Treatment for Hemolytic Disease of the Fetus and Newborn
Hemolytic disease of the fetus and newborn (HDFN), often called erythroblastosis fetalis, is a blood disorder that occurs when the blood types of a mother and baby are incompatible. For reference, “Hemolytic” means breaking down of the red blood cells and “Erythroblastosis” refers to the making of immature red blood cells.
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How is Hemolytic Disease of the Fetus and Newborn Treated?
If your unborn baby’s count is very low, your doctor will probably suggest a blood transfusion for your baby (intrauterine blood transfusion). This procedure is typically done at the time of the first cordocentesis in an effort to minimize the risk or puncture of the umbilical vein. At the time of the initial cordocentesis, a small sample of blood is taken from the baby’s umbilical cord and a rapid assessment of the hematocrit (baby’s blood count) will be performed in the same room. Since most babies are generally very active inside the womb, your doctor will probably want to administer a medication to keep your baby from moving during the procedure. This is usually accomplished by administering a drug called vecuronium, which will temporarily stop your baby from moving so that the doctor may give the baby a blood transfusion. The drug is usually administered into the umbilical cord after the initial blood sample is obtained. The effects of the drug usually last between three and four hours. At that time you will begin to feel the baby move again. By giving this medication, blood transfusions to the baby are much easier for the doctor and much safer for your baby. If the initial blood count shows the baby to be very anemic (hematocrit less than 30%), your doctor will typically begin an intravascular transfusion, which is a type of intrauterine transfusion where the blood is injected directly into the umbilical cord. Once the correct amount of blood is injected, the needle is removed. Often an additional amount of blood will be place into the baby’s abdomen in a type of procedure called an intraperitoneal transfusion. The blood placed into the abdomen is absorbed slowly into the baby’s blood vessels over a ten-day to two-week period. This allows the baby to have a better blood count when the next intrauterine transfusion is scheduled.
Because the baby will continue to destroy many of his/her own red blood cells, the baby will likely need several transfusions before birth. The number of transfusions varies but generally ranges between two and eight. These procedures are usually performed two to three weeks apart until approximately 35 weeks of gestation (eight months and three weeks).
Are there any other forms of treatment for Hemolytic Disease of the Fetus and Newborn other than intrauterine transfusion?
On rare occasions because of an extremely high antibody titer or a previous history of a very sick fetus early in pregnancy, your doctor may feel that specialized treatments may be required before the first intrauterine transfusion. At about 10 weeks’ gestation you may be scheduled for plasmapheresis. In this procedure, a tube will be placed into a vein and your blood will be washed with a specialized machine. This machine removes the liquid part of your blood (plasma) that contains the antibodies. The liquid portion is then replaced with albumin, a sterile protein solution made from human blood. The plasmapheresis is usually done three times (every other day) in the tenth week of the pregnancy. The major risk to plasmapheresis involves a low blood calcium level. This may cause some tingling in your lips, but rarely requires treatment. Typically, your antibody titer will drop in half after the three plasmapheresis procedures.
Because your body will realize that there is not as much antibody present after plasmapheresis, it will try to replace the antibody. In of an effort to prevent this, your doctor may prescribe intravenous immune globulin (IVIG). This medication is made from antibodies from many individuals. It will fool your body into thinking that you do not need to make more anti-red cell antibody. In addition it may prevent the remaining antibody from crossing over to your baby. Intravenous immune globulin is administered intravenously over 6 to 8 hours. The first treatment is given the day of your last plasmapheresis and repeated the following day. Treatments are then given once each week using a home health care agency until 20 weeks of pregnancy (five months). The major side effect of intravenous immune globulin appears to be severe headache. This can usually be prevented by taking two extra-strength acetaminophen tablets (Tylenol®) before each injection of intravenous immune globulin. In some cases the headache can be as severe as a migraine and may require admission to the hospital. The highest chance for this is when you receive the first two doses of the IVIG after the plasmapheresis. After these doses, the chance for developing a severe headache is much less. Other side-effects of IVIG include nausea or a mild rash on the palms of your hands.
Will I have to be admitted to the hospital for intrauterine transfusion?
No. You will be asked to come to the hospital as an outpatient the day prior to your scheduled procedure to have a tube of blood drawn to crossmatch blood for the transfusion. This must be repeated every time your baby has a transfusion. You will then be required to come to the hospital approximately several hours before the procedure is scheduled to begin. The intrauterine transfusion itself is performed in the operating room and lasts approximately one hour. You will be observed for two to three hours after the procedure, then allowed to go home. Your doctor will ask you to come to the office the following day to look at your baby with ultrasound and make sure everything is fine.
Will I be put to sleep for the intrauterine transfusion?
No. You will be awake during the procedure. A local “numbing” medication will be injected into your skin where the needle will be inserted to prevent any discomfort. This will be performed twice for the two parts of the intrauterine transfusion. An anesthesiologist will also give you medications through your IV to make you sleepy during the procedure.
Are there any risks to the procedure?
Yes. When a needle is inserted into the womb, the risk of uterine contractions increases. You will probably be given a medication in the form of a shot that is injected under the skin called terbutaline. This medication will cause your heart rate to increase and may make you feel very shaky. On rare occasions, you may have to receive a second shot of terbutaline in the recovery room if preterm contractions are noted after the procedure. Additional small risks to the procedure involve the risk of introducing infection onto the bag of waters around the baby as well as the risk of premature rupture of the bag of waters. Finally, there is about a 5% chance that the baby’s heart rate could slow down during the procedure. If this would happen, the needle will be removed from the umbilical cord. This usually causes the heart rate to recover to normal. However in some cases, the baby’s heart rate may remain slow. Once you reach a point in pregnancy when the baby could survive in the nursery, your doctor may elect to deliver your baby by emergency C-section. You will be put to sleep in these cases by the anesthesiologist. A special pediatric team will be immediately available to care for your baby should this happen.
Your doctor may also recommend steroid injections due to the risk of premature labor and/ or delivery associated with intrauterine transfusion. Research studies have demonstrated that administration of steroids (betamethasone) to the mother increases the rate of development of an unborn baby’s lungs and also helps to prevent additional complications of prematurity such as bleeding into the baby’s brain (intraventricular hemorrhage) and spontaneous perforation of the baby’s intestine (necrotizing enterocolitis). Steroid injections are generally administered as a shot in your buttocks between 24 and 34 weeks of gestation.
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The Fetal Center at Children's Memorial Hermann Hospital
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6410 Fannin, Suite 210
Houston, TX 77030
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