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L.C.H.

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Everything posted by L.C.H.

  1. so, to answer some questions folks have asked - this is with a negative DAT on babe (would not consider it if the DAT was positive unless really, really stuck for product) these are usually moms who had their 28 wk dose, but then had either episode of bleeding or motor vehicle accident or other trauma, and got one additional dose (300 micrograms) of RhIg in the third trimester. Or, alternatively, moms who got their 28 wk dose but then delivered well before 40 wks.
  2. We've had to do some finagling in a couple cases (in light of the continuing blood shortage) and are also in the process of reviewing our SOPs, and we are curious about other folks' practices with the following setting: Mom has anti-D due to RhIg at the time of delivery. Baby is Rh-positive and needs product. Our current SOP is that we must give Rh-negative products to the baby, because of the mom's residual RhIg showing. I've had to override this a couple times recently in order to either comply with other maternal antibodies, or to get a young-enough unit on the fly. Am wondering if there is actually any utility in hewing to this in our SOP, since presumably baby's Rh-positive cells are already keeping any residual maternal RhIg tied up. Curious how others handle this scenario!
  3. OK, follow-up as promised with results of the D chip - and I have some reading up to do on these. Overall predicted RhD phenotype: D+ (weak partial) Alleles: - RHD*weak partial 4.0 encodes p.201Arg and p.223Val - Hybrid RHD*D111a-CE(4-7)-D does not encode D but encodes partial C as part of r'S haplotype The report includes a reference: "Experience with RHD*weak D type 4.0 in the USA," Blood Transfusion 2018:6: 1-3.
  4. I also should get up earlier to contribute! thank you all for the suggestions! In response to some of the ideas - her pregnancy loss end of last year and surrounding OB care was entirely through my institution, and I know we didnt give her any RhIg of any sort. Could find no evidence of ITP (handful of CBCs over months have been dead normal), no evidence of any underlying autoimmune disorder. No evidence of getting IVIG or any other antibody-based treatment. The only possible autoimmune trigger I recognized was the strep throat, but that's a long shot and anyhow she was promptly treated. And we don't use gel. Overnight we came up with some of the same ideas as y'all - warm auto with anti-D specificity, an anti-LW, or a D antigen variant. Just hearing from the manager we ran her against some O negative cord cells this morning; does not look like an anti-LW. We are opting to use what is left of the sample to send to reference for the D chip. I'll definitely update once we have more info!
  5. Since PathLabTalk just asked folks to please participate by making a post, I'll offer up our conundrum of the day - we haven't yet done much workup: Young healthy woman had early pregnancy loss last year, she typed twice as O pos, no antibodies, did not get any products. We did not have to do a weak D on her. Now in early pregnancy again; early this month she showed O pos, antibody screen pos, antibody not ID'ed, positive DAT, no lab evidence of lysis. We asked for more tubes but they sent only one, now several weeks later. Again O pos, antibody detected, though decreased in intensity - and now is ID'ed as anti-D Both times the antibody has been stronger than would be expected for RhIg, and anyhow I can find no instance of her having been given RhIg. In Feb she had strep throat but she was treated, so I don't think it is a post-strep autoimmune phenomenon (plus I dont think that usually manifests against RBC antigens?) Anyone seen anything like this? We are going to again ask for more tubes so we can send her to reference center. I will post follow-up as we work this out.
  6. OK i dont really understand this, but i asked for more specifics - and our backup computers are evidently attached to the network but in a weird limited fashion where they get a solitary incoming dump every four hours, of BB data, but otherwise do not receive network activity, and have no "outgoing" channel. when we were hacked, one was due for a dump and got hacked, the other was instantly quarantined off-line and so had almost all (except the last few hours worth) of BB data. also was just told it is also now stashed in some quarantined part of the cloud? this is waaaay over my head in terms of IT though. sorry i cant explain it any better :-(
  7. Our inpatient consents are good for the duration of the admission. Outpatient consents are only good for the one visit, with two exceptions: 1) A onc/chemo pt, where the consent covers the time period of the entire outpatient chemo course 2) A pregnant pt, where the consent covers the entire outpatient portion of the pregnancy (usually chronically anemic women who are not responding to iron and need occasional pRBCs to bump up). That consent doesnt cover the admit for delivery though - that's a separate consent (hello, DIC MTPs!)
  8. We tell our clinicians to do exactly that, yes. Likely it won't turn into an anaphylactic event, but it could, so STOP and initiate a transfusion workup. Give benadryl and watch the patient. For future transfusions, pre-treat with benadryl - even though it's likely a response to that one specific donor's plasma proteins, and a bag from a different donor may not provoke a reaction.
  9. In terms of hacking- we have two offline PCs, one here and one at our sister hospital, that contain backups of BB data for both hospitals (dont know how often we back it up though). we were hit by ransomware last June (downtime for a week in the middle of COVID, yay)and then found out IT had connected one of those two "offlines" to the network, and it was gone. We still had one lonely functioning PC, tho, with the entire systems' BB data, adn it got us through what was otherwise a very, very dicey time.
  10. thanks for all the responses! looks like most folks, like us, have the KBs read in hematology. And the inspector was OK with it; i think he'd just been looking at our BB personnel competency forms, but when he asked for the KB staff competencies he didnt like the (slightly different) format that our heme dept uses. He was a very seasoned inspector, so when he said BB, not heme, most often reads KBs, I just got curious if our institution is really an outlier in that respect. Seems not!! thanks!
  11. Greetings all - We are having an AABB inspection, and a curious question has come up. The inspector is accustomed to KBs being read by blood bank personnel, so any issuance of RhIg (more than the typical vial) is based ona result coming out of blood bank, and acted on by blood bank. However, in our lab, KBs are read by heme, and it's now created some confusion around which lab section 'owns' the competencies. Our heme lab uses a slightly different format for competencies (a problem in and of itself, but not the issue at hand), and the inspector is a bit discomfited by this. I have only worked in two hospitals, and in both, KB was read by heme but actedf on by BB. and this question simply hasnt come up during inspections previously. so as an informal survey, I am just curious - which lab section reads and results your KBs?
  12. we require two types before issuing type-specific blood, and has to be two different samples from two different sticks. we bill for both.
  13. "Interesting topic, we had a 32 bed NICU and I don't remember ever transfusing platelets." we have a larger NICU, but have transfused plts to babies twice already this week, so it's not uncommon from where I sit. we have NAIT babies very frequently, as well as babies that bleed, drop their plts, need to go to surgery, and we bump their platelets first.
  14. If the antibody is no longer present in this pregnancy, then so far, so good! but some antibodies can wax and wane, and if this fetus is positive for an 'offensive' antigen, that antibody may start kicking up again in mom during the pregnancy. If you know which antibody caused it last time, you can look up and see if it is one that tends to wax and wane. Personally, I'd be concerned that the mom you describe could have HDFN again with this current fetus if the fetus has the offending antigen and mom's immune system catches wind of it. I am unclear on the recommendation that titering would only be done with the first pregnancy - our titer levels are what trigger OBs to order Dopplers for fetal anemia, so I don't know how titers could just be passed over simply b/c it's a different pregnancy. We often see the same woman come back across years with multiple pregnancies, and yes, if we find a clinically significant antibody, we do start chasing titers, regardless of whether she has ad the antibody in the past.
  15. We've had this happen also, and in a perfect world I'd prefer the OBs resume titers in a bit (give the RhIg time to wane) to see if anti-D is shooting up. We've been burned twice in the past six months where OBs stopped checking titers and switched to Dopplers, which showed decreased risk of fetal anemia, and the babes came out with peripheral blood full of erythroid precursors - right on down to erythroblasts - requiring emergent exchange. So I personally would request a repeat titer closer to delivery, just so you know what you may be dealing with. I don't trust the Dopplers (sorry, radiology!)
  16. Also low in southern new england; we were unable to make a full Rh-neg MTP pack this week for an Oneg postpartum bleed.... fortunately they didnt use all the reds and the Rh-pos came back to us. eesh!
  17. Malcolm, thank you for the article! I hope to get to it today. It appears cff DNA testing is available in the US for some things (DiGeorge, for instance), but I am not readily finding a lab that offers RHCE testing. Am going to keep looking. I guess my main concern is that since anti-c can kick up later in pregnancy, if we see an early anti-E in mom, should we advise to 1) test dad (or fetus with cff if i can find it) for not just E but also c antigen and/or 2) request an additional screen later in the pregnancy to see if anti-c has come up? (presuming mom is c-negative)
  18. ahh, i've been at a specialty hospital for too long, i forgot FOB is also fetal occult blood. :-)
  19. oops, John C. Staley - sorry for the abbreviations! MFM = maternal-fetal medicine; FOB = father of baby
  20. Hello, all - We've been having some back and forth with our MFM department and their handling of maternal antibodies. When the mom has an antibody, they test dad for the antigen, and then stop following if negative, and are resisting any change to this (see below for why i find this a problem). I pulled the ACOG Practice Bulletin 192, March 2018 and indeed that is the standard of care per ACOG (although there was NO reference for that entire section of the paper, so i dont know where that info came from). However, we had a case (with MFM) earlier this year where mom had an anti-E on her initial T+S, and they tested dad, dad was negative, so they stopped following.... Then six months later just before delivery we find an anti-c with a roaring titer, with a problematic outcome. So I am kinda not OK with just testing dad and letting it all go when it comes to Rh antigens. Any words of wisdom here? I am going to be tangling with MFM over policy in the new year, and this is certainly on the docket. thank you -
  21. Pathologist here. I realize this inquiry is kinda old now, and i am sorta curious to find out the resolution of this issue from the OP. I can see if the tech wanted to send a photo as a 'curbside' to see if it is a skiptocyte that maybe this would be OK, and up to the individual tech if they choose to use their phone for that. However, I find it a little weird (and bad practice) that the pathologist who is director is not around/onsite at least once a day to look at slides. If it's for a real review, then no, too bad. There are those numbered hashmarks on all scope stages so you can send along the coordinates of the area of concern. Alternatively, and it depends on the scope model you use, but one place I worked you could flip the condenser down and dot the cell on the underside of the slide. Takes the right scope and some practice, but is doable.
  22. we have a 70 bed NICU in new england; we have about 3 neonatal exchanges each year. however, we've have had two in the past month; one for maternal:fetal ABO incompatibility (due to B, strangely), and one for anti-D HDN (no hydrops) that they tried to manage first with IVIG but after a couple weeks moved on to an exchange.
  23. Malcom Needs, thank you, I will check it out!
  24. i ended up finding a reference that actually provided the half-life of rhogam, which is the product we use, and the minimum blood concentration needed to prevent immunization. it's the math behind the 28 week dose covering up to 40 weeks comes from, i dont know why neither I nor my BB manager learned this during our training! i also pinged a senior OB I trust about this stuff, and he said she's very likely covered by what she's already got, but can redose if so desired. So since we gave her 300 mcgs a week ago, we advised that she is very likely completely covered (she should still have almost the full dose in her system just one week out), but that OB can dose again if she feels squirrely about it. D. Salkin, thanks for your input! sounds about like what i ended up with.
  25. quick addendum - evidently we do not give microdoses, so she got a full dose for the amnio, which should cover the D&C!
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