Anti-M isoimmunization...fetal hydrops OR NOT

Had a NOB, G2P1, pt come in with routine NOB lab evaluation results showing pt with antibodies to Anti-M. Pt had no previous history or knowledge about having Anti-M. Of course my great teaching preceptor gave me "homework" to research what Anti-M was all about:

Anti-M antibodies are generally "naturally occurring" which means that they develop as the result of exposure to M-antigens found in the environment - usually expressed on bacteria or viruses.

In most cases the only type of antibodies that individuals develop to these types of antigens are of the IgM subclass. IgM antibodies are very large and cannot cross the placenta and cause any problems for the baby. Occasionally (as can also occur with the A and B major blood group antigens), an individual will develop IgG antibodies to the M-antigen. IgG antibodies CAN cross the placenta and, indeed, are actively concentrated on the fetal side. Usually, these IgG antibodies are antibodies to a wide variety of things that are “foreign” to our bodies that we have been exposed to during our lifetimes and they provide protection for the baby against common environmental pathogens (e.g., viruses and bacteria) for the first 4-6 months of the baby's life following birth.

However, if a pregnant woman has IgG anti-M antibodies and the baby happens to have M antigens on its red blood cells, the antibodies can attach to the red blood cells and mediate their destruction by the baby's own immune system, ultimately resulting in fetal anemia and, in the worst case scenario, fetal hydrops and even death (as can occur with "Rh-disease"). This is uncommon with anti-M antibodies, but has been described on numerous occasions in published literature. As with "Rh-disease", the risk for fetal complications generally increases with the level of the IgG anti-M antibody titers the pregnant woman has.

The first steps are to find out if the pregnant woman has IgG antibodies and if her partner is M-antigen positive on his red blood cells. If he is not, then their babies cannot be affected. If he is M-antigen positive, and the pregnant woman has IgG antibodies, then her antibody levels (titers) should be ascertained and followed serially during the pregnancy. Severe fetal anemia usually is a risk when high titer anti-M is present as IgG antibodies. High/increasing titers would make this a referral/transfer of pregnant pt to high risk OB for further management.

If the IgG anti-M titers are 32 or higher, then the baby should be monitored serially for evidence of significant fetal anemia (just like we do with Rh-isoimmunization) by performing peak systolic velocity (PSV) measurements on the baby's middle cerebral artery using Doppler Flow Velocimetry. Bilirubin studies are also performed through amniocentesis or PUBS (percutaneous umbilical blood sampling), to detect increased bilirubin levels. These levels are plotted on a Lily Curve to determine severity of disease and a plan of action. EGA less than 28 weeks with NO sign of fetal hydrops-can give IVIG for 5 days and repeat in 15-21 days. For MILD/No disease evidence-baby goes to term and induction is performed. For INTERMEDIATE disease-baby goes to 36-38 weeks and induction is performed. For SEVERE disease-depending on EGA, baby is transfused OR delivered ASAP.

If the baby does develop significant anemia, then it should be either transfused with M-negative blood or delivered, depending on the severity of the anemia and the gestational age at which the baby gets in trouble. It would be a good idea for the couple to discuss their situation with a specialist in Maternal-Fetal Medicine before they conceive again. Future subsequent children can be increasingly affected by hemolytic disease of the newborn.

My/our pt was counseled on the above information and educated about the need to follow serial IgG ant-M titers through her pregnancy.

link more Info here about anti-M at p. 556...

EDS & pregnancy

21 y/o G1P0 at gest week 26 c/o constant and intense lower abdominal pain, a feeling "pulling" pressure bilaterally and fatigue. As we discussed what round ligament pains are and why she may feel this, hers reportedly are "more severe." It was later discovered on history review that she had Ehlers Danlos Syndrome (EDS).

One source defines EDS as "an inherited genetic disorder that affects the body's connective tissues and prevents the body from functioning in the way that it should. Symptoms of EDS include:joints that move beyond the normal range of motion, which can lead to dislocations and chronic pain, extremely delicate skin that is susceptible to injury, overly stretchy skin, which makes the skin vulnerable to damage and exposes a person's internal organs to harm. EDS abnormalities such as these are caused by faulty collagen, which is the substance that gives strength and elasticity to connective tissues in the skin, joints and blood vessel walls."*There are 6 types or grades of EDS, one of the worst being Vascular EDS for obvious reasons.

With this and such patients in pregnancy, there is an increased risk for premature delivery, excessive bleeding (during or post c-section and vaginal delivery w/ tearing), miscarriage and other maternal complications. In utero, the vascular EDS may lead to placental rupture placing the fetus in demise. Excessive skin stretching (doughy), malleable bone changes and others can place the patient/client at risk for falls which can lead to a "bleeding events" (connective tissue disorder, as well).

Genetic counseling with a geneticist / expert genetic counselor (like Dr. Seibert......) during preconception, pregnancy and in the PP period is vital as there is no cure for this. The risk versus benefit of pregnancy and the impact on both mom and baby (medical/surgical complications, risk of genetic transmission to baby, lifestyle adjustments etc) should be discussed. Management of symptoms includes pain medications, warm compresses and physical therapy, referral for interdisciplinary/ancillary services (SW, MH, OT, Heme).

I found this very interesting. A "live" one!

* How stuff works. com

Vag Delivery Plans foiled by a .........Fibroid

My preceptory and I saw a 34 year old G2 P-O A-1, 36 weeker during a routine OB appointment. This patient had a large fibroid (confirmed via U/S) located in the lower uterine segment, in lay terms-very near her cervix. It was interesting to learn more about fibroids and the problems they can potentially cause throughout a pregnancy during this patient's visit. The patient offered no complaints with the exception of feeling minor lower abdominal pain, most likely attributed to round ligament stretching. She confirmed fetal movement and an ultrasound revealed normal fetal growth for gestational age. Although she had hoped for a vaginal delivery, my preceptor explained the risks that this fibroid posed to such a delivery method. A vag-delivery could be complicated by shoulder dystocia, labor dystocia, and postpartum hemorrhage. My preceptor then proceeded to explain to the patient that a VBAC incision may not be possible because the fibroid is located where a low transverse incision is usually performed. The only, and perhaps the best option available to this patient involved making a vertical incision through the contractile portion of the uterus. However, this option is not without risk; for if the body of the uterus cannot contract properly, the risk for post-partum hemorrhage increases. The patient agreed to a c-section (vertical incision) and was aware of the reasons why this method was best for her and her baby. She did ask why the fibroid could not be conveniently removed after the c-section-to this inquiry my preceptor responded that performing a myomectomy after a c-section can really increases the risk for massive hemorrhage since a gravida uterus is highly vascular. At the end of the visit, the patient seemed very satisfied with the the information that was provided to her. I could tell that she may have been feeling a little down after learning that a vag delivery was not the best option. But as she was leaving she mentioned that whatever method is best for her baby is the route she chooses.

greg b

Bonding on the NOB

For those of you who know me, I'm pretty chatty. I tend to wear my emotions on my sleeves and I love to talk about babies. So you can imagine how exciting a new OB appt. is for me; and usually for the pt. I learned a tough lesson a few days ago on developing my style and relationship w/a patient, particularly during a new OB appt. (where I am meeting a new patient and have yet to establish a viable pregnancy). I performed the dating US on a G1P0 with her partner happily looking on. Thank God my preceptor was standing right next to me and immediately took over when we quickly realized there was no fetal heart movements. The way she handled this case of a missed abortion was compassionate. She told the couple the facts: there was no heartbeat and the baby had stopped growing sometime in the last week (by US, the fetus measured 9 weeks, 4 days and based on her LMP she would have been at 10 weeks). She presented her with all the options: do nothing; serial HCG and a repeat US in three days to confirm that there is no heartbeat- since we could be off on the due dates and maybe this was a 7 week pregnancy (highly doubtful); or D&C. Most importantly, she told them there was nothing they had done to cause this and that it happened in 20% of pregnancies. They chose to do the serum testing/repeat US. My preceptor said she did it so they could have time to process this event- it was the humane and right thing to do. It also taught me the value of not doing some of the education/bonding upfront, but waiting till the exam was finished. What if I had already started talking to her about whether she'd breastfeed the baby, or talked to her about what whether they wanted a boy or girl (things I have done on a NOB visit). You have to draw a fine line at some point- and this is unnatural to me. I don't like being cold and matter of fact: I always said that's why I became a nurse, and not a physician. But as a provider, this would not have been a therapeutic relationship at this juncture. Later on, as they'd become a ROB pt., then we could "grieve" together, as we'd have established a relationship over time. I know this post is all kind of jumbled, but I thank you for letting me share my thoughts on what was a difficult visit for me. Luckily I amazingly held it together during the visit, but it made me really assess how I need to approach the NOB patients from now on.

Where are the PMHNPs when you need them!!

A 25 year old dependent wife, G5 P1 at 17+6 EGA presents to clinic for “routine” OB care. Patient was obviously been crying prior to my entrance into the room. She had a somewhat flat affect, refused to make eye contact, was disheveled and answered questions in single syllables only. After talking to the patient while measuring fundal height and listening for fetal heart tones, patient still denied being upset or having any symptoms of depression. Patient had little interest in any information presented to her other than lab results for STDs, but finally asked if it was possible to take psych medications while pregnant. When asked why she thought she needed psych medications, she said that she needed medication to help her “chill out” because she was afraid she was going to hurt someone. Patient stated that she was under the care of a civilian mental health provider that she had tried to contact unsuccessfully (provider was off today). Today she reported overwhelming homicidal thoughts increasing over the last two days toward her spouse (currently deployed) and his lover (in the local area). Patient stated that this amount of rage scared her and that she did not feel safe being in proximity to this woman since she had a plan for homicide (which she would not share) It was obvious that the patient needed a mental health evaluation, but the question was how to make it happen both safely and expeditiously.

There are mental health services available in the clinic, but my preceptor was told that the patient needed to be evaluated by the on-call psych resident in the ED at the Portsmouth hospital. The patient refused transport via ambulance because she had to pick up her 5 year old from school and had no friends in the area to assist her. Clinic staff was adamant that we could not force someone to receive care (or transport). During the course of her trips to pharmacy and lab (for OB issues) while we were trying to figure out what to do with her, she became increasingly upset. Mental health sent several people to the pharmacy waiting room (for what purpose I am not really sure – she was cooperative to this point and did not present an immediate threat to herself or anyone near her). Upon seeing this large group of people coming toward her, the patient refused all care after that, refused to return to the OB clinic, and denied needing any help. She was allowed to leave the clinic with no plan for follow-up, no counseling, and no plan for supervision of any kind.

I realize that we cannot force dependents to receive care, but I am certain that there is a caveat of some sort when safety is an issue. Also, this patient was not refusing care, she was refusing transport to the hospital via ambulance because of child care issues. I got the impression that if we could have worked that out, she would have gladly gone to the ED…she came in asking for help!

This case reminded me how important it is to know the resources in your area as well as the benefit of having good relationships and POCs for each of the tenant commands that you serve.

Postpartum perineal lacerations

29 y/o G2P2 presents for 6 week postpartum visit s/p forceps assisted vaginal delivery resulting in a 4th degree perineal laceration. Review of systems remarkable for persistent perineal pain relieved with Motrin, flatus incontinence, occasional constipation, and difficulty cleaning stool from rectum after defecating. Denies urinary incontinence or urgency. Pelvic exam remarkable for healing perineal wound right of midline with sutures coming out without signs of infection. Anal sphincter had good tone, vaginal sphincter tone diminished. She also had a small posterior rectocele and anterior cystocele. Rest of the exam was nl. These were obvious signs of pelvic floor disruption with possible anal sphincter problems. As far as management, the provider was not too concerned, but I did recommend kegel exercises. I also thought we could have done more for her. The literature is unclear about how aggressive early management should be or when it should be initiated, when there are signs of pelvic floor disruption. Surgery is certainly not an option unless symptoms are severe and she is done childbearing, but perhaps this patient may have been a candidate for pelvic floor physical therapy. 3rd and 4th degree perineal lacerations or episiotomies can have significant long-term consequences and the sequela (constipation, anal sphincter dysfunction, pelvic organ prolapse, urinary incontinence, perineal pain, rectovaginal fistulas) is what we are most likely to see in our practices as FNPs.

Wait up! I bearly touched her!

I recently saw a 19 y/o G1P0 pt at 38 weeks, Kay, with a history of Hyperthyroidism and DM in the L&D unit. This was not readily apparent to me at the time, while thumbing through tones of info in her charts. She came in through triage for “frequent and painful, unrelenting contractions.” After further assessment with a pelvic, nitrazine paper and NST, she was admitted. Upon insertion of an IV, she near flew off the bed, screaming, and cursing up a storm. The nurse thought this was strange and looked closely at her charts. Kay had a history of Bipolar disorder, hence the overly exaggerated response to the IV insertion, I learnt.
Women with chronic mental health disorders such as Bipolar , can and will get pregnant, some planned, many may not be. It is important to screen and ask women about mental health history, the use of prescribed medication for the illness and ask “are you still taking your medications, if not, why?” Teaching and counseling comes into play her because some women may choose to stop taking these meds once they find they are pregnant.
According to the National Alliance on Mental Illness (NAMI), Lithium and first generation antipsychotics like Haldol are still safe to use in pregnancy (Category D) if deemed necessary. Concerns about relapse, maternal safety, hydration status (if meds are taken) and fetal well-being present an opportunity to educate, reeducate, and/or refer. Preconception counseling and the impact of these disorders during and after pregnancy (beacuse of breast feeding) is vital.