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Background
The Rh factor (ie, Rhesus factor) is a red blood cell surface antigen that was named after the monkeys in which it was first discovered. 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. Rh incompatibility can occur by 2 main mechanisms. The most common type occurs when an Rhnegative 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, [1] invasive obstetric procedures, or normal delivery. Rh incompatibility can also occur when an Rh-negative female receives an Rh-positive blood transfusion. In part, this is the reason that blood banks prefer using blood type "O negative" or "type O, Rh negative," as the universal donor type in emergency situations when there is no time to type and crossmatch blood. The most common cause of Rh incompatibility is exposure from an Rh-negative mother by Rh-positive fetal blood during pregnancy or delivery. As a consequence, blood from the fetal circulation may leak into the maternal circulation, and, after a significant exposure, sensitization occurs leading to maternal antibody production against the foreign Rh antigen. Once produced, maternal Rh immunoglobulin G (IgG) antibodies may cross freely from the placenta to the fetal circulation, where they form antigen-antibody complexes with Rh-positive fetal erythrocytes and eventually are destroyed, resulting in a fetal alloimmune-induced hemolytic anemia. Although the Rh blood group systems consist of several antigens (eg, D, C, c, E, e), the D antigen is the most immunogenic; therefore, it most commonly is involved in Rh incompatibility. Recommendations for screening for Rh incompatibility are available from the US Preventive Services Task Force.[2]

Pathophysiology
The amount of fetal blood necessary to produce Rh incompatibility varies. In one study, less than 1 mL of Rh-positive blood was shown to sensitize volunteers with Rh-negative blood. Conversely, other studies have suggested that 30% of persons with Rh-negative blood never develop Rh incompatibility, even when challenged with large volumes of Rh-positive blood. Once sensitized, it takes approximately one month for Rh antibodies in the maternal circulation to equilibrate in the fetal circulation. In 90% of cases, sensitization occurs during delivery. Therefore, most firstborn infants with Rh-positive blood type are not affected because the short period from first exposure of Rh-positive fetal erythrocytes to the birth of the infant is insufficient to produce a significant maternal IgG antibody response. The risk and severity of sensitization response increases with each subsequent pregnancy involving a fetus with Rh-positive blood. In women who are prone to Rh incompatibility, the second pregnancy with an Rh-positive fetus often produces a mildly anemic infant, whereas succeeding pregnancies produce more seriously affected infants who ultimately may die in utero from massive antibody-induced hemolytic anemia. Risk of sensitization depends largely upon the following 3 factors: 1. Volume of transplacental hemorrhage 2. Extent of the maternal immune response 3. Concurrent presence of ABO incompatibility The incidence of Rh incompatibility in the Rh-negative mother who is also ABO incompatible is reduced dramatically to 1-2% and is believed to occur because the mother's serum contains antibodies against the ABO blood group of the fetus. The few fetal red blood cells that are mixed with the maternal circulation

are destroyed before Rh sensitization can proceed to a significant extent. Fortunately, ABO incompatibility usually does not cause serious sequela. Rh incompatibility is only of medical concern for females who are pregnant or plan to have children in the future. Rh-positive antibodies circulating in the bloodstream of an Rh-negative woman otherwise have no adverse effects.

Epidemiology
Frequency
United States Only 15% of the population lack the Rh erythrocyte surface antigen and are considered Rh-negative. The vast majority (85%) of individuals are considered Rh positive. Rh sensitization occurs in approximately 1 per 1000 births to women who are Rh negative. The Southwest United States has an incidence approximately 1.5 times the national average, which likely is caused by immigration factors and limited access to medical care since blood typing is a routine part of prenatal care. Even so, only 17% of pregnant women with Rh-negative blood who are exposed to Rh-positive fetal blood cells ever develop Rh antibodies.

Mortality/Morbidity
During the course of Rh incompatibility, the fetus is primarily affected. The binding of maternal Rh antibodies produced after sensitization with fetal Rh-positive erythrocytes results in fetal autoimmune hemolysis. As a consequence, large amounts of bilirubin are produced from the breakdown of fetal hemoglobin and are transferred via the placenta to the mother where they are subsequently conjugated and excreted by the mother. However, once delivered, low levels of glucuronyl transferase in the infant preclude the conjugation of large amounts of bilirubin and may result in dangerously elevated levels of serum bilirubin and severe jaundice. Mildly affected infants may have little or no anemia and may exhibit only hyperbilirubinemia secondary to the continuing hemolytic effect of Rh antibodies that have crossed the placenta. Moderately affected infants may have a combination of anemia and hyperbilirubinemia/jaundice. In severe cases of fetal hyperbilirubinemia, kernicterus develops. Kernicterus is a neurologic syndrome caused by deposition of bilirubin into central nervous system tissues. Kernicterus usually occurs several days after delivery and is characterized by loss of the Moro (ie, startle) reflex, posturing, poor feeding, inactivity, a bulging fontanelle, a high-pitched shrill cry, and seizures. Infants who survive kernicterus may go on to develop hypotonia, hearing loss, and mental retardation. Another serious life-threatening condition observed in infants affected by Rh incompatibility is erythroblastosis fetalis, which is characterized by severe hemolytic anemia and jaundice. The most severe form of erythroblastosis fetalis is hydrops fetalis, which is characterized by high output cardiac failure, edema, ascites, pericardial effusion, and extramedullary hematopoiesis. Newborns with hydrops fetalis are extremely pale with hematocrits usually less than 5. Hydrops fetalis often results in death of the infant shortly before or after delivery and requires an emergent exchange transfusion if there is to be any chance of infant survival.

Race
Approximately 15-20% of Caucasians, as opposed to 5-10% of African Americans, have the Rh-negative blood type. Among individuals of Chinese and American Indian descent, the incidence of Rh-negative blood type is less than 5%.

CLINICAL PRESENTATION:

History
History of prior blood transfusion Rh blood type of the mother Rh blood type of the father (55% of Rh-positive men are genetically heterozygous for the Rh antigen and, therefore, produce Rh-negative offspring when mating with Rh-negative women 50% of the time.) Previous pregnancies, including spontaneous and elective abortions Previous administration of Rh IgG (RhoGAM) Mechanism of injury in cases of maternal trauma during pregnancy Presence of vaginal bleeding and/or amniotic discharge Previous invasive obstetric procedures, such as amniocentesis, cordocentesis, chorionic villous sampling, or ectopic pregnancy Note that a large fetal-maternal hemorrhage may occur without symptoms and with little or no evidence of trauma. Therefore, a high index of suspicion is warranted and a low threshold for treatment is indicated.

Physical
Evaluation of the vital signs and primary survey of the airway and cardiovascular system are indicated to ensure maternal stability. A thorough pelvic examination is required. In situations in which abdominal and/or pelvic trauma is a consideration, inspect for evidence of bruising that may suggest the possibility of significant fetomaternal hemorrhage. When an infant with an Rh-negative mother is delivered in the emergency department, a thorough physical examination of the infant must be performed after initial stabilization, and a neonatal clinician must be consulted immediately. Physical findings may vary from mild jaundice to extreme pallor and anemia with hydrops fetalis.

Causes
Factors that influence an Rh-negative pregnant female's chances of developing Rh incompatibility include the following: Ectopic pregnancy Placenta previa Placental abruption Abdominal/pelvic trauma In utero fetal death Any invasive obstetric procedure (eg, amniocentesis) Lack of prenatal care Spontaneous abortion

Laboratory Studies
Prenatal emergency care Determination of Rh blood type is required in every pregnant female. 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. When a high clinical suspicion of large fetomaternal hemorrhage is present (>30 mL blood), the Kleihauer-Betke acid elution test often is performed. The Kleihauer-Betke test is a quantitative measurement of fetal red blood cells in maternal blood, and it can be valuable for determining if additional amounts of Rh IgG should be administered. The amount of Rh IgG required for treatment after sensitization is at least 20 mcg/mL of fetal RBCs. Point-of-care blood tests have become available for use in the emergency department and have been shown to have very high sensitivity and specificity in determining Rh status. [3] Obtaining maternal Rh antibody titers can be helpful for future follow-up care of pregnant females who are known to be Rh negative and may be initiated from the ED. High levels of maternal Rh antibodies suggest that Rh sensitization has occurred, and further studies, such as amniocentesis and/or cordocentesis, may be necessary to evaluate the health of the fetus.

Postnatal emergency care Immediately after the birth of any infant with an Rh-negative mother in the ED or prehospital setting, 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. A positive direct Coombs test result confirms the diagnosis of antibody-induced hemolytic anemia, which suggests the presence of ABO or Rh incompatibility. Elevated serum bilirubin measurements, low hematocrit, and elevated reticulocyte count from the neonate can help determine if an early exchange transfusion is necessary. An emergent exchange transfusion, preferably performed in a neonatal intensive care setting with experience in this procedure, is required in infants born with erythroblastosis fetalis, hydrops fetalis, or kernicterus.

Imaging Studies
In the ED, ultrasonography of a pregnant female with suspected Rh incompatibility is limited to pelvic ultrasonography. Fetal ascites and soft tissue edema are definite signs of severe involvement. Once hydrops fetalis has developed, the sonographic evidence includes scalp edema, cardiomegaly, hepatomegaly, pleural effusion, and ascites.

Other Tests
Perform fetal monitoring in cases of suspected fetal distress. Abnormal fetal heart tones and ultrasonographic evidence of fetal or placental injury are indications of worsening fetal condition requiring emergent delivery, ideally in a center specializing in high-risk obstetric care.

TREATMENT: Prehospital Care

When possible, prehospital care personnel should direct their efforts on stabilization of the mother and infant, followed by immediate transport to a facility specializing in high-risk obstetric and neonatal care.

Emergency Department Care

ED care of the pregnant woman with Rh-negative blood and a suspected fetomaternal hemorrhage varies depending on the presentation of the patient and the gestational age of the fetus. If the mother has Rh-negative blood and has not been sensitized previously, administer human anti-D immune globulin (Rh IgG or RhoGAM) and refer the woman for further evaluation. If the mother has been sensitized previously, as determined by elevated level of maternal Rh antibodies, administration of Rh IgG is of no value. In this situation, prompt referral to a center that specializes in high-risk obstetrics is warranted. When an infant with Rh incompatibility is delivered in the ED, a more aggressive approach is required, centering on respiratory and hemodynamic stabilization of the infant and determining the need for an emergent exchange transfusion and phototherapy.

Consultations
Refer every pregnant female with Rh incompatibility to a medical center specializing in high-risk obstetric care.

MEDICATIONS:

Medication Summary
Rh IgG, first released for general use in 1968, has been remarkably successful in the prevention of Rh incompatibility. In the Rh-negative mother, the preparation is administered after a suspected fetomaternal hemorrhage. The exact mechanism by which passive administration of Rh IgG prevents Rh immunization is unknown. The most likely hypothesis is that the Rh immune globulin coats the surface of fetal RBCs containing Rh antigens. These exogenous antibody-antigen complexes cross the placenta before they can stimulate the maternal endogenous immune system B cells to produce IgG antibodies. Since Rh IgG became the standard of care in the United States, the risk of Rh incompatibility has been reduced from 10-20% to less than 1%. 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. 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. 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.

Blood derived product

Class Summary
This agent is effective in preventing Rh isoimmunization.
View full drug information

Human anti-D immune globulin (RhoGAM, BayRho-D, Rhophylac, HyperRho)

Suppresses immune response of nonsensitized Rh O (D) negative mothers exposed to Rh O (D) positive blood from the fetus as a result of a fetomaternal hemorrhage, abdominal trauma, amniocentesis, abortion, full-term delivery, or transfusion accident. Should be administered if the patient is Rh negative, unless the father also is Rh negative.

Follow up:
Further Inpatient Care
After administering Rh IgG in the ED, promptly refer the Rh-negative pregnant mother of an Rh-positive fetus to an institution equipped for high-risk obstetric care.

Deterrence/Prevention
Stress the importance of early prenatal care to each pregnant female who presents to the ED. Early administration of Rh IgG in conjunction with early prenatal care is the best means to prevent Rh incompatibility.

Complications
Emergent delivery of an infant with hydrops fetalis should be as nontraumatic as possible. Ideally, a neonatologist who is prepared to perform an exchange transfusion should attend to the infant immediately

nursingcrib.com/.../rh-incompa

RH Incompatibility
Definition Rh incompatibility is a condition which develops when a pregnant woman has an Rh-negative blood type and the fetus she carries has Rh-positive blood type. The Rh factor (ie, rhesus factor) is an red blood cell surface antigen that was named after the monkeys in which it was first discovered. Rh incompatibility, also known as Rh disease, is a condition that occurs when a woman with Rhnegative blood type is exposed to Rh-positive blood cells, leading to the development of Rh antibodies. Rh incompatibility can occur by two 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 delivery. Rh incompatibility can also occur when an Rh-negative female receives a blood transfusion that contains Rh antigens. In part, this is the reason that blood banks prefer using blood type O-negative or type-O, Rh negative, as the universal donor type, especially in females. The most common cause of Rh incompatibility is exposure to an Rh-negative mother by Rh-positive fetal blood during pregnancy or delivery, whereby red blood cells from the fetal circulation leak into the maternal circulation. After a significant exposure, sensitization occurs and maternal antibodies are produced against the foreign Rh antigen. Once produced, maternal Rh immunoglobulin G (IgG) antibodies may cross freely from the placenta to the fetal circulation, where they form antigen-antibody complexes with Rh-positive fetal erythrocytes and eventually are destroyed, resulting in a fetal alloimmune-induced hemolytic anemia. Although the Rh blood group systems consist of several antigens (eg, D, C, c, E, e), the D antigen is the most immunogenic; therefore, it most commonly is involved in Rh incompatibility. Causes, incidence, and risk factors During pregnancy, red blood cells from the fetus can get into the mothers bloodstream as she nourishes her child through the placenta. If the mother is Rh-negative, her system cannot tolerate the presence of Rh-positive red blood cells. In such cases, the mothers immune system treats the 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 the placenta into the fetus, where they destroy the fetuss circulating red blood cells. First-born infants are often not affected unless the mother has had previous miscarriages or abortions, which could have sensitized her system as it takes time for the mother to develop antibodies against the fetal blood. However, second children who are also Rh-positive may be harmed. Rh incompatibility can cause symptoms ranging from very mild to fatal. In its mildest form, Rh incompatibility causes hemolysis (destruction of the red blood cells) with the release of free hemoglobin into the infants circulation. Hemoglobin is converted into bilirubin, which causes an infant to become yellow (jaundiced). The jaundice of Rh incompatibility, measured by the level of bilirubin in the infants bloodstream, may range from mild to dangerously high levels of bilirubin. Hydrops fetalis is a complication of a severe form of Rh incompatibility in which massive fetal red blood cell destruction (a result of the Rh incompatibility) causes a severe anemia resulting in fetal heart failure, total body swelling, respiratory distress (if the infant has been delivered), and circulatory collapse. Hydrops fetalis often results in death of the infant shortly before or after delivery. Kernicterus is a neurological syndrome caused by deposition of bilirubin into the brain (CNS) tissues. Kernicterus develops in extremely jaundiced infants, especially those with severe Rh incompatibility. It occurs several days after delivery and is characterized initially by loss of the Moro (startle) reflex, poor feeding, and

decreased activity. Later, a high-pitched shrill cry may develop along with unusual posturing, a bulging fontanel, and seizures. Infants may die suddenly of kernicterus. If they survive, they will usually later develop decreased muscle tone, movement disorders, high-pitched hearing loss, seizures, and decreased mental ability. Rh incompatibility develops only when the mother is Rh-negative and the infant is Rh-positive. Special immune globulins, called RhoGAM, are now used to prevent this sensitization. In developed countries such as the US, hydrops fetalis and kernicterus have decreased markedly in frequency as a result of these preventive measures. Pathophysiology The amount of fetal blood necessary to produce Rh incompatibility varies. In one study, less than 1 mL of Rh-positive blood has been shown to sensitize volunteers with Rh-negative blood. Conversely, other studies have suggested that 30% of persons with Rh-negative blood never develop Rh incompatibility, even when challenged with large volumes of Rh-positive blood. Once sensitized, it takes approximately one month for Rh antibodies in the maternal circulation to equilibrate in the fetal circulation. In 90% of cases, sensitization occurs during delivery. Therefore, most firstborn infants with Rh-positive blood type are not affected because the short period from first exposure of Rhpositive fetal erythrocytes to the birth of the infant is insufficient to produce a significant maternal IgG antibody response. The risk and severity of sensitization response increases with each subsequent pregnancy involving a fetus with Rhpositive blood. In women who are prone to Rh incompatibility, the second pregnancy with an Rh-positive fetus often produces a mildly anemic infant, whereas succeeding pregnancies produce more seriously affected infants who ultimately may die in utero from massive antibody-induced hemolytic anemia. Risk of sensitization depends largely upon the following 3 factors: 1. 2. Volume of transplacental hemorrhage Extent of the maternal immune response

3. Concurrent presence of ABO incompatibility The incidence of Rh incompatibility in the Rh-negative mother who is also ABO incompatible is reduced dramatically to 1-2% and is believed to occur because the mothers serum contains antibodies against the ABO blood group of the fetus. The few fetal red blood cells that are mixed with the maternal circulation are destroyed before Rh sensitization can proceed to a significant extent. Rh incompatibility is only of medical concern when transfusion is needed and during pregnancy. Rh positive antibodies circulating in the bloodstream of an Rh-negative woman have no adverse effect in the nonpregnant state.

www.medicinenet.com/script/main/art.asp?.. He's Positive, She's Negative: What's That Do to Baby?

By Carolyn Strange WebMD Feature A: It's always a good idea for any couple to think ahead and prepare for pregnancy, so Mom and baby can be as healthy as possible. When facing the potential for Rh disease, as you two are, it's even more important. You'll probably want to educate yourselves about Rh incompatibility. And in any case, make sure you find a health-care provider who understands Rh disease, and with whom it's easy to communicate.

One thing is clear -- your baby will have type O blood. What's not clear is whether your baby's blood will be Rh-positive or Rh-negative, and that's what makes all the difference. Rh disease of the newborn arises from incompatibility of the Rh factor between the mother and baby. It's a bit simplistic, but you can think of the Rh factor as a protein that is either present (positive) or absent (negative) on red blood cells. Exact percentages vary with race, but most people are Rh-positive. A woman with Rh-negative blood has nothing to worry about if her baby is also Rh-negative, and a woman with Rh-positive blood need not worry at all. Problems arise only with Rh-negative mothers and Rh-positive babies. Usually the first pregnancy goes fine. It's a subsequent Rh-positive baby who may be at risk. The mother herself is in no danger. Normally, maternal and fetal blood supplies don't mix during pregnancy, but during childbirth, some fetal blood may enter the mother's system. If the mother is Rh-negative and the fetus is Rh-positive, the woman's immune system responds with antibodies to the Rh factor. The chances of responding, and the strength of the response, increase with each Rh-positive pregnancy. In a subsequent pregnancy these antibodies cross the placenta and enter fetal circulation. If the next fetus is also Rhpositive, the mother's antibodies destroy fetal red blood cells. The baby may be born anemic or jaundiced, and in severe cases many fetuses have died. Although treatments are available to save affected babies - including transfusing Rh-negative blood, sometimes even prior to birth - preventionobviously makes more sense. The trick is to block the mother's immune system from becoming sensitized to the Rh factor. An injection of anti-Rh antibodies (widely known by the trade name RhoGAM) given to the mother soon after birth neutralizes any fetal blood cells in her circulation before her immune system has a chance to respond. Subsequent pregnancies should be like the first, as if the woman was never exposed to the Rh factor. That's the theory, and quite often things work just that smoothly. Now for some real-life complexities. RhoGAM is useless if a woman is already sensitized. Any pregnancy event with the potential for fetal-maternal blood mixing can sensitize the mother. That includes certain placental abnormalities, tubal pregnancy, miscarriage and invasive procedures such as abortion or amniocentesis. The chances of mixing and sensitization are lower earlier in pregnancy, but there's still a risk. Most experts recommend a RhoGAM shot at 28 weeks to head-off sensitization, as well as after birth. RhoGAM doesn't hurt the fetus because there are different kinds of antibodies and the ones in RhoGAM are a type that won't cross the placenta, so never reach the fetus. Once a woman has had this shot, she should make sure everyone involved in her health care knows. Otherwise, when she has blood tests, they might wrongly assume that she has become sensitized. RhoGAM shots aren't necessary if the fetus has Rh-negative blood, but that usually isn't known until birth. An amniocentesis at 18 weeks can tell you, but also carries a small risk of sensitization. "When they do an amnio, the doctor should know she's Rh-negative and try not to go through the placenta," says Dr. Amos Grunebaum, director of Maternal-Fetal Medicine at St. Luke's-Roosevelt Hospital

Center in New York, and a vice president of OnHealth.com. "They should go to a doctor who will only stick once, and with the smallest possible needle," he says. In your case, whether your baby has Rh-negative or Rh-positive blood depends on your genes. You can be Rh-positive two ways. You might be what's called homozygous, meaning you carry two positive Rh-factor genes, one from each of your parents. If so, your baby will have Rh-positive blood. Or you might be what's called heterozygous, meaning you carry one negative and one positive gene. In that case, your baby has a 50/50 chance of having Rh-positive blood. If you happen to know that one of your parents is Rh-negative, then you know you have one negative gene and that you're heterozygous. If both your parents are Rh-positive, you can't assume anything, because, like you, they might be either heterozygous or homozygous, and you have no way of knowing which genes you got. Some people worry that RhoGAM is a blood product. "Nobody has ever gotten AIDS or hepatitis from it," Dr. Grunebaum says. You may hear that sometimes even with RhoGAM a woman becomes sensitized. That can happen, and it's unfortunate, but it's no reason to avoid the shot. Or you may hear that some Rh-negative women have given birth to multiple Rh-positive babies, without benefit of RhoGAM, and everyone was fine. That can happen, too, but it's no reason to take chances. The benefits of RhoGAM seem to far outweigh the risks, but you'll want to discuss this when you find that knowledgeable, communicative doctor.

www.pregnancy.org/.../rh-incompatibility-and...

Rh Incompatibility and Why You Need RhoGAM

In cases of Rh incompatibility, a baby's red blood cells have a substance called the Rh D factor, and the mother's blood cells do not. In medical terms, the baby is Rh positive and you are Rh negative. If some of the baby's red blood cells leak into your system, your body may produce antibodies to the Rh D factor (a condition called sensitization). These antibodies can cross the placenta and destroy the red blood cells in your unborn baby or in the next Rhpositive baby you have.

How Does it Occur?

Rh incompatibility occurs only if you are Rh negative and your baby is Rh positive. It does not occur if you are Rh positive and your baby is Rh negative. In most cases you will not be exposed to the baby's blood until you give birth. This usually means that your first baby is not affected. However, large amounts of the baby's blood often leak into the mother during delivery. If you are Rh negative, the next Rh-positive baby you have could have problems if you have developed antibodies. Occasionally, in the following situations, some of the baby's blood may leak into your system during pregnancy:

After amniocentesis or other invasive procedure During a miscarriage or abortion During an ectopic pregnancy If you bleed heavily during pregnancy. If you are Rh negative and you received Rh-positive blood in a transfusion, you may have developed antibodies that will cause Rh incompatibility. In most cases, development of antibodies (sensitization) can be prevented, but if antibodies are formed, they will cross the placenta and can cause serious damage to the red blood cells of an Rhpositive baby.

What are the Symptoms?

You will have no symptoms. Symptoms and signs of the problem are seen in the baby if he or she develops hemolytic disease. In this condition, the baby's red blood cells start to break down, causing anemia. The baby may have other problems due to the anemia, such as jaundice and, after birth, breathing problems. The baby might even die in the womb if too much of the baby's blood is destroyed.

How is it Diagnosed?
Women at risk for Rh incompatibility can be identified with the routine blood tests done at prenatal visits with the doctor. The tests include:

Blood type Rh type Antibody screening If you are Rh negative and have antibodies against the Rh D factor, Rh incompatibility may be a problem. If you are Rh negative, the blood of the baby's father should be tested. If the father's blood is Rh positive, the baby has a chance of inheriting Rh-positive blood from the father. If the father is Rh negative, there will not be a problem because the baby will have no chance of inheriting Rh-positive blood. Some of the tests used to diagnose and assess hemolytic disease in the baby before and after birth are:

Amniocentesis Cordocentesis Ultrasound Non-stress tests Blood tests

How is it Treated?
If you have already been sensitized by a previous birth, your baby may develop hemolytic disease before birth. If this happens, your baby may need a blood transfusion in the womb before birth. Sometimes early delivery by cesarean section is necessary. If you have not been sensitized, you will be given an injection of Rh-immune globulin at about 28 weeks of pregnancy, and within 72 hours after a birth, miscarriage, abortion, or amniocentesis. The Rh-immune globulin contains antibodies to the Rh D factor. These antibodies will destroy any red blood cells from the baby that have entered your blood. You will not have a chance to form your own antibodies to the Rh D factor. If you receive the injection at 28 weeks and after delivery, sensitization will be prevented and Rh incompatibility should not be a problem during your next pregnancy. It is important to receive Rh-immune globulin in all cases when the baby's blood could leak into your system, including:

Rh Incompatibility and Why You Need RhoGAM

All pregnancies including ectopic (tubal) pregnancies Early miscarriages After chorionic villus sampling After amniocentesis

How Long Will the Effects Last?

Sensitization usually doesn't happen until after the birth of an Rh-positive baby. Therefore, in most cases Rh incompatibility is not a problem during a woman's first pregnancy and delivery of an Rh-positive baby. However, later pregnancies and deliveries may be affected unless the mother is treated with Rh-immune globulin after EVERY birth, miscarriage, and abortion. Sensitization is permanent and the effects are usually worse with each subsequent pregnancy.

Preventing Problems with Rh Incompatibility?

This complication of pregnancy has not occurred often since the discovery of Rh-immune globulin (also called RhoGAM). Rh-immune globulin can prevent sensitization. It is given to an Rh-negative woman shortly after every delivery, miscarriage, or abortion. It is also given to a pregnant Rh-negative woman after amniocentesis, any bleeding episodes, and during the seventh month of pregnancy

Definition
One of the first tests performed at the beginning of a pregnancy is blood-type. This basic test determines your blood type and Rh factor. People with different blood types have proteins specific to that blood type on the surface of their red blood cells. There are four blood types (A, B, AB, and O). Each of the four blood types is additionally classified according to the presence of another protein on the surface of red blood cells that indicates your Rh factor. If you carry this protein, you are Rh positive. If you don't carry the protein, you are Rh negative. Most people, about 85%, are Rh positive. But if a woman who is Rh negative and a man who is Rh positive conceive a baby, there is the potential for incompatibility. The baby growing inside the Rhnegative mother may have Rh-positive blood, inherited from the father. Statistically, at least 50% of the children born to an Rh-negative mother and an Rh-positive father will be Rh positive.
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Blood Flow to Fetus

2011 Nucleus Medical Media, Inc.

Causes
Rh incompatibility occurs when a woman is Rh negative, but her fetus has inherited Rh-positive blood from the father. It rarely occurs in a woman's first pregnancy. She only becomes sensitized to the fetus's Rh-positive blood once she comes in contact with it. This is usually not until very late in pregnancy or during childbirth when fetal red blood cells can cross into the mothers blood system through the placenta or its attachment site to the uterus. This can also occur during a miscarriage , induced abortion , or ectopic pregnancy . In rare cases, it can happen during an amniocentesis or other invasive testing procedures related to pregnancy. A woman can also become sensitized to Rh-positive blood if she receives an incompatible blood transfusion . In most cases of Rh incompatibility, there are not disease manifestations. If maternal antibodies develop against Rh-positive proteins, then these antibodies could affect a current or future fetus during pregnancy. This is called Rh isoimmunization.
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Risk Factors
A risk factor is something that increases your chance of getting a disease or condition. Risk factors include: Being a pregnant woman with Rh-negative blood who had a prior pregnancy with a fetus that was Rh positive Being a pregnant woman who had a prior blood transfusion or amniocentesis Being a pregnant woman with Rh-negative blood who did not receive Rh immunization prophylaxis during a prior pregnancy with an Rh-positive fetus

Symptoms
Symptoms and complications only affect the fetus and/or newborn. They occur when standard preventive measures are not taken and can vary from mild to very serious. The mother's health is not affected. Symptoms of the fetus or newborn baby include: Anemia Swelling of the body (also called hydrops fetalis), which may be associated with: Heart failure Respiratory problems Early: High bilirubin level (greater than 18 mg/cc) Extreme jaundice Absent startle reflex Poor suck Lethargy

Kernicterus (a neurological syndrome), which can occurs in stages:

Intermediate: High-pitched cry Arched back with neck hyperextended backwards (opisthotonos) Bulging fontanel (soft spot)

Seizures Late: High-pitched hearing loss Intellectual disability Muscle rigidity Speech difficulties Seizures Movement disorder

Diagnosis
There aren't any physical symptoms that would allow you to detect on your own if you are Rh incompatible with any given pregnancy. If you are pregnant, it is standard procedure for your healthcare provider to order a blood test that will determine whether you are Rh positive or Rh negative. If the blood test indicates that you have developed Rh antibodies, your blood will be monitored regularly to assess the level of antibodies it contains. If the levels are high, an amniocentesis would be recommended to determine the degree of impact on the fetus.
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Treatment
Since Rh incompatibility is almost completely preventable with the use of prophylactic immunization (immune globulin injection of RhoGAM), prevention remains the best treatment.

Immune Globulin Injection

You will be given an injection of Rho immune globulin at week 28 of the pregnancy. This desensitizes your blood to Rh-positive blood. You will also have another injection of immune globulin within 72 hours after delivery (or miscarriage, induced abortion, or ectopic pregnancy). The injection further desensitizes your blood for future pregnancies.

Treatment to Newborn
Treatment of a pregnancy or newborn 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 newbornThis is done to rid the infant's blood of the maternal antibodies that are destroying the red blood cells. Control of congestive failure and fluid retention Exchange transfusion (may require multiple exchanges) Phototherapy

Kernicterus:

Outcome
Full recovery is expected for mild Rh incompatibility. Both hydrops fetalis and kernicterus represent extreme conditions caused by the breakdown of red blood cells, called hemolysis. Both have guarded outcomes; hydrops fetalis has a high risk of mortality. Longterm problems can result from severe cases, including:
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Cognitive delays Movement disorders Hearing loss Seizures

Prevention
Rh incompatibility is almost completely preventable. Rh-negative mothers should be followed closely by their obstetricians during pregnancy. If the father of the infant is Rh-positive, the mother is given a midterm injection of RhoGAM and a second injection within a few days of delivery. These injections prevent the development of antibodies against Rh-positive blood. This effectively prevents the condition. Routine prenatal care should help identify, manage, and treat any complications of Rh incompatibility. Last reviewed September 2011 by Igor Puzanov, MD Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

http://www.med.nyu.edu/content?ChunkIID=11595#prevention