Congratulations!

Congratulations on your baby! All life is special and deserves to be celebrated. Antibodies can be a scary thing, but with a little help, everyone can understand them. Let's get started.  To better understand this page, read about Prenatal Testing and Prenatal Complications

Prenatal Interventions

Rhogam

Intrauterine Transfusions (IUTs)

IVIG

Plasmapheresis

Erythropoietin

Phenobarbital

Steroids

Early Delivery

Prenatal Interventions

There are a variety of interventions that are possible to help ISO babies. Here are some of the more common ones.

Rhogam

What is it?

Rhogam is anti-D Immune globulin. It is a shot that can prevent Rh D- women from becoming sensitized (1).


When is it done?

Rhogam is done at 28 weeks, and again within 72 hours of delivery (birth, miscarriage, abortion), amniocentesis, or hemorrhage.


Where is it done?

Rhogam can be given at the hospital or the doctor's office.


Why is it done?

Rhogam is done to prevent sensitization. If your blood type is A-, AB-, B- or O-, you will be given Rhogam to attempt to prevent ISO from happening in the first place. Approximately 17% of Rh D–negative women who deliver an Rh D–positive fetus become sensitized if Rhogam is not administered appropriately. (17) Once you are sensitized however (once they detect anti-D antibodies in your blood), Rhogam does no good and can throw off important test results. 


How often is it done?

Rhogam is usually done twice per pregnancy. If you get pregnant again, and aren't sensitized, you will need to get Rhogam again (even if pregnancy ends in miscarriage or abortion).


How is it done?

The doctor or nurse will give you a shot in either the arm or the butt. Some offer the choice, others prefer the butt because the muscle is larger and it is believed to absorb the medication better.


Because Rhogam has reduced the risk of sensitization to less than 1% of susceptible pregnancies, other antibodies have increased in relative importance. These include antibodies to other antigens of the Rh blood group system (ie, c, C, e, E) and other atypical antibodies known to cause severe anemia, such as anti-Kell (ie, K, k), anti-Duffy (ie, Fya), and anti-Kidd (ie, Jka, Jkb).


If you have ANY antibody that is not anti-D, and your blood type is A-, AB-, B-, or O-, GET YOUR RHOGAM!

Intrauterine Transfusions (IUTs)

What is it?

An IUT is an Intrauterine Transfusion. It is a blood transfusion for the baby while they are still inside of you. Doctor's usually have great results with IUTs. About 75% of babies with hydrops survive, while more than 90% of babies without hydrops survive (19).


When is it done?

IUTs are generally done between 18 and 35 weeks. Sometimes an IUT can be done as early as 16 weeks, but it is very difficult to do before 18 weeks. After 35 weeks, there is more risk with doing an IUT compared with delivery and a transfusion after birth (20).


Where is it done?

IUTs are done in the hospital. Usually in a surgical suite.


Why is it done?

An IUT is done to prevent baby from dying. When the baby is anemic, they do not have enough red blood cells for their body to work properly. Just like how we would die if we lost too much blood, the baby is losing too much blood and needs a transfusion.


How often is it done?

IUTs are done anytime the baby is anemic (not just for ISO). For most doctors, an IUT will be done any time a baby's MoM reaches 1.5 or higher. Some doctor's also do them on a schedule since the baby will need more blood as it grows (which is approximately every 3 weeks). Many doctors use a formula to calculate how long the blood will last based on starting and ending counts. How often an IUT is done depends on each individual case and the doctor. Ask your doctor when he thinks an IUT will need to be performed, and how often.


How is it done?

IUT procedures vary by doctor and hospital. In general, you can expect:

Sedation for you and baby (sometimes paralytic for baby to prevent injury)

Pain medication and anesthesia to numb the area

The doctor will use an ultrasound to guide the needle into the umbilical cord of the baby and to monitor his health. If the baby is under too much stress, the procedure will be stopped and further action may be taken.

Once the needle is in, a sample of baby's blood will be taken and the hemoglobin (or sometimes hematocrit) will be checked. This is called a cordocentesis or percutaneous umbilical cord blood sampling (PUBS for short), and tells the doctor how anemic the baby is and how much blood will be needed.

Once the amount of blood is decided, the doctor gives that exact amount to the baby and takes a final hemoglobin reading to see how successful the transfusion was.

The needle is removed and it is off to recovery to rest and wait for the medications to wear off.

The doctor will probably continue to monitor baby for a few hours before sending you home. Some doctors prefer an overnight stay, while others do not.

Depending on the doctor, you may be asked to be on bed rest, or reduced activity for a day or two before resuming your normal routine.


What do the numbers mean?

Normal hemoglobin increases from about 10 to 11 g/dL at 17 weeks, to about 14 to 15 g/dL at term. If baby's hemoglobin is 2 g/dL lower than normal, he is considered mildly anemic, 2-7 g/dL lower is considered moderately anemic, and anything 7 g/dL or more below normal is considered severely anemic (20).


Additional Information

IUTs suppress the bone marrow. This means that baby will not make as many red blood cells. In many ways this is good because there will not be baby's own blood to be attacked by the antibodies. Instead, it will be donor blood that will be safe from attack. Because the bone marrow is suppressed, ISO babies are at risk for late onset anemia. Additional tests after birth will be used to closely monitor baby.


Note: If your baby has had IUTs, the state required newborn blood screening may be off (it may be testing donor blood and not baby’s blood), and should be repeated at 1 year of age.

  • Getting prepped for IUT.
    Getting prepped for IUT.
  • Ready to go for the IUT.
    Ready to go for the IUT.
  • After IUT.
    After IUT.
Getting prepped for IUT.
Getting prepped for IUT.

Plasmapheresis

What is it?

Plasmapheresis is the removal of the blood plasma. It is then replaced with antibody free plasma or a plasma substitute.


When is it done?

Plasmapheresis is usually done at 12 weeks.


Where is it done?

Plasmapheresis can be done in the hospital, outpatient infusion center, or doctor's office.


Why is it done?

Plasmapheresis is done to remove the antibodies from the body. Because antibodies are found in the blood plasma, removing the plasma removes the antibodies. The fewer antibodies there are, the less baby will be attacked. Plasmapheresis does not remove the blood itself. Blood is returned to the patient. Once the antibodies are removed, plasmapheresis is usually followed with IVIG to block any remaining antibodies from crossing the placenta and to keep antibody production down.


How often is it done?

Frequency varies by case, but generally it is done 3 times the first week. This will hopefully remove a majority of the antibodies from Mom's system.


How is it done?

An IV or port is placed in a good artery. This will remove the plasma. A machine separates the plasma from the blood. The blood and replacement plasma will be returned through a second needle placed in the arm or foot. (32)

  • Permacath placed at 10 weeks. Removed at 24 weeks during first IUT.
    Permacath placed at 10 weeks. Removed at 24 weeks during first IUT.
  • Plasmapheresis
    Plasmapheresis
  • Plasmapheresis machine
    Plasmapheresis machine
Permacath placed at 10 weeks. Removed at 24 weeks during first IUT.
Permacath placed at 10 weeks. Removed at 24 weeks during first IUT.

IVIG

What is it?

IVIG stands for intravenous immunoglobulin. It is a product made from human blood plasma.


When is it done?

IVIG is usually done between 12 and 20 weeks (5). It is also sometimes used after birth to treat high bilirubin31. Occasionally doctors will use IVIG when doing an IUT, but this is rare. There was also one case report of giving IVIG to the baby at 30 weeks with anti-M.


Where is it done?

IVIG can be administered at the hospital, outpatient infusion center, doctor's office, or sometimes at your home.


Why is it done?

IVIG blocks some of the receptors in the placenta and makes it so that the antibodies cannot cross over to the baby. It also makes it so that you will produce less antibodies because your body sees IVIG as an antibody and decides that it doesn't need to make any more. (5)


How often is it done?

IVIG is usually done once per week. (5)


How is it done?

IVIG is administered slowly through an IV, or possibly a port depending on how often you need to receive treatment. It can cause side effects like headache, nausea, vomiting, fever and fatigue. Many women report getting multi-day headaches from the IVIG. Your doctor can sometimes give you something for the pain.

Note:Some women have an allergic reaction to the IVIG. If this is the case, talk with your doctor about trying a different brand. Some women have no reaction when they switch brands.

  • The first dose of IVIG, administered in the hospital.
    The first dose of IVIG, administered in the hospital.
  • IVIG
    IVIG
  • Additional doses of IVIG administered at home.
    Additional doses of IVIG administered at home.
  • IVIG and 1 year later with a healthy baby.
    IVIG and 1 year later with a healthy baby.
The first dose of IVIG, administered in the hospital.
The first dose of IVIG, administered in the hospital.

Erythropoietin (EPO)

What is it?

Erythropoietin is a hormone produced by the kidneys. It promotes the formation of red blood cells by the bone marrow. It can be made in a laboratory and used as a treatment for anemia. (35)


When is it done?

Erythropoietin can be done prenatally, or after birth. It appears to be most effective after 24 weeks gestation (34).


Where is it done?

Erythropoietin can be administered at the hospital, outpatient infusion center, or doctor's office.


Why is it done?

Erythropoietin is done to help prevent late onset anemia. Especially in IUT babies, the bone marrow is suppressed, causing low levels of erythropoietin, and red blood cells are not being made. Erythropoietin is given to decrease the need for a transfusion. (33)


How often is it done?

Varies by doctor.


How is it done?

Erythropoietin is administered slowly through an IV, or possibly a port depending on how often you need to receive treatment.

Phenobarbital

What is it?

Phenobarbital is a narcotic and sedative drug.


When is it done?

Phenobarbital is taken in the last couple of weeks of pregnancy.


Where is it done?

Phenobarbital can be taken at home.


Why is it done?

Phenobarbital improves liver function. When blood cells break down, they turn into bilirubin, which is removed by the liver. Getting the liver to mature faster can help reduce the amount of bilirubin and reduce jaundice.


How often is it done?

Phenobarbital is typically taken 3 times per day for the last 10 days of pregnancy (assuming planned induction/delivery date).


How is it done?

Phenobarbital is a pill you swallow.

Steroid Shots

What is it?

Steroid shots are an injection of corticosteroids, a synthetic form of natural human steroids.


When is it done?

Steroid shots are usually done between 25 and 33 weeks, but may be done later depending on situation. (36)


Where is it done?

Steroid shots can be given in the hospital or doctor's office.


Why is it done?

Steroid shots are done to help baby's lungs mature more quickly. This reduces the risk of complications and death from prematurity. (36)


How often is it done?

Steroid shots are done in “courses”. One course is 2 injections given about 24 hours apart. (36)


How is it done?

A shot is given into the arm, leg, or butt.

Additional Information
Steroids will artificially lower your MoM score from the MCA scans. The doctor needs to take this into account and not assume that baby is no longer anemic if you have had a dose of steroids. Steroids are also only effective within a couple of days of delivery. You may need another round of steroids before early IUTs or before early delivery if your last round was more than 2 weeks prior. See the steroid page for more information.

Early Delivery

What is it?

Early delivery is when the baby is delivered prior to 38 weeks. This happens when it's in the best interest of the baby to be outside of the womb, instead of inside (and under attack) any longer.


When is it done?

Early delivery can occur at any time once the age of viability, 24 weeks, is reached.


Where is it done?

Early delivery happens in the hospital, preferably one with a high level NICU. It generally involves a c-section, but not always. In which case, you will be taken to a surgical suite.


Why is it done?

Early delivery happens when the baby is in too much distress. It can happen if you go into labor and it cannot be stopped, or if you have complications from an IUT. It can also happen if baby's health is deteriorating too quickly, or in cases of a hemorrhage. Regardless of why it happens, there will be an entire team of doctors closely watching your little one and giving him the treatment he needs.


It is always a good idea to talk with your doctor about the possibility of an early delivery to find out what his criteria for an early delivery is, and what the plan would be. If possible, try to tour the hospital's birthing area and the NICU. Knowing your way around and meeting some of the highly trained staff can go a long way towards reassuring you and taking off some of the stress/fear of the unknown.