Manuel V. Gallego Foundation Colleges Inc.

Cabanatuan City

RH INCOMPATIBILITY

Rh incompatibility is a condition which develops when a pregnant woman has a Rh-negative blood type
and the fetus, she carries has Rh-positive blood type.

PATHOPHYSIOLOGY
Fetus Rh (+) blood

Mother Rh (-) blood

Rh antibodies form in mother’s blood within

72 hours after delivery or abortion of Rh (+)
baby

Fetus in subsequent
pregnancy

Hemolysis of RBC

Destroy RBC
serum bilirubin

production of immature RBC (erythroblasts) Jaundice

Unconjugated bilirubin pass to brain

Enlarged liver and
spleen

Kernicterus

Erythroblastosis fetalis
CAUSES
During pregnancy, red blood cells from the unborn baby can cross into the mother's bloodstream through
the placenta.

If the mother is Rh-negative, her immune system treats Rh-positive fetal cells as if they were a foreign
substance and makes antibodies against the fetal blood cells. These anti-Rh antibodies may cross back
through the placenta into the developing baby and destroy the baby's circulating red blood cells.

When red blood cells are broken down, they make bilirubin. This causes an infant to become yellow
(jaundiced). The level of bilirubin in the infant's bloodstream may range from mild to dangerously high.

Because it takes time for the mother to develop antibodies, firstborn infants are often not affected unless
the mother had past miscarriages or abortions that sensitized her immune system. However, all children
she has afterwards who are also Rh-positive may be affected.

Rh incompatibility develops only when the mother is Rh-negative and the infant is Rh-positive. Thanks to
the use of special immune globulins called RhoGHAM, this problem has become uncommon in the
United States and other places that provide access to good prenatal care.

CLINICAL MANIFESTATIONS
Mild Rh incompatibility:
•    Positive direct Coombs
•    Evidence of hemolysis in the infant’s blood
•    Elevated cord blood bilirubin

Hydrops fetalis:
•    Severe anemia
•    Heart failure (cardiac failure)
•    Enlarged liver (hepatomegaly)
•    Respiratory distress
•    Bruising or purplish bruise-like lesions on the skin (purpura)

Kernicterus — Early:
•    High bilirubin level (greater than 18 mg/cc)
•    Extreme jaundice
•    Absent Moro (startle) reflex
•    Poor breast-feeding or sucking
•    Lethargy

Kernicterus — Mid:
•    High-pitched cry
•    Arched back with neck hyperextended backwards (opisthotonos)
•    Bulging fontanel (soft spot)
•    Seizures

Kernicterus — Late (full neurological syndrome):

•    High-frequency hearing loss
 •    Mental retardation
•    Muscle rigidity
•    Speech difficulties
•    Seizures
•    Movement disorder
DIAGNOSTIC TESTS
Early Diagnosis – Pregnancy for Rh incompatibility
 H/O previous blood transfusions
 Blood group and Rh status of pregnant woman
 Rh antibody titer for Rh negative woman at the first pregnancy visit and repeat at 32-38 weeks of
pregnancy (ICT)
 Normal titer is    0
 Minimal ratio     1:8
 Chorionic villus sampling in early pregnancy.
 Amniocentesis and amniotic fluid spectrophotometry for bilirubin
 Regular ultrasound from 14-18 weeks onwards – look for fetal ascites and subcutaneous edema
(hydrops fetalis)

Early Diagnosis – After Birth for Rh incompatibility

 Determination of fetal blood group and test for alloimmunization (DCT) from cord blood at the
time of delivery.
MEDICAL MANAGEMENT
Since Rh incompatibility is almost completely preventable with the use of RhoGAM, prevention remains
the best treatment. Treatment of the already affected infant depends on the severity of the condition.

Mild:
 Aggressive hydration
 Phototherapy using bilirubin lights

Hydrops fetalis:
 Amniocentesis to determine severity
 Intrauterine fetal transfusion
 Early induction of labor
 A direct transfusion of packed red blood cells (compatible with the infant’s blood) and also
exchange transfusion of the newborn to rid the blood of the maternal antibodies that are
destroying the red blood cells
 Control of congestive failure and fluid retention

Kernicterus:
 Exchange transfusion (may require multiple exchanges)
 Phototherapy

NURSING MANAGEMENT
During Phototherapy:

1. Remove clothing to proper skin exposure.

2. Turn infant frequently to expose all skin area.
3. Record and report jaundice and blood levels of bilirubin.
4. Record and report if any change in body temperature
5. Cover and check eyes with eye patches to prevent eye injury.
a. Be sure the eyes close before applying eye patch to prevent corneal irritation
b. Should be loose enough to avoid pressure.
c. Eye patches should be changed every 8houly and eye care given.
6. Nurse should expect the infant’s stools to be green and the urine dark because of
photodegradation products.
7. Serum bilirubin and hematocrit should be monitored during therapy and for 24 hours following
therapy.
8. In case of breast milk jaundice stop breast feeding temporarily.
9. Maintain feeding intervals to prevent dehydration.

PREVENTION
 Screening for the blood group of all pregnant women.
 Arrange for further investigations if the woman is Rh negative.
 Anti D (RhoD or RhoGAM) injection 300µg IM for the mother at 28 weeks of gestation.
 Anti D (RhoD or RhoGAM) injection 300µg IM for the mother within 72 hours of an abortion,
delivery of Rh positive baby or after procedures like amniocentesis or chorionic villus sampling.