Rh Incompatibility

Rh Incompatibility or Isoimmunization is defined as the development of antibodies

against the antigens of another individual of the same species. The antigens which are present

on the human red blood cells (RBCs) are mainly ABO antigens (A, B, AB), rhesus D antigen

(Rh-D) and infrequently other atypical rhesus (Rh) antigens. The ABO blood group antigens

may also sometimes cause isoimmunization in a mother having O positive blood group and

carrying an A, B or AB positive fetus. When a woman and her unborn baby carry different

Rhesus (Rh) protein factors, their condition is called Rh incompatibility. It occurs when a woman

is Rh-negative and her baby is Rh-positive.

Rh stands for rhesus monkeys, in whose blood this antigen was first found. A simple

blood test can determine blood type, including the presence of the Rh factor. About 85 percent of

white Americans and 95 percent of African Americans have the Rh factor and are known as Rh-

positive. Those without the Rh factor are Rh-negative. A positive or negative symbol after

your blood type indicates your Rh factor. For example, “blood type: AB+” might be written on

your medical record. The Rh factor is a specific protein found on the surface of your red blood

cells. Like your blood type, you inherit your Rh factor type from your parents. Most people are

Rh-positive, but a small percentage of people are Rh-negative. This means they lack the Rh

protein.

Rh incompatibility, also known as Rh disease, is a condition that occurs when a woman

with Rh-negative blood type is exposed to Rh-positive blood cells, leading to the development of

Rh antibodies. The Rh discovery had immediate practical importance because it explained a

relatively common medical disorder known as erythroblastosis fetalis. In this condition, an Rh-
negative woman who becomes pregnant with an Rh-positive fetus (an unborn child) sometimes

develops anti-bodies against the Rh factor in the fetus. This development usually causes no

problem during the woman's first pregnancy, since the number of anti-bodies produced tends to

be small.

Rh incompatibility can occur by 2 main mechanisms. The most common type occurs

when an Rh-negative pregnant mother is exposed to Rh-positive fetal red blood cells secondary

to fetomaternal hemorrhage during the course of pregnancy from spontaneous or induced

abortion, trauma, invasive obstetric procedures, or normal delivery

ANATOMY AND PATHOPHYSIOLOGY

Rh factor is an antigen found on the surface of red blood cells. Red blood cells with the

antigen are said to be Rh positive (Rh+). Those without the surface antigen are said to be Rh

negative (Rh-). Blood used in transfusions much match donors for Rh status as well as for ABO

blood group, as Rh- patients will develop anemia if given R+ blood. Rh typing is also important

during abortion, miscarriage, pregnancy, and birth, as mother and fetus may not be Rh-

compatible.

Your Rh factor doesn’t directly affect your health. However, Rh factor becomes

important during pregnancy. Rh factor plays a critical role in some pregnancies. If a woman who

is Rh-negative becomes pregnant by a man who is Rh-positive, the fetus may inherit the Rh

factor from its father and be Rh-positive. If the blood of the fetus becomes mixed with the

mother's Rh-negative blood, a disease called erythroblastosis fetalis can occur in future

pregnancies, resulting in destruction of the fetus's red blood cells, brain damage, and even death.
The mixing of blood does not normally occur but may take place before or during birth if a tear

in the placenta (the organ through which nutrients pass from the mother to the fetus) allows some

fetal blood to enter the mother's circulatory system. If this happens, the fetus's red blood cells

bearing the Rh factor stimulate the mother's white blood cells to produce antibodies against the

foreign antigen. The mother's blood is now sensitized to the Rh factor.

Once a mother's blood is sensitized, the antibodies her body produces in response to the

Rh antigen can cross the placenta and attach to the red blood cells of any Rh-positive fetus that

she carries. This results in the rupture of the fetus's red blood cells, causing anemia (a condition

marked by weakness and fatigue due to a reduced number of red blood cells). Severe anemia can

lead to heart failure and death. The breakdown of red blood cells also causes the overproduction

of a reddish-yellow substance called bilirubin. An infant with high levels of bilirubin will

develop jaundice (have a yellowish appearance) and may suffer brain damage.
CLINICAL MANIFESTATIONS

Rh incompatibility symptoms in your unborn baby can range from mild to life-

threatening. When your antibodies attack your baby’s red blood cells, hemolytic disease can

occur. This means your baby’s red blood cells are destroyed.

When your baby’s healthy red blood cells are destroyed, bilirubin will build up in their

bloodstream.

Bilirubin is a chemical that’s created from the breakdown of red blood cells. Too much

bilirubin is a sign that the liver, which is responsible for processing old blood cells, is having

trouble. Your baby may have one or more of the following symptoms if their bilirubin levels are

high after birth:

 jaundice, a yellowing of the skin and whites of the eyes

 lethargy

 low muscle tone

These symptoms will subside after completing treatment for the Rh incompatibility.

DIAGNOSTIC FINDINGS

1. In a pregnant woman with Rh-negative blood type, the Rosette screening test often is

the first test performed. The Rosette test can detect alloimmunization caused by very

small amounts of fetomaternal hemorrhage.

2. Amniotic bilirubin scan (also known as ΔOD450) is a prenatal testing procedure

. Results interpreted using a Liley or Queenan chart (Queenan chart is reported to

have higher diagnostic accuracy for identifying severe anemia). The Liley curve is

divided into three zones.

A result in Zone I indicates mild or no disease. Fetuses in zone I are usually followed

with amniocentesis every 3 weeks.

A result in zone II indicates intermediate disease. Fetuses in low Zone II are usually

followed by amniocentesis every 1-2 weeks.

A result above the middle of Zone II may require transfusion or delivery.

3. Obtaining maternal Rh antibody titers can be helpful for future follow-up care of

pregnant females who are known to be Rh negative. Maternal serum antibody Rh titer

>15 IU/mL indicates high risk of severe fetal anemia.

 4. Immediately after the birth of any infant with an Rh-negative mother examine blood

from the umbilical cord of the infant for ABO blood group and Rh type, measure

hematocrit and hemoglobin levels, perform a serum bilirubin analysis, obtain a blood

smear, and perform a direct Coombs test.

5. A positive direct Coombs test result confirms the diagnosis of antibody-induced

hemolytic anemia, which suggests the presence of ABO or Rh incompatibility.

TREATMENT

PREGNANT MOTHER

The current recommendation is that every Rh-negative nonimmunized woman who

presents to the ED with antepartum bleeding or potential fetomaternal hemorrhage should

receive 300 mcg of Rh IgG IM. For every 30 mL of fetal whole blood exposed to maternal

circulation, 300 mcg of Rh IgG should be administered [1]. A lower 50-mcg dose preparation of

Rh IgG is available and recommended for Rh-negative females who have termination of

pregnancy in the first trimester when fetomaternal hemorrhage is believed to be minimal.

Because of its short half-life, Rh IgG routinely is administered once at 28-32 weeks’

gestation and again within 72 hours after birth to all Rh-negative pregnant females as a part of

routine prenatal care.

NEONATE
 You will not need treatment for Rh incompatibility problems, but your baby might. He may

need to be delivered early. He may also need any of the following:

 Phototherapy: This is done to help reduce jaundice.

 Blood transfusions: Blood transfusions may be given through the umbilical cord and after

birth to treat severe anemia.

 Immunoglobulins: This is an injection of antibodies to help reduce the destruction of red

blood cells.

NURSING MANAGEMENT

https://emedicine.medscape.com/article/797150-overview

https://medicalnotebook.wordpress.com/2012/12/04/rh-incompatibility-in-pregnancy/

https://link.springer.com/article/10.1007/s40556-014-0013-z