Hemolytic Anemia of the Newborn – ABO Incompatibility

Hemolytic Anemia of the Newborn ABO incompatibility happens when the mother’s blood has anti-A and or anti-B antibodies, and the fetus RBC have A and or B antigens. This happens most commonly when the mother is type O ABO group because her blood will contain both anti-A and anti-B antibodies, but it is still possible to occur in other blood types if there is a mismatch. When this mismatch occurs, the antibodies create complexes with the antigens on the fetus’s RBC initiating the process of hemolysis.

Symptoms/ presentation of the disease: The antibodies are class IgM, which means that they are too physically large to pass through the placenta into the fetus during pregnancy, and only becomes a problem when the baby’s blood encounters the mothers during delivery. This is why without adequate peri-natal care we will not know it is a problem until delivery. The by-product of RBC death is a compound called bilirubin. Throughout pregnancy, the placenta is responsible for filtering this out of the baby’s blood but after delivery the baby’s liver and spleen are not mature enough to filter it out of the blood leading to a build-up in the body. This leads to jaundice or yellowing of the skin and sclera. This also is the cause of the more serious conditions like hydrop fetalis in which bilirubin builds up on areas of the brain that impairs function. The loss of RBC or anemia also decreases the oxygen carrying capacity of the baby’s leading to a decrease in the amount of energy produced during metabolism; the presents as weakness.

Diagnostic evaluation: The diagnosis of this disease process is through physical assessment in combination with blood tests. Physical assessment would show the symptoms listed above. Blood tests would look at the CBC, hematocrit, concentration of Bilirubin, and a test called the direct coombs test. CBC and hematocrit show the overall loss of RBC in the blood of the newborn; this would be used to measure the extent of the disease. The amount of bilirubin would be expected to decrease as interventions are implemented. The actual diagnostic tool used to definitively diagnose this disease is the direct coombs test which looks directly at the RBC of the baby to determine is the anti-antibodies are bound to them; a positive result would indicate the presence of these antibodies and a diagnosis.

Treatment: treatments mentioned in the podcast included phototherapy, increased fluid intake, and blood replacement. Phototherapy is used to break down the bilirubin so that the baby’s body is able to fully process it. Increasing fluid intake promotes the excretion of bilirubin in the stool. Blood replacement is used in more severe cases; this involves “washing” the baby’s blood to remove the antibodies that are the causative agent.

A gap in content that I found was looking at the future family planning of a mother born to a child with Hemolytic disease of the Newborn ABO incompatibility. There was potential to go over the genetic component that causes the ABO blood group type of your child and subsequent development of this problem.

The genes involved in the blood typing have 2 alleles and the child will receive one allele from each parent. If the mother is O blood type, like in the example, that means she has 2 copies of the “O gene” and that she will always pass on one copy of the “O gene”. The other copy will come from the father. For example, if the father was type A there are 2 possible combinations that he is able to pass along; he will have either 2 copies of “A gene” or one “A gene” and one “O gene”. If the father had one copy of the “O gene” and one copy of the “A gene” then there is a 50% chance he will pass on an “O gene” and 50% chance that he will pass on an “A gene”; meaning there is a 50% chance that the child will receive 2 copies of “O gene” leading to type O blood group type and 50% chance that the child will receive one “O gene” type and one copy of the “A gene” leading to type A blood group type. This would mean that there would be a 50% chance of ABO incompatibility. This information could be used to support the mother with planning for children in the future and inform their decision to have more children given this risk.

In addition to this, it would have been helpful to discuss the process in which RBC are hemolyzed. For example, which cells are involved and are there important cell signalling proteins that are responsible for this process.

This podcast was fun to listen to and used facilitated peer teaching to provide the information as the main form of teaching. They involved 2 different mother’s along with an expert nurse on the topic. This made the information provided more relatable, engaging and created a sense of community for the population that this information is geared towards. When someone else has experienced something similar to you and felt similar things as you then it has a validating effect; keeping in mind that every experience has different contributing factors that change the way someone manages the anxiety around it. I found that they created a simulated supportive environment for questions and inquiry about the topic.

The second positive feedback was that the way the information provided was very engaging. The information was presented in a way that was not a list of facts or a complicated pathophysiology flow. The team broke it up into important topics that flowed into one another using this method. Further, the questions and interjections from the host created an almost interactive feel in which the questions I had we asked and consequently answered by the group. Overall, it was super fun to listen too. Thank you Team Better Out Than In!

I found myself really looking for things to change because the group did really well highlight the important facts about the disease process.

However, I think that mention of the caregiver role in this disease would be a helpful addition. This is a scary and traumatizing experience for the parents of a child born with Hemolytic Anemia of the Newborn ABO Incompatibility. I can imagine that there is a lot of helplessness, guilt and other negative emotions involved when there is a problem with their child that they do not understand. We teach parents that they need to take care of themselves in order to be able to care for their new child successfully. I would have offered resources such as mental health support, peer groups or other new parents groups. I can appreciate that this is highlighted in the responses from the mothers interviewed in this podcast, but it would have been a great addition.

A second thing I would have liked to change is a personal preference. I am not sure that the subtitles added to the presentation of the podcast and would have found myself less distracted from listening without them.

I believe that this particular topic will be difficult to integrate into my own practice because I do not plan to work in labour and delivery, paediatrics or NICU. There would be an extreme series of unfortunate events that would lead to this being part of my own future practice.

With all that said, the pathophysiology is similar to one of the processes that cause a transfusion reaction. Part of performing blood checks is ensuring the ABO group of the donor blood is compatible with the recipient. If a mistake were to be made during the required checks, we have potential to be infusing incompatible blood along with incompatible antibodies. This would lead to antigen-antibody complexes on the recipient RBC. The biggest difference is the maturity of body systems to manage the change, however both have potential to cause tremendous harm. Knowing that infusing an incompatible blood type will cause the patients RBC lyse and the patient will become really sick will strengthen the importance of these checks within my own practice and understanding of how this process would occur was strengthened by this podcast.

Secondarily, I believe that this podcast exemplified strengths-based communication. Sometimes it can be difficult to get lost in the stories of our patients. It is a balancing act between getting your points across while still validating their experience and supporting the patient through difficult times. I believe their approach recognized this in the way that Ester validated Allison in her concerns while still addressing the questions that she had. I really enjoy hearing how others navigate these situations, and it really helps me build on my own communication skill.

This podcast also armed me with more knowledge about something that I was having a hard time wrapping my head around since it does not directly impact the population I intend to care for. However, if I happen to care for a pregnant person I will advocate for adequate peri-natal care to ensure that these types of testing are done so that my patient and healthcare professionals can be best prepared to support them.