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RH Isoimmunisation
RH Isoimmunisation
Definition:
The Red Cells Of The Fetus Or Newborn Are Destroyed By
Maternally Derived Alloantibodies
Innocuous Antibodies:
Most Of These Antibody Are IgM Therefore Cannot Cross The Placental Barrier
E.G. Those Directed Against Such Specificities As A, P(1), Le(a), M, I, IH And
Sd(a).
IgG antibodies, Their Corresponding Antigens Are Not Well Developed At Birth
E.g. Lu (b), Yt (a), And VEL —
Diagnosis of Rh isoimmunization
The Rh Antigen- Biochemical Aspects:
Du Variant
Frank D Positive
eCd/EcD D positive
Antigenicity of the Rh surface
protein:
genetic expression of the D
eCd allele.
Number of specific Rh
antigen sites.
Ec D Interaction of components of
the Rh gene complex.
Exposure of the D antigen
on the surface of the red cell
The Mechanism of Development of the Rh Immune Response:
Without treatment:
less than 20% of Rh D incompatible pregnancies
actually lead to maternal isoimmunization
ABO Incompatibility
Why Not All the Fetuses of Isoimmunized Women
Develop the Same Degree of Disease?
The Non-responders:
ABO Incompatibility:
o Second Step:
The RBCs are then washed and suspended in serum containing
antihuman globulin (Coombs serum).
Red cells coated with maternal anti-RhD will be agglutinated by
the antihuman globulin (positive indirect Coombs test).
The Direct Coombs Test
Ultrasonography
Amniocentesis
Indications:
Complications:
Total Risk of Fetal Loss Rate 2.7% (Fetal death is 1.4%
before 28 weeks and The perinatal death rate is 1.4% after
28 weeks).
Bleeding from the puncture site in 23% to 53% of cases.
Bradycardia in 3.1% to 12%.
Fetal-maternal hemorrhage: occur in 65.5% if the placenta
is anterior and 16.6% if the placenta is posterior.
Infection and abruptio placentae are rare complications
MONOCLONAL ANTI-D
Most polyclonal RhIg comes from male volunteers who are intentionally
exposed to RhD-positive red blood cells.
Potential Problems:
infectious risk
solve supply problems.
ethical issues
Blood Loss:
o Abnormal Placental Separation (Abruptio Placentae) Or Placenta Previa
o Traumatic Tear Of The Umbilical Cord
o Occult Blood Loss In Utero As A Result Of Fetomaternal Hemorrhage.
o A Chronic Twin-to-twin Transfusion In Identical Twins
Infections:
Hemoglobinopathies:
The RH Antigen
Diagnostic algorithm for neonatal anemia. *Note that the direct antiglobulin (Coombs)
Monthly Maternal Indirect Coombs Titre
Paternal Rh Testing
Rh Positive Rh-negative
Cordocentesis or Deliver
Paternal Rh Testing
Rh Positive Rh-negative
Repeat
Amniocentesis every < 35 to 36 weeks > 35 to 36
2-4 weeks And Fetal lung weeks Lung
immaturity maturity
Delivery at or near term present
Intrauterine
Transfusion
Repeat Amniocentesis
every 2-4 weeks
< 35 to 36 weeks > 35 to 36 weeks
And Fetal lung immaturity Lung maturity present
Delivery at or near term
Intrauterine Delivery
Transfusion
Finland — 10 to 12 percent
Indo-Eurasians — 2 percent
Blood and Rh(D) typing and an antibody screen should always be performed at the firs
Below the critical titer there is a risk of mild to moderate, but not severe, fetal or
neonatal hemolytic anemia. Fetal assessment with invasive techniques (eg,
amniocentesis, fetal blood sampling) is required when a critical titer is present
or if the patient has had a prior significantly affected pregnancy (eg, intrauterine
fetal transfusion, early delivery, fetal hydrops, neonatal exchange transfusion).
The purpose of these invasive tests is to determine whether severe fetal
anemia is present.
Ultrasonography