Hemolytic Disease of the Newborn – ABO Incompatibility – Ravneet Sandhu

ABO incompatibility is a condition that occurs when the mothers blood group type is different from the fetus. When a mother has type O blood, and the fetus has type A, B, or AB blood the baby has antigens, which is a protein on the red blood cells (RBCs), that the mothers’ body does not carry. Since the mother has no antigens, her body will produce anti A and anti-B antibodies against that antigen. The IgG anti-A antibodies bind to the antigens on the RBC marking them to be destroyed. If these antibodies cross the placenta and bind to the fetal RBCs, a reaction occurs. The reaction causes the destruction of fetal RBCs which is called hemolysis. During this process, sensitization would not occur because the antibodies the mother has are naturally occurring meaning they will be present in all pregnancies. Routine blood type screening occurs in the first trimester to determine if this will be a risk.

Some symptoms of this may be anemia, pale appearance, lethargy, high bilirubin levels and jaundice. The jaundice occurs because the broken-down RBCs produce bilirubin which is a yellow pigment that is normally removed by the placenta during pregnancy, and by the liver once the baby is born. However, in cases where newborns have hemolysis or are premature, the bilirubin may not be removed from the liver causing jaundice.

A treatment that is used for jaundice in newborns is phototherapy which can lead to a full recovery. In severe cases, IVIG may be used which works to decrease hemolysis by blocking receptors on macrophages, preventing the antibody from bursting.

The key to prevent complications with ABO incompatibility is early recognition during pregnancy and close monitoring postpartum as this is when you are at highest risk.  Additionally, hemovigilance, a surveillance procedure that tracks blood donor and recipient information is vital to detect errors early on. In severe cases, a direct Coombs test may be performed and if it is positive, it means the antibodies were attacking the fetal RBCs causing them to die faster than they could be replaced. A complication is severe hemolytic anemia which can end up causing hydrops fetalis. This can cause symptoms such as skin edema, pericardial effusions, pleural effusions, respiratory distress and ascites. If left untreated and not diagnosed through an ultrasound, it can lead to kernicterus which is bilirubin induced neurological damage that can result in cerebral palsy, neurodevelopmental issues, or death.

There were not many gaps in content that I had noticed throughout the podcast; however, there was a point where I believe it would have been valuable to expand to help enhance my understanding on this condition. For me, maternity and neonatal concepts are not ingrained in my mind as I would like them to be. Since this is not my area of interest, I am a bit unfamiliar with some of the core concepts.

One example that stood out was when the nurse explained in the first case scenario that the chance of the baby’s blood mixing with the mother’s blood during pregnancy is very unlikely, but more likely during delivery. While it was mentioned that this is why it is crucial to monitor both the baby and mother postpartum, I found myself unclear on why the risk of blood mixing increases specifically during delivery. It would have been valuable for the podcast to briefly touch on the reasoning behind this increased risk.

From my understanding of why this would occur is that the placenta serves as the barrier between the mother and the baby during pregnancy, and the integrity of the placenta during delivery is compromised. This would then increase the risk of the fetal blood cells to enter the maternal bloodstream. Additionally, it made me think of cases where placental abruption or cord trauma occurs. If these complications were present in either of the case scenarios that were presented, would there be different interventions that are used or different monitoring protocols to manage the risk? I believe a brief explanation of the mechanisms behind blood mixing during delivery would have enhanced my understanding of this condition.

For me, the whole podcast was very well thought out and it supported my learning in multiple ways. The song that was sung at the beginning and throughout was helpful in keeping me engaged and motivated to continue listening. It made the content, and the setting seem more comfortable and less overwhelming to listen to.

The most helpful teaching-learning strategy that was used in the podcast was the sense of realism that was brought to it through the patient scenarios. It was very valuable to hear the point of view from two different mothers, one with a mild case, and one with a severe one. I appreciated how these two were separated and thoroughly explained one after the other. As someone who learns best through examples and real-world scenarios, I found this approach effective in deepening my understanding. The comparison of both the case scenarios presented allowed me to see the differences in the signs and symptoms, diagnostics, and the different approaches in treatment.

By understanding the different patient histories and experiences, I was able to solidify my learning and understand the clinical indicators and different decision-making processes that were used in both the scenarios. During the case scenarios, I wanted to highlight the positive impact it made on my learning when prompting questions were asked. One question that stood out to me was “Is there any way to prevent this from happening if the mother had another baby with a different blood type?” This prompted me to think about preventative strategies in the future and think beyond just the case scenario that was presented to us.

If I had the opportunity to make one change to the video, it would be to incorporate more perspectives throughout the video. While the podcast was effectively presented using the case scenarios, I think it would have been interesting to hear the experience of family members such as partners, as this could provide a more emotional connection for listeners that may have had similar experiences or problems during pregnancy.

Oftentimes in pregnancy, the focus is primarily on the person carrying the child, and the baby. When complications arise in times like this, I believe the experience of those around the one being impacted would be beneficial to hear. Partners may experience different emotions ranging from fear to anxiety, and by giving them a voice in this podcast, it can highlight how important it is to include them in discussion’s as well.

This inclusion could help listeners who have been through similar experiences feel more understood. For instance, listeners who may have had a complicated pregnancy or had someone close to them have one might feel that it makes them feel heard when hearing the emotional challenges of other people. It would also foster a more inclusive environment of what it’s like to go through pregnancy from the perspective of someone not carrying the baby. I think in nursing we often focus on only the patient and don’t incorporate the ones around them as much as we should. I think incorporating this perspective would help healthcare workers also understand the significance of involving families in care.

Learning about Hemolytic disease of the newborn due to ABO incompatibility will be very valuable to my future practice as a nurse. Although I may not pursue a role in obstetrics or neonatal care in my practice, the knowledge gained from this will still play a role in my practice. This condition can present anywhere I am in the hospital so understanding it will ensure I am prepared to respond effectively.

A key takeaway I had from this podcast was the importance of early and appropriate management of the condition. As a nurse, I understand the importance of hemovigilance even stronger than I did prior, and it will be crucial in managing these cases. While ABO typically presents with mild symptoms, if untreated and not recognized, it can lead to severe cases of anemia, or kernicterus if not treated right. Monitoring a mother postpartum and during delivery is very important to recognize potential complications early on in pregnancy. One way I plan to integrate this is that I will routinely monitor an infant for jaundice. Since jaundice is often the first noticeable sign of this condition, it will be important to assess the infant’s skin tone and sclera for any yellowing that has occurred. Alongside this, monitoring lab results will also be critical to determine if interventions are needed. For example, checking hemoglobin levels and direct Coombs tests to determine the severity of the reaction.

Beyond focusing on the infant, I have learnt early detection will be needed for the mother. I will pay attention to maternal history of pregnancies to determine if it is a risk for the current pregnancy. If a mother has experienced ABO incompatibility in a previous pregnancy, it will most likely occur again. Understanding the maternal history of pregnancies will help me integrate the interventions I have learnt in this podcast in a timely manner to prevent severe cases.

The importance of early recognition that this podcast highlighted in the case of ABO incompatibility is something I will bring into my future practice regardless of the context. It highlights the importance of doing thorough assessments and health histories as much as possible to anticipate any complications in the future. This is not only the case for areas such as neonatal care, but this is important everywhere in healthcare and can help prevent many adverse outcomes in care.