Post-partum workup

[RRay]

In the post-partum workup that has the fetal screen in it...  I've never seen the battery NOT include at least a screen as well.  I can't find any requirements for what it does or doesn't have to include.  Do you include a screen as well, or just the fetal bleed screen?  Am I missing some sort of accreditation checklist item?

[jayinsat]

17 hours ago, RRay said:

In the post-partum workup that has the fetal screen in it...  I've never seen the battery NOT include at least a screen as well.  I can't find any requirements for what it does or doesn't have to include.  Do you include a screen as well, or just the fetal bleed screen?  Am I missing some sort of accreditation checklist item?

I am not sure I understand your question. 

If the mother had an admission type and screen and was rh negative, then all that would be required post-delivery is the fetal bleed screen. Why would you want to repeat and antibody screen post delivery?

[MAGNUM]

We used to include a type and screen in our Rhogam workups, but about 15 years ago we opted to just provide the fetal screen. There is no requirement to provide a screen at that time.

[BankerGirl]

1 hour ago, jayinsat said:

I am not sure I understand your question. 

If the mother had an admission type and screen and was rh negative, then all that would be required post-delivery is the fetal bleed screen. Why would you want to repeat and antibody screen post delivery?

We do the same as Jayinsat.

[RRay]

I agree @jayinsat that the additional screen is redundant.  Building a new LIS, and planning to get rid of the antibody screen.

I'm just questioning because it is strange that all of my experience and IRL peers has had a post partum workup that included a screen.   Seems like one of those "always been" situations.

 

Thanks folks! 

 

[Malcolm Needs ☆]

3 minutes ago, RRay said:

I agree @jayinsat that the additional screen is redundant.  Building a new LIS, and planning to get rid of the antibody screen.

I'm just questioning because it is strange that all of my experience and IRL peers has had a post partum workup that included a screen.   Seems like one of those "always been" situations.

 

Thanks folks! 

 

Agreed.  The ONLY time we might perform anything like a post-partum screen is if the baby's DAT is positive, and the baby has clinical signs of HDFN, but the mother has not been shown to have an alloantibody in her circulation during the pregnancy.  In such a case, we may well test the maternal plasma (or an ABO adsorbed and eluted sample of the plasma) against the paternal red cells (if available) to see if the antibody is directed against a low prevalence antigen expressed on the paternal red cells.  Having said that, however, this would only be useful in a further pregnancy with the same male, as providing the present baby with a unit for top-up or exchange would be easy if the antibody is directed against a low prevalence antigen

[SBBSue]

Not all of our moms get a type and screen when admitted.  I agree that the screen is redundant, but I am wondering if we did it for the sake of consistency, when a large portion of our staff was generalists.  At least we no longer repeat the antibody ID when they have D from RhIg. 

[RichU]

On 5/12/2023 at 9:16 PM, SBBSue said:

Not all of our moms get a type and screen when admitted.  I agree that the screen is redundant, but I am wondering if we did it for the sake of consistency, when a large portion of our staff was generalists.  At least we no longer repeat the antibody ID when they have D from RhIg. 

How do you know a positive screen isn't caused by an alloantibody underlying the prophylactic anti-D unless you do an ABID?

[RRay]

I think they're meaning don't repeat the ABID on a post partum positive screen when you've already performed the ABID on the admit type and screen likely done within 24hrs of each other.

[RichU]

Ah ok. Makes sense.

Cheers

[AMcCord]

If we've done an antibody screen when the patient was admitted, we cancel the screen on the RhIG workup. If the patient only had a blood type ordered on admission, we do a screen.

[Mabel Adams]

There used to be a regulation that the birth parent not be sensitized to D to be a RhIG candidate.  We trust that the baby lacking a positive DAT due to anti-D is sufficient evidence and have not done anything but the needed Fetal Screen in a couple of decades, even when we didn't do admission T&S routinely.  I think key is what will we do differently with the results?  If you detect anti-D, you will assume it is RhIG and give RhIG again.  If the Ab screen is negative, you will give RhIG.  The test doesn't change the treatment so why do it?  This assumes that a strong anti-D, clearly due to sensitization, would cause the baby to have a positive DAT and therefore any needed workup would be completed for that reason.

[Mabel Adams]

Anyone else remember when the RhIG used to come with some of it in a separate vial which we had to test against the patient's cells? I guess to prove that they really were Rh negative.  We definitely had to do an antibody screen with that.  That was before 28-week RhIG or Fetal Screen/rosette tests.

[AMcCord]

18 hours ago, Mabel Adams said:

Anyone else remember when the RhIG used to come with some of it in a separate vial which we had to test against the patient's cells? I guess to prove that they really were Rh negative.  We definitely had to do an antibody screen with that.  That was before 28-week RhIG or Fetal Screen/rosette tests.

Oh yeah.... that dates us. 

And I remember doing antibody screens post RhoGAM, prior to patient discharge, to 'see if the RhoGAM dose was adequate'. No anti-D detected = give more RhoGAM. Something the OB folks thought seemed like a grand idea before the fetal bleed screen was available. Fortunately fetal screens came out about then. We were able to convince the docs to stop with the ABS orders by running parallel tests with the fetal bleed screen for several months to demonstrate how meaningless the antibody screen idea was.. 

[Malcolm Needs ☆]

27 minutes ago, AMcCord said:

Oh yeah.... that dates us. 

And I remember doing antibody screens post RhoGAM, prior to patient discharge, to 'see if the RhoGAM dose was adequate'. No anti-D detected = give more RhoGAM. Something the OB folks thought seemed like a grand idea before the fetal bleed screen was available. Fortunately fetal screens came out about then. We were able to convince the docs to stop with the ABS orders by running parallel tests with the fetal bleed screen for several months to demonstrate how meaningless the antibody screen idea was.. 

The trouble was that, in those days the anti-D immunoglobulin was known as "anti-D for Mum's Bums" in the UK, as the shot was given in the gluteal muscle.  But, there was an awful lot of fat in that muscle, so the anti-D had a habit of "staying there", rather than being adsorbed into the blood stream.  This meant that, even when the dose of anti-D immunoglobulin was calculated from the Kleihauer-Bekte test, the actual dose reaching the circulation was far lower than the calculated dose, and women used to produce allo-anti-D as a result.  Nowadays (at least in the UK) the shot is given in the lateral deltoid muscle, where there is a good deal less fat, and so the shot is adsorbed into the circulation much easier, and so there are fewer cases of maternal allo-anti-D.

I realise that this is a very vague explanation, and that there are many other causes of anti-D immunoglobulin being less than effective (such as giving it to the father, or even to the ambulance staff (SHOULD be unbelievable, but is actually true), but it does show just how complicated such a simple thing as this can be.

[AMcCord]

On 6/2/2023 at 11:37 AM, Malcolm Needs said:

I realise that this is a very vague explanation, and that there are many other causes of anti-D immunoglobulin being less than effective (such as giving it to the father, or even to the ambulance staff (SHOULD be unbelievable, but is actually true), but it does show just how complicated such a simple thing as this can be.

Nothing is ever simple, is it? Especially when you get other folks involved.

I stopped a dose of RhoGAM from being given to the baby. I've had nurses squirt some out of the syringe because "it's an early miscarriage, they don't need the full dose". I asked how they were calculating that dose and how did they know how much they squirted out...no answer . 

[Mabel Adams]

On 6/2/2023 at 9:37 AM, Malcolm Needs said:

The trouble was that, in those days the anti-D immunoglobulin was known as "anti-D for Mum's Bums" in the UK, as the shot was given in the gluteal muscle.  But, there was an awful lot of fat in that muscle, so the anti-D had a habit of "staying there", rather than being adsorbed into the blood stream.  This meant that, even when the dose of anti-D immunoglobulin was calculated from the Kleihauer-Bekte test, the actual dose reaching the circulation was far lower than the calculated dose, and women used to produce allo-anti-D as a result.  Nowadays (at least in the UK) the shot is given in the lateral deltoid muscle, where there is a good deal less fat, and so the shot is adsorbed into the circulation much easier, and so there are fewer cases of maternal allo-anti-D.

I realise that this is a very vague explanation, and that there are many other causes of anti-D immunoglobulin being less than effective (such as giving it to the father, or even to the ambulance staff (SHOULD be unbelievable, but is actually true), but it does show just how complicated such a simple thing as this can be.

Does anyone remember the humorous/terrifying thread on here more than a decade ago of all of the insane things we had heard of?  "I can't hang this plasma on my patient, it's liquid and the doctor ordered FROZEN plasma".  Or, "I don't care if the plasma isn't thawed yet, I need to hang it stat! Send it up now!" "I ordered that blood culture stat and it's been 2 hours.  Why don't I have a result yet?!"

[AMcCord]

16 hours ago, Mabel Adams said:

Does anyone remember the humorous/terrifying thread on here more than a decade ago of all of the insane things we had heard of?  "I can't hang this plasma on my patient, it's liquid and the doctor ordered FROZEN plasma".  Or, "I don't care if the plasma isn't thawed yet, I need to hang it stat! Send it up now!" "I ordered that blood culture stat and it's been 2 hours.  Why don't I have a result yet?!"

Oh yeah! That was fun (sort of).....