21 terms

Erythroblastosis fetalis, pediatric

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Overview
Hemolytic disease of the fetus and neonate
Stems from an incompatibility of fetal and maternal blood
Also known as hemolytic disease of the newborn
Overview-Pathophysiology
Each blood group has specific antigens on red blood cells (RBCs) and specific antibodies in the serum.
The maternal immune system forms antibodies against fetal cells when blood groups differ, most commonly in type-O mothers with fetuses with type A or type B blood.
This can cause hemolytic disease even if fetal erythrocytes don't escape into the maternal circulation during pregnancy due to the presence of naturally occurring antibodies.
Overview-ABO incompatibility
Each blood group has specific antigens on red blood cells (RBCs) and specific antibodies in the serum.
The maternal immune system forms antibodies against fetal cells when blood groups differ, most commonly in type-O mothers with fetuses with type A or type B blood.
This can cause hemolytic disease even if fetal erythrocytes don't escape into the maternal circulation during pregnancy due to the presence of naturally occurring antibodies.
Overview-Rh incompatibility
During her first pregnancy, an Rh-negative female becomes sensitized (during such procedures as amniocentesis, delivery, and abortion) by exposure to Rh-positive fetal blood antigens inherited from the father.
A female may also become sensitized from receiving blood transfusions with alien Rh antigens; from inadequate doses of Rho(D) (RhoGAM) given to a mother before or after delivery; or from failure to receive Rho(D) after significant fetal-maternal leakage during abruptio placentae (premature detachment of the placenta), ectopic pregnancy, amniocentesis, chorionic villus sampling, or placental trauma or manipulation.
A subsequent pregnancy with an Rh-positive fetus provokes maternal production of agglutinating antibodies, which cross the placental barrier, attach to Rh-positive cells in the fetus, and cause hemolysis and anemia.
To compensate, the fetal blood-forming organs step up the production of RBCs, and erythroblasts (immature RBCs) appear in the fetal circulation.
Extensive hemolysis releases more unconjugated bilirubin than the liver can conjugate and excrete, causing hyperbilirubinemia and hemolytic anemia.
Overview-Causes
Rh-negative mother is exposed to Rh-positive red cells of the fetus due to asymptomatic fetomaternal hemorrhage during pregnancy.
Overview-Incidence
ABO incompatibility occurs in about 12% of pregnancies, most commonly first pregnancies.
Rh isoimmunization currently occurs in 10.2 cases per 10,000 births.
Rh negativity is more common in Whites than in Blacks and is rare in Asians.
Rh sensitization occurs in 6.7 cases per 1,000 births.
Overview-Complications
Fetal distress necessitating immediate delivery
Fetal death in utero
Disseminated intravascular coagulation
Severe anemia
Heart failure
Kernicterus
Assessment-History
Mother Rh-positive; father Rh-negative
Antigen-antibody response developed during previous pregnancy
Blood transfusion
Maternal history (for erythroblastotic stillbirths, abortions, previously affected children, previous anti-Rh titers)
Assessment-Physical Findings
Pallor
Edema
Petechiae
Bile-stained umbilical cord
Yellow- or meconium-stained amniotic fluid
Mild to moderate hepatosplenomegaly
Hydrothorax
Pulmonary crackles
Cardiomegaly
Heart murmur
Jaundice prior to 24 hours of age
Hepatosplenomegaly
Splenomegaly
Ascites
Anasarca
Hypoglycemia
Diagnostic Test Results-Laboratory
Paternal blood typing is positive for ABO and Rh.
Amniotic fluid analysis shows increased bilirubin and anti-Rh titers.
Bilirubin levels of 5 mg/dL or greater are present in cord blood.
Conjugated bilirubin concentration is greater than 2 mg/dL or more than 20% of the total serum bilirubin.
Maternal indirect Coombs' test during pregnancy is positive; direct Coombs' test of umbilical cord blood measures RBC (Rh-positive) antibodies in the neonate (positive only when the mother is Rh negative and the fetus is Rh positive).
Neonatal cord hemoglobin level less than 10 g indicates severe disease.
Many nucleated peripheral RBCs are present.
Reticulocyte count is increased.
Diagnostic Test Results-Imaging
Radiologic studies show edema and, in hydrops fetalis, the halo sign (edematous, elevated, subcutaneous fat layers) and the Buddha position (fetus' legs are crossed).
Ultrasonography may reveal hepatomegaly, abdominal enlargement, ascites, or signs of hydrops fetalis.
Treatment-General
Phototherapy (exposure to ultraviolet light to reduce bilirubin levels)
Intubation of neonate
Removal of excess fluid
Maintenance of body temperature
Red blood cell transfusion for symptomatic infant without signs of circulatory overload
Exchange transfusion for severe anemia and hyperbilirubinemia
Breast-feeding
Treatment-Medications
Intrauterine-intraperitoneal transfusion (if amniotic fluid analysis suggests that the fetus is severely affected and isn't mature enough to deliver)
Exchange transfusion
Diuretics, digoxin, or inotropic agents to manage heart failure
Immune globulin (IG) in combination with intrauterine transfusion; IG infusion in a neonate to reduce the number of exchange transfusions or duration of phototherapy needed
Colony-stimulating factor, such as epoetin alfa, to correct anemia
Treatment-Surgery
Early delivery (usually 2 to 4 weeks before term date, depending on maternal history, serologic test results, and amniocentesis)
Nursing Considerations-Nursing Diagnoses
Impaired gas exchange
Impaired tissue integrity
Ineffective breathing pattern
Neonatal jaundice
Risk for decreased cardiac perfusion
Risk for imbalanced body temperature
Risk for imbalanced fluid volume
Risk for impaired parent/infant/child attachment
Risk for impaired skin integrity
Nursing Considerations-Expected Outcomes
exhibit adequate ventilation and oxygenation
demonstrate intact tissue integrity
maintain an effective breathing pattern
demonstrate a reduction in bilirubin levels
remain hemodynamically stable
maintain a fluid balance within normal limits
maintain a normal temperature
demonstrate appropriate interaction with the neonate
maintain skin integrity.
Nursing Considerations-Nursing Interventions
Encourage the parents to express their fears concerning possible complications of treatment.
Promote normal parental bonding by modeling appropriate behaviors and pointing out positive characteristics of the neonate.
Encourage parental participation in the neonate's care; encourage the mother to breast-feed if that is her chosen feeding method.
Assist with exchange transfusions and phototherapy as indicated.
Maintain adequate hydration and provide meticulous skin care if phototherapy is used; obtain daily weights.
Initiate feedings every 2 to 3 hours.
If the mother is breast-feeding, ensure that it is done on demand.
Obtain specimens for laboratory testing, including serial bilirubin levels.
Administer medications for heart failure as ordered.
Administer Rho(D) I.M., as ordered.
Nursing Considerations-Monitoring
Cardiopulmonary status including heart rate and rhythm, lung sounds
Temperature
Bilirubin levels
Airway and ventilation
Transfusion complications
Intake and output
Skin color and integrity
Parental adaptation to ill neonate
Parental bonding behaviors
Nursing Considerations-Associated Nursing Procedures
Amniocentesis, assisting
Amnioinfusion, assisting
Arterial line blood gas sampling, pediatric
Blood and blood product transfusion, pediatric
Blood and blood product transfusion reaction management, pediatric
Blood pressure assessment
Blood pressure assessment, neonate
Calculating and setting an IV drip rate
Cardiac monitoring
Cardiopulmonary status monitoring, pediatric
Exchange transfusion, assisting, pediatric
Family therapy
Fetal demise care
Fetal heart rate monitoring
Fiber-optic phototherapy pads and blankets use, neonate
Finger and heel sticks, pediatric
Gestational age determination
Heat lamp use, infant
Height measurement
Intake and output assessment
Intrauterine fetal blood transfusion patient care
Isolette preparation
IV bag preparation
IV bolus injection
IV cardiovascular drug administration, pediatric
IV catheter insertion
IV pump use
IV volume-control set preparation
Labor, care during
Length measurement, infant or toddler younger than 24 months
Neonatal eye prophylaxis
Neonatal heart rate assessment
Neonatal size measurements
Oxygen administration, nasal prongs, neonate
Parent-infant bonding
Phototherapy
Postmortem care, pediatric
Priming IV tubing
Promoting psychosocial adaptation in a neonate
Pulse assessment
Pulse oximetry, pediatric
Respiration assessment
Respiratory rate assessment, neonate
RhoGAM administration
Spiritual care
Temperature assessment
Thermoregulation after delivery
Thermoregulation in the nursery
Umbilical artery catheter blood withdrawal
Umbilical vessel catheter insertion, assisting, neonate
Umbilical vessel catheter maintenance, neonate
Venipuncture
Vitamin K administration, neonate
Weight measurement
Weight measurement, neonate
Patient Teaching-General
disorder, diagnosis, cause, and treatment, including the need for possible intubation, phototherapy, or exchange transfusion
fact that most neonates do well with appropriate monitoring and treatment
prescribed medication therapy, including drugs, dosages, rationales for use, and frequency and duration of administration
measures for neonate care during exchange transfusion or phototherapy
importance of interacting with the neonate to facilitate bonding and attachment
preventive measures for recurrence, including maternal screening for Rh sensitization and the use of RhIG in the third trimester, after birth, and any time a risk exists for potential mixing of fetal and maternal blood (such as miscarriage or ectopic pregnancy).
Patient Teaching-Discharge Planning
Encourage follow-up appointments.
Refer the parents to community support services as necessary.
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