BY PROF.

AFSHAN AMBREEN
DEFINITION:

 It is an immunological disorder that occur in a

pregnant Rh –ve patient carrying an Rh +ve fetus.
PATHOPHYSIOLOGY

 Rhesus positive and negative RBC’S

 Rhesus complex---- D antigen.
 Rhesus sensitization
 Fetal to maternal hemorrhage.
 Primary sensitization.
 Secondary sensitization.
 Hemolysis leading to anemia and hyperbilirubinemia congestive
cardiac failure hydrops fetolis IUD
 Incid
 Fetal RBC cross to maternal circulation

Maternal immune system recognizes foreign

antigens if fetus Rh + and mother Rh –

Antibodies are formed against fetal antigens

Subsequent pregnancy with Rh+ fetus,

immune system activated
and large amounts of Ab formed

IgG Ab cross placenta & attack fetal RBC

Fetal anemia, hydrops, etc

Fetal complications of Rhesus iso
immunization

 FETAL ANEMIA
 Compensatory fetal erythropoises leading to fetal liver
and spleen enlargement causing erythroblastosis
fetalis.
 Fetal anemia leading to hypoxia and placental
hyperplasia.
FETAL ANEMIA

 Fetal anemia causing hypoxia + acidosis

 Increased cardiac output high output cardiac failure
 Generalized edema Hydrops fetalis
Fetal hyperbilirubinemia

 No problem for fetus.

 Useful tool for assessment of degree of hemorrhage.
NEONATAL COMPLICATIONS:
1- Anemia
2- Jaundice
Management

 Rhesus isoimmunized mother :

 Aim of management is to asses the risk & sensitivity
of intrauterine fetal Hemolysis.

This is based on following factors

a) Last obstetrical history
b) Anti D antibody level --- indirect comb's test in
dilution
Contd

 Anti D antibody titer ---

immunoassay.
c) Fetal blood group.
 PATERNAL GENOTYPE Rh D :
 Homozygous– 100% Rhesus +ve fetus.
 Heterozygous – 50 % rhesus +ve fetus.
 FETAL BLOOD SAMPLING
 AMNIOCENTESIS
 FREE FETAL DNA IN MATERNAL PLASMA
d) Ultrasound
 Hydrops fetalis.
 Placental hyperplasia.
 Doppler
 Size of fetal spleen
and liver.
e) Amniocentesis:
- Fetal bilirubin concentration in
amniotic fluid can be used as an
indirect mean of determining fetal
anemia.
- Sphenophotometric analysis of
amniotic fluid is done & change in
optical density-- inter a light of
wavelenght.
f) CTG
 Management of fetal anemia

Intra uterine blood transfusion of O –ve blood crossed matched against

maternal serum.
INDICATION:
When haematocrit falls down to 15 – 20% and hemoglobin deficit of >7 g/
dl at a particular gestational age.
ROUTE:
- intravenous blood transfusion
- intraparitoneal blood transfusion
DELIVERY

 TIME: prolonged pregnancy as close to the term as

possible.
 MODE: LSCS
CARE OF NEWBORN

 SAMPLE OF CORD BLOOD IS TAKEN TO CHECK :

 Blood group and Rh factor.
 CBC
 Reticulocyte count.
 Direct comb's test.
 Serum total bilirubin
CARE OF NEWBORN

 EXCHANGE BLOOD TRANSFUSION:

When Hb. is < 10 g/ dl or serum total bilirubin > 340
mol/ L
 PHOTOTHERAPY:
Converts indirect bilirubin to direct bilirubin.
 PHENOBARBITOL:
Matures the liver enzymes.
Management of Rhesus –ve non
immunized mother
 Risk of silent fetomaternal hemorrhage is 1%
 Indirect comb's test at booking visit , 28 and 34 weeks of
gestation.
 The basic objective is prophylaxis against Rhesus
sensitization.
 To identify any event which may lead to fetomaternal
hemorrhage
 Abortions
 Ectopic pregnancy
 APH
 D&C
 CVS amniocentesis ,fetal blood sampling
 ECV, Delivery
Contd

 To quantify the amont of haemorrhage .

 KLEIHAUER – BETKE TEST
 5 fetal RBC’S IN 50 low power microscopic field
represents a transplacental haemmorhage of 0.25 ml.
 ADMINISTRATION OF Anti D Ig antibody
 Dose: for each 4 ml fetal blood in maternal circulation ,
500 iu of anti D should be given.
Contd

 TIMINGS: within 72 hours of event.

 ROUTE: intramuscular
 GESTATION: before 20 weeks – 250 iu
after 20 weeks -- 500 iu.