Hemolytic Disease of the Newborn- Rh Incompatibility

Hemolytic disease of the newborn (HDN) due to Rh incompatibility does not typically cause problems during the first pregnancy, as there hasn’t been any mixing of Rh-positive and Rh-negative blood types. Without exposure, the mother’s immune system hasn’t created defences against the baby’s blood. However, during the first pregnancy, the mother’s body produces IgM antibodies, which are too large to cross the placenta. Once these antibodies are produced, the mother becomes sensitized and develops antibodies that can target Rh factors in future pregnancies.

In a second pregnancy of a mother with Rh- blood and a fetus of Rh+ blood, these antibodies (now in the form of IgG from sensitization) can cross the placenta. IgG antibodies can then recognize and attack the Rh-positive blood cells of the fetus, leading to the breakdown of red blood cells in the newborn. This can result in complications such as jaundice, lethargy, and severe cases like heart failure, organ enlargement, and hydrops fetalis (fluid buildup in two or more areas of the baby’s body).

In this case of Rh incompatibility, a preterm emergency cesarean section was necessary. The newborns affected by HDN show symptoms like jaundice and lethargy, spending time in the NICU.

For mothers at risk of Rh incompatibility, an indirect Coombs test is performed to detect antibodies in the mother’s blood that could target Rh+  red blood cells. If HDN is suspected in the baby, a direct Coombs test is conducted on the newborn’s blood to confirm if antibodies are already coating the baby’s red blood cells, indicating immune-mediated hemolysis. Further testing to measure fetal-maternal hemorrhage includes the rosette test, and the Kleihauer-Betke (K-B) acid elution test. These tests help guide the need for interventions and preventive treatments. In cases of known sensitization or high-risk pregnancies, regular antibody screenings are done to monitor the baby’s health and detect any early signs of anemia or hydrops fetalis.

Rhogam is commonly administered as a preventative measure. This injection contains antibodies that “trick” the mother’s immune system, preventing it from attacking an Rh-incompatible fetus. Rhogam is typically given during and after delivery and is recommended for all pregnancies beyond the first.

The podcast was well laid out and the pathophysiology was clear and easy to understand in this format. I did not notice any gaps in the explanation of pathophysiology, treatment, diagnostics, or symptoms.  During the section about diagnostics I had to rewind an relisten a couple times to gain a clear understanding of the diagnostics for hemolytic disease. Theses test where all explained in the podcast including when they are used and what they tell us. It was explained in a large chunk of dialogue from the doctor.  The format of this project being a podcast and having audio only, maybe going into further detail about the testing or having the patient reiterate her understanding of diagnostics in the conversation could be a way to integrate this information more. Although more back and forth in the interview presents challenges when there is time constraints, I have heard some podcast that will do a little side note to dive into a section that is harder to understand to give the reader more context. For example maybe the doctor could have addressed how the Kleihauer-Betke (K-B) acid elution test got its name to solidify the deeper understanding. Another avenue I think could address this would be the use of multimedia, being able to hear as well as see the names of the tests on the screen could have formed a quicker connection for me, especially with complex names. Or maybe including a image of a timeline of when all the tests are done during pregnancy from conception to birth.

I found it very beneficial the way the podcast was laid out as an interview with a case study embedded in it. The interview followed a natural flow of the progression of hemolytic disease in newborn. The way the case study unfolded being told by the mother made it very easy to follow the progression of this disease process. The interview style and having a teaching and learning relationship between the mother and the doctor allowed for an easy transition to discuss all the points required for this project. I also like how the podcast incorporated a teaching and learning portion at the end where the doctor gave the recommendation of rogram for future pregnancies and the mother had an opportunity to give advice on the subject based on her learning.

It was interesting and easy to follow having the information laid out as a back-and-forth conversation as opposed to listening to one person lecture. Having the interviewer ask prompting questions made it easy to follow where the conversation was going and provided clear transitions from the topics covered. I also like the way that the mother used layman’s terms and then the doctor would reiterate using medical terminology such as the mother saying that her baby was yellow and the doctor calling it jaundice. This format allowed for a larger target audience as medical professionals could easily follow along with the doctors terminology, but connections and understanding could also be made by anyone interested in Hemolytic disease. This topic is something anyone planning on having children should understand so I appreciate that is was delivered this way.

I am also wondering if the role of the doctor could have been a nurse. I think everything that was discussed was in a nurse’s scope of practice to educate a patient on. I think if the role was of a nurse, it would help empower a nurse’s place in having a leadership role and also empower nurses listening to provide this education to their patients. I don’t know what prenatal care looks like in the current system; I am assuming checkups are done with a doctor which would indicate that the doctor is doing most of the education. I wonder with the current doctor shortage in BC, if we are seeing more expecting mothers in acute care or primary care setting, shifting the education piece to a nursing role. The nurse will have a big role with the mother in the case of Rh incompatibility, as we know nurses spend way more time at the bedside than doctors in acute care; having this education done from a nurse who already has a rapport with the mother but strengthen understanding of the risks.

Obstetrics is not a patient population that I have worked with much in my practice so far. We have learned about blood typing and Rh factor as well as complications of pregnancy during this program a few times but it is still something that I do not feel overly confident on. Listening to this podcast gives me some ideas on how I could provide teaching to my patients.

I think my biggest takeaway is the importance of education about rhogam to protect future pregnancies. it prevents the mother’s immune system from becoming sensitized to Rh-positive blood. This ensures the safety of current and future pregnancies, protecting the baby from HDN complications. Rhogam is given routinely as a preventive measure to Rh-negative mothers during the third trimester, after any event where fetal blood might mix with maternal blood (like trauma or invasive procedures), and after delivery if the newborn is Rh-positive. It has been proven safe and effective for both mother and baby, with minimal side effects. Rhogam is the reason we do not see more fetal death or decondition due to Rh incompatibility.

In my practice it is important to recognized signs of a critical finding hemolytic disease in newborns such as jaundice, edema, and lethargy. Also being aware of what a high risk pregnancy looks like and what interventions are required. Knowing what the results of tests such as the Coomb test indicates will be important for early intervention and education.

The podcast also emphasized the importance of reviewing and confirming patients’ understanding, especially during pregnancy (a time when individuals may feel overwhelmed with medical information). For those without a medical background, clear communication is essential to ensure they fully understand procedures and interventions, such as blood testing, preventive measures, and Rh incompatibility management. In cases of Rh incompatibility, interventions like the administration of Rh immunoglobulin (Rhogam) can prevent sensitization, protecting future pregnancies. Ensuring patients comprehend these preventive steps and the significance of treatments helps support informed consent and trust in healthcare team and their birth plan. Regularly checking comprehension and providing additional teaching as needed can empower patients to make informed decisions throughout their pregnancy.