- Only IgG antibodies are of concern, as they can cross the placenta; IgM antibodies do not. If the antibody identified is known to cause HDN, the amount of antibody in maternal serum is determined and evaluated over the progression of the pregnancy. The critical titer level for each antibody differs. All women with a positive antibody screen of a clinically significant antigen should have further evaluation, and those with critical titer levels may require the care of a maternal fetal medicine specialist.
- With regards to sensitized Rh D negative women, identifying paternal blood type and antibody status can be done. If paternity is certain and the father is Rh negative, no further management is necessary.
- If paternal blood type is unknown or is Rh positive, fetal blood group is determined by chorionic villi sampling, fetal blood sampling, or cell free fetal DNA (cffDNA) testing, if available (Vivanti et al., 2016). If the fetus is Rh D positive, the amount of maternal serum anti D is monitored regularly and serial ultrasound scans are done to evaluate severity of HDN. Active hemolysis is indicated by a rising level of maternal anti D. Serial Doppler assessment of the peak systolic velocity in the middle cerebral artery (MCA) is the standard to detect fetal anemia. If a fetal blood test confirms anemia, depending on its severity, a blood transfusion can be done in utero to replace the lysed fetal RBCs. Blood transfusions may also be needed to correct anemia in the newborn period. During this period, there may also be a sharp rise in the level of bilirubin in the neonate, which can be lowered by phototherapy and exchange transfusions.
- Maternal risks include dysfunctional labor, infection, operative birth, operative vaginal birth, perineal trauma, and postpartum hemorrhage.
- Fetal risks include macrosomia, shoulder dystocia, meconium-stained fluid, decreased placental reserve, and uteroplacental insufficiency, oligohydramnios (fetal distress during labor, fetal acidosis, cord compression, etc.)
- During an auscultated acceleration test (AAT), the FHR is auscultated, and the number of beats in 5 seconds is counted and plotted in a grid that converts the beats to beats per minute. This is done in alternating 5 second intervals for 3 minutes. If an acceleration of 2 bpm in a 5 second period associated with fetal movement is detected, the AAT is considered reactive.
- If no acceleration is detected in the first 3 minute period, an attempt is made to elicit fetal movement, and the FHR is auscultated for another minute. If no acceleration with movement is detected in this additional minute, the process to elicit fetal movement is repeated, and the FHR is auscultated for another 2 minutes.
- If no acceleration is detected in the additional 3 minutes of auscultation, then the AAT is considered non reactive. Nonrandomized studies have shown that the AAT produces comparable results to the NST, and may be a reasonable alternative to the NST, particularly in settings and/or situations where electronic fetal monitoring is unavailable or impractical.
Multifetal pregnancies are categorized by the number of ova fertilized at conception and the timing of cleavage of the embryo. Timing of division of the single zygote in monozygotic twinning may result in three combinations. This depends on how many amnions (amniotic sacs) and one or two chorions. The chorion proliferates to form the placenta which makes the chorion determine the placenta. If division occurs 3 days after conception, so the zygote hasn't implanted into the uterine wall, the multifetal gestations will have separate placentas, two chorions, and two amnions, resulting a monozygotic, diamniotic, dichorionic (di/di) twin pregnancy. If division occurs between 3 to 7-8 days after conception, the fetuses will share a placenta but have separate amnions, resulting in a monozygotic, diamniotic, monochorionic (di/mono) twin pregnancy. If the division occurs after the eighth day, the fetuses will share the same chorion, placenta, and amnion, resulting in a monozygotic, monoamniotic, monochorionic (mono/mono) pregnancy. One third of all twin pregnancies are identical, monozygotic. • Multifetal gestations
• Short interval between pregnancies
• Anemia prior to pregnancy
• Poor nutrition
• Low socioeconomic status
• Diet poor in iron-rich foods- clams, oysters, liver, beef, shrimp, turkey, enriched breakfast cereals, beans, and lentils
• Diet in poor iron absorption enhancers- orange juice, grapefruit, strawberries, broccoli, and peppers
• Diet rich in foods that diminish iron absorption- diary products, soy products, spinach, coffee, and tea (eating nonfood substances such as laundry starch and clay),
• GI diseases affecting absorption
• Excessive blood loss at delivery
• Heavy menses
- Increased bloating
- The current definition (Rome III) includes onset associated with changes in the frequency or composition of the stool and pain relief with defecation, lasting for more than 6 months.
- To meet the diagnostic criteria, the symptoms need not be continuous. Intermittent symptoms totaling 12 weeks are considered significant.
- Increased or decreased stool frequency, abnormal stool formation (either hard or watery), bloating, difficulty in the passage of stool (straining, urgency, or failure to completely empty the bowel), and mucus in the stool are further confirmation of the diagnosis.
- Education about IBS, reassurance about the course and management possibilities, and dietary modification are important in helping women manage their symptoms effectively
- The American Gastroenterological Association has made conditional recommendations supporting the use of antispasmodic medications, tricyclic antidepressants, and various medications for symptom relief
- Assess for underlying anxiety disorders and depression
- Poorly controlled asthma can lead to maternal complications such as gestational diabetes, hypertension, preeclampsia, placental abruption, preterm birth (PTB), and intrapartum complications such as cesarean section, and rarely, death.
- Fetal complications of severe asthma include increased risk of stillbirth, fetal growth restriction (FGR), PTB, low birthweight, and a small but significant increase in cleft lip and palate.
**The magnitude of perinatal risk is related to the severity of maternal asthma. Improving asthma control in pregnancy has the potential to improve not only the woman's health but also that of her child.
- avoidance of substances that the individual can identify as headache triggers (e.g., cheese, alcohol, chocolate), stress reduction, and stable patterns of eating and rest.
- Care of women with migraines during pregnancy starts with avoidance of migraine triggers, adequate fluid and rest, and use of acetaminophen. Formulations that include butalbital, acetaminophen, and caffeine are considered safe for short-term use (4-5 days per month). Triptans have vasoconstrictive effects that could theoretically cause vasoconstriction in the placenta, but sumatriptan (Imitrex) has been studied in pregnant women and not found to be associated with adverse effects.
- Referral to physician if other medications are needed.
Having four or more of the following signs and symptoms:
- antinuclear antibodies,
- lupus antibodies,
- hemolytic anemia or thrombocytopenia,
- seizures or psychosis,
- persistent proteinuria, pleuritis, or pericarditis,
- arthritis in two or more joints,
- oral pharyngeal ulceration,
- discoid lupus,
- "butterfly" rash on the face.