Transfusion – Antenatal Serology —
Training activity: 2

Details

Perform investigation and interpret results for pregnancies at risk of HDFN

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Triage of samples to inform testing
• Perform antibody investigations and interpret clinical significance relating to guidelines
• Interpret additional antibody panels as required

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to investigating and interpreting results for pregnancies at risk of HDFN.
• Review learning outcomes which relate to standards/guidelines, performing/interpreting investigations for HDFN, identifying testing algorithms, and predicting the risk of HDFN.
• What criteria define a successful investigation and accurate interpretation in this context?
• What are the expected outcomes of applying appropriate testing algorithms and interpreting results correctly to predict HDFN risk?
• Discuss with your training officer to understand the range of investigations you should be competent in and the expected level of detail in your interpretations.

What is your prior experience of this activity?

• Think about what you already know about the aetiology and pathogenesis of HDFN and the factors determining the clinical relevance of an antibody.
• What do you know about the common laboratory investigations for HDFN, such as antibody screening, identification, titration, and quantification?
• Consider possible challenges you might face in performing or interpreting these tests, such as:
  • Weak antibodies
  • Complex antibody mixtures, or
  • Interpreting titration/quantification trends

Think about how you might handle these.

• Recognise the scope of your own practice for this activity, meaning knowing when you would need to seek advice regarding difficult antibody interpretations, unexpected results, or high-risk cases.
• Acknowledge how you feel about undertaking this activity, recognising the potential impact of your results on patient management.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in performing HDFN-related serological techniques and applying testing algorithms.
• Identify the specific insights you hope to gain into correlating laboratory findings with clinical risk and applying your knowledge of HDFN pathogenesis.

What additional considerations do you need to make?

• Consult actions identified following previous experience with antibody investigations or titration/quantification.
• Identify important information you need to consider before embarking on the activity, such as relevant antenatal serology standards and guidelines, the patient’s history e.g., previous transfusions, pregnancies, affected babies, and previous antibody results.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate during the investigation and interpretation of results for pregnancies at risk of HDFN?
• Are you encountering situations such as:
  • Unexpected results or discrepancies e.g., atypical antibody behaviour or results not fitting the patient’s known history, requiring you to consider alternative explanations
  • Challenges arising from weak antibodies, prozone effects, incomplete patient history, or the urgency of the request
  • Complex antibody mixtures or difficulty interpreting quantification/titration trends

How are you reacting to the unexpected development?

• How is this impacting your actions? Did you adapt or change your approach to the investigation or interpretation in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately making decisions about interpreting atypical antibody behaviour and adjusting the testing plan based on the findings
  • Adapting your serological technique e.g., performing dilution steps or using different enhancement methods to handle weak antibodies or prozone effects
  • Seeking immediate expert advice from a senior colleague or clinical scientist if you are uncertain about the significance of a finding or if the interpretation is complex
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your investigation algorithm to complex cases? Is it affecting your confidence in justifying the interpretation and planned next steps?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying the testing algorithms, or needing support because the interpretation of a rare antibody is beyond your current scope for interpretation and reporting?
• What are you learning as a result of the unexpected development? For example, are you learning a more effective approach to interpreting complex titration trends, or gaining critical insight into the correlation between laboratory findings and clinical risk prediction for HDFN?

 

On action

What happened?

• Begin by summarising the key points of the experience of investigating and interpreting results for a pregnancy at risk of Haemolytic Disease of the Foetus or Newborn (HDFN). What initial screening and follow-up tests did you consider or perform e.g., IAT, antibody quantification/titration?
• Consider specific events, actions, or interactions which felt important, such as specific results that were challenging to interpret or integrate with clinical information. Acknowledge how you felt when faced with potentially complex findings.
• Include any ‘reflect-in-action’ moments where you adapted to the situation as it unfolded. For instance, describe when your immediate interpretation of a test result (e.g., a rising antibody titre) led you to immediately adapt your investigation plan or flag the case as higher risk.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding the specific laboratory features that indicate risk of HDFN and how to interpret complex results. What skills in performing or interpreting tests for HDFN investigation e.g., titration/quantification did you develop? Were there knowledge gaps about specific antibody characteristics, HDFN pathogenesis, or testing algorithms?
• Compare this experience against previous engagement with similar activities. For instance, has your ability to recognise and investigate pregnancies at risk of HDFN improved?
• Identify any challenges you experienced e.g., interpreting weak antibodies, limited clinical details and how you reacted to these. Were you able to overcome them effectively?
• Did you need to seek advice or clarify results or interpretation with a senior scientist or clinician? Did you ensure your interpretation and suggestions were within your scope of practice?
• Acknowledge any changes in your own feelings now you are looking back on the experience regarding your confidence in investigating and interpreting results for HDFN risk.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt. For example, identifying specific areas related to HDFN investigation or interpretation that you need to study further e.g., specific antibody types, criteria for intervention.
• How will this experience change your approach to interpreting serology results in pregnant patients?
• Do you need to practise any aspect of the activity further, such as performing or interpreting specific tests like antibody titration or quantification?

Beyond action

Have you revisited the experiences?

• Reviewing your past experiences investigating and interpreting results for pregnancies at risk of Haemolytic Disease of the Foetus or Newborn (HDFN), what specific actions for development did you identify in previous reflections? Have you focused on improving your knowledge of specific antibodies, understanding testing algorithms, or nuances of result interpretation in this context? How ready are you to apply this enhanced knowledge in performing these investigations and interpretations?
• Have you engaged in professional storytelling or discussions with colleagues about complex HDFN cases or the interpretation of challenging antibody results? Did these conversations provide new insights that have altered your perspective on investigating and interpreting results for HDFN?

How have these experiences impacted upon current practice?

• How does your accumulated experience and reflection on performing and interpreting HDFN investigations prepare you for observed ‘in-person’ assessments such as a DOPS on performing antibody quantification/titre, or an OCE discussing clinically significant antibody results with an obstetrician/midwife?
• How has your understanding of HDFN investigations and interpretation developed and evolved over time? Are you more confident in investigating higher-risk pregnancies or interpreting unexpected results? Can you now more readily identify situations where expert advice is needed regarding HDFN investigations and interpretation, ensuring you are working within your scope of practice?

Relevant learning outcomes

#	Outcome
# 1	Outcome Practice in accordance with antenatal serology standards and guidelines.
# 2	Outcome Perform acceptance testing of samples requiring antenatal investigation.
# 3	Outcome Perform and interpret clinical and laboratory investigations to identify cases of haemolytic disease of the fetus or newborn (HDFN).
# 4	Outcome Identify sequential testing algorithms appropriate to the samples under investigation for HDFN.
# 5	Outcome Predict current and future pregnancies at highest risk of HDFN.