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Isoimmunization: A High Risk Pregnancy
Abstract Number: F 74
Abstract Type: Case Report/Case Series
INTRODUCTION: Isoimmunization in pregnancy occurs when a mother with Rh-negative blood is exposed to blood of a fetus that is Rh-positive. Rh sensitization will lead to the production of maternal antibodies against the Rh-positive RBC. An Rh-positive fetus or neonate may then be at risk of developing hemolytic disease. These antibodies may not be problematic during a woman’s first pregnancy, since the sensitization may not occur until delivery, but subsequent pregnancies may present increased risk to the Rh positive fetus. Rh negative mothers benefit from early prenatal visits and on-going care, often from an Obstetrician trained in Maternal Fetal Medicine (MFM) to deal with problems that might arise.
CASE PRESENTATION: SA is a 25-year-old female, G6P2122, who presented to labor and delivery with decreased fetal movement at 34 weeks gestation. The patient’s prenatal course was significant for Rh isoimmunization and percutaneous umbilical cord blood sampling (PUBS) and fetal blood transfusion on 5 different occasions starting at 26 weeks gestation. Regional analgesia, combined spinal epidural (CSE), was used on each occasion and fetal paralysis administered when requested by MFM. On this admission the decision was made to induce labor and a CSE was placed upon patient request. Three hours later the patient was taken for an emergent cesarean section do to nonreassuring fetal heart rate (NRFHR) and epidural anesthesia was used. The surgical course was uneventful and a male neonate was delivered with APGARS of 3(1minute) and 7 (5 minute). The neonate was transported to the NICU and given a blood transfusion.
DISCUSSION:This case is a woman with known Rh sensitization and a fetus that demonstrated severe fetal anemia on numerous occasions during the pregnancy. Regional analgesia was employed for each PUBS and fetal transfusion, which provided optimal conditions for mother, fetus and MFM performing the procedures. When the patient presented to Labor and Delivery at 34.2 weeks gestation with complaints of decreased fetal movement the decision was made to induce labor. Four hours after admission a CSE was placed for labor analgesia upon patient request. The decision was made to proceed for a Cesarean delivery 1.5 hours after initiation of analgesia due to a NFHR. After delivery the neonate was anemic on admission to the NICU and given a blood transfusion. It is apparent that the fetus had a low reserve do to the maternal isoimmunization and resultant anemia.
CONCLUSION: Regional analgesia and anesthesia for pregnancies complicated by maternal isoimmunization is important in providing maternal comfort and optimal conditions for PUBS, fetal transfusion, and delivery.
REFERENCES: Nicolaides KH, Rodeck CH. Maternal serum anti-D antibody concentration and assessment of rhesus isoimmunisation. BMJ 1992; 304:1155
Wallerstein H (1946). Treatment of severe erythroblastosis by simultaneous removal and replacement of blood of the newborn. Science, 103, 583-4