Katlyn Carter

Practice Guideline Last updated: 10/22/18

Evaluation and Management of Different Blood Types and Factors

Definition:
Two Main Incompatibility Problems: ABO Incompatibility & Rh Incompatibility
ABO
Blood type is determined by the presence or absence of certain antigens or factors that are found
on the red blood cell (RBC). Human blood is divided into four major factor groups: A, B, AB,
and O. Each major factor has a specific protein or antigen (called an agglutinogen or isoantigen).

Blood Group Isoantigen on RBC Isoantibodies in Serum

O Functionally silent Anti-A & Anti-B (universal donor)
A A Anti-B
B B Anti-A
AB A and B Neither (universal recipient)
(Frye, 2007)

ABO incompatibility is more common, but relatively less severe, than other blood
incompatibilities. It occurs only when the newborn blood cells contain the A- or B-antigen.
There are only a few A and B antibody-binding sites on the fetal RBC and most anti-A and anti-
B isoantibodies are IgM (a variety too large to cross the placenta). Those that do cross the
placenta can bind to other cells besides RBCs. ABO reactions only rarely worsen with
subsequent children. Infants at risk are as follows:

 A or B infants for to O mothers (represent 50% of cases that develop problems)

 B or AB infants born to group A mothers
 A and AB infants born to group B mothers
 Babies from one of the above categories who become jaundiced within 24 hours
with varying degrees of anemia, reticulocytosis, and RBC destruction who have a
positive direct antiglobulin (Coombs) test; and for whom other causes of
hemolysis can be ruled out

The risk of maternal Rh sensitization after a pregnancy with an ABO-compatible, RhD-pos fetus
is 16%, but if the baby is ABO-incompatible, RhD-Pos, the incidence falls to 1.5-2%.
(Frye, 2007, p. 130)
Rh
Rh stands for Rhesus monkey (a species that was commonly used in blood factor-related
research). Rh factors are second only to the major ABO blood groups in reactivity. The Rh factor
was first identified in the 1930’s as a protein sometimes bound to red blood cells. People that
have this protein are identified as Rh positive (Rh+) and those without it are Rh negative (Rh-).
The Rh factor is differentiated as antigens C, D, E, c and e, with D being the antigen most
frequently associated with hemolytic disease of the fetus and newborn. These four account for
more than 99% of the clinical issues involving the Rh system (there are other minor factors other
than RhD that can pose a risk to the fetus, see below). A woman who does not have the protein
(so, Rh-) can react and her antibodies can attack Rh(D) + blood and is incompatible. This can
have devastating effects on the mother and the fetus. The mother can become sensitized from a
previous blood transfusion or a mixing of blood from a previous pregnancy then the infant was
Rh positive.

If the mother has had an antibody reaction (called immunoglobulin antibodies or IgG), this can
cause problems with future pregnancies in the event the future fetus is Rh positive. These IgG
antibodies can easily cross the placenta and attach themselves to any antigens found on Rh (D)
positive red blood cells. This can result in fetal hydrops, fetal anemia, hemolysis,
erythroblastosis fetalis, and stillbirth. An effected baby may develop anemia, jaundice, and/or
other blood-related problems.

In the 1960’s, an anti-D serum was created and approved to be given in the third trimester and
after birth if the infant is Rh+ (or in the event of miscarriage, abortion, trauma, or any situation in
which maternal and fetal blood may mix at any point in the pregnancy or immediate postpartum).
This provides passive immunization for women that prevent them from developing permanent
antibodies, protecting future fetuses from an antibody attack. However, treatment using anti-D
immunoglobulin is unnecessary if the fetus is also Rh-, so further testing may be done including
testing the father. If he is also Rh-, no further testing is necessary. If mother is Rh- and father is
Rh+, further testing is necessary.

Other (accounting for less than 1% of clinical issues involving the Rh system)
Minor Factors Other than RhD That can Pose a Risk to the Fetus (Frye, 2007, p. 138)

 Minor Factors Associated with Severe Hemolytic Disease

Antigen System Specific antigen within each system
Kell K (K1)
Rhesus c
Private Good, Wright
  Less Common Factors Associated with Mild to Severe Hemolytic Disease (for complete
list see Frye, 2007, p. 138-139)

Antigen System Specific antigen within each system

Cotton Coa, Co3
Diego ELO, etc.
Duffy Fya

Assessment (FIRST Trimester)

 Risk Factors (in the 1st Trimester)
 Lab tests confirm mother is Rh negative
 Previous blood transfusions
 Unexplained fetal losses
 Stillbirth
 Ectopic pregnancy
 Termination of pregnancy at more than 8 weeks since LMP

 Subjective Symptoms
 If the woman reports that she or her partner is Rh negative
 If the woman reports experiencing any other risk factors
 Previous RhIG injection

 Objective Symptoms
 Lab tests confirming mother is Rh negative
 Maternal blood shows antibodies

 Clinical Test Considerations:

 Blood type and factor & antibody screen (indirect antiglobulin test) at onset of care
 If mother is RhD positive (or weak RhD pos with neg antobody screen) no further
testing is necessary
 If mother is RhD neg OR she has a pos antibody screen for a problematic factor, test
the (biological) father
 If the mother and father are RhD neg, no further testing is necessary
 If the mother is neg and father is pos, further tests or precautions ARE necessary.
(if an antibody screen comes back positive, labs routinely do an antibody ID to
determine the specific type of antibodies detected)

Management Plan
 Therapeutic measures to consider:
 Attempt to minimize the chances of blood-mixing occurring during pregnancy (for those
who wish to minimize sensitization problems, who may refuse RhIG (for religious or
other reasons), or those who were previously sensitized to a minor factor)
 A good diet to help establish and strengthen the placental bed
 Citrus fruit and juice 3 times daily and a daily dose of 1000 mg vit C to help
strengthen the placenta and membranes
 Eliminate fluoridated water and toothpaste
 1 g powdered, activated charcoal daily to help absorb toxins
 1 tsp magnesium powder in water daily
 Kelp, sea vegetables, or mineral supplements daily to strengthen the placenta
 ½ cup elder flower infusion daily as anti-inflammatory
(Frye, 2007. p. 141)
 Complimentary measures to consider:
 Client education and shared decision making
 Consider more regular antibody screening during pregnancy for those who refuse
RhIG (Every 4 weeks)

 Considerations for pregnancy

 Miscarriage
 Stillbirth
 Problems with future pregnancies

 Client and family education

 Provide information about the following
 Rh and blood type status
 Rh immune globulin
 Prophylaxis and desired result
 Potential risks with RhIG
 Transfusion0type adverse reactions
 Mercury sensitivity or reactions with RhoGAM
 Potential risks without RhIG
 Maternal sensitization
 Fetal hydrops or other complications with future pregnancies
 Difficulty of cross-matching blood for the woman in the future
 Potential for jaundice in the infant due to Rh or ABO incompatibility
(Tharpe, et al., 2016)

 Follow-up
 Document
  Consider further testing
 If mother is RhD positive (or weak RhD pos with neg antobody screen) no further
testing is necessary
 If mother is RhD neg OR she has a pos antibody screen for a problematic factor, test
the (biological) father
 If the mother and father are RhD neg, no further testing is necessary
 If the mother is neg and father is pos, further tests or precautions ARE necessary.
(if an antibody screen comes back positive, labs routinely do an antibody ID to
determine the specific type of antibodies detected)
 For those who refuse antenatal RhIG, perform antibody screen (indirect Coombs) every 4
weeks

Indications for Consult, Collaboration, or Referral

 OB/GYN or perinatology
 For Rh-negative mother with a positive antibody screen
 Evidence of large fetomaternal bleed
 Transfusion-type reactions
 For diagnosis outside the midwife’s scope of practice
(Tharpe, et al., 2016)

__________________________________________________________________
Assessment (SECOND Trimester)
 Risk Factors (in the 2nd Trimester)

 Subjective Symptoms
 Objective Symptoms
 Clinical Test Considerations:

Management Plan
 Therapeutic measures to consider:
 Complimentary measures to consider:
 Considerations for pregnancy, delivery, and breastfeeding
 Client and family education
 Follow-up
Indications for Consult, Collaboration, or Referral
__________________________________________________________________
Assessment (THIRD Trimester)
 Risk Factors (in the 3rd Trimester)
 Lab
 Subjective Symptoms
 Objective Symptoms
 Clinical Test Considerations:

Management Plan
 Therapeutic measures to consider:
 Complimentary measures to consider:
 Considerations for pregnancy, delivery, and breastfeeding
 Client and family education
 Follow-up

Indications for Consult, Collaboration, or Referral

References
Frye, A. (2007). Understanding Diagnostic Tests in the Childbearing Year: A Holistic Approach.
Labrys Press.

King, T. L., Brucker, M. C., Kriebs, J. M., & Fahey, J. O., Gegor, C. L., Varney, H.
(2015). Varney's midwifery. Jones & Bartlett Learning.

Sullivan, A. (2006). Midwife's Guide to Antenatal Investigations. Elsevier Health Sciences.

Tharpe, N. L., Farley, C. L., & Jordan, R. G. (2016). Clinical practice guidelines for midwifery
& women's health. Jones & Bartlett Publishers.