When Brittany Pineda learned she was pregnant with her fourth child, she knew she would go to The Fetal Center1 at Children’s Memorial Hermann Hospital in Houston for pregnancy care.
“There was never any question about it,” says Pineda, who lives in Metairie, Louisiana, with her husband, Carlos Pineda, and their three children. “By the time I was pregnant with my third child, a son, I knew of Dr. Moise but wasn’t yet an expert on Rhesus alloimmunization.” Maternal-fetal medicine specialist Kenneth J. Moise, MD, is co-director of The Fetal Center at Children’s Memorial Hermann Hospital and a professor with dual appointments in the department of Obstetrics, Gynecology and Reproductive Sciences and the department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth).
During her first pregnancy, Pineda was unaware that her blood was Rh negative and her husband’s was Rh positive. “When they drew my blood before inducing labor, they discovered the Rh sensitization,” she says.
Rhesus alloimmunization, also known as Rh-induced hemolytic disease of the fetus and newborn (HDFN) and erythroblastosis fetalis, occurs in response to an antibody formed by the mother, most commonly after a miscarriage or during delivery when the baby’s Rh-positive blood mixes with the mother’s Rh-negative blood. It is preventable when Rh-negative women with Rh-positive partners are given injections of Rhesus immune globulin to halt the production of antibodies, typically at 28 weeks of pregnancy and again after delivery.
The Pinedas had a second daughter in June 2014, and by her third pregnancy, Brittany Pineda was well aware that she had Rh antibodies but was unaware of how at risk she was.
“At 21.4 weeks we did an intrauterine transfusion in New Orleans, and my son passed away after the procedure,” Pineda says. “I had read that death from the procedure is extremely rare, with a risk of only 1 percent. We fell in that 1 percent.”
When Pineda became pregnant again in March of 2018, she communicated by phone and email with Dr. Moise, whom she found by joining a closed maternal isoimmunization support group on Facebook. Her maternal-fetal medicine specialist in New Orleans ordered an indirect Coombs test, or titer, to check her blood for antibodies that might attack her baby’s red blood cells. The result showed a titer of 2048, higher than the critical value range of 16 to 32.
After plasmapheresis at 10 weeks failed to bring her antibody titer down and intravenous immune globulin (IVIG) caused severe headaches, Dr. Moise asked her to go to her local maternal-fetal medicine specialist for an in-utero Doppler ultrasound of her son’s middle cerebral artery (MCA) to measure the peak systolic velocity. The test indicated the baby was anemic.
At that point, she transferred her care to Dr. Moise and the couple started traveling to Houston. In July 2016, at 15 weeks and four days of pregnancy, with a high titer and high MCA reading, Dr. Moise did an intrauterine transfusion in the baby’s abdomen. It was the earliest one he had ever done.
In total, Pineda had nine transfusions, at weeks 15, 16, 18, 20, 22, 25, 27, 29, and 32. “We made the 10-hour drive between our home and Houston for each transfusion,” she says. “There was never a question about doing it. Dr. Moise’s expertise and knowledge are astonishing. I trusted him with my child’s life.”
At 20 weeks, Dr. Moise tried to hit the umbilical cord for a transfusion and the needle popped out. “Knowing that I’d lost a son to a cord accident, I wanted to wait before doing another transfusion,” she says.
At 25 weeks, her baby had a very slow heart rate and almost required an emergency delivery by C-section. “We thought we were going to lose him. The entire team was there in the OR ready to deliver if we needed them,” she says. “It was very scary but I knew I was in great hands. The baby’s heart rate resolved on its own, and I was happy that I had made it to viability after losing my first son.”
After two more intrauterine transfusions, Pineda faced a decision. “I could deliver at 32 weeks or go to Houston for my ninth transfusion. I knew I was a severe case. I had already had the maximum number of transfusions Dr. Moise had done. I wrote down my pros and cons, and I thought, I’ve trusted him eight times and now I’ll trust him with number nine. My goal was to get to 34 or 35 weeks.”
At 35 weeks, Pineda faced another decision: whether to deliver in New Orleans or go to Houston for a tenth transfusion in hopes of carrying her baby to full term. “I was taking phenobarbitol to help mature his liver. He wasn’t moving as much with the drug, and Dr. Moise directed me to go to the hospital in New Orleans right away. ‘Let’s get him out to make sure he’s okay,’ he said. I was induced that night and Mikah Kristian Joseph was delivered on November 18, 2018. We chose his second middle name to honor Dr. Kenneth Joseph Moise.”
“My only regret was not delivering in Houston,” Pineda says. “When you walk through the doors of Children’s Memorial Hermann Hospital, everything about the place tells you it’s going to be okay.
“Mikah’s case was extreme, and we came out on the good side,” she adds. “The experience was a lot to go through and you pray that everything will work out. We’re very thankful for the children we have and feel that we’ve stopped in a good place. Mikah is doing amazingly well. We’re forever indebted to Dr. Moise.”
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Located within the Texas Medical Center, The Fetal Center is affiliated with McGovern Medical School at UTHealth Houston, UT Physicians and Children’s Memorial Hermann Hospital.