Rh alloimmunization

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Definition

• Rh alloimmunization-hemolytic anemia of fetus/neonates secondary

to passage of antibodies against fetal Rh antigen.
Synonymus: Hemolytic ds of the newborn
:Rh isoimmunization
:Rh sensitization
:Erythroblastosis fetalis

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• Incompatibility with respect to D-antigen is the most common cause
of serious hemolytic disease of fetus and new born.
• Presence of Rh-D antigen on individual erythrocytes labels her/him as
Rh-positive while D-negative indicates its absence.
• 85% of population are Rh-positive and 15% are Rh-negative.

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Genetic expression
• Rh-system of blood grouping comprises five major antigens (D,E,C,c,e)
genotypicaly located on the short arm of chromosome 1.
• About 60% of individuals with Rh-positivity are heterozygous while
40% are homozygous.
• Patients with Du positive are also considered as D+ve.

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Causes
• Three circumstances must exist:
1. Fetus must be Rh positive, mother Rh negative
2. Sufficient RBC must enter mother’s circulation.
3. Mother must have immunogenic capacity to produce antibody
against antigen.

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Causes…
• In 15-50% of births, FMH sufficient to cause
isoimmunization in susceptible individuals
(patients) occurs. This is responsible for 90% of
cases of isoimmunization.
• Large bleeds (> 30ml) occur in 1% of cases.
• The following may be responsible for increased risk
of isoimmunization:

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 • Cesarean delivery
• Multiple gestation
• Placenta previa/ Abruptio placenta
• Manual removal of placenta
• Intra uterine manipulation
• Amniocentesis
• External cephalic version
After 38 day of conception fetal RBCs express Rh
antigen.

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 Pathophysiology
• Sixty to seventy percent of individuals are
responders and develop an antibody to relatively
small volumes of red cells.
• A small percent of this group can be called hyper
responders in that they will be immunized by very
small quantities of red cells.
• The second group of individuals (10 to 20 percent)
can be immunized only by exposure to very large
volumes of cells.
• The 10 to 20 percent of individuals who remain
appear to be nonresponders.
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Pathophysiology…
“Nonresponders”:
*ABO incompatibility-decreases to1-2%
Anti-A or Anti-B antibodies damage RBCs before immune response

*10-20% of women even with large amount of RBCs

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Cont’d
*As little as 0.1 mL RBC stimulating an anti-D response in some
subjects and reaching a maximum of 80 percent responders to one
unit (450 mL).
*16% of Rh negative mother alloimmunized in first pregnancy(half in
6 months after delivery) ,half in the next pregnancy called
SENSIBILIZED.
*1-2% sensitized during antepartum

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Cont’d…
• The vast majority of RhD alloimmunized women produce an IgG
response as their initial antibody
• The human antiglobulin anti-D titer can usually be detected after 5 to
16 weeks.
• Anti-D IgG is a nonagglutinating antibody that does not bind
complement. This results in a lack of intravascular hemolysis.
• Sequestration and subsequent destruction of antibody-coated red
cells in the fetal liver and spleen are the mechanism of fetal anemia.

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Cont’d…
• Reticulocytosis from the bone marrow can be detected by fetal blood
sampling
• Erythroblasts are released from the fetal liver once the hemoglobin
deficit reaches 7gm/dl
• In an effort to increase oxygen delivery to peripheral tissues, fetal
cardiac output increases

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Cont’d…
• Hydrops fetalis (the accumulation of extracellular
fluid in at least two body compartments) is a late
finding in cases of fetal anemia.
[Link] hepatic erythropoietic function with
subsequent depressed synthesis of serum proteins
has been proposed as the explanation for the lower
serum albumin levels that have been detected.
2. Tissue hypoxia due to anemia enhances capillary
permeability
[Link] overload due to ongoing hemolysis

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Management of unsensitized Rh-ve/
Du-neg. pregnancy
 Indirect coomb’s test at initial visit- Negative.
 Father Rh +ve or unknown status.
Repeat Coomb’s indirect test at 28 weeks of
gestation and give 300 g of Rh. immune globulin if test result is
negative.
Check Rh status of new born at delivery(direct coomb’s test)

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 If Rh +ve /Du +ve or unknown status give
300g immune globulin to mother.
 if father Rh –ve /paternity certain.
• No prophylaxis needed.

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Anti D Ig
• Anti-D immune globulin is a sterile solution containing IgG anti-D
(anti-Rh) manufactured from human plasma.
• A single 300 microgram dose contains sufficient anti-D to suppress the
immune response to 15 mL of Rh-positive red blood cells (1
microgram = 5 IU).
• A single 50 microgram dose contains sufficient anti-D to suppress the
immune response to 2.5 mL of Rh-positive red blood cells.

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Anti D…
• MECHANISM OF ACTION — The mechanism whereby anti-D immune
globulin prevents alloimmunization remains unproven.
1. rapid macrophage mediated clearance of anti-D coated red blood
cells .
2.A significant number of Rh(D) antigen sites on fetal red blood cells
in the maternal circulation are not bound by passive anti-D; therefore,
epitope masking is not the reason.

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Anti D …
• Guideline:
*Antepartum:At first ANC , at 28wks & postpartum antibody
screening should be done.
-If negative Anti D Ig 300microgram I.m. should be given at 28wks.
-A second dose of anti-D immune globulin or termination of
pregnancy is advised if the patient has not delivered within 12wks of
the first dose. - -After checking Rh type of the neonate postpartum
dose will be given in 72hrs of delivery

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Anti D…

• Postpartum dose can be omitted if Anti D is given during pregnancy

for some indications(eg APH,ECV,amniocenthesis… in the last 3weeks.

• If anti-D immune globulin is inadvertently omitted after delivery, it

can be given in 28days.

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Anti D Ig…
A dose of 50 mcg is effective through the 12th
week of gestation due to the small volume of red
cells in the fetoplacental circulation (mean red cell
volume at 8 and 12 weeks is 0.33 mL and 1.5 mL,
respectively)
 Ectopic pregnancy
Multifetal reduction
genetic amniocentesis
chorion villus sampling
fetal blood sampling
abortions
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Cont’d…
300 micrograms of anti-D immune globulin should
be given in association with testing for
fetomaternal hemorrhage;
Fetal death in the second or third trimester Blunt
trauma to the abdomen (including motor vehicle
accidents)
Antepartum hemorrhage in the second or third
trimester (eg, placenta previa or abruption)
External cephalic version
Hydatidiform mole

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Anti D Ig…
• 300microgram is enough to protect against maternal sensitization
from as much as 15 mL red blood cells (30 mL Rh(D)-positive fetal
whole blood).
• Routine testing of all women for excessive fetomaternal bleeding at
the time of delivery should be performed.

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Alloimmunized pregnancy

Indirect coombs test:

1. The RBCs are then washed and suspended in serum containing
antihuman globulin (Coombs serum).
2. Red cells coated with maternal anti-Rh(D) will be agglutinated by
the antihuman globulin, which is referred to as a positive indirect
Coombs test.

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Alloimmun…
• The direct Coombs test is done after birth to detect the presence of
maternal antibody on the neonate's RBCs.
• It is performed by placing the infant's RBCs in Coombs serum;
maternal antibody is present if the cells are agglutinated.

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Alloimmunized…
Determine fetal Rh status:
1. If father is Rh negative & paternity is certain; no
further assessment is needed.
2. If he is Rh positive; check for zygosity b/c if
homozygous all his children are Rh positive, if
heterozygous 50% chance being Rh negative.
3. If found to be hetrozygousPCR from amniotic
fluid or chorionic villous sampling will determine
Rh status of fetus.

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Alloimmunized…
• After Dx of sensitization,why fetal Rh status determination needed?
*sensitization could be from previous husband.
*Could be from blood transfusion.
So avoids expensive & hazardeous procedures.

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 THANK YOU!!!

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