Dr. Kara Markham, (M.D. University of Cincinnati Medical Center) a maternal fetal medicine specialist and expert in the pregnancy management of alloimmunization and HDFN, answers questions from The Allo Podcast listeners.
Bethany and Molly chat with Dr. Kara Markham, (M.D. University of Cincinnati Medical Center) a maternal fetal medicine specialist and expert in the pregnancy management of alloimmunization and HDFN. They ask questions from the allo community, and end with Bethany and Dr. Markham in a trivia competition about HDFN.
During this grab bag episode, Bethany, Molly and Dr. Markham discuss the following, and more:
Resources mentioned in this episode:
Research for this episode provided by Bethany Weathersby and Molly Sherwood of the Allo Hope Foundation. Find more information at allohopefoundation.org.
The Allo Podcast is produced and edited by https://www.mediaclub.co
Bethany Weathersby:
The information shared on The Allo Podcast is not intended as medical advice. Your medical care decisions should be made in consultation with your physician who is familiar with your specific case.
Molly Sherwood:
Hi. Welcome to The Allo Podcast by the Allo Hope Foundation. I'm Molly Sherwood.
Bethany Weathersby:
And I'm Bethany Weathersby. Today is going to be a grab bag of stuff. Really great stuff. Yes, I'm really excited. There's so much to discuss with this disease as we know, and it doesn't always fit neatly into one episode topic. So, we thought we'd do a Q&A of the most common questions we hear from other women. We also invited Dr. Kara Markham from our medical advisory board to join us and weigh in, and I'm so glad that she's with us today on the show.
Dr. Kara Markham:
Yes. Hi. I am thrilled to be here. Thank you for inviting me.
Bethany Weathersby:
Yes, welcome.
Molly Sherwood:
We're so excited to have you. I need to know more about the story of how this relationship came to be between you, Dr. Markham and Bethany.
Dr. Kara Markham:
We were talking about this a little bit on offline and we don't remember, quite frankly. I know it's been a while. It's been over a decade, I think.
Bethany Weathersby:
We do not remember. It's all a blur.
Molly Sherwood:
Wow.
Bethany Weathersby:
The best guess I have is Dr. Moise mentioned Dr. Markham to me when I was looking for an expert MFM for HDFN with my rainbow baby pregnancy after Lucy died, so that was with my pregnancy with Nora. And I was determined to find the best care because we were told Nora had a 0% chance of survival. And so he said Dr. Markham in Ohio. I chose Dr. Moise because I didn't want to be cold in Ohio.
Molly Sherwood:
You have to have boundaries of what you're willing to do.
Dr. Kara Markham:
But we-
Molly Sherwood:
That's fair.
Bethany Weathersby:
Yeah, I really considered it. But since then, she's been on my radar, and then other patients just talked about what phenomenal care they had from her, and I think that's how we connected. And then I just started referring patients to her and seeing really, really great outcomes and patient testimonies, of course.
Dr. Kara Markham:
And I've certainly been honored to be a part of this relationship and to take care of these patients who I know are experiencing a lot of anxiety and fear. Sometimes, I don't need to do anything other than counsel them and provide them with support.
Molly Sherwood:
And that's very valuable and rare.
I want to know, Dr. Markham, how did this become a little niche for you? Because being an MFM is already a niche and you're already probably doing a bunch of very specialized things. But why is this something that you're now known for?
Dr. Kara Markham:
I was fortunate enough to work with a mentor who specialized in this, Dr. Richard O'Shaughnessy at Ohio State, when I was going through my maternal fetal medicine fellowship. I always had an interest in ultrasound and fetus and procedures that very much fits with my personality and skillset. And through that relationship with him, it developed further. I really do consider myself very fortunate to have worked with this amazing physician and expert in the field.
Bethany Weathersby:
And also, I just want to say that patients of hers say that she's really attentive emotionally, to their emotional and psychosocial burden of this disease. Not just like, "I'm going to treat the physical disease." They always feel really safe and secure and heard by you. And that's so important.
Dr. Kara Markham:
That's really good to hear. I take a lot of pride in that, to be honest. We can all do the book learning and maybe even be able to do procedures, but that's only half of the battle with these type of conditions. So, I'm proud to be able to provide that side of things as well.
Bethany Weathersby:
I think it's easily overlooked, especially because the mother with this type of condition isn't physically in danger. There's no harm to her and so she's kind of pushed to the side, but there is. It's just kind of unseen harm, I think.
So now that we've heard a little bit about Dr. Markham, I'm really glad that she's going to share her wisdom and expertise with us as we go through some of these questions. And we have some really good questions to answer. We posted on our social media platforms and in our support group for patients, and we told them we were having this conversation today. We asked them if they had any questions they really wanted us to answer. And so, we have a list of those questions ready to go.
Dr. Markham, since you are the expert here, we'll ask you these questions and then we probably won't be able to help ourselves from occasionally chiming in.
Molly Sherwood:
Yeah, probably not, but we'll still try to keep it tight. The producer is going to start sending us messages like, "God. Move on." Because we're framing a bunch of questions.
Bethany Weathersby:
Yeah. He said, "Do you have too many questions?"
And we were like, "Hmm. Sorry."
Molly Sherwood:
Yeah, exactly.
Dr. Kara Markham:
Challenge accepted.
Molly Sherwood:
So, we're going to go through these questions and then I have a little surprise segment for you two because both of you have been very, very involved in the development of our anonymous patient questionnaire study, which we've talked about throughout the season. And we have the results from it but neither of you have seen them. So, I'm going to ask some questions of you just about what you would guess about our patient population, at least, that we learned from our questionnaire. Like, what are the top three most common antibodies that women have and things like that. Get your answers, and then I'll tell you what the reality was, at least in our study.
Bethany Weathersby:
Sounds fun.
Molly Sherwood:
So we'll do that, too.
Dr. Kara Markham:
Sounds like a plan.
Molly Sherwood:
Cool.
Bethany Weathersby:
All right, I'll start with the first question. Is there anything we can do in pregnancy to lower the antibody titer level?
Dr. Kara Markham:
Medically, yes. You as an individual outside of the medical world, no. So, it's really important that I think patients know that they don't cause this disease and they can't prevent this disease, short of testing every potential father of your baby for antigen status. You can't prevent this from happening. Now, we can potentially prevent what we call sensitization to the RhD antigen through Rh immunoglobulin, but that's the only available immunoglobulin of that type. A lot of this is, unfortunately, out of women's hands, and they don't even know about this disease until it becomes an issue.
Now in pregnancy, with medical care, there are some things that can be done to lower titer levels, specifically giving intravenous immunoglobulin. The goal of which is, basically, to do just that. To tamped down the immune response so that these potentially troublesome immunoglobulins that we worry about or antibodies that we worry about are present at a lower level. May not prevent having problems with the baby entirely but it may delay it, and that's really important.
There's also something called plasmapheresis, the goal of which is to directly remove antibodies from maternal circulation. Data surrounding that is not quite as robust as with the intravenous immunoglobulin.
Bethany Weathersby:
I was just going to say, I think, do the titers come... They bounce back after the plasmapheresis, correct? Often?
Dr. Kara Markham:
Exactly.
Molly Sherwood:
If anyone's curious, we talk about IVIG and plasmapheresis a little bit in our Severe Disease episode.
Bethany Weathersby:
Sorry, I just want to add. Just because they do bounce back, it doesn't mean that it's not useful treatment. That's just what our bodies do. They replace, they know. Our body's like, "Hey, we need these antibodies for this pretend danger."
Dr. Kara Markham:
The thought is that-
Right. The parent and danger to baby. The idea is that it would be done in addition to intravenous immunoglobulins, so you tamp down those antibody levels by removing them directly with plasmapheresis and then give the IVIG, as we call it, to tamp down the ongoing immune response to rebuild those.
Molly Sherwood:
Okay. This next question, I actually just pulled this quote directly from a patient's comment in Facebook because she tells her personal story in it a little bit, but it touches on something that apparently was also talked about a good bit at the ACOG annual meeting this year.
This patient says, "I was alloimmunized with anti-D due to three different doctors refusing to administer RhoGAM after a bleed in my first trimester. It is my third pregnancy, first with anti-D, and I had a subchorionic hemorrhage in the last pregnancy." So, she probably had a bleeding episode. "I was immediately given RhoGAM by my previous OB and told it was vital with the bleed and me being Rh-negative. Then after switching clinics, this pregnancy and finding out I was sensitized, I contacted the previous OB clinic that denied me RhoGAM. They told me it's not recommended just for spotting. My question is, is RhoGAM really not recommended for Rh-negative women who haven't been sensitized in the event of spotting? And if not, how do we change this? I feel like my alloimmunization was completely preventable."
Dr. Kara Markham:
That is a controversial question. So it sounds easy, but it's not easy. The thought is that early in pregnancy, the amount of red blood cells that the baby makes is so low that if that enters the circulation, it shouldn't be able to cause a maternal immune response. That's the reason that some experts propose not giving RhoGAM with those first trimester bleeding events or miscarriages. Now, the flip side to that argument is, what is the harm? Particularly, in a resource-robust location such as the United States. What is the harm of giving RhoGAM just in case that amount of fetal blood exposure would be enough to cause that response? And we know that RhoGAM is a very safe... I'm using RhoGAM, but really, I should be saying Rh immunoglobulin because there are some different formulations out there. We know that it's safe. It doesn't cause maternal significant side effects or complications, and that's out of millions of doses that have been studied. But it is potentially, there's cost with it. There is a shot with it. There's some sort of downside.
So I think, for me, I tend to err on the safe side because I don't think there's much downside to it. But if we think about best use of utility, of resources, that would be the argument. That giving us medication that may not be beneficial for most patients has low yield if we think more from a population standard.
Molly Sherwood:
Like a global perspective of it, yeah.
Dr. Kara Markham:
Exactly.
Molly Sherwood:
Interesting. So it sounds like different centers just adopt different protocols on it, I suppose?
Dr. Kara Markham:
Yeah, I think that's correct.
Molly Sherwood:
Why don't hospitals or blood banks screen for additional antigens when transfusing women of childbearing age? This seems like a category of alloimmunization where, at least, a certain percentage of sensitizations could be prevented.
Dr. Kara Markham:
That's definitely true. And in particular, the antibody or antigen that comes up most frequently with, is Kell. It's whether or not we should be cross-matching women of reproductive age who need blood for the Kell antigen. And certainly, experts who do what we do would love to see that happen. But again, it comes down to that more of a population view and resource allocation. It's not as efficient, so it could be a delay in getting the mom or the person that blood, which can be of significant importance if we're talking about a patient who is hemorrhaging and needs blood. It's from a more of a population standpoint. The financial considerations for each blood bank and hospital also play into it. It would be wonderful, but from more of a bird's-eye view, I guess is the word I'm looking for, it's often not valued because we're not seeing the downstream effects for most individuals.
Interesting, I read a paper not too long ago. I think it was from trauma surgeons where they polled women asking them if they would be okay getting Kell-positive blood, knowing that it could cause...
Molly Sherwood:
We know these guys, yeah.
Bethany Weathersby:
Yeah.
Dr. Kara Markham:
So I was like... I mean, interesting, but you just cannot... Those patients who answered that survey, they just have no basis to really make that determination. They have no idea what this disease is like, and it's a shortsighted view. I would love to see us have more of a long-sighted view in reproductive-aged women.
Molly Sherwood:
Yeah. We'll let you know.
Bethany Weathersby:
I'm working on it.
Molly Sherwood:
We're helping them ask that same question, but actually in our population. So, that would be good to know.
Dr. Kara Markham:
Interesting.
Molly Sherwood:
We have talked, in recent conversations, with that trauma community. I think it's no one's fault but there's a disconnect because they don't see the effectiveness in practice because they're just in a different specialty. But they have talked about just the overall scarcity of even getting O-negative blood, of course. So, I can't imagine the extra complication or... Not complication, but just the extra hurdle of cross-matching blood also for Kell antigen status.
Dr. Kara Markham:
Cost, availability, time. All of that, yeah.
Bethany Weathersby:
I was going to say, they could screen the donor blood and only give Kell-negative to everybody. But I guess, we're short on blood. I believe in Europe, they do that.
Molly Sherwood:
Oh, really?
Bethany Weathersby:
Yes.
Dr. Kara Markham:
Probably part of that.
Bethany Weathersby:
Yeah, we're behind here in the US.
Molly Sherwood:
Okay. So, it can-
Dr. Kara Markham:
I think that's correct.
Molly Sherwood:
All right. New mission.
Bethany Weathersby:
Yeah, it can. Yes. Okay, let's move on. Is breastfeeding safe after birth or can it cause continued or worsened hemolytic disease following birth due to the transfer of antibodies through the breast milk to the baby? I have seen that iron being administered to baby after birth is not recommended for anemia, or I should probably say hemolytic anemia. Is iron okay for mom to take throughout pregnancy for low iron levels, maternal anemia?
I see. So, there's two questions. Is breastfeeding safe for the baby? And then, is the mother taking iron supplements during pregnancy safe as well for the baby?
Dr. Kara Markham:
That is a great question. And I will be honest that I'm not as well-versed in baby's response in breastfeeding. Once the baby is delivered-
Bethany Weathersby:
That's what Dr. Moise-
Dr. Kara Markham:
... a little bit about the care-
Bethany Weathersby:
Yeah, you're kind of like an inside baby.
Dr. Kara Markham:
Exactly. I don't know what to do with them.
Bethany Weathersby:
Dr. Moise says, "I only treat babies who can't cry."
Dr. Kara Markham:
Exactly.
Bethany Weathersby:
So funny.
Dr. Kara Markham:
So, I don't have a good answer for that. I mean, we know that breast milk is very valuable and that it has so many antibodies. I don't know how much of certain antibodies are absorbed into fetal circulation versus broken down by gastric secretions, and therefore may not get into the baby circulation. I don't know the answer to that.
Molly Sherwood:
Yeah, that's interesting. We'll have to look into that. I mean, we always just tell patients, "Just feed them as much as you can," whether it's breast milk or formula so that can help them process their bili. And I think even the new AAP guidelines on high bili had a reference to some study that showed babies who were fed nine or more times a day had more rapid bili drops than other babies.
Bethany Weathersby:
Regardless of whether it was formula or breast milk.
Molly Sherwood:
Right. But that's regardless of... Right.
Dr. Kara Markham:
What I'm saying is breast is best, but fed is better.
Bethany Weathersby:
Yes.
Molly Sherwood:
I like that.
Dr. Kara Markham:
Yeah, exactly.
Molly Sherwood:
This is random but I think this is the right episode for this. Bethany, will you tell us the weird things that your HDFN babies do now?
Bethany Weathersby:
Oh my gosh.
Molly Sherwood:
There's a couple. And this is so cool, Dr. Markham. This is really bizarre.
Bethany Weathersby:
Yeah. I think I've been too embarrassed to ask an MFM this because it sounds really gross.
Molly Sherwood:
Well, here we go.
Bethany Weathersby:
So, I'm just going to embarrass myself. I'm not really that embarrassed.
Dr. Kara Markham:
Not with me.
Bethany Weathersby:
Yeah. Okay.
Dr. Kara Markham:
Just all of our listeners.
Bethany Weathersby:
Just you and everyone else. Okay.
Dr. Kara Markham:
Yes, and everyone who ever listens to this.
Bethany Weathersby:
All right. My three surviving HDFN babies, they're now seven, five, and two, totally healthy. They all had multiple IUTs. They had a very stressed-out mother carrying them through pregnancy, super stressed out with PTSD and all those things. And then they all had intervention after birth and multiple transfusions as well. So their whole lives, just these three... I also have two older boys who... That was before I developed the antibody, so these two boys don't have this weird stuff.
But the three babies who had HDFN, they constantly ask if they can crunch ice, like eat ice. That is their favorite thing. They are not anemic now because I've checked. That's just something they love to do.
Dr. Kara Markham:
If that's what you think of, it's what we call pica, where-
Bethany Weathersby:
Right.
Dr. Kara Markham:
... people who are really anemic will chew ice or eat cornstarch or all sorts of unusual things.
Molly Sherwood:
How weird is that.
Bethany Weathersby:
Right. So I'm just like, "Is this-"
Dr. Kara Markham:
What happens in the womb has a lot of implications outside of the womb that we don't know about. There's definitely this theory called fetal programming. We know that if a baby is, for example, growth-restricted, so a small baby because the placenta is not working, that child is more likely to have adulthood obesity, heart disease, some downstream effects.
Bethany Weathersby:
Wow.
Dr. Kara Markham:
So that exposure to stress, probably inflammation. All of that can reset things and have implications lifelong.
Bethany Weathersby:
Wow. I-
Molly Sherwood:
That makes sense.
Bethany Weathersby:
It does. And then I'm going to go Google that so hard after this. Fetal programming, is that what you said?
Dr. Kara Markham:
Fetal programming.
Bethany Weathersby:
Okay.
Molly Sherwood:
Cool.
Bethany Weathersby:
And then the other thing they do is all three of them, since they were babies and even now they're older, if they get startled, if they are afraid or if they're in pain, they stop breathing. They can't take a breath. It's like this intense response. Sometimes they'll start changing color, like they cannot inhale. I've looked it up, that's something breath-holding spells. They say some babies do it and then when they pass out, they breathe again. They said one of the factors that makes babies or children more likely to do this is if they are anemic.
Dr. Kara Markham:
Crazy. Yeah, if there's just something that happens early and during pregnancy, they have this prolonged state of anemia, maybe it just changes or alters their parasympathetic or sympathetic system in some way to even though they're not anemic, they still have that saturated response.
Bethany Weathersby:
Yeah, it seems like that.
Dr. Kara Markham:
That's interesting. It's very interesting.
Bethany Weathersby:
Yes. And they were anemic. I mean, even though they were getting great treatment, they're dropping down, they did have prolonged anemia.
Dr. Kara Markham:
Stop scaring your kids, Bethany. Oh my gosh.
Molly Sherwood:
Just put them in a bubble. That's all you have to do.
Bethany Weathersby:
Oh, exactly. Right?
Dr. Kara Markham:
Exactly. [Inaudible 00:15:15]
Bethany Weathersby:
Okay. Thank you for answering that. That was so good.
Dr. Kara Markham:
It's definitely okay for moms to take iron. My training, I'm just going to give you a little bit of backstory. To do what I do, you go through an obstetric and gynecology residency. That's four years. Then, you do a maternal fetal medicine fellowship for three years. And during that fellowship, you learn a lot about things like placenta, how it functions, some of these nitty-gritty basic science stuff. And I mentioned this because I have forgotten almost all about that basic science stuff. At this point in my career, I focus on the clinical stuff. My guess is that the transport of iron from mom to baby, and I can certainly find this out for sure. But my guess is it's not an open-ended channel. That it can be saturated so that the baby gets the iron that the baby needs from mom but can downregulate that transport if the baby has the iron that it needs.
Bethany Weathersby:
I'm wondering if they're asking about it because of the problem of too much iron for the baby. So, that would still work in that way. Like, being filtered.
Dr. Kara Markham:
Right. My thought is that if the baby has extra iron, that maybe it downregulates the transport from mom to baby so we're not continuing to overload.
Bethany Weathersby:
All right, next question. At our pre-conception appointment, five years after our last sensitized baby, my titers showed too low to titer. We were obviously super excited and hopeful that we would have a relatively low-risk, easy pregnancy. By our 12-week visit, it had already jumped to 512. Why do the doctors even bother with titers if it won't actually prove the severity of the disease?
Dr. Kara Markham:
I'll be honest. If I see someone for pre-conception, I don't necessarily check their titer because it really isn't going to tell me much.
Bethany Weathersby:
Right.
Dr. Kara Markham:
But it gets to, again, all these things that we don't know the answers to. Like, why do titers increase so much early in pregnancy? It makes sense to me later in pregnancy because there's ongoing exposure from fetal blood getting into maternal circulation. But early in pregnancy... We previously talked about how the fetus isn't making many red blood cells so there's a pretty low volume of exposure, so why should that trigger a rise in antibody? So, it may be more something on the maternal side that pregnancy is a state of altered immunity, so it may just make the pregnant individual prone to having these higher levels irrespective of what the baby is doing. But to some degree, titers are really, really important in the first tier of monitoring. So I talk about tiers of monitoring.
The first tier is determining if the baby is at risk for anemia. All women go through that tier when they have a typing screen. If you have an antibody, what type of antibody that is and how high is that level? The second tier is determining screening the baby for anemia with middle cerebral artery Dopplers. And then the third tier is treating the baby if needed. If a woman has a low antibody titer, particularly if we're talking about certain antibodies, then I don't want to move to tier two unnecessarily when we know that middle cerebral artery Dopplers are great at telling us if a baby is not anemic but will have...
Some babies that we worry about anemia, they test positive for anemia based on that ultrasound. But then we do testing, the baby's not anemic. Bottom line is, titers are really important if they're low. But once they get to a high value in pregnancy, I don't repeat them. We've reached that critical value and we move on to the second tier with the ultrasounds. But more important to me with this type of situation is not knowing what the titter is before pregnancy but what is it early in pregnancy. And most importantly, what is it starting at 16 weeks.
Bethany Weathersby:
So it sounds like the starting point for those decisions about monitoring is that titer during pregnancy, the starting point is not your titer before pregnancy.
Dr. Kara Markham:
I went off on a little tangent there. Sorry.
Bethany Weathersby:
No, that's good because this leads to another question that we have that I'm just going to ask you now because it's very related to this.
If I wait long enough between pregnancies, won't my titer go down and make the next pregnancy safer?
Dr. Kara Markham:
No, unfortunately not. There's still this we call an amnestic response. I think that's how you pronounce it. Where your body, even if it's been years, if it's exposed again to this foreign protein or antigen or whatever, it ramps the immune system right up.
Bethany Weathersby:
Amnestic like amnesia, but the opposite. I'm definitely remembering this.
Molly Sherwood:
I remember now.
Dr. Kara Markham:
Exactly.
Molly Sherwood:
Because we do have some patients whose doctors tell them to wait. Like, "Can you wait two years or something?"
Dr. Kara Markham:
I tell women to wait that just based on general pregnancy. We know that safe spacing is important in pregnancy. Women ideally should wait at least a year and a half to conceive, if not two years. Shorter spacing doesn't allow the mom's body to heal, can make it hard for her to bond with the current child as well as the future child. And it is associated with an increased risk of preterm birth, so preterm labor. So, I tell all women to wait at least a year and a half, but I don't tell women with hemolytic disease that they have to wait longer than someone who doesn't have that disease.
Bethany Weathersby:
So, there's no point in waiting for your titers to drop to get pregnant again. Okay.
Molly Sherwood:
I'm going to go out of order and ask another question that I think is relevant to this. Which is, would you say that there's a titer threshold at which you would consider starting plasmapheresis and IVIG? Because we've heard some women that their hospitals have a particular threshold in their protocol.
Dr. Kara Markham:
I think that's a hard question to answer with a blanket answer because there are a lot of factors. So, it depends a lot on their history. For me, the importance of IVIG and plasmapheresis... There are downsides with that. IVIG is not a very pleasant drug. I don't know if you had side effects related to it, Bethany, but-
Bethany Weathersby:
They were terrible.
Dr. Kara Markham:
Yeah, it's awful.
Bethany Weathersby:
Josh called it hospice care.
Dr. Kara Markham:
Exactly.
Bethany Weathersby:
It's not a funny joke, but I mean-
Dr. Kara Markham:
No, it's awful. Women feel crummy. It's time-intensive, it's costly. It's not a benign drug. And so, I really personally use that medication for the women who are at risk for needing a transfusion before 24 weeks. I know transfusions are scary, but if I can start them after 24 weeks, I feel very confident that I can safely perform them. I can support the woman through them and we can have a good outcome. The outcomes with transfusions are there are more complications and more fetal losses if they have to be started prior to 24 weeks. So, I don't use an antibody titer per se. I use the maternal history. We know that, assuming that the baby has the antigen of question, with each subsequent pregnancy, disease is going to get worse. So if I had someone who in her first alloimmunized pregnancy need to deliver at 36 weeks because of a FYA antibody concerns for anemia, I can almost guarantee she's not going to need a transfusion at less than 24 weeks with her next pregnancy. It's just not that severe of a worsening effect, so I'm not going to put her through IVIG and plasmapheresis.
Whereas if I have somebody with Kell antibodies who needs her transfusion at 25 weeks, the next pregnancy, she's going to need an early transfusion if the baby has that antigen. So, that's the patient population that I want to use the IVIG and the plasmapheresis on, is to prevent those early transfusions. Delay them until later.
Molly Sherwood:
When is the ideal start time for you to do IVIG and plasmapheresis?
Dr. Kara Markham:
Late first trimester.
Molly Sherwood:
Okay.
Bethany Weathersby:
Can I ask you an even trickier question? Let's say, you are my doctor with my first sensitized pregnancy. So Kell, first sensitized pregnancy, first titer at six weeks was 1,024. That was my case. I asked my MFMs, "Can we try plasmapheresis and IVIG because I'm concerned about such a high titer with Kell? Just from things I'd read online."
And they said, "No, this baby you're carrying has to die first. And then if that happens, we can maybe offer that with your next pregnancy." Which is what happened.
Dr. Kara Markham:
I don't agree with that. Again, it's very individualized. If I had somebody who had, like I said, FYA. Usually causes later disease, neonatal disease. Whereas with Kell, Kell's a bad antibody. And so if I have a woman, even if it is her first alloimmunized pregnancy and she has those really high titers, she may be a candidate because she could develop fetal anemia and need a transfusion at prior to 24 weeks.
Bethany Weathersby:
Right.
Dr. Kara Markham:
Their history matters, the antibody itself matters, the titer matters. All those three things should be considered and we should individualize that decision for our patients.
Bethany Weathersby:
Okay, that's a great answer. And also, the fact that it's a first sensitized pregnancy does not cancel out all of the other things you just mentioned, correct?
Dr. Kara Markham:
It doesn't.
Bethany Weathersby:
Okay.
Molly Sherwood:
That's a good point.
Bethany Weathersby:
We kind of see that a lot. Don't we, Molly?
Molly Sherwood:
We do, yeah.
Bethany Weathersby:
Just a whole lot of reassurance that nothing bad will happen because it's your first sensitized pregnancy.
Molly Sherwood:
Yeah.
Dr. Kara Markham:
I wish.
Bethany Weathersby:
I know. Wouldn't that be nice? Yeah. Okay, thank you for answering that. All right.
Molly Sherwood:
Okay, here's one that comes up all the time. Because the guidelines are a little vague, do we do MCA scans every week or every two weeks?
Dr. Kara Markham:
Classically, I would say every two weeks is the older teaching. But again, I think in general, I do them weekly, but I do have a certain group of patients who may be candidates for every other week. Once I establish a baseline, establish a trend, I can more individualize it. But again, somebody who has something like Kell or D, they're getting them weekly, in my opinion. Just because things usually aren't going to change quickly but they can change quickly, particularly with Kell. I group little c in with Kell as well but those are the bad players. And so, weekly MCA Dopplers, in my opinion, should be done. Whereas some of the less malignant antibodies, once we establish that the baby is doing well and we don't have a rising MCA Doppler, then maybe you could space them out a little bit later in pregnancy.
Bethany Weathersby:
In those cases, do you think it really is not possible for the anemia to come on that quickly within those two weeks to cause harm to baby?
Dr. Kara Markham:
I think with some of the antibodies, it's going to be exceedingly rare for that to happen.
Bethany Weathersby:
Okay.
Dr. Kara Markham:
Now in general, I would err on the side of caution, particularly. And again, it partly depends on what the woman's situation is. There are some areas around me that are very resource-poor. And so if I have a woman who has to travel two hours to get to me for an MCA Doppler and she has an antibody that usually doesn't cause problems and she's been stable, then that may be the population or the patient that I would say, "Okay, we can maybe ease some of this logistic and financial burden for you and do it every other week."
Whereas if I have somebody who lives in town, I'm going to be much more likely to say, "Let's just do it weekly." Or I have somebody who has Kell or D or little c, I'm going to be... Even if she has to travel, I'm going to have to say, "Unfortunately, this is what needs to be done. Let's see if we can help you with that."
Bethany Weathersby:
And just to clarify, all of these scenarios are women who have critical-
Dr. Kara Markham:
Exactly right.
Molly Sherwood:
I was going back, sometimes we have patients who say, "I really feel like I want weekly MCAs and my doctor is insisting on every two weeks. What can I give to them to help request this?" And we struggle to find good resources. But I did just find one of the original publications with Dr. Murray who developed the MCA scan. And in his discussion, he did say, the couple... Basically, in the study that he did, the couple of times where the anemia was missed could have been caught if they had reduced to one week intervals. And that's what he put in his discussion section. That perhaps, one week intervals would be a way to avoid that.
I ended up giving that patient that paper as a potential help if they want to bring that to their doctor. But I wonder why that hasn't consistently carried through elsewhere.
Bethany Weathersby:
Yeah, because we have seen that decision play out with women who do have Kell or do have extremely high titers. And we've seen a good amount of losses happen in those cases. Just this is an anecdotal, of course, and we do have the benefit of having this volume of patients we see these stories play out. The anemia was caught too late.
Dr. Kara Markham:
I mean, that's always the key. The default to me should be weekly. My absolute goal with MCA Doppler is to identify a baby that is anemic and needs blood but is not yet sick from that anemia. It's not hydropic, has a hemoglobin above five, just eats blood. That's the goal. And so, I don't want to wait two weeks and let the baby get sick when I can see the patient a little bit earlier and intervene before we get to that point.
Molly Sherwood:
Listening to the way you talk, it's clear that you judge each patient on a case-by-case basis, and there's a lot of finesse to managing this disease. There's not a cut and dry rule.
Dr. Kara Markham:
There really is.
Bethany Weathersby:
Okay, here's a good question. Good might not be the right adjective there.
Molly Sherwood:
Challenging?
Bethany Weathersby:
Yeah. But it is one that, again, we see it often. What do you think keeps doctors from being willing to refer patients to other experts? And what can be said to a doctor like that to encourage them to be open to referral or collaboration with another physician?
Dr. Kara Markham:
I think it's human nature. I mean, we've done all this training and presumably, if someone is managing this disease, they think they know what they're doing. I think, to me, the key with a lot of medicine is it's just becoming so overwhelming, the amount of diseases and the nuances of the care. And so I'm the first to admit that, "Yes, I'm a high risk doctor and I manage women who have gestational diabetes. But am I on most up to date with the literature regarding..." I mean, I read the big studies but I don't read the little nitty-gritty studies. There's just so much now that...
I mean, I think someone said this, "You already did so much training to do MFM. How did you become an expert in this field?" I think it's important to recognize that there's too much for us, even in MFM, even in that, I should say relatively small category, there's too much for us to know everything about everything. And my goal is to keep patients safe and keep their babies as safe as possible. But that's my mindset about it. And unfortunately, for some physicians, they don't necessarily have that mindset because they do have all this training and they do keep up with the most common journal articles, the ones with the biggest impact. And I think it can be really hard to advocate for yourself in those situations.
And what I would say is, you don't have to have your doctor refer you to another doctor. You can seek that yourself. If you don't think you are getting the care that you should be getting... And that's hard because I don't want to put that on the patient to make that assessment. But if they bring up the possibility of going to someone who has more experience and the doctor says, "No, I don't think that's necessary." You don't need him or her to refer you. You can reach out to another office yourself and they will see you and take care of you as needed. And it maybe... I mean, there are many times that I've said, "You're in great hands with your doctor. They're doing a great job. I will make recommendations for you to come back here if you need a transfusion."
But in the meantime, there are more than people doing your MCA Doppler, they're doing that every week, they're doing the right thing. But it is just hard for doctors sometimes to recognize their limitations.
Bethany Weathersby:
And I think what you just said, that collaboration piece is so important, and I wish that that could happen for every patient that needed it just smoothly. Like, "I'll handle the IUDs and then your local MFM can do all of the monitoring."
Dr. Kara Markham:
And it happens for many diseases in fetal therapy, thinking about the broader group of diseases that we treat. For example, if you have a set of identical twins that share a placenta, they can get into trouble where they need very high-level surgery. And I don't think there's an MFM on the planet that would do that surgery without truly having trained. I mean, all that level of training may vary, but they're going to have had some level of training and hopefully will be well-qualified to do that. So, MFM doctors do not hesitate to refer. Here, for example, where I work for that surgery, they think of these needle-based procedures as being different. They have a better skill level to do these.
And to be honest, I think with time, these procedures are less likely. And with advancements in the field, made them become less likely. So then, I think patients will be referred more readily without pushback. But for now, I think it's important. Again, although I hate to put the onus on the patient, but to advocate for yourself and realize that it is perfectly within your right to request second opinion to request care at somewhere else.
Molly Sherwood:
I love that you acknowledge that it's unfortunate but maybe necessary, that that burden is on the patient. And I think that explains or at least contributes to so much of the anxiety that we see in patients because they see it proven over and over again, "Oh, if I didn't ask this question, if I didn't worry about this, if I didn't research this, then this could have happened." And they realize that it actually is on them and they start to lose their trust. It starts to create a lot of fear and anxiety and responsibility. It's unfortunate, but I think right now in our disease, it's still necessary, which I hate. But it kind of is.
Dr. Kara Markham:
Right.
Bethany Weathersby:
And I think they don't want to hurt their doctor's feelings. That sounds silly, but really, it's a real issue. And also, confrontation is uncomfortable, especially if you're the patient and not the medical expert and you're saying, "I don't really love the care and I need a second opinion." That's so hard to say. I mean...
Dr. Kara Markham:
Right. That's really hard. You don't have to tell them.
Bethany Weathersby:
You're right. Thank you. That's a good point.
Dr. Kara Markham:
If you don't want to do the confrontation, don't say it.
Molly Sherwood:
Yeah.
Bethany Weathersby:
Yeah.
Dr. Kara Markham:
Not that I'm advocating for not telling your doctor things, but...
Molly Sherwood:
Right. But if in that case, yeah.
Dr. Kara Markham:
There are situations where it's not necessary.
Bethany Weathersby:
Okay, I remember what I wanted to say. Just I wish that we could somehow get the mindset out there that doctors cannot know everything about every condition and they're not expected to, and the patients can know that too and understand that they are human. Right now, it seems like the doctor is like a God. They know everything and they can treat everything. I don't know if physicians feel that expectation on them or that pressure.
Dr. Kara Markham:
I think that belief is changing. With younger doctors, I think there is more of a recognition of one's limitations. But it is going to be a slow change.
Bethany Weathersby:
And just coming from my patient perspective, I love when a doctor says, "I don't know." Really. That gives me so much confidence in that doctor because they're admitting what they don't know. And if they're like, "I'm going to look into it and get back to you," that makes me feel so safe.
Dr. Kara Markham:
I can't tell you the number of times I've said to patients, "Your doctor did the right thing they sent you to me. Perfect. I couldn't be happier with what they did."
Bethany Weathersby:
I think that perceived sense of, "Oh, I'm inadequate if I refer this patient." It's actually the opposite.
Molly Sherwood:
Maybe it just depends on where they trained, but how much exposure do you think the average MFM gets to IUTs?
Dr. Kara Markham:
It really does depend where one trains. You've got larger volume centers and lower volume centers. I don't think the average exposure is robust. I don't think that if I had... When I came out of fellowship, I wasn't ready to just go out on my own and do transfusions. I still had that relationship and I had a very heavy, because that was what I was planning to do. My third year of fellowship is three-year process, was there for almost all of them and it was a high volume center. But even then, I still had that mentor relationship for at least a couple of years before I've said, "Okay, I can do this on my own."
So I think even at high volume centers, there may be some situations depending on where they're going to practice or where they have been trained, that they are competent coming right out of fellowship. But I think for most MFMs, there's ongoing skill development and learning that occurs after fellowship.
Bethany Weathersby:
All right. We have a couple more questions that came from our Instagram. It says, "When I need blood after delivery," which is an if question. Hopefully, no one needs. "If I need blood after delivery, do both antibodies I have in transfused blood need to be null? Meaning, does the blood I receive have to be negative for both of the antigens that I have antibodies to?"
Dr. Kara Markham:
Ideally, yes. And the reason I say ideally and not just a strong yes is if you're in an emergency situation, they're going to give you O-negative blood and they're not going to type cross that for all the other antigens. But yes, if you're getting blood, it's necessary. But there's levels of emergency, right? So, if time permits and/or we already have that data, then yes. If you have a big E and little c antibodies, then they're going to cross-match the blood so that the blood they give you is big E-negative and little c-negative, so they don't trigger a response for you.
Bethany Weathersby:
And one way to avoid that stressful situation is to just make sure that your doctors are ordering blood ahead of time before you go in to deliver. Not that we can always predict exactly when we will deliver. But if you can, if you have a scheduled induction or C-section, make sure that they have donor blood on hand for you that's matched with your antibodies just in case.
Dr. Kara Markham:
And oftentimes, that situation will delay things. Meaning, that if I have somebody who has these antibodies, she comes in that day and needs a C-section and it's not emergency... Yes, we need to do the C-section but we've got some time, we're not going to go back for the C-section until I know that we have blood available that is specifically matched to her. So even if the blood hasn't been gotten beforehand, if you have time, you can still do things safely. And blood banks know that. That's what they do all day every day.
Bethany Weathersby:
Good to know. All right, just a few more quick questions. This was another awkward one, so I will ask you. Unless you want to, Molly?
Molly Sherwood:
Okay. I'm not dying to. You go ahead.
Bethany Weathersby:
Personally, I am asked by this question a lot and I think a lot of women feel embarrassed to ask it. Which I always feels, I guess, like an honor that they feel safe enough to ask me. But they're like, "There's no one else in my life that I could ask this weird question."
Okay, here's the question. Is it safe to have an orgasm during pregnancy if you have antibodies? Since orgasm causes blood flow to increase, does that mean my antibodies are increasing towards my baby?
Dr. Kara Markham:
I would never be embarrassed to ask an OB-GYN that question because that's what we deal with day in and day out. Pregnancy may be my specialty, but women's health is my passion, and that includes all aspects of women's health. But the shorter answer is we really don't know if that causes increased antibody levels. But it kind of gets back to that question about the placenta. Just because there's more blood flow to the uterus doesn't mean there's going to be more antibody that crosses the placenta because it's not a wide open channel allowing antibodies to go from mother to baby. There is a transport system and that can be saturated to where... I mean, my thought would be it's such a short-lived process that it's not going to cause any harm.
Bethany Weathersby:
Good to know. All right. So, have all the orgasms.
Dr. Kara Markham:
Do you. You could do it.
Bethany Weathersby:
Yeah, you do you.
Dr. Kara Markham:
Exactly. Stress relief is important.
Bethany Weathersby:
You're right. All right.
Molly Sherwood:
We have one more question. We'll try to be quick and then we're going to do my special quiz.
Bethany Weathersby:
Yes, we got to do that. Okay.
Molly Sherwood:
I insist. I'm excited about it. Okay. Why would my titer go up if my baby is supposedly antigen negative?
Dr. Kara Markham:
Short answer is we don't know.
Molly Sherwood:
Cool. But it does happen, yeah.
Dr. Kara Markham:
It may be just related to the immune response of the mother changing in pregnancy.
Molly Sherwood:
And her blood flow. I mean, the amount of blood she's producing is just going up in general, right? Like, her total blood volume.
Dr. Kara Markham:
Total blood volume increases. Usually, things get diluted though, like red blood cells. Yes, there's increased red blood cell production but it's at the same level as increased vascular blood volume, so it gets diluted. Which is why women are usually anemic. But my short answer is probably just related to the immune system changing in pregnancy. But if you know your baby is negative, I don't care if you have a bazillion antibodies. If your titer is a bazillion, there's nothing for it to bind to, it's not going to cause anemia.
Bethany Weathersby:
Yes. Good point.
Molly Sherwood:
Okay, guys. Let's do the special quiz.
Bethany Weathersby:
Let's do it, Molly.
Molly Sherwood:
Okay. I feel like many people wonder how their disease and their story compares to other allo moms. I mean, all the time, people are like, "What are the chances my titers might go up?" Or, "Who else has anti-M antibodies?" Or whatever. They always want to know these things. So, we are going to turn to our patient questionnaire study with which both of you were heavily involved with the development of the study. And it gave us so many gems that I really appreciate looking at because I think one thing that's very valuable about it is we have 127 moms participate and they reported on 200 allo pregnancies. And it's spread out across the country, so a lot of publications that come out about our disease are from centers that routinely treat this disease and are very, very good at it. And they publish their results on their outcomes in their centers, which is so helpful in its own way but it doesn't give us this broad understanding of what the disease looks like across the country.
Keep in mind, these are all US alloimmunized women. So I'm going to give you some questions about these pregnancies and you can each guess, and then I'll tell you the answers. And I wrote the answers down somewhere else so you guys can't see them in the script.
Bethany Weathersby:
Ooh, I love it.
Molly Sherwood:
So, nobody knows the answer to these.
Okay. What do you guys think are the top three antibodies that allo women have?
Dr. Kara Markham:
I still think D and Kell. Big C, maybe?
Molly Sherwood:
Interesting, okay. What do you think, Bethany?
Bethany Weathersby:
I would say Kell and D. And I'm going between little c and E, but I think I'm going to go with little c.
Molly Sherwood:
Okay.
Dr. Kara Markham:
And they might say M. It's common. It just usually doesn't cause a problem.
Bethany Weathersby:
Wow.
Molly Sherwood:
So in this order, Kell, big E, and D.
Bethany Weathersby:
Oh. We were both wrong.
Molly Sherwood:
Isn't that cool? And it's different for different countries.
Dr. Kara Markham:
Big E would've been my next guess.
Molly Sherwood:
Yeah. So-
Dr. Kara Markham:
I can always say that after the fact.
Molly Sherwood:
Yeah, right. I know. It depends. I was looking up some other countries just to get a variety for us. In Nigeria, by the way, the sensitization rate in one study I found in Nigeria of 1,200 pregnant women, 5.8% of them were sensitized. Whereas the typical for the US is less than 1%. And their most common antibodies were D, LeB, and LeA, which is the Lewis blood group. And big C.
Bethany Weathersby:
Whoa.
Dr. Kara Markham:
Wow. It makes sense because it's a resource-poor nation, so they don't have-
Molly Sherwood:
Right. They're not getting RhoGAM consistently.
Dr. Kara Markham:
And it also makes a lot of sense that it varies by nation because of the genetics involved.
Molly Sherwood:
Right.
Bethany Weathersby:
Yes.
Dr. Kara Markham:
So, different populations have different chance of being negative for an antigen. And if all population is negative for that... Not all. Most of the population is negative, then nobody's going to form antibodies to that.
Molly Sherwood:
Right.
Dr. Kara Markham:
That's interesting.
Molly Sherwood:
Isn't that cool? I have one from Sweden. The Swedish have this awesome pregnancy registry of over a million pregnancies that I would just give anything to do to study on it. But anyway, they keep really good electronic health record data. Anyway, their sensitization rate is 1.3% and their most common antibodies are big D, big E, and LeA from the Lewis blood group.
Bethany Weathersby:
Wow.
Dr. Kara Markham:
I wonder if we're even checking for LeA. I mean, we don't usually even report it. Well, maybe report it but it's clinically insignificant.
Molly Sherwood:
Interesting.
Bethany Weathersby:
Good question.
Dr. Kara Markham:
And I will say I'm not dissing the Swedish, our wonderful Swedes. That is a wonderful pregnancy database but it is also very homogenous.
Molly Sherwood:
Yes, that's probably true.
Bethany Weathersby:
Absolutely.
Molly Sherwood:
That's a good point.
Dr. Kara Markham:
I mean, they're wonderful, but you see a publication that they put and it's like 99% Caucasian, BMI 20. You're like, "Okay." [inaudible 00:37:38]
Bethany Weathersby:
Totally applicable here.
Molly Sherwood:
Yeah, that's a good point.
Bethany Weathersby:
Right.
Molly Sherwood:
And then last one, Korea. Sensitization rate, 2.8%. Same three antibodies in that order. D, E, LeA.
Dr. Kara Markham:
Wow.
Bethany Weathersby:
Interesting. Can I just say one? I know we were running out of time but I got to say one thing about Korea. I used to live in Korea and teach English in Korea. I love that country and the people there. Part of their culture is you are supposed to check blood type with you and your partner before you get married.
Molly Sherwood:
Wow.
Bethany Weathersby:
That has always been their tradition.
Molly Sherwood:
Interesting.
Bethany Weathersby:
And it stems from this. I mean, it's like generations and generations and generations. You had to go have your blood type checked before you were allowed to get married.
Molly Sherwood:
That's so interesting.
Dr. Kara Markham:
I'm going to South Korea in one week.
Bethany Weathersby:
Seriously?
Molly Sherwood:
What? [inaudible 00:38:11]
Dr. Kara Markham:
Yes.
Bethany Weathersby:
Is that your first time going? Oh, I got to give you some...
Dr. Kara Markham:
Yeah, I'm really exited.
Bethany Weathersby:
Are you going to Seoul?
Dr. Kara Markham:
Seoul and Jeju Island. I think that's how you pronounce it. And-
Bethany Weathersby:
Yes, that's the best.
Dr. Kara Markham:
... what is the other... There's another bigger city.
Bethany Weathersby:
Busan?
Dr. Kara Markham:
Yes.
Bethany Weathersby:
Yes. That's close, too.
Dr. Kara Markham:
My niece was adopted from South Korea and she just graduated from high school. So, the family trip for her graduation.
Bethany Weathersby:
Oh my goodness.
Molly Sherwood:
Cool.
Bethany Weathersby:
Jeju Island is amazing.
Dr. Kara Markham:
I heard it's beautiful.
Bethany Weathersby:
It's like volcanic rock, beaches, and... Okay. All right. Anyway, I thought it was interesting that- [inaudible 00:38:41]
Sorry. That they, still today, check the blood type-
Dr. Kara Markham:
It's interesting.
Bethany Weathersby:
... based on that [inaudible 00:38:44].
Dr. Kara Markham:
It's surprising that their sensitization would be +2%, yeah.
Molly Sherwood:
Yeah. Surprising that it's 2.8%.
Bethany Weathersby:
You're right, yeah.
Molly Sherwood:
That was 1,500 pregnant women.
Dr. Kara Markham:
I guess, it depends on what they're checking for. I mean, you can check for all the antigen that's under the sun.
Molly Sherwood:
Yeah, that's true.
Bethany Weathersby:
Yeah.
Molly Sherwood:
Okay. What percent of alloimmunized pregnancies... In our samples, that's 200 pregnancies from 127 women. So, some of this was their second or so on pregnancy. What percent of those do they have more than one antibody?
Bethany Weathersby:
Oh, gosh.
Dr. Kara Markham:
I'm going to say 40.
Molly Sherwood:
Hmm?
Bethany Weathersby:
Thirty percent.
Molly Sherwood:
Forty-three.
Bethany Weathersby:
Wow, Dr. Markham.
Dr. Kara Markham:
That's kind of a cheat. Ohio State where I trained had this big database and we looked at that. So it was like 40% D, 40% multiple, and then 20% of other mishmoshes.
Molly Sherwood:
How interesting. Okay, cool. That's good for me to see that this is perhaps, a good representative sample.
Dr. Kara Markham:
Yeah. If someone has a publication, it's me showing that there are worse outcomes, unfortunately, with multiple antibodies.
Molly Sherwood:
Yes. Oh, that's cool. I must've read that before I knew you because I have read that study, too.
Dr. Kara Markham:
There're two. There's one by [inaudible 00:39:37] and then we kind of piggybacked off of it.
Bethany Weathersby:
Oh, yeah. Yes.
Molly Sherwood:
Cool. We'll have to link to that. Okay. What percent of alloimmunized pregnancies ended up being antigen positive? Meaning, the baby did have the antigen that the mom's antibodies attacked. So we would call these pregnancies affected.
Dr. Kara Markham:
Seventy.
Bethany Weathersby:
Fifty-two percent.
Molly Sherwood:
This is so fun. I'm loving this right now. Seventy-nine.
Dr. Kara Markham:
Oh, my. What?
Molly Sherwood:
Yeah, 79.
Bethany Weathersby:
Seriously?
Dr. Kara Markham:
It makes sense if you think about them having the same partner, you're already self-selected for that partner who has those antigens. So then, it's not going to be that 50/50 consideration you might get if it's new partners type of thing. That's why I guess a higher than-
Molly Sherwood:
Yeah.
Bethany Weathersby:
Wow.
Dr. Kara Markham:
But that's still higher than [inaudible 00:40:17].
Bethany Weathersby:
I'm blown away by that, yeah.
Molly Sherwood:
This is so fun, guys. All right. There's three more questions. What percent of affected pregnancies, the ones we just talked about, where the baby who does have the antigen do titers reach critical?
Dr. Kara Markham:
Sixty?
Bethany Weathersby:
Now, I just want to copy whatever you say.
Dr. Kara Markham:
No, don't.
Bethany Weathersby:
Okay. My real answer would be... I'm going to go low. I'm going to lowball at 40%.
Molly Sherwood:
Eighty-three, guys. Eighty-three.
Bethany Weathersby:
Oh my gosh.
Dr. Kara Markham:
Oh, that's high.
Molly Sherwood:
I think it could be also a lot... The top antibody in our group was Kell, and we call any titer critical.
Dr. Kara Markham:
Yeah, that's true.
Bethany Weathersby:
That is true. But still.
Molly Sherwood:
Yeah, it's a lot.
Dr. Kara Markham:
They also have the self-selected populations to answering the survey.
Molly Sherwood:
Okay. What percent of pregnancies with affected babies and with a critical titer... So this is the group we just talked about. So, affected babies with a critical titer require an IUT.
Dr. Kara Markham:
I'd say 50.
Bethany Weathersby:
Forty-five.
Molly Sherwood:
Forty-one.
Dr. Kara Markham:
Nice pick up.
Bethany Weathersby:
I guess that makes sense because I think I've always heard that 50% of babies will be affected, but then some of them will be far enough along that they get delivered and therefore won't need an IUT. So I guess, less than 50% makes sense.
Molly Sherwood:
Cool. Okay, I'm glad this is kind of tracking. This is good. All right, last one. What percent of affected antigen positive babies require NICU time? Any NICU time.
Dr. Kara Markham:
Eighty-five.
Bethany Weathersby:
I would say, 70.
Molly Sherwood:
Sixty-three.
Bethany Weathersby:
Oh.
Dr. Kara Markham:
Cool. That's lower than I would've thought.
Molly Sherwood:
Isn't it interesting?
Dr. Kara Markham:
We always told, training in medicine, if you don't know the answer, either say 15 if you think it's low or 85. So, that's why [inaudible 00:41:35] that one.
Molly Sherwood:
I love that logic.
Dr. Kara Markham:
You'd be surprised how often you're somewhere in the right.
Bethany Weathersby:
Wow. But that is a tricky one because some severely affected babies do not need NICU time.
Dr. Kara Markham:
They need care after the fact.
Bethany Weathersby:
My daughter had five IUTs and then my son had seven IUTs. Neither one of them required any NICU time because they were not producing any of their own red blood cells and they were tanked up. And so, it came weeks later.
Molly Sherwood:
That was good.
Dr. Kara Markham:
That's good information to give patients, for sure.
Molly Sherwood:
Yeah. So that'll be our first paper that we'll all be on.
Dr. Kara Markham:
Can't wait. Yeah, we'll talk about that more.
Bethany Weathersby:
This was really fun.
Molly Sherwood:
This was so fun.
Dr. Kara Markham:
It was fun, yes.
Molly Sherwood:
We should've done this way longer. We probably need to let Dr. Markham [inaudible 00:42:11].
Bethany Weathersby:
We do. We got it right now. Okay. Thank you so much for sharing your time and your expertise with us. I feel like I learned so much just during this recording for that.
Dr. Kara Markham:
Thank you for inviting me. And I think more importantly, thank you for the work you guys do. It is unbelievably important for these patients who are somewhat at sea, and you give them something to hold on to. So, thank you.
Bethany Weathersby:
Whether you're a patient, provider, or otherwise affected by antibodies in pregnancy, we are here for you. We have great resources on our website at allohopefoundation.org. That's allo, spelled A-L-L-O, hopefoundation.org.
Molly Sherwood:
Thanks for listening. The Allo Podcast is a production of the Allo Hope Foundation. It was researched and written by Bethany Weathersby and me, Molly Sherwood. It is produced and edited by CJ Housh and Eric Hurst of Media Club. The Allo Podcast is sponsored by Janssen Pharmaceutical Companies of Johnson & Johnson.