1 / 14

Antibody positve screen in an Rh- 29 y/o P1

Antibody positve screen in an Rh- 29 y/o P1. Scott Ikeda 9/23/08 Obstetrics Rotation. Admission Data. 29 y/o G 6 P 1041 @ 38 0 weeks by LMP (12/24/07) c/w 27 wk sono. EDD 9/29/08. Pt c/o LOF at 11pm, clear, with ctrx q10 min, now q4 min. +FM, -VB. Admission Data Cont’d. PN Issues/Care

titania
Download Presentation

Antibody positve screen in an Rh- 29 y/o P1

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Antibody positve screen in an Rh- 29 y/o P1 Scott Ikeda 9/23/08 Obstetrics Rotation

  2. Admission Data • 29 y/o G6 P1041 @ 380 weeks by LMP (12/24/07) c/w 27 wk sono. EDD 9/29/08. Pt c/o LOF at 11pm, clear, with ctrx q10 min, now q4 min. +FM, -VB.

  3. Admission Data Cont’d • PN Issues/Care • No prenatal visit records in EPF or ASObgyn, however labs and sonograms available. Pt did not bring records with her. • Rh negative: s/p Rhogam ~25 weeks • PN Labs • O- Ab-, GCT 132 --> GTT 75/153/124/114; no record of pap, GC/Chlam; all others wnl • Sono • 4 sonos btwn 272 weeks and 372 weeks, all c/w LMP, AFV wnl, no anatomic anomalies seen. However, fetus was noted to be >97% for weight, last EFW at 372 weeks = 3879g.

  4. Admission Data Cont’d • POBHx • 2003: 7.5lb F, NSVD, term, no complications • 2005: SAB • 2006: TOP with D&C, SAB • 2007: TOP with D&C • PGynHx • Menarche @ 14, irreg. avg 28d/1-2d; no h/o f/c/p; abnl pap in 2004, HPV+  LEEP 2005; no h/o STI except HPV.

  5. Admission Data Cont’d • PMedHx • No asthma, HTN , DM • PSurgHx • None, except D&C noted previously • Allergies • NKDA • Meds • None • SocHx • No tob/etoh/drugs, in college for Med. Asst., works in sales, lives w/ mother and sister, FOB involved, unplanned preg • Fam Hx • Non-contributory

  6. Phys Exam • BP 130/71, P73, R20, T98.4 • FHR 130’s baseline, +mod var, -accels, -decels • Toco q2-3 min • SVE 5/90/-1 • EFW 3900, vertex by sono • CV, Pulm, Abd exams wnl, trace LE edema b/l

  7. Assessment & Plan • 29 y/o P1 at 380 weeks, here for SROM at 11pm. • Admit to L&D, collect routine labs • FEN/GI: NPO except ice, IVF at 125cc/hr D5LR • Fetal status: overall reassuring, EFW 3900, vertex. Continue EFM. • Labor: Active labor, adequate pelvis. Expectant mgmt, anticipate NSVD. • GBS: Negative. No tx indicated. • O-, Ab-: may need Rhogam post partum pending fetal assessment. • Pain: requesting epidural, anesthesia aware

  8. L&D Course • 5am - 6-7/90/-1, due to lack of progress, IUPC placed to measure adequacy of ctrx • 6:15am - O-, Ab+, ctrx indadequate, no change in SVE, reassessed as latent/early active labor, pitocin started, antibody ID sent • 8:45a - rim/0 • 9:30a - FD/0, began pushing • 10:41a- NSVD, male, 4285g; midline episiotomy, McRoberts & suprapubic pressure. • Antibody ID = Anti-D due to Rhogam. Neonate B-, Direct Coombs -

  9. Rh Alloimmunization • Nomenclature: ABO blood type plus Rh(D)+, Rh(D)- • Rh+, Rh- commonly used but technically incorrect due to other types of Rh Ab (C, c, E, e) and D antigen variants. • Rh(D)- epi • Caucasians 15%, African Americans 8%, Indo-Eurasians 2%, Native Am & Eskimo 1-2%, Basques 30-35%, Finnish 10-12%. • 60% homozygous, remainder heterozygous

  10. Pathogenesis • Rh(D)- maternal exposure to Rh(D)+ RBCs • Main cause: Transplacental fetomaternal hemorrhage • Iatrogenic causes: re-using needles, mismatched transfusions, stem cell transplants • Assoc w/ SAB, TOP, ectopic preg, invasive in-utero procedures, fetal death, abd trauma, maternal hemorrhage, AGA, delivery • Small amounts (<1ml) fetal RBCs cross placenta in nearly all pregnancies.

  11. Fetal Effects • Hemolytic disease of the newborn • Maternal anti-Rh Ab crosses the placenta and binds to fetal RBCs • RBCs targeted for destruction in spleen • Anemia  pallor, high output cardiac failure;  protein synthesis as liver shifts to RBC production  edema; jaundice, possible hepatosplenomegaly, possible neurological sx

  12. Prevention • Blood type and antibody screen at first prenatal visit (USPSTF A recommendation) • Repeat screen at 24-28 wks gest unless FOB known Rh(D)- (USPSTF B recommendation) • Administer 300mcg Rh(D) immunoglobulin to unsensitized women at 24-28 wks gest • If Rh(D)+ (or weakly +) infant delivered, give another IG dose within 72 hours • Unless FOB known Rh(D)-, give IG after amniocentesis, SAB or TOP • Insufficient evidence for giving IG for other procedures (USPSTF). However, ACOG recommends for CV sampling, fetal blood sampling (A), and consider IG admin for threatened abortion, 2nd/3rd trimester antenatal bleeding, external cephalic version, abdominal trauma (C).

  13. For the Alloimmunized Patient • See flowchart • Indication for high-risk OB, or MFM specialist referral

  14. Sources • American College of Obstetricians and Gynecologists (ACOG). Prevention of Rh D alloimmunization. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 May. 8 p. (ACOG practice bulletin; no. 4). • Hemolytic disease of the newborn. dynaweb.ebscohost.com. • Moise Jr., Kenneth. Pathogenesis and prenatal diagnosis of Rhesus (Rh) alloimmunization.www.uptodate.com. • U.S. Preventive Services Task Force (USPSTF). Screening for Rh(D) incompatibility: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2004 Feb. 4 p.

More Related