Negative Pregnant Mother, Research Paper Example

Pregnancy presents a vast array of symptoms, conditions and potential health problems. While most problems have indicators such as physical signs and symptoms, a person’s blood type can create problems which cannot be physically felt. Rhesus (Rh) is the measure for the four major blood types: A, B, AB, or O. The types of antigens on the blood cells determines the blood type. The Rh factor is a specific type of a protein which is located on the surface of red blood cells; D antigen. The Rh factor is either positive or negative. When a couple decides to have a child, their blood types will determine if there is a potential problem. A mother who is Rh-negative with a father who is Rh-positive can create a problem should the fetus inherit the Rh factor from the father. If the fetus and the mother have differing Rh factors and any of the baby’s blood mixes with the mother’s blood, it can trigger the mother’s body to produce antibodies, cross the placenta and literally attack the baby’s blood.

Women without the Rh D antigen are Rh-negative and can become sensitized or maternal alloimmunization, during pregnancy or following the birth if the baby is Rh-positive. They will begin to produce antibodies against the Rh-positive baby. Once the Rh protein enters a Rh-negative mother’s bloodstream it is recognized as foreign and her body reacts to protect her immune system and creates antibodies to clear her system; leaving a record of this in order to protect her in the future (Wickham, 2005).  This occurs in the same way a person’s body would react to any infection. This may or may not affect the current pregnancy; however, production of antibodies can cause hemolytic disease of the fetus and newborn in subsequent pregnancies (Dixon, 2008). A fetus affected by a hemolytic disease will secrete abnormally high levels of bilirubin directly into the amniotic fluid. There are several ways sensitization can occur such as in the event of a miscarriage, an ectopic pregnancy or a blood transfusion. Chorionic villus sampling or an induced abortion can also create this problem.

The Rh D antigen was first discovered in the 1950s when about one out of every two Rh-negative women became sensitized to the antigen and lost her baby (Cerrato, 2006). As this problem began to gain notoriety and studies began to determine ways to prevent this problem, the morality rates dropped drastically. By 1986 studies such as amniocentesis, amniotic fluid analysis, and intrauterine transfusions were being practiced and the odds of the child surviving in this situation had vastly improved (Cerrato, 2008). Detecting the problem during pregnancy is the key to proactively monitoring and attempting to keep both the mother and fetus safe.

There are more than 100 antigen varieties on red blood cells and the RhD is the most common with the RhD positive being dominant. RhD-negative status varies among the different ethnic groups: in white, 15% are RhD-negative; in African American, 5% to 8% are RhD negative; and in Asians and Native Americans, 1% to 2% are RhD-negative (Hensley, Coughlin, & Klein, 2009). The chance of susceptibility varies among women. Some will become sensitive with only a small amount of blood while others will need a greater quantity to produce the sensitization. Sensitization, also called alloimmunization, can occur during the third trimester and during birth, following miscarriage, termination, antepartum hemorrhage or abdominal trauma (Dixon, 2008).  An RhD immunoglobulin has been identified which can be given to an Rh-negative mother during pregnancy for prophylactic treatment which has shown to be effective in reducing the risk.

Nursing Process

Analysis with cell-free DNA testing of the Rh-negative mother is one test which is thought to be beneficial in preventing sensitization. This test starts with a maternal blood sample subjected to DNA amplification and gel electrophoresis to pinpoint the presence of the specific DNA sequence for the RhD protein (Cerrato, 2006). DNA is taken out and heated to be able to determine the DNA chains. After cooling it is reheated in the presence of a polymerase, triggering the synthesis of additional copies of each strand (Cerrato, 2006). This creates a pattern which indicates the presence of a DNA fingerprint identifying the antigen. The negative side of this test is there have been false-positive results; however, accuracy to 99.1% has been demonstrated.

Nursing diagnoses in the NANDA system in this situation would be Rh negative pregnant mother. A risk diagnosis in this case is sensitization or alloimmunization. It is possible that a patient in this situation could develop a host of medical problems specific to the baby to include jaundice and hemolytic disease. A syndrome diagnosis in this circumstance could include depression, anger, and psychosomatic abdominal discomfort and sleep pattern disturbances.

Identification and planning for an Rh negative pregnant mother includes identifying rhesus isoimmunization by testing the mother’s blood in the early stages of pregnancy. If the blood work demonstrates antibodies have begun to develop the mother can be offered the immunoglobulin to prevent build-up of the antibodies. This is typically given around 28 weeks of pregnancy. If the baby proves to be Rh positive at birth the immunoglobulin can be given again at the time of birth.

Determining if treatment is necessary with the immunoglobulin requires both the physician and the patient deciding what is in the best interest for the mother and child. Current culture uses prophylactic pharmaceutical products to a large number of people with little work having been done to determine whether women at risk have been determined (Wickham, 2005). This fact should be a consideration in the goals and priorities for the treatment planning.

Treatment of an Rh negative mother includes an indirect Coomb’s test to detect Rh antibodies in the maternal blood which is typically performed throughout the pregnancy at intervals done at 20, 32 and 36 weeks. A positive Coomb’s test means that immunoglobulin injections may be the needed as pharmacotherapy for the patient.  This can be given at 28 weeks gestation. After birth if the postpartum antibody screen is negative a second dose of the immunoglobulin is typically given if the infant proves to be Rh-positive.

Management of an Rh-negative mother includes an ultrasound to detect and monitor the baby. Monitoring of the mother’s blood regularly to detect an abnormalities or increase level of antibodies. In some cases early delivery around 36 weeks gestation is recommended. In some cases intrauterine blood transfusions may be necessary.

Safety considerations include recognizing the risks associated with accepting or declining immunoglobulin injections. Obviously the risks associated with declining the injections include the elevated chances of becoming isoimmunized, which has serious implications for future pregnancies (Wickham, 2005). The couple facing this situation also has to make considerations for limitations on the size of the family they desire. The risks associated with accepting the injections include short-term side effects including localized pain and inflammation from the injection sites. Also reported problems include fever, lethargy, headaches and general malaise. A more serious consideration is the risk of anaphylactic shock and the longer-term risk of transmission of infectious disease (Wickham, 2005). The patient should be counseled that immunoglobulin is a human blood product with inherent risks.

Achieving the goal of a healthy mother and baby depends on the identification and decisions for using immunoglobulin or not. The positive side is the prevention of sensitization in the mother and a healthy new baby. The negative complications regarding the child include obstacles such as hydrops fetalis which is the most severe complication in the fetus demonstrated by widespread tissue damage with edema.  The liver and spleen of the baby will enlarge and death while in the uterus is a serious possibility. Icterus gravis neonatorum is a common complication demonstrated by the baby after birth developing jaundice. Treatment consists of exchange transfusion of the baby’s blood. Kernicterus results from an elevated amount of bilirubin produced from fetal red blood cells being destroyed which in turn can destroy the basal ganglia and medulla of the baby’s brain. Another complication is hemolytic anemia which can require a blood transfusion.

Current and future implications for practice include education for mothers on the choice between accepting or declining immunoglobulin injections. Many women when faced with the idea of receiving a human blood product will want to discuss the real need for this. Whereas women who were told they would benefit from the injection will simply accept this without question (Wickham, 2005). It has not been determined whether women understand the risks associated with human blood products versus their desire for future children are in question with Rh-negative pregnancy.

Kleihauer test is useful in measuring the fetal hemoglobin which is transferred to the mother’s bloodstream from the fetus. This determines the amount of immunoglobulin needed to prevent the formation of antibodies in the mother. The implications of Kleihauer testing which may result in a woman needing higher levels of the immunoglobulin may prove to a longer hospital stay than desired. At risk individuals are also a consideration for evidence based practice. Recognizing women with thrombocytopenia and haemostatic disorders should not receive intramuscular injections. Patients with haemoglobinaopathies may produce fetal haemoglobin themselves causing persistent positive Kleihauer tests (Wickham, 2005). Patients should never be left alone after an infection of immunoglobulin due to these risks.

Nursing personnel can practice effectively and efficiently if they familiarize themselves with these risks and complications as well as the benefits derived. Understanding the screening tests and normal versus abnormal values is critical to nursing care. Understanding the group of women who should not be given immunoglobulin reduces the risks of adverse effects and the serious risk of anaphylaxis. A standardized protocol for quality assurance is beneficial in the successful treatment of an Rh-negative pregnant mother (Bianchi, Avent, Costa and van der Schoot, 2005). Such protocols ensure the prevention confusing clinical scenarios. This saves the costs and risk associated with invasive as well as non-invasive testing.

Personal nursing care also includes helping the couple to understand and get through the complications and risks associated with an Rh-negative mother and Rh-positive father. The worry associated with this condition can cause the couple to spend this time distraught over the well-being of the baby and miss the job associated with a normal pregnancy. Helping the patient to understand the testing and results also aids in alleviating the distress the parents may be dealing with.

Statistically there are approximately 85% of the population who are Rh-positive. While this and current technology limit the incidence of complications of an Rh-negative mother developing sensitization, the problem still exists. Prenatal routine care with the identification of problems is delivering health care in a proactive manner to ensure the safety and health of both the mother and the baby.

References

Bianchi, D. W., Avent, N. D., Costa, J., & van der Schoot, C. (2005). Noninvasive Prenatal Diangosis of Fetal Rhesus D. Obstetrics & Gynecology, 106(4), 841-844.

Cerrato, P. L. (2006, April 15). The battle against Rh disease is about to get a lot easier. Contemporary OB/GYN, 54-58.

Dixon, L. (2008, September). Rh(D) immunoglobulin – what is the evidence for routine prophylaxis during pregnancy. Midwifery News, 32-33.

Hensley, J. G., Coughlin, K. P., & Klein, L. L. (2006, August 8). A curious case of anti-D antibody titer. Journal of Midwifery & Women’s Health, 497-502.

Wickham, S. (2005). Anti-D: helping women make informed choices. British Journal of Midwifery, 13(4), 225-228.