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isoimmunizatin alloimmunization hemolytic disease

Our ISO story 

Prelude: I've always been a planner. Some might even say a perfectionist. Any choice is meticulously researched and cross referenced. My first husband said I missed my calling as a lawyer. My second clarified: "presector". We find ourselves here in 2014. I researched my way, at last, into a healthy, stable, happy marriage. Thus commenced an unloading of my years of natural birth research onto my poor unsuspecting Kenyan husband. I scoffed about statistics and variables, turned up my nose at dating ultrasounds (clearly I had been charting my ovulation and knew implantation to the day!), shopped for organic cloth diapers on the off chance I failed at EC, and ordered an organic woven baby wrap. We hired an amazing crunchy home birth midwife with big hippy-meets-university-professor energy. I shopped online for birth tubs and woven wraps. But we plan, and God Plans. My belly grew and I have a short torso, so it's no concern. And grew. But I was 10 lbs at birth so not shocking. And grew. But maybe my charting HAD been off after all. And I grew. And my crunchy hippy professor midwife insisted that I go get that ultrasound not long after my 28 week rhogam injection (lead free, of course) And it was twins. Boys when I'd been sure it was a girl, and all I could do was calculate disposable diapers per month in my head. They came by emergency c section due to preeclampsia at 37 weeks. They were over 7 lbs each and perfect. I received 2 injections of rhogam post birth, not so worried about a miniscule lead content by then, thankful this amazing product existed at all and that I had two bouncing baby boys to show for it. 


A Tangent: Any time the discussion of rhogam arises I remember my maternal grandmother. A chain smoking ranchers daughter from eastern Missouri who gave birth to 5 children, including a set of twins, only to lose 3 of them shortly after birth. The two survivors, my father and his half sister, both A- blood type. Rhogam and the like didn't exist then. They called it "blue baby syndrome" and that was that. Rhogam was the one intervention I hadn't questioned in the depths of my natural birth euphoria, and even with what was to come later, and knowing everything I know now, I still wouldn't skip a dose. 

Sensitization: Let's skip ahead here to 2016-2017. Pregnant again. Still meticulously planned of course, still mourning my natural birth that never was, now a badge wearing VBAC warrior. I hunted up a hospital with attached birth center. I continued breastfeeding my 2 year old twins. I resumed shopping for cute little girl things and at that first ultrasound my only question was "how many?" There would be no surprises this time, older and wiser was I! But we plan, and God Plans. At my 28 week appointment I had the typical antibody screen, followed by that good old rhogam to the hip. I recall vividly my sweet husband asking me to explain this injection to me as we left the appointment. I told him in brief, "it keeps my immune system from attacking the baby’s red blood cells since your blood has a different type than mine." I said this with full confidence.


We got home and as usual I hopped on the web portal to check and research my numbers and results. Antibody screen positive Anti D. Titer 1:128. A slight flutter in my chest didn't prevent me from hopping onto PubMed to pick apart what exactly this meant for my VBAC plans. I held it together till the midwife called. She was hesitant. Not my crunchy-hippy-professor, just a sweet and to the point lady among many in the clinic, but I heard a quiver in her voice. "Hey hun, did we by chance give you the rhogam BEFORE they drew your blood?" Unequivocally, "No". And some part of me knew this was way more than a maybe no VBAC as I started to cry. She was sympathetic, scheduled me to get in to talk to a Maternal Fetal Medicine specialist and for a specialized ultrasound of the babies Middle Cerebral Artery ASAP (both of which my frantic internet search had confirmed were important).


We commenced weekly scans and by 31 weeks they were looking far more carefully. I had an app on my phone and entered Peak Systolic Velocities and gestational ages in real time as they scanned. At 32 weeks my boy (obviously it was another boy) showed numbers above the range of safety. The MFM doubted the scans, but her numbers looked the same.  We decided to do a PUBS the next day. They used a large needle to draw blood from the placental end of the cord as it was right smack on the front, and confirmed that yes, in fact, he was already anemic. They hustled to get blood available and since I'd undergone the PUBS with little fanfare despite no drugs, I was given the uncommon option of doing the IntraUterine Transfusion with just local anaesthetic so long as I consented to having an IV placed in case they needed to perform an emergency c-section. They used much the same approach as the PUBS and gave my third son a blood transfusion in utero, and I was again in awe of having such options available that my grandmother could have only dreamed of.

isoimmunizatin alloimmunization hemolytic disease
isoimmunizatin alloimmunization hemolytic disease

My first isoimmunized baby was born after a 4 day long induction. I got my VBAC, and with midwives to boot, and my beautiful boy was rushed off after a quick latch to NICU at 35 weeks gestation and around 5 pounds 8 ounces. He had a line placed through his umbilical cord stump through which he received IVIG and three more blood transfusions while we waited for my antibodies to die off inside his tiny body. He spent 3 weeks under lights to keep his bilirubin levels from getting high enough to do permanent damage, and he was poked almost daily for much of that time to be sure everything was working and an exchange transfusion could be avoided. I pumped my milk, a whole new experience, and he had to be fed much of it through a tube down his nose. He was a beautiful sweet soul from the get go and we were so grateful to bring him home after a full

month in the NICU; even if we did have to put around an oxygen tank weighing twice as much as him for another couple months while he learned to make his own blood again. He never took to the breast, and I finally learned the one motherhood judging lesson I never did with my twins: fed really is best. He grew and thrived and some part of me felt like, with this treatment available, why not go another round? 


ISO baby 2: We plan, and God Plans, after all. We crept into 2018, and though the tracking was significantly less finessed with 3 under 3, I managed.  Soon enough number 4 was on the way. An antibody screen and titer later and the results were unchanged: Antibody screen positive. Anti D. Titer 1:128. We met with the team. I had apparently become somewhat of a legend, with all my big questions and my shockingly affected first sensitized pregnancy. The MFM personally introduced me to the ultrasound technician. I told the story so many times it became sadly rote, though no less important.

My girl, for it finally was the girl I kept expecting, was a wild one from the start. Refusing to cooperate, she famously shook her head during scans. We started at 17 weeks and frequently had to scan 2 times a week due to her moving and shaking. We got our first concerning scan around 26 weeks. There had been some shuffling and the previous doctor who had been qualified to perform our IUT was gone so we were transferred to the children's hospital for her, while my care remained in my comfort zone with the midwives. We bought another week, and then proceeded to her first transfusion of 3. She was low, much lower than they had anticipated. And she had never slowed down at all. During that first transfusion she needed 3 shots of paralytic because she just couldn't sit still. After, I could feel the moment the drugs wore off and the fresh blood hit her system. She performed a mighty barrel roll that caused the fetal monitors on my belly to roar to life and then go quiet as she finally escaped their range, very much to the panic off our nurse.


It's amazing what can become routine. "Oh I'm sorry, tomorrow I'm going to have several large needles through my abdominal wall and uterus to try and stick the long and winding cord of my daughter so she has enough blood to not die. Maybe we can do that Monday?" Weeks passed and my girl only built up her reputation as a fiesty thing. She had more needle sticks in the womb than most have their first year, and she just kept trucking, seeming at most annoyed by all the fuss. I picked out a warriors name for her and struggled to give my boys the attention they deserved before they had to split me another way. I prepared for another long haul on the NICU, 1 am trips down dark downtown streets to fruitlessly try and nurse a baby who only wanted to sleep from the pain he was in. But our girl had other plans. She came roaring into the world at 37 weeks, less that 25 hours after the induction began, at 8 pounds 11 ounces. She latched like a champ and didn't want to let go. Once again she was carted off to NICU AND got her belly line in. They did IVIG, and I asked about transfusions. Her counts were great. We had her under lights, but it wasn't nearly so desperate- apparently more intervention inside has meant less for her outside. Not sure how I missed that in my research. 

At only 9 days old (with the last three at my insistence) we brought her home. The oxygen tank came too of course.  At 6 weeks old she needed one last transfusion. After many a poke to see if she had finally turned it around she had and then we were done as quickly as we'd begun. 


So here we are, at the tail end of 2019 with four beautiful children, all the outcomes of incredible advances in medicine and God's Plan's. If there is a moral to this story I suppose it would be that we prepare, research, analyze, and plan, but we should never forget to leave room for God's bigger and better plans to come in and teach us something we didn't realize we need a to learn. 

isoimmunizatin alloimmunization hemolytic disease
isoimmunizatin alloimmunization hemolytic disease
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