeks before this blood test)? If I have been truly sensitized, do such low levels really indicate a favorable outcome for the pregnancy? I was hoping for a homebirth, but now all I want is a fullterm healthy baby. Thank you for your insight.
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