Legal Briefs: Anemia From Rh Hemolytic Disease of the Fetus and Newborn

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A 3,480-g male infant was born at 36 weeks' gestation to a 32-year-old gravida 1 para 1 woman whose pregnancy was complicated by a group B Streptococcus –positive cervical culture result and hemolytic disease of the fetus and newborn (HDFN) due to Rh incompatibility. The prior pregnancy resulted in an infant who was healthy but whose records were unavailable during litigation. On an early prenatal visit for the current pregnancy, the mother's antibody screen result was positive with a titer of 1:8, at which point the obstetrician gave her an injection of anti-Rh antibodies (Rho[D] immune globulin, sold under the brand name RhoGAM). The pregnancy was not monitored for HDFN; the antibody titers were not drawn again until the day of delivery. The plaintiff obstetrician was critical of the treating obstetrician for administering RhoGAM because the patient was already sensitized, for not following the antibody titers, and for not performing aggressive fetal surveillance required in an Rh sensitized pregnancy. He pointed out that the antibody titers of 1:32 or less require serial antibody titers every 2 to 4 weeks. When and if the titers become 64 or greater, then titers and serial amniocentesis become necessary. Because the mother experienced decreased fetal movement for 1 day, her obstetrician admitted her for an evaluation. The plaintiff experts pointed out that decreased fetal movement underscored the anemia, indicating the fetus' attempt to conserve energy. The biophysical profile was found to be 2/10, the only normal score being normal amniotic fluid volume. Of note was an increase in liver size and mild ascites on the fetal ultrasonogram. Pericardial and pleural effusions were not present. The plaintiff experts pointed out that abdominal fluid collections precede pleural and pericardial effusions in hydrops from HDFN. The antibody titer was 1:2,048. The plaintiff obstetrician pointed out that this …