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- [00:00]
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Well, podcast family, you know, we can do things pretty cheesy here on the show. Here on the show. And that's exactly where we're going with this. It's another edition of you asked, we answer. I don't even know what game show theme this is. All right, shut it. Shut it. You want to keep doing it? No, shut down. Shut it down. My goodness. All right, podcast family, here's where we're going. It's you asked, we answered. I don't know, we think it's kind of catchy. I think it's kind of neat because outside of things that we do that that's in print or up and coming, our podcast community, which is global, sends in great questions and the questions that are sent in become podcast topics. So I've got two really good, super clinical, right in the trenches questions that we're going to answer. And they make sense because intuitively you're like, huh, don't we know that already? Until you actually stop and go, wait, what is the answer to that? Because both of these, you've got to dig through the data. It's kind of fascinating. We're going to get into this. The first question has to do with rhig, commonly called rhogam, although that's one company's brand name. There's others, but rh immunoglobulin. Here's the question and here's where we're going So a podcast family member said, hey, I got a patient who had routine run of the mill prophylaxis. She got her rhogam or her rhig at 28 weeks. Everything was good. Then about two weeks later, she had, you know, a minor, you know, fall onto her side. No big deal. It wasn't like a car accident or anything, but still, you know, labeled as minor trauma. Does she need an additional dose of rhig if it's very recent in time from her RHIG routine prophylaxis? All right, now, when you first think about this, you're like, dude, she just got rhogam. Why would you give her another dose? Because the guidance is kind of tricky and it's a little contradictory. So we're gonna get into this. We're gonna talk about the traditional half life of RHOGAM or RHIG versus how long the protection typically lasts. Or what is the recommendation from the college regarding RHIG and RH negative patients with either unknown fetal RHD status or with fetuses that are suspected to be RHD positive based on cell free DNA? Uh, what? The guidance there says one thing, and then in the same document which we're gonna get into is Practice Bulletin A181, says something a little bit different. So you gotta tease it out. So again, the first question is this. If a patient gets rhogamous routine at 28 weeks like she's supposed to, and then within a short time thereafter, in this case, it was like two weeks after, has minor trauma, does she need another dose of rhogam? It seems pretty easy to answer, but once you stop and you're like, wait, well, does she? Yes or no, we're gonna get into that, as well as, where does KD fit into that? And the pros and cons and the limitations of that test. The second question comes from a separate listener, podcast family member, who says, hey, there's been times when I enter a patient abdomen at C section, and lo and behold, there's like, the serosa is open, the myometrum is open, but the kid's still in the cavity. And every everybody is good, baby's happy, she's asymptomatic, but is that still considered a uterine rupture? Now this podcast family member, because I was about to answer, oh, is it a window? But he answered this in the next statement, which was, now, remember, the cirrhosa is absent. So I get that a window is when the malmutrim is separated, but the cirrhosa is intact. But in this case, there's been a couple of cases where I've done a section and lo and behold, the malmitrim and the serosa are open, but the kid is just hanging out like, hey, who opened up the sunroof? Is that still considered a rupture? It's a fascinating question, and we've got lots of data actually on that that is called the silent or the asymptomatic uterine rupture, otherwise known as the partial uterine rupture. Fascinating. And yes, there is data on that. So we're going to get into the risks for complete uterine rupture versus partial, how one presents versus the other. So those are the two questions that we're going to get into. So we're going to cover two things here. Rhig as routine prophylaxis. That's fine. And then whether repeat dose is needed after trauma. Because the answer for trauma is one thing because. But the answer for birth is the other. It's a little contradictory in the college guidance. So I'm going to tell you what to do with this kind of tricky guidance and give us real world practical insights of what I would do and what I think the data demands. But the guidance is a little contradictory. So two things. We're going to answer the rhig thing and then we're going to tackle this issue of the partial uterine rupture. So that's it. You asked, we answered. It's cheesy, but I'm gonna go with it. Here we go, Michael. I'll take a vowel for 300. What was that? Wheel of Fortune? Is that what that thing was? All right, all right. Shut that down. I think I've set it up enough. We'll be right back. The world moves fast. Your workday even faster. Pitching products, drafting reports, analyzing data. Microsoft 365 Copilot is your AI assistant for work, built into Word, Excel, PowerPoint, and other Microsoft 365 apps you use, helping you quickly write, analyze, create, and summarize so you can cut through clutter and clear a path to your best work. Learn more@Microsoft.com M365 copilot My dad taught.
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This is Dr. Chapa's obgyn no spin podcast. All right, podcast family, let's start with the hold RHIG thing because we thought we figured this thing out. But remember in 2024 there was a little controversy about Rhig. And I want to say that rather than Rhogam, because it's not a sponsor and Rhogam is just one type. But if it accidentally comes out and I say rogam, please know I'm not trying to give any kind of commercial props. It's just that sometimes we're so ingrained in our language, in our vernacular, to say rog, but we really should be saying rhig. So anyway, it is what it is. Potato, potaho. So anyway, 2024, we did have recent RHIG controversy. Remember that ACOG said, well, the risk of sensitization under 12 weeks and 0 days is really small. So if a patient has either an induced termination of pregnancy or a spontaneous abortion, then you know, you can kind of defer or decline checking RH status in her because the risk of ISO or alloimmunization is really quite small under 12 weeks. So it's not a big deal. That was ACOG's stance. Now MFM said, hey, wait a minute, we deal with alloimmunization all the time. So Society of Maternal Fetal Medicine said, we're not on board with that. So we still think even though the risk is really small is not zero. So SMFM says, yeah, under 12 weeks it's reasonable to ask the patient if she wants our RH testing and to offer her RHOGAM just to cover all bases. Right? So we've had some controversy regarding RH ig. Then not long ago we actually had an RHIG shortage and I've covered that on this show when that happened. It's now gone, thankfully. But remember that it is a precious medication or therapy because it still requires human blood donation. So on to say rhig. We do got to respect it. If a patient is RH negative, then consider NIPS testing for RHD fetal determination, because that's very accurate. Rather than everybody just getting RHIG routinely without checking the baby, at least we can try to triage and save some of that. If the baby is deemed to be RHD negative by molecular assay through cell free DNA, that's very good. Anyway, that has nothing to do with what we're talking about here except that rhig has been in our radar in recent communications from the college. All right, so the question that we were supposed to answer, and we are going to answer right now, is if a patient had routine rhig administration in pregnancy, like at 28 weeks, like she's supposed to, and then say one or two weeks later, she has some kind of trauma, does she need an additional dose? Now, we're gonna get to KB in a minute. We'll talk about that in a little bit. But the short answer, let's just get to it right now and be done with this is yes, absolutely she does. She still needs an additional dose even though she had the prophylactic. 28 week to 30 week RHIG administration, you still need to give it. Now that's pretty clear. Now let me explain why. Now, number one, it is true that the protection can last about 10 to 12 weeks. It still has a MEAS antibody, measured antibody in the maternal circulation after administration. That is true. However, the half life of the rhig administration, so time for half of it to go away is really doesn't take all that long. It goes away by like day 23 or 24. So I remember three weeks. So at three weeks, you're already down to half. All right, so the rhig administration at 28 or 30 weeks, that's to prevent small micro breaks that happen naturally in the fetal maternal. A barrier that can sensitize the patient. That's kind of like a baseline therapy. Okay. Any sensitizing event or potential sensitizing event, could that be trauma? That could be external, cephalic version, whatever. Anything that. That could lead to a potential maternal and fetal break in that. In that barrier needs separate rhig administration. So, yes, the short answer is even if the patient had recent R H I G administration, a new trauma event requires another dose. All right, now if you're going. Is that my opinion? Where did that come from? No, it's not my opinion at all. It is right out of Practice Bulletin 181, and the wording is very clear here. All right, so the wording states, and I'm going to give it to you directly, that any potential break in the fetal maternal barrier still requires an additional dose because the risk of sensitization is high. So let me put it to this way. It's like a patient who has diabetes and they're on lantus. Lantus is kind of your long acting kind of like your basal rate to control blood sugars. However, they still may need prn, lispro or regular for the acute episodes. It's the same thing here. All right, every potential break in the fetal maternal barrier needs to be covered by additional rhogamy. Now, this is where people get things kind of confused because they go, well, what I'll do is I'll check an antibody screen and if she still has a detectable antibody, because it's passive immunity that you're going to find on an indirect antibody screen, I know she's still got some coverage, and if her KB is negative, then that's great. I'm not going to give her any. But remember that after trauma in an RH negative, non sensitized patient, we're not getting the KB stain to not give rhogam. So in other words, we don't get a KB scan as a justification as to not to give it. We get a KB stain to figure out if she only needs one or more doses of RhoGam. So even if the KB is negative, you still give a dose of RhoGam because it may have micro breaks after that blood test was checked. All right, so that's one of the confusing things about the KB stain, is that if it's negative, it doesn't mean you don't need a dose of RhoGam. It means you only need one and you don't need additional dosages. Remember that one ampoule of a full dose RhoG, which is 300 micrograms, should cover about 15 mls of fetal red blood cells or 30 mls of fetal whole blood because the baby's hematocrit is 50%. Right. So 30 mls whole blood or 15 mls of fetal red blood Cells is covered by one ampoule or one dose of standard RhoGam at 300 micrograms. That's a lot, guys. 30 mls of baby blood is a lot. So it's really rare to need more than one dose of RhoGam unless there's really significant maternal fetal hemorrhage. All right, so in practice bulletin 181, it's very clear. It says in any potential break, like trauma, then it is recommended to give RHOGAM to cover anything else that is like the lispro version of the insulin in our diabetic analogy. Whereas the lantus, the prophylactic dose is just kind of like for maintenance. Okay, so that is very, very clear from the college. So let me read this directly from a College Practice Bulletin 181, and then I'm gonna Give you a little bit of confusion here. Cause it's a little tricky in this issue. Okay? So that's why one guidance. Guys, practice bulletin 181. If you actually read it thoroughly, it's actually contradictory. I'm going to tell you this in a minute. So the rationale is that routine prophylactic dose at 28 weeks is to prevent alloimmunization from micro breaks or spontaneous breaks in the fetal maternal barrier. However, any possible sensitizing event requires its own prophylactic treatment to cover for any other potential risks for alloimmunization. And ideally, that should be done, remember, within 72 hours. That is all in ACOG's practice bulletin 181. Nothing new there. So here's a cat. Did y' all catch that? So regardless of the dose of RHOGAM given, any traumatic episode should have its own administration of rhogam. That's right out of the bulletin. However, here's where it's confusing and it's a little. It's a little contradictory. And guys, I'm very thankful for my time on the ACOG OB Practice Committee and consensus committees. I learned a lot doing that. I'm not on that anymore. But this is kind of confusing. And it kind of went through all of the. Of the copy edits and even the board of directors. But this one's confusing. So listen to this. Remember we just said that any potential trauma should have RHIG administration regardless of when the prophylactic dose was given? Makes sense. That's fair. But listen to this from the same Practice guidance. In a separate question In Practice Bulletin 181, it talks about doses of RHOGAM after birth. Okay, now this is again, super confusing. Remember, this is 2017 practice bulletin 181. So listen to this quote. The median half life of anti D immune globulin is 23 days in the third trimester. Fine. I remember three weeks, whatever. Same thing they go on to say. Quote. Listen to this. If delivery occurs within three weeks of the standard antenatal anti D immune globulin, the postnatal dose may be withheld in the absence of excessive fetal maternal hemorrhage. End quote. Did y' all get that confusing? So this is why this was a good question from our podcast family member. Did y' all catch this? So on the one hand, it says, oh, prophylactic dose. No, that's for micro breaks. That's just for spontaneous. For spontaneous bleeds. That's for small issues. Any other trauma, you need to give a separate dose. But what's the biggest trauma, you know, quote, end quote, that a patient may have that can lead to sensitization at the end of pregnancy? That's delivery. Delivery is a big risk for fetal maternal hemorrhage, especially if there's manual placental removal or PPH or an abruption. But nonetheless, ACOG says if delivery occurs. Guys, I'm reading directly from the practice bulletin. If delivery occurs within three weeks of the standard antenatal anti D immunoglobulin administration, the postnatal dose may be withheld in in the absence of excessive maternal fetal hemorrhage. End quote. So do you see the two issues here at delivery? Don't worry about it. If she got RHOGAM within three weeks and she delivers like two weeks later, you don't have to give another dose. You may consider withholding that. That doesn't make any sense. So knowing that contradiction, is that weird or what? Guys, knowing that contradiction, let me give you a real world application. As SMFM stated regarding RHOGAM or rhig use under 12 weeks, the risk of fetal maternal hemorrhage is so big at delivery, especially if it's at a section or there's PPH or there's manual placental removal or an abruption. Not giving RHIG at the time of delivery, even if she had recent RHIG administration within the three weeks could be a little risky. And I'm not again being contrary to the college. I just find it interesting. Then the same bulletin, it says, oh, any trauma, any trauma in the third trimester requires its own dose of RhoGam regardless of previous prophylactic dose. But then you get to deliveries like, nah, if it happened within three weeks, like let's say she had a trial aversion at 36 weeks or 37 weeks, nothing happened. She gets a dose of RhoGam, delivers a week later, you're good. No, the risk of alloimmunization is so high and the potential morbidity is so great. Personally, I would give her another dose. I would of course get a KB stain, make sure that one dose is enough because KB stain is the standard. If you're going to give a dose of RHOGAM after delivery or after trauma to make sure that one is enough, in addition to an antibody screen to make sure that she's not already sensitized. But it's interesting. Again, remember I said at the intro it's kind of contradictory. So on the one hand it says if trauma happens, give RHIG regardless of the prophylactic dose. And then on the other hand, it says if delivery happens within three weeks, you may not need to give the postnatal dose. Unbelievable. A little confusing. Short answer is, and let's put this question to bed, give rhig. When in doubt, just give it. Also, remember that if you draw an antibody screen after RHIG has been given, it should be a low level positive. Most titers for passive anti D are about 1 to 4 or less. All right, so anything higher than that is weird and could mark new sensitization. Which is why, remember, guys, as a reminder, and we've covered this in past episodes, you never give Rhig at 28 or 30 weeks without first checking the antibody screen to make sure that that antibody screen should read 0. Because afterwards, for at least three weeks afterwards and up to 12 weeks, based on some studies, you're gonna get a positive antibody screen by indirect coombs with a tatter less than one to four. All right, so the podcast family member who asked, should we give Rhogam even if the prophylactic dose was recently? Yes, absolutely. Even though the half life is about three weeks and can last in the body, based on their BMI and level of clearance, anywhere from 10 to 12 weeks later, the risk of alloiminization is so high that the prophylactic dose is just meant as a baseline maintenance and shouldn't take the place of PRN dosages. Just like Lispro is for maintenance. I'm sorry, Lantus is like for maintenance. And then Lispro or regular insulin in the diabetic analogy, is for acute episodes of hyperglycemia. Okay, so I like that analogy. I've taught that to residents and medical students for years. That the 28 week RHIG is your maintenance kind of dose. That's your Lantus insulin, so to speak, on the diabetic analogy. And then the PRN dosages are your Lispro or regular as needed for potential episodes where the patient may be in jeopardy. Okay, Fascinating. Fascinating, because it is not very clear in Practice Bulletin 181. That's why I said you had to go dig through the data. Okay. Nonetheless, I'm not mad at anybody. I'm very thankful for my time again on the ACOG OB practice committee and the consensus committee. I still got some editorial work in a draft of something that we'll leave confidential for now, but all to say is, yeah, that's a little confusing. Now that we put that to bed, let's get onto our second issue, which has to do with finding an asymptomatic uterine rupture at C section. Remember that? A separate podcast family member said, hey, I entered the abdomen and there's been rare cases, but it's happened where I enter and whoa. The serosa has a break in it. And under that, the myometrum is separated, but the amniotous sac is intact. That is a term that is called the silent uterine rupture, otherwise known as the partial uterine rupture. So let's do our terms. Remember that a window is a myometrum is separated, but the serosa is intact, still in utero. A partial uterine rupture is when the serosa has a break in it, the myometrum has a break in it, but the kid is still in the cavity and the amniotic sac is intact. And then a true complete or symptomatic uterine rupture is where the serosa has a break in it, the malmitrium has a break in it, and the child has either partially or completely extruded from the uterine cavity. That is a complete rupture. Lo and behold. Here's what's interesting, guys. Partial ruptures actually make up about 50% of the entire bucket of uterine ruptures as a category. So yes, they do happen totally. So half of them tend to be symptomatic, and those are the ones that have fetal heart rate deceleration, have potentially bleeding, have loss of uterine tone or fetal station. The prototypic and stereotypic findings of uterine rupture, that's with a complete. By definition, a partial uterine rupture is asymptomatic and silent. Crazy, huh? So both fetal and maternal morbidities are obviously higher with the symptomatic complete rupture, whereas the partial tends to be, again, an incidental finding, but still must be repaired per usual. But the thing that doesn't change is, just as with a complete uterine rupture, that patient should be educated that in the future she should really have a scheduled plan C section. Because uterine rupture may qualify for late preterm early term delivery. Or at least consider delivery at 37 weeks. All right, 36 weeks. If it's a classical malmutrial invasion like a classical section or myomectomy, and some say with the previous rupture, you can get out as early as 36. I think 37 is fine as long as they are asymptomatic and not have a history of preterm labor. Okay, so the biggest risk factor Here it is, guys. For a complete uterine rupture is TOLAC number one. What's higher than that is TOLAC with Pitocin. Those obviously increase the risk of complete uterine rupture, though the overall number is still pretty low. The rate of rupture, no question, as a partial or silent, is most likely linked to previous cesarean section. That is true, but it's also been linked as to patients without a C section. And, guys, we've covered this. We had a previous episode called uterine rupture in the unscarred uterus, where things like adenomyosis perhaps, or just potentially a D and C that had a uterine perforation as a point of weakness. So you can have a uterine rupture without a C section, and those tend to be more partial uterine ruptures. All right, so our podcast family member had a question. What do I call that? Is that still a rupture? Absolutely. It's called a partial or a silent uterine rupture as opposed to a complete or symptomatic uterine rupture. And it is a thing. One study showed that it was a pretty easy split, about 50, 50 in the total pool of uterine ruptures. So half are symptomatic, the other half are found incidental. Like the patient is, you know, failure to progress or whatever. And then you go in, you're like, oh, well, that's why you. You weren't changing because your uterus got a hole in it. That's a partial or a silent uterine rupture. So it is a thing. Not all uterine ruptures, thankfully, are catastrophic. Some are indeed found as an incidental finding. Fascinating, fascinating, fascinating. All right, podcast family, this has been a pretty quick, I think quick episode called you ask, we answer. So we've covered two things. The rhig issue, which, again, at first blush, you're like, I think I know what to do with that. But if you read the guidance, it's a little confusing. If there's a doubt, give rogam. The risk of isoalloimmunization is so high and the risk of RHIG is so low that that it really demands coverage in the. Here it is, guys. RH negative, not sensitized patient whose child is either unknown RHD status or obviously known to be rhd, either by an invasive means or now by cell free DNA. Okay, and then we've covered, of course, the partial urine rupture. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, let's take it home.