Hemolytic Disease of the Newborn (HDN) – ABO Incompatibility – Patho Part B Assignment – Sebreena Lalani

ABO Incompatibility Overview and Pathophysiology: Antibodies involved: IgG (small) and IgM (large – involved, but cannot cross placenta).

A pregnant individual has a certain blood type (O-Positive/Negative) and the baby that individual is carrying has a different blood type (A, B or AB-Positive/Negative). The baby has an antigen (protein on RBC’s) that the pregnant individual does not have causing the immune system to react (Baby’s Possible Antigen: A, B, or AB). The pregnant individual has no antigens, but antibodies A, B, or both. This can cause the first and subsequent pregnancies to be affected as the pregnant individual has antibodies present for the baby’s antigens. The pregnant individual’s IgG antibodies cross the placental barrier because they are small and bind to the baby’s RBC’s. This causes a reaction and marks them to be destroyed through Hemolysis. ABO Incompatibility is less severe (yet more common) than Rh Incompatibility, but still needs immediate care, treatment, and monitoring.

Symptoms of Baby:

• Hemolysis: Destruction of RBC’s.
• Hemolytic Anemic: Disorder where RBC’s are being destroyed faster than they can be made – Low Hemoglobin (Hgb) levels.
  • Kernicterus: Bilirubin-Induced Neurological Damage.
• Tired
• Yellow Skin/Jaundice: Excess Bilirubin.
• Hydrops Fetalis: Abnormal build up of fluid in body tissues and organs.
  • Skin Edema
  • Pericardial Effusions
  • Pleural Effusions
  • Ascites
  • Respiratory Distress
• Cerebral Palsy
• Sensorineural Deafness
• Neurodevelopmental Issues
• Death

Diagnostics:

• Testing and Monitoring Bilirubin Levels of Baby Postpartum:
• Increased Bilirubin Levels = Jaundice (Yellow Skin)
• Direct Coombs Test (DCT): Test done on newborn’s blood sample to determine foreign antibodies attached to newborn’s RBCs causing antibody-mediated hemolysis.
• Positive DCT: BAD – Newborn has antibodies against RBCs = Hemolysis.
• Negative DCT: Normal – Newborn does not have antibodies against RBCs.
• Indirect Coomb’s Test: Test done on pregnant individual’s blood sample to determine if there are antibodies against newborn’s Rh in the pregnant individual’s blood.
• Positive = Antibodies present against fetal RBCs and is sensitized.
• Negative = Antibodies absent and pregnant individual is not sensitized.
• Ultrasound: Check for Fluid Buildup in Baby.
• Monitoring Hemoglobin (Hgb) Levels.

Prevention: No specific way to prevent, but early detection is important!

• Routine screening and blood typing pregnant individual in first trimester.
• Close monitoring of pregnancy and baby throughout pregnancy and postpartum until full recovery.

Treatment: Rapid treatment is crucial for baby.

• IVIG – Intravenous Immunoglobulin: An antibody and biological agent given via IV. This therapy involves infusing a patient with antibodies used to treat certain health conditions that can compromise the immune system. This product decreases hemolysis by blocking the FC Receptors and preventing antibody covered RBC’s from bursting, thus normalizing the compromised immune system.
• Exchange Transfusion (Last Resort): Taking some of the baby’s destroyed blood and replacing it with donor blood to remove the pregnant individual’s antibodies.
  • Hemovigilance: A surveillance procedure to track transfusion information of both donor and recipient. It can also detect where errors can occur and prevent them.
• Phototherapy for Jaundice.
• Hydration: Through breastfeeding and Supplemental Formula = Aides in excretion of Bilirubin through GI Tract via bowel movements.

Overall, this was a great presentation that was very insightful and informative. There was so much information provided and only 10 minutes to cover said information. So, great job everyone! One gap that stood out to me was the lack of explanation on treatments. There was a wide variety of treatments discussed throughout the presentation, but what those treatments consisted of and why they were being done was not explained in great detail. For example, the presenters talked about phototherapy but did not explain what phototherapy was and its benefits.

Moreover, when discussing diagnostics, not all diagnostic tests were touched on, for example, they talked about a Direct Coomb’s Test (DCT) which was what one individual’s newborn had done, but they did not touch one what an Indirect Coomb’s Test was and what that test consisted of. Again, there was only so much you could explain in the allotted 10-minute time frame, so I do think this group did a fantastic job, but if given more time, maybe covering other tests and treatments would have contributed to the learning experience!

Additionally, the information was quite scattered throughout the presentation. I noticed that in order to understand a full picture of the pathophysiology, I had to replay the video a couple of times and look at the time sheet to follow the content effectively and efficiently. I really liked the way this content was carried out in conversation as it felt natural and comfortable, plus the information was all there, but it took some extra time to connect the dots and understand the overarching picture.

This podcast showcased a combination of teaching and learning strategies; however, the one that stood out to me was experiential learning through peer collaboration, interactive questioning, and active listening. The entire group participated, interacted with one another, and shared their own experiences on ABO Incompatibly. I thought this was a very effective way to present the content because the presentation felt like a conversation where questions could be asked to clarify and solidify the content being learned. I also liked how each individual explained their experience because we got a taste of what ABO Incompatibility looks like in a newborn from different lenses (nurse/expert and pregnant individuals), what warning signs to look out for, and the urgency of immediate treatment and monitoring. So, I think this group did a wonderful job of highlighting each topic (Patho, S/S, Diagnostics, Treatment) through said experiences. One more thing I found great about this approach was, it felt like a safe space was created for discussion between everyone involved. This is a very scary health concern for new parents that puts their already vulnerable newborn in a life-threatening state. So, the encouragement to ask questions and support being provided through this form of teaching and learning is very useful and comforting for those involved and anyone listening to the podcast.

I found it really difficult to think of something to change for this presentation as everyone did such an amazing job! The flow was great and all the topics were talked about. Moreover, I think the video, artwork, and content were all beautifully done.

However, one recommendation that I have to further enhance this presentation would be using more lay terms or further explanation of medical terms for non-medically backgrounded individuals to understand. As a fourth-year nursing student, there were some terms that I was not familiar with as well and had to Google to understand what was being said, for example: Kernicterus or Hydrops Fetalis.

Health literacy is notably very low within our current population, so having information that is easy to understand and connect with is important in order to reach more people and spread awareness effectively. Health literacy is the ability to access, understand, use, and communicate health related information to enforce positive and beneficial health decisions for self or others.

A second recommendation I had was providing a summary to close off the podcast presentation and recap the key points that were touched on. I think this is more of a personal preference, but a quick overview/summarization of everything that was talked about would really help tie everything together and reinforce the overall message of presentation!

My future goals include working in labour, delivery, post-partum, and NICU, so I think this presentation was extremely useful for my future practice. Assessing newborns is a huge part of this form of specialty nursing as it would provide me with crucial information during a newborns first few days of life. ABO Incompatibility is a common disorder that occurs amongst many pregnant individuals. This disorder can cause severe and life-threatening side effects to the newborn that needs to be addressed immediately.

After learning this content, I feel I am more equipped with knowledge on the topic of HDN and ABO Incompatibility, and feel I can contribute to educating and advocating for proper pre- and post- natal care for both the pregnant individual and babe. Education on the subject and knowing what signs to look for can prove resourceful when being faced with this disorder in practice as it helps both staff and parents understand what is happening.

Additionally, when listening to the presenters, I noticed that lack of health literacy also contributed to the distress these families experienced. In practice, trying to explain health care in more lay mans terms is often suggested to help patient’s feel more included in their care and maximize their autonomy and participation (patient-centered approach). So, another goal for the future would be to keep health concepts simple to understand, try to answer questions to the best of my ability, and make sure my patients are grasping and comprehending the information they have been provided prior to making any health decisions (informed consent) or being discharged home.

In the podcast, Allison mentioned she felt regret not asking more questions and having a better understanding of what happened to her newborn. As nurses, we want all our patients to leave the hospital feeling they have been adequately cared for and restored to optimal health. We want patients and families to feel safe, important, and heard. The way Ester answered her questions, making her feel safe and heard was a great form of safe, compassionate, and empathetic nursing care which is how we should all care for our patients in future practice!