INTRODUCTION
During Pregnancy, the mother and the fetus
have different Rh protein factors, this
condition is called Rh incompatibility.
Like our blood type, we inherit our Rh factor
type from our parents. Most people are Rh-
positive, but a small percentage of people are
Rh-negative
Rh factor doesn’t directly affect the health.
However, Rh factor becomes important
during pregnancy.
Rh FACTOR
• Proteins (antigens) occurring only on surface of
RBC’s
• Rh + if proteins present
• Rh – if proteins absent
• A+, A-, B+, B-, AB+, AB-, O+, O-
• Most important for pregnancy
• Inheritance is Autosomal Dominant
• 15% Caucasian population are Rh-
Rh DISEASE?
Rhesus disease is a condition where antibodies in a
pregnant woman's blood destroy her baby's blood
cells. It's also known as haemolytic disease of the
fetus and newborn (HDFN).
If the mother is Rh-negative and her baby is Rh-
positive, during pregnancy (and especially during
labor and delivery) some of the fetus's Rh-positive red
blood cells may get into the mother's bloodstream.
SENSITIZATION – The process in which mother’s
body will try to fight them off by producing antibodies
against them.
Usually placenta acts as barrier to fetal blood entering
maternal circulation.However,sometimes during
pregnancy or birth,fetomaternal haemorrhage (FMH) can
occur. The woman’s immune system reacts by producing
anti-D antibodies that cause sensitisation
EVENTS FOR RHESUS DISEASE
Miscarriage
Termination of pregnancy
Antepartum haemorrhage
Invasive prenatal testing (amniocentesis cordocentesis
etc.)
Delivery
Ectopic pregnancy
PATHOPHYSIOLOGY
CAUSES
A difference in blood type between a pregnant woman and
her baby causes Rh incompatibility. The condition occurs if
a woman is Rh-negative and her baby is Rh-positive.
RISK FACTORS
This may have happened during:
An earlier pregnancy (usually during delivery).
An ectopic pregnancy, a miscarriage, or an induced
abortion. (An ectopic pregnancy is a pregnancy that starts
outside of the uterus, or womb.)
A mismatched blood transfusion or blood and marrow
stem cell transplant.
An injection or puncture with a needle or other object
containing Rh-positive blood.
SYMPTOMS
Rh incompatibility can cause symptoms ranging from very
mild to deadly.
Mildest form- Rh incompatibility:
1-Hemolysis (Destruction of the red blood cells) with the
release of free hemoglobin into the infant's circulation.
2- Jaundice (Hemoglobin is converted into, bilirubin which
causes an infant to become yellow.
Severe form- Rh incompatibility
1- Hydrops fetalis (Massive fetal red blood cell
destruction).
2- It causes Severe anemia Fetal heart failure
Death of the infant shortly after delivery.
Total body swelling.
Respiratory distress (if the infant has been delivered)
Circulatory collapse.
Kernicterus. (Neurological syndrome in extremely
jaundiced infants)
It occurs several days after delivery and is characterized
initially by...
A) Loss of the Moro reflex.
B)Poor Feeding.
C) Decreased activity
At last it may lead to death of the child immediately after
its birth
Diagnosis
MCA doppler
Cell free DNA
Kleihauer test
Amniocentesis and liley graph
Direct coomb’s test
SCREENING TESTS
ABO & Rh Ab at 1st prenatal visit At 28 weeks
Postpartum Bleeding
Antepartum bleeding and before giving any immune globulin
Neonatal bloods ABO, Rh
GOLD STANDARD TESTS
• Indirect Coombs:
mix Rh(D)+ cells with maternal serum
anti-Rh(D) Ab will adhere
RBC’s then washed & suspended in
Coombs serum
RBC’s coated with Ab will be agglutinated
• Direct Coombs:
mix infant’s RBC’s with Coombs serum
maternal Ab present if cells agglutinate
Ultrasound Parameters
Non Reliable Parameters:
Placental thickness
Umbilical vein diameter
Hepatic size
Splenic size
Polyhydramnios
Visualization of walls of fetal bowel from small amounts
intra abdominal fluid may be 1st sign of impending
hydrops
U/S reliable for hydrops (ascites, pleural effusions, skin
edema) – Hgb < 70
COMPLICATIONS
DURING PREGNANCY
Mild anemia, hyperbilirubinemia and jaundice.
Severe anemia with enlargement of the liver and spleen.
Hydrops fetalis.
AFTER BIRTH
Severe hyperbilirubinemia and jaundice.
Kernicterus
Management
Anti D immunoglobulin
Fetal blood transfusion (fetal Hct <30%)
Phototherapy
Routes of administration-
Into umbilical vein at the
point of cord insertion
Into intrahepatic vein
Into peritoneal cavity
Into fetal heart
Transfused blood-
RhD negative
Crossmatched with a maternal sample
Densely packed (Hb around 30g/L)
White cell depleted and irradiated
Screened for infection including CMV
PROPHYLACTIC VACCINATIONS
During every pregnancy
After a miscarriage or abortion
After prenatal tests such as amniocentesis
and chorionic villus biopsy
After injury to the abdomen during
pregnancy
