11.06 Erythroblastosis Fetalis

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Overview

  1. Other name: Hemolytic Disease of the Newborn
  2. An immune response from the fetus, which attacks RBC’s, that occurs when antibodies from the mother pass through the placenta – typically during the birth process when the placenta separates

Nursing Points

General

  1. Mom: Typically NOT an issue with the first pregnancy, but can be with subsequent pregnancies
    1. Body will attack future pregnancy as an immune response to blood mixture
    2. This is why mom gets Rhogam
  2. Treatment is focused on the infant, while mom merely receives a dose of RhoGAM and should not experience any further issue herself
    1. See the lesson on Rh immune globulin
  3. Baby: RBC’s get destroyed and therefore cannot function, resulting in anemia (hemolytic anemia)
  4. Hemolysis → elevated bilirubin levels
  5. Normally, jaundice can be seen in newborns around day 3
    1. If seen in first 24 hours after birth, suspect pathological hyperbilirubinemia

Assessment

  1. Quickly developing jaundice, within 24 hours of birth
  2. Anemia, draw a CBC to assess
  3. Elevated bilirubin levels
  4. Positive direct/indirect Coombs test

Therapeutic Management

  1. After delivery, cord blood is sampled. If infant is Rh-negative, there is no need for further intervention
    1. We’re looking for those antibodies that attack their RBC’s and if they’re not there, we’re good!
  2. Frequent bilirubin levels drawn
  3. Phototherapy
  4. Rarely a newborn may need a blood transfusion that replaces their blood with Rh-negative blood to stop the destruction, and then they are gradually given their own blood back

Nursing Concepts

  1. Human development
  2. Lab values
  3. Gastrointestinal/Liver Metabolism

Patient Education

  1. Make sure parents know the plan of care
  2. Help parents understand ways to bring the bilirubin down
    1. Phototherapy
    2. Increase feedings

Reference Links

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Video Transcript

In this lesson I will explain erythroblastosis and what this means for the patient and your role in their care.

With erythroblastosis fetalis we have a few things going on. Blood mixture between mom and baby has occurred. This blood between mom and baby is incompatible. We can either have this occur because of the Rh factor or because of ABO incompatibility. So mom has a Rh negative blood type and had blood mixing that could cause this in a future pregnancy or more commonly mom has an “O” blood type and there is incompatibility because the baby is A, B, or AB. So for the Rh the mom won’t have a big problem. She will receive rhogam to protect future pregnancies and because of rhogam it is rare that this would be the cause of erythroblastosis. It is typically our ABO incompatibility that causes the problem. For the baby this can be a big problem. There has been blood mixture so now the baby has blood that doesn’t belong to him or her. So the baby will have an immune response to try and break down these red blood cells that don’t belong. So we have hemolysis. So because of hemolysis there can be hemolytic anemia because these red blood cells are being destroyed. This will cause hyperbilirubinemia. Remember bilirubin is formed from broken down red blood cells. So with hemolysis we get high bilirubin levels. The bilirubin can’t be cleared adequately because there’s so many destroyed red blood cells that are built up. So this will cause jaundice. You can see on this image here it is showing the Rh incompatibility. The Rh antibodies mix and start attacking the fetal erythrocytes. So their blood cells are attacked and start breaking down or having hemolysis.

On assessment this little ones will be jaundice, so yellow color and this jaundice quickly develops in the first 24 hours. The jaundice is caused by hyperbilirubinemia. Those elevated bilirubin levels develop from the hemolysis of red blood cells. Anemic from the hemolysis of red blood cells. So paleness might be observed. Lab work assessment will show a positive direct coombs test. The coombs test detects whether there is blood mixture that has occurred. It is drawn off the umbilical cord of the placenta after birth. It will tell us the baby’s blood type and if it is coombs positive or negative. Positive means maternal blood mixture has occurred and antibodies are developing. So positive coombs equals positive blood mixture which equals newborn hemolysis of these blood cells which will cause hyperbilirubinemia, jaundice, and possible anemia if too much hemolysis occurs.

This coombs stuff can get a little confusing. So there is either a direct coombs or indirect coombs. I want to make sure you understand the difference. The direct coombs is most commonly used. Indirect coombs is used in specific cases where blood mixture is suspected. The direct coombs is drawn from fetal blood after delivery. This blood is taken from the umbilical vein so that you don’t have to stick the baby. You will get either a positive or negative result. Positive mean positive for antibodies again baby’s blood. Negative is good and means no mixture or antibodies have occurred. The indirect is drawn from mom during pregnancy. This test is done on mom during pregnancy. It looks for antibodies. If antibodies are present then if blood mixture occurs the maternal antibodies would enter the fetal blood and cause the baby to have hemolysis of red blood cells. So the biggest difference here is direct is done after birth from baby’s blood and indirect is drawn on mom during pregnancy.

Now what will our management look like? After delivery, cord blood is sampled and usually on “O” blood types. Some hospitals do it on all blood types but usually it is only the “ O” types because of incompatibility. If the baby is AB type they could react to the antibodies of the “O” blood type. So that is why “O” i s the biggest concern and require further intervention. So further intervention will be frequent bilirubin labs to watch for a rise. Phototherapy will be done if the bilirubin gets high to help break it down so it can be excreted. In some cases the newborn may need a blood transfusion that replaces their blood with Rh-negative blood to stop the destruction, and then they are gradually given their own blood back. Remember Rh negative means no antibodies so giving this will stop the hemolysis.I’ve seen this happen once where there had been a severe mixture occur during the pregnancy. The baby was born super pale and anemic and ended up needing a transfusion. This mother was positive for cocaine so there was some thought that a mild abruption had occurred from cocaine use and caused a blood mixture to occur. Parents will just need to be educated on the plan of care and any interventions we are doing.

Our concepts are human development, lab values, and liver metabolism because we will be watching lab values and bilirubin is broken down by the liver to be excreted.

Let’s review our key points. Erythroblastosis fetalis occurs where there is somehow a blood mixture between mom and baby and the blood types are incompatible. This will cause the baby’s body to attack the blood cells and cause hemolysis. So now we have a lot of broken down blood cells building up which will cause hyperbilirubinemia and jaundice.

Make sure you check out the resources attached to this lesson and review the key points. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 10

A nurse is caring for a three day old, full-term infant who requires phototherapy for increased levels of bilirubin in the body. Which of the following nursing diagnoses is most appropriate for this infant? Select all that apply.

  • Question 2 of 10

The nurse is caring for a two-day-old baby who requires phototherapy for a bilirubin level of 13 mg/dL. During phototherapy, the nurse should monitor for which of the following? Select all that apply.

  • Question 3 of 10

The nurse is training a new graduate nurse who is caring for an infant receiving phototherapy for hyperbilirubinemia. Which of the following statements by the new nurse indicates a need for further education?

  • Question 4 of 10

A newborn is recieving phototherapy for hyperbilirubinemia. Which of the following is the priority nursing intervention?

  • Question 5 of 10

A 3-day old infant requires phototherapy for elevated bilirubin levels. Which of the following is part of nursing care for an infant undergoing phototherapy? Select all that apply.

  • Question 6 of 10

A nurse is setting up phototherapy for a newborn infant with an elevated bilirubin level. When preparing the phototherapy, which intervention must the nurse utilize to ensure the effectiveness of the process?

  • Question 7 of 10

A nurse needs to perform an indirect Coombs test. The client asks what this test is. What is the best response by the nurse?

  • Question 8 of 10

A nurse is assessing laboring clients for the risk of Hemolytic Disease of the Newborn. Which of the following scenarios could cause this problem?

  • Question 9 of 10

The nurse is discussing jaundice with a concerned mother of a newborn. The nurse knows that if a baby has sustained hyperbilirubinemia, the primary concern is what?

  • Question 10 of 10

A nurse is caring for an O+ mother whose newborn is A+, Coombs positive. What is the significance of this finding?

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