RH INCOMPATIBILITY

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.
 INTRODUCTION

• 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.
• A condition that occurs during pregnancy if
a blood and her
blood. Mother’s body create Rh
antibodies against the baby’s blood.
• Also known as haemolytic disease of the
fetus and newborn(HDFN).

Oct-15
4
Rhesus Incompatibility
 Potential sensitizing events for Rhesus Disease

• Miscarriage
• Termination of pregnancy
• Antepartum haemorrhage
• Invasive prenatal testing (amniocentesis,
cordocentesis etc.)
• Delivery
• Ectopic pregnancy
●
An rh +ve father and rh -ve mother may conceive an rh +ve
baby

●
This usually isnt a problem if it’s the mothers 1 st pregnancy with an rh
+ve child because the blood circulation is separate from that of the baby

●
At birth or after an abortion or misscarriage rh +ve blood cells from the baby enter the mothers
blood stream. And mothers immune system recognizes the cells as foreign and develops antibodies
against them

●
In a subsequent preg.with an rh +ve baby there is the risk that it will develop rh disease . Even
though the blood circulation of the mother is separate from that of the child , the antibodies in her
system can cross the placenta

●
Enter the blood stream of the baby and cause its RBC to be killed

A reduction in the RBC leads to the the condition  hemolytic anemia. Hemolytic anemia is a
●

condition in which red blood cells are destroyed faster than the body can replace them.
●
Red blood cells contain hemoglobin an iron-rich protein that carries oxygen to the body.
Without enough red blood cells and hemoglobin, the baby won't get enough oxygen.
●
Hemolytic anemia can cause mild to severe signs and symptoms in a newborn, such as
jaundice and a buildup of fluid.

●
Jaundice is a yellowish color of the skin and whites of the eyes. When red blood
cells die, they release hemoglobin into the blood. The hemoglobin is broken
down into a compound called bilirubin. This compound gives the skin and eyes
a yellowish color. High levels of bilirubin can lead to brain damage in the baby.

●
The buildup of fluid is a result of heart failure. Without enough
hemoglobin-carrying red blood cells, the baby's heart has to work harder to
move oxygen-rich blood through the body. This stress can lead to heart
failure.

●
Heart failure can cause fluid to build up in many parts of the body. When this
occurs in a fetus or newborn, the condition is called hydrops fetalis.
●
Severe hemolytic anemia can be fatal to a newborn at the time of birth or
shortly after.
 CAUSES •Abdominal/pelvic
trauma
•Ectopic pregnancy •In utero fetal death
• Partial molar •Any invasive obstetric
pregnancy procedure (eg,
•Blighted amniocentesis)
ovum •Lack of prenatal care
•Antepartum •Postpartum
bleeding (Rh+baby)
•External •Spontaneous
version abortion
•Platelet
• Hemolytic anemia
• Progressive anemia which eventually leads
to congestive HF and tissue hypoxia
• Portal HPT ~ obstruction of the portal
veins
• Hydrop fetalis- generalized edema
• Kernicterus- unconjugated bilirubin crosses
the BBB and damages the basal ganglia
• Jaundice-⬆bilirubin in infant’s blood 1
Oct-15 Rhesus Incompatibility
2
 SIGNS IN AN UNBORN BABY
• Rh incompatibility can cause symptoms
ranging from very mild to deadly. In its
mildest form, Rh incompatibility causes the
destruction of red blood cells. There are no
other effects.
• If the baby develops rhesus disease while still
in the womb, they may become anaemic
because their RBCs are being destroyed faster
than usual by the antibodies. If the anaemic is
severe, internal swelling may result.
Oct-1
13
 SIGNS IN A NEWBORN BABY

• Hemolytic anemia
₋ Pale,
₋ increased breathing rate,
₋ poor feeding
• Jaundice
₋ Dark skin
₋ Yellow sclera, palms and soles
• Kernicterus
•₋ Motor sensory and mental deficiencies
• Low muscle tone (hypotonia)
• Lethargy
• Swelling or edema (hydrops fetalis)

Oc15
 Signs of fetal anemia

• Polyhydramnios
• Enlarged fetal heart
• Ascites and pericardial effusions
• Hyperdynamic fetal circulation
(MCA doppler)
• Reduced fetal movements
• Abnormal CTG with reduced
variability
 COMPLICATION

During
After birth
pregnancy
●
Mild anemia, ●
Severe
hyperbilirubinemia and
jaundice. hyperbilirubine
●
Severe anemia with mia and
enlargement of the liver
and spleen.
jaundice.
●
Hydrops fetalis. ●
Kernicterus
 INVESTIGATIONS:
• At the first antenatal visit, all women are
screened for blood and Rh type.
• If a woman has Rh-negative blood, the
paternal blood type and zygosity (if paternity
is certain) are determined. If the father has
Rh-positive blood, maternal Rh antibody titres
are measured at 26 to 28 weeks.
• Maternal serum antibody titre is a guide to
disease severity.

Oct-15 Rhesus Incompatibility 17

 INVESTIGATION CON….
Anti-D level Outcome
<4IU/mL HDFN unlikely
4-15IU/mL Moderate risk of HDFN
>15IU/mL High risk of hydrops fetalis

• If antibody levels rise, the baby should be

examined for signs of anaemia.
• Fetal middle cerebral artery (MCA) blood flow is
measured at intervals of 1 to 2 weeks depending
on titres and patient history. The purpose is to
detect high-output heart failure and fetal anaemia.
• Using MCA doppler: the peak of MCA velocity
– Rise - high probability of anemia
Oct-15 Rhesus Incompatibility 18
 INVESTIGATION CON….
• Spectral photometry of amniotic fluid - used to measure
the level of bilirubin as an indirect indicator of fetal
haemolysis.
• Ultrasound examination of the fetus at risk for Rh
incompatibility may reveal subcutaneous oedema, ascites,
pleural effusion, or pericardial effusion, all of which are
consistent with severe fetal anaemia in an affected fetus.
• A rosette test can be used to rule out significant
fetomaternal haemorrhage. If results are positive, a
Kleihauer-Betke (acid elution) test or flow cytometry can
measure the amount of fetal blood in the maternal
circulation.

Oct-15 Rhesus Incompatibility 19

 MANAGEMENT
IDENTIFICATION

UNSENSITIZED
PREGNANCY
MANAGEMENT

MANAGEMENT

SENSITIZED
PREGNANCY MANAGEMENT
 MANAGEMENT OF RH-VE UNSENSITIZED
PREGNANCY
I. Identification of pregnancies at risk at the initial
ANC visit.
– Determine blood group & Rh factor and indirect
coombs test for antibody screening for all
pregnant mothers.
II. Management of unsensitized pregnancy
• Repeat indirect coombs test at 28 weeks and at
36 weeks. If negative consider antepartum
prophylaxis with 300 micrograms of anti D
gamma globulin at 28 weeks. If positive manage
as sensitized pregnancy.

Oct-15 Rhesus Incompatibility 21

 MANAGEMENT OF RH-VE UNSENSITIZED
PREGNANCY
• Provide anti D prophylaxis in cases with amniocentesis,
APH, external cephalic version.
• Following delivery determine blood group of the newborn
and antibody screening. If the newborn is Rh negative no
further treatment is needed. If newborn is Rh positive and
antibody screen is positive, monitor the newborn for
haemolysis and manage next pregnancy as sensitized and
give anti D gamma globulin to mother within 72 hours. The
usual dose is 300 micrograms but ideally should be
determined by the extent of fetomaternal hemorrhage.
This is done by performing Kleihauer Betke test (acid
elusion test). For abortion of less than 12 weeks gestation
the dose is 50 micrograms.

Oct-15 Rhesus Incompatibility 22

 MANAGEMENT OF SENSITIZED
MOTHER
• Measurement of antibody levels in titers at
regular intervals,
• Amniocentesis for bilirubin levels
• Serial ultrasound for detection of hydrops and
management of neonatal anemia and
hyperbilirubinemia.
• Therefore, referral of these women is the
correct approach at health center level.

Oct-15 Rhesus Incompatibility 23

 Treatment

• Intrauterine transfusion
• Elect time of delivery
• Exchange transfusion after delivery
• Phototherapy after delivery
• Top-up transfusion
(Hb falls below 7g/dl, prophylactic :oral folate)

Oct-15 Rhesus Incompatibility 24

 Intrauterine transfusion
• The fetus can die in utero from severe anaemia and
hydrops before he can be delivered.
• An intrauterine transfusion can prolong the life in utero
of a fetus to a gestation where the risks of prematurity
are estimated as being less than those of the Rh disease.
This can be done by an:

Oct-15 Rhesus Incompatibility 25

 INTRA UTERINE FETAL TRANSFUSION

INTRAPERITO
NEAL
TRANSFUSIO
N

INTRAVASCU
LAR
TRANSFUSIO
N
 INTRA PERITONEAL TRANSFUSION
 Blood is transfused to fetal peritoneal cavity under USG
guidance.
 It can be started at 18 weeks and repeated at intervals of 1-
3 weeks to 32-34 weeks.
 Type and amount of blood –blood group “o”.
 Rh negative packed cell cross matched with the mother are
to be transfused.
 The quantity of blood is to be calculate as number of weeks
of gestation.
 The blood is to be infused slowly(5-10ml) through a
polythene tube that has been threaded through an
introducing needle inserted in to the fetal abdomen under
guidance.
INTRA VASCULAR TRANSFUSION
 Transfusion is made through umbilical cord vessel near its insertion in
to the placenta under guidance of USG.
 Blood group “o” Rh negative packed cells compatible with
mothers blood are transfused.
 Check the Hematocrit value at intervals during the procedure
to determine the volume.
 Goal: Achieve haematocrit of 50% ;Repeat transfusion is given
2 weeks.
 Volume overload –fetal injury, preterm labour, fetal maternal
hemorrhage,.
 Fetal surveillance with USG and continuous electronic fetal
monitoring.
 Betamethasone (24 mg in divided dose) should be administered to the
mother 24 hours before transfusion from 26 weeks onwards to enhance
pulmonary maturity.
 Choose time of induction and best
method of delivery
• Balance the risks of prematurity (too soon) with
that of worsening Rh disease (too late).
• Consider the risks of vaginal delivery and be
prepared for a lower segment Caesarean section
(LSCS).
• Usually done only after 34 weeks of gestation.
• The paediatric team should be in close and a
senior paediatrician present at the delivery
• fresh Rh-negative blood available.

Oct-15 Rhesus Incompatibility 29

 Resuscitation and Exchange
transfusion
• Good resuscitation is
essential. In an anaemic and • In severe Rh haemolytic
premature infant, lung disease of the newborn, an
disease is common. It can umbilical artery catheter
be due to: should be inserted as soon
as possible to assess and
 Surfactant deficiency control PaO2 and pH.
at very early delivery. • Central venous
 Pulmonary oedema pressure should be
from anaemia and measured.
hypoproteinaemia.  Drain pleural effusions
 Hypoplastic and ascites at
lungs secondary to resuscitation.
pleural effusions.
Oct-15 Rhesus Incompatibility 30
 Resuscitation and Exchange
transfusion
Indication for exchange
Transfusion:  2. Late: Usually done for
hyperbilirubinaemia.
1. Early: Decision mainly • The aims:
based on cord haemoglobin  Treat anaemia.
(in addition consider history of  Washes out IgG antibodies.
previously affected babies).  Decreases degree of
haemolysis.
• Cord haemoglobin <12g/dl.
 Removes bilirubin.
• Strongly positive Coombs’ test.  Prevents kernicterus.
• Cord bilirubin >85mmol/l.

Oct-15 Rhesus Incompatibility 31

 Phototherapy
• Placing newborn baby
under a halogen or
fluorescent lamp with
their eyes covered.
• Lowers the bilirubin levels in
the baby’s blood through
photo-oxidation.
• During phototherapy,
intravenous hydration is
required.

Oct-15 Rhesus Incompatibility 33

PREVENTION
 Anti-D immunoglobulin 300 micro gram of D Antibody is given
to D-negative, non sensitized mothers to prevent the hazards of
sensitization.
 Anti-D globulin is provided to D-negative mothers after
miscarriage , evacuation of molar pregnancy or ectopic
pregnancy.
 It is also administered when there is heavy feto maternal
bleeding such as placental abruption, intrauterine
manipulation.
 Dose of 300 micro gram D-antibody will neutralize about
15ml of red cells.
 Rosette test is done to all such mothers to know the accurate
amount of Anti-D required.
• 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
Oct-15 Rhesus Incompatibility 37
 Erythroblastosis fetalis: A disease of fetuses and newborns
caused by the mixing of fetal Rh-positive blood with maternal Rh-
negative blood and resulting in rupture of fetal red blood cells.