Rh iso-immunization

By Dr Arbaaz shahid
Blood group is defined in 2
:ways
ABO group (O, A, B, AB).

Rhesus system (C, D, E antigens).

 .ABO group (O, A, B, AB)
About 20% of all infants have an ABO maternal
blood group incompatibility
 but only 5% are clinically affected. Because
antibodies are (IgM)( cannot cross the placenta and
therefore cannot gain access to fetal erythrocytes)
Hemolytic disease of the newborn (HDN) due to
ABO incompatibility
less severe than Rhesus incompatibility.
 Rhesus system (C, D, E
.antigens)
This system includes five red cell
proteins or antigens: c, C, D, e, and E. No
“d” antigen.
The presence or absence of D antigen
site determines whether an individual is
Rh positive or Rh negative.
The incidence of Rh-negative genotype
is 5 to 10% in India
 Pathology of rhesus isoimmunization
1. Rh-positive red cells of the fetus enter into the
maternal circulation
2. the first immune response in the mother is the
formation of IgM antibodies (they do not cross the
placenta) and therefore the first baby is usually
unaffected.
3. Subsequent antigen exposure leads to an increased
response and IgG formation in the mother, which does
cross the placenta and destroy the fetal red blood cells
(RBC) leading to reticulocytosis, anemia, heart failure
and hydrops.
The first child is generally not
:affected because
fetomaternal hemorrhage occurs late in pregnancy
or during delivery and antibody response slowly
(over 2–6 months)
The initial maternal immunoglobulin M (IgM)
antibody are formed, which do not cross the
placenta.(molecular weight that is too large to
cross the placenta)
What are the fetal and neonatal complications
?that may occur when mother is immunized
1. Hydrops fetalis.
2. Intrauterine fetal death or early neonatal death
due to cardiac failure.
3. Icterus gravis neonatorum.
4. Congenital anemia of the newborn.
Prevention of rhesus iso-
:immunization
• During pregnancy
routine antenatal prophylaxis with
anti-D : All women who are RhD –ve
are offered anti-D prophylaxis 500 iu
at 28 and 34 weeks regardless of
sensitizing events or previous
administration of anti-D.
After the potentially sensitizing event a
dose, anti-D Ig should be given as soon as
possible but always within 72 hours.
If it is not given it can be taken within 10–28
days may provide some protection.
• if <20 weeks, 250 IU of anti-D given IM
• if >20 weeks, 500 IU of anti-D given IM
• A Kleihauer test should be performed.
Further anti-D can be given if indicated by
this test.
 the Kleihauer–Betke test:
 it is screening test
 should be performed within 2 hours of delivery to
identify the amount of fetal–maternal hemorrhage.
 Fetal erythrocyte contain Hb F which is more resistant
to acidic solution (citric acid phosphate buffer) or
alcohol denaturation than adult Hb A, so after
exposure to acid only fetal cells remain, The acid is
able to elute adult hemoglobin, but not fetal
hemoglobin, from the red blood cells. As a result, on
subsequent staining the fetal cells appear rose pink in
color, while adult red blood cells appear as “ghosts.
Should be performed before administration of anti-D
 
Direct Coombs’ test:
 This test aims at detecting the maternal
antibodies that may be bound to the
surface of fetal RBCs and is performed
after baby’s birth.
 Washed infant’s RBCs are incubated with
the Coombs’ serum (antiglobulin
antibodies). If agglutination is produced,
the direct Coombs’ test is positive. This is
indicative of the presence of antibodies on
the surface of RBCs
Indication for administration of anti-D
immunoglobulin (sensitization events causing
:fetal-maternal hemorrhage)
First trimester
1. spontaneous abortions
2. induced abortions (medical Termination of
pregnancy)
3. ectopic pregnancy
4. Molar pregnancy
5. Threatened abortion: (only if the bleeding
repeated, heavy or associated with abdominal
pain).
 Invasive prenatal testing ( amniocentesis,
chorion villus biopsy& cordocentesis )
 Antepartum haemohage( APH): Bleeding
associated with placenta Previa or abruption
 Intrauterine fetal demise
 Antepartum trauma :Blunt trauma to the
abdomen (includes motor vehicle accidents)
 Manual placental extraction
 External cephalic version
 Administration of Rh-positive blood
components to Rh-ve female.
Postnatal prophylaxis:
immediately after delivery if
1. The infant is Rh positive.
2. The direct Coombs’ test on
umbilical cord blood is negative.
This test reveals (whether or not)
irregular antibodies cover the
infant’s red cells.
3. The fetal blood group Rh- positive
A second dose of 500 IU anti-D
immune globulin should be
administered within 72 h of delivery
She may be given up to 10–28 days
after delivery to avoid sensitization.
This amount is capable of
neutralizing the antigenic potential
of up to 30 ml of fetal blood (about
15 ml of fetal cells)
• It is routinely administered as Intramuscular
injections, best given into the deltoid muscle,
(injections into the gluteal region often only
reach the subcutaneous tissues and
absorption may be delayed).
• A Kleihauer test should be performed. Further
anti-D can be given if indicated by this test.
• Why are not all the babies born following
Rh incompatibility affected?
1. The particular woman may be immunologic non
responder.
2. There may be associated ABO incompatibility.
3. Less volume of fetal blood entering into the
maternal circulation. Minimal volume required is
0.1 mL.
4. Fetal response to maternal antibodies varies on
fetal sex. Rh-D positive male fetuses run the higher
risk of severe hemolysis and death, compared to a
female fetus
Why there are still many cases of
isoimmunisation occurring during
??pregnancy, Despite Anti-D prophylaxis
 
1. failure to administer anti-D
2. administration of inadequate doses
3. late administration
4. Silent fetomaternal hemorrhages.
Management of patient
found to be Rh-negative
 
:Full history
1. Husband blood group
  2. in primigravida : previous history of blood
transfusion
3. In a parous woman: a detailed obstetric history.
4. History of fetal affection in the form of stillbirth
or neonatal death due to severe jaundice
following one or two uneventful births is quite
suggestive.
5. Previous history of hydrops fetalis
6. History of receiving anti-D immunoglobulin in
previous pregnancies
7. Current pregnancy sensitizing events
:Examination

No specific finding is observed on general or systemic

physical examination
 :Investigations
Blood group and Rh of the husband:
• If Negative: No further testing as the baby will
be also Rh –ve and the pregnancy will be
managed as normal.
• If positive: consult with a blood bank pathologist
to determine the paternal genotyping
(homozygous or heterozygous)
• → homozygous of Rh antigen → fetus is likely to
be affected 100
• → heterozygous of Rh antigen → fetus is
affected only in 50% cases.
Cell-free fetal DNA:
Non-invasive prenatal determination of
fetal Rh D , from maternal blood samples
one at 14 weeks
using a conventional PCR for Y
chromosome, it can be used to prevent
unnecessary prophylaxis.
• → if an antigen-negative fetus is found,
no further testing is warranted.
  Indirect coomb's test or Rh antibody titer :

• the maternal serum is incubated with

Rh-positive erythrocytes and Coomb’s
serum (antiglobulin antibodies).
• The red cells will agglutinate if Rh
antibodies are present in the
maternal plasma.
  
Management

according to Maternal indirect coomb's

test if:
Rh-negative unsensitized pregnant
woman(indirect coomb’s test negative)
Rh-negative sensitized pregnant
woman(indirect coomb’s test positive)
 
 
Group 1: Management of the Rh-
negative, unsensitized pregnant
woman(coomb’s test negative)
The goal during pregnancy is to keep her
from becoming sensitized.
 Follow up by indirect coomb’s test at
booking visit if it negative repeat at 20, 24,
and 28 weeks.
Give routine antenatal prophylaxis
with anti-D immune globulin at 28
weeks (confirm that the patient
indirect coomb’s test negative prior to
treatment).
the pregnancy should not be allowed
to pass the expected date
Care during delivery to minimize the
risk of fetomaternal hemorrhage
During labor
1. Not to give prophylactic ergometrine
during second stage of labor.
2. Gentle handling of the uterus during
the third stage.
3. If the manual removal of the placenta
is required, it should be performed
gently
During cesarean delivery
1. To avoid blood spillage into the
peritoneal cavity.
2. To avoid routine manual removal
of the placenta.
3. Early cord clamping.
 After delivery

Postnatal prophylaxis: it given (within

72 hours). (Though can be given up to 10-
28 days)
 Check for “excessive” fetomaternal
hemorrhage and treat with additional
doses of Rh immune globulin if exposure
is greater than 30 mL of fetal Rh-positive
blood.
 
  
Group 2: Management of the Rh-negative, sensitized pregnant
woman

1. Indirect Coombs’ test (ICT) positive at any ANC visit.

2. estimation of ( Anti-D antibody) titer
repeat it monthly if stable result
every 2 weeks( from 28 weeks until delivery or when
there is rising titer)
The titer < 1:16, expectant management until 38 weeks.
if it becomes ≥1:16, investigate for fetal anemia every
week by MCA Doppler at 1-2 week interval
Referral to a fetal medicine specialist should
occur for an intensive neonatal care unit,
arrangements for exchange transfusion and
an expert neonatologist
• when there are :
rising antibody levels/titres above a specific
threshold
or ultrasound features suggestive of fetal
anemia.
Doppler study:Middle cerebral artery
(MCA)-peak systolic velocity (PSV) is the
mainstay to assess fetal anemia.
Begin serial MCA Doppler assessments
at 18 weeks of gestation
Repeat Middle cerebral artery (MCA)-
peak systolic velocity (PSV) at 1- to 2-
week interval
If MCA-PSV: ≤1.5 MoM for gestational
age, follow the same protocol for
antenatal monitoring and delivery,
Evaluated every 2 weeks from at least 32
weeks until delivery for fetal well-being
(nonstress tests, modified biophysical
profile ,Doppler assessment)
A value >1.5 multiples of the
median (MOMs) for gestational age:
predicts moderate to severe fetal
anemia .indication for( cordocentesis
and intrauterine fetal transfusion for
a fetal hematocrit of less than 30%.
 Serial ultrasonography may detect fetal hydrops
and anemia. The important features are:
1. Polyhydramnios
2. increased placental thickness (greater than 4
cm)
3. pericardial or pleural effusion
4. Ascites
5. echogenic bowel
6. dilatation of cardiac chambers
7. enlargement of spleen and liver umbilical vein
dilation and fetal edema (hydrops)
 Cardiotocography: Sinusoidal trace and
decelerative pattern in an affected fetus.
 
 Amniocentesis: it is invasive and
increases the risk of sensitization.by
using The spectrophotometry ;In
presence of bilirubin there is a
“deviation bulge” at Δ OD450 is plotted
in Liley’s chart and accordingly the
management is decided
 
 :Ultrasound guided cordocentesis
Indication: Elevated peak systolic MCA Doppler
velocities (>1.5 MOM).
Benefits:to detect
•fetal blood grouping, Rh type
•hematocrit (accurate Assessment of fetal anemia)
•direct Coombs’ test
•reticulocyte count
•total bilirubin level
•Fetal hematocrit value <15% is associated with
hydrops
Fetal blood transfusion is lifesaving in a
severely anemic fetus (hematocrit <30%,
Hb<10 gm/dL) that is too premature . the
aim is to restore hemoglobin levels
preventing hydrops or death. It can be
started at 18 weeks and repeated at
intervals of 1–3 weeks up to 32–34 weeks.it
performed only in fetal medicine units
 
:Rout of blood transfusion

Intravascular route.
into the umbilical vein
into the intrahepatic vein
Into the fetal heart.
Intraperitoneal :into the peritoneal
cavity (less used)
 What is the type, nature and amount of blood to
?be transfused
1.Rh negative, whole blood with the same blood
group to that of the baby or with group ‘O’.
2.Relatively fresh- less than 5 days old.
3.Cross-matched with a maternal sample.
4.Densely packed (Hb usually around 30g/L) so
that small volumes are used.
5.White cell depleted and irradiated.
6.Screened for infection including CMV.
7.The amount is about 160 ml/kg body weight of
the baby
 
 
:Time and mode of delivery
Time
In mild affection, the pregnancy may be
continued up to 38 weeks and then termination
.is to be done
In severe affection: terminate the pregnancy
around 34 weeks after maternal steroid
.administration
 
:Mods of delivery
:Vaginal delivery
Amniotomy is quite effective, if termination
.is done near term
Vaginal prostaglandin gel (PGE2) could be
.used to make the cervix ripe
Cesarean section: In cases when
termination has to be done prematurely
(34–37 weeks), the cervix will be
unfavorable and considering the severity
of affection and urgency of termination
 
Fetal hydrops
 Fetal hydrops
This is the most serious form of Rh
hemolytic disease (HDFN). Of all cases
of fetal hydrops:
90% are due to a non‐immune cause
10% have an immune etiology.
 
Causes of Nonimmune
Hydrops Fetalis (NIHF)
and Associated Clinical
Conditions
Thank you