RH – ISOIMMUNIZATION
Dagnachew K.
Introduction
• RH factor (ie. Rhesus factor) is a red blood cell surface
antigen that was named after the Monkey it was first
discovered.
• RH incompatibility also called RH disease is a condition
that occurs when a women with Rh-negative blood type is
exposed to Rh-positive blood cells, leading to the
development of Rh antibodies.
Introduction cont…
• Rh blood group system consists of several antigens (e.g.
D, C, c, E, e)
• The D antigen is by far the most immunogenic.
Rh incompatibility can occur by two main mechanisms.
• Rh-negative pregnant mother is exposed to Rh-positive
fetal red blood cells secondary to fetomaternal
hemorrhage.
• Rh-negative female receives an Rh-positive blood
transfusion.
Pathophysiology
Fetomaternal hemorrhage
• Occurs when the fetal blood cells leak to the maternal
blood circulation
• Spontaneous or induced abortion
• Trauma
• Invasive obstetric procedures
• Normal delivery
Pathophysiology cont…
• After significant exposure sensitization occurs leading to
maternal antibody production against the foreign Rh
antigen.
• Maternal Rh immunoglobulin G (IgG) antibodies may
cross freely from placenta to the fetal circulation.
• Antigen-antibody complex formed
• Antibody-induced hemolytic anemia.
Pathophysiology cont…
• The amount of fetal blood necessary to produce Rh
incompatibility varies.
• In one study, less than 1ml of fetal blood was shown to
sensitize volunteers with Rh-negative blood.
• Once sensitized, it takes approximately one month for Rh
antibodies in the maternal circulation to equilibrate in the
fetal circulation.
Pathophysiology cont…
• In 90% of cases, sensitization occurs during delivery.
• Therefore, most1st born infants are not affected because
short period from first exposure.
• The risk and severity of sensitization increases with each
subsequent pregnancy involving a fetus with Rh-positive
blood.
Risk of sensitization depends largely upon the following
three factors:
1. Volume of fetomaternal hemorrhage
2. Extent of maternal immune response
3. Concurrent presence of ABO incompatibility
Effects on the fetus and the newborn
Mildly affected infants
– May have little or no anemia
– May exhibit only hyperbilirubinemia
Moderately affected infants
– May have a combination of anemia and jaundice
In severe cases progressive anemia, fetal
hyperbilirubinemia, hydrops fetalis, kernicterus and death.
Effects on the fetus cont…
• Another serious life threatening condition observed in
infants affected by Rh incompatibility is erythroblastosis
fetalis
• Characterized by severe hemolytic anemia and jaundice.
• Severe form of erythroblastosis fetalis is hydrops fetalis.
• Characterized by cardiac failure, edema, ascites,
pericardial effusion, and extramedullary hematopoiesis.
• Newborns with hydrops fetalis are extremely pale
Treatment
• Determine the blood group and Rh factor of the partner.
• Indirect Coomb’s test at 28 and 36 weeks.
• If the anti body screen is negative, provide anti D gamma
globulin with in 72 hours.
• If the anti body screen is positive monitor the new born
for hemolysis and manage the next pregnancy as
sensitized.
Treatment cont…
• Provide anti D prophylaxis.
• Usual dose is 300 mcg of Rh IgG IM.
• A 50 mcg dose of Rh IgG is available and recommended
for first trimester pregnancy termination.
• Ideally dose is depend on the amount of fetomaternal
hemorrhage determined by Kleihauer-Betke acid elusion
test
Treatment cont…
• If the mother has been sensitized previously, as
determined by elevated level of maternal antibodies
administration of Rh IgG is of no value.
• Measurement of antibody level in titers at regular intervals.
• Amniocentesis for bilirubin levels
Treatment cont…
• Serial ultrasound for detection of hydrops fetalis
• Management of neonatal anemia and hyperbilirubinemia.
• Measurement of bilirubin and provide phototherapy for
the new born.
• Respiratory and hemodynamic stabilization of the infant.
• Determine the need for emergent exchange transfusion.
What is ABO incompatibility?
• ABO incompatibility results when the fetal blood
type is different from the mother’s blood type.
• When the blood types differ, the mother creates
antibodies against the fetus’ incompatible blood type.
These antibodies enter the placenta and begin to
destroy the fetus’ blood cells
What are the symptoms?
• Incompatible maternal and fetal blood type as determined by
prenatal testing, jaundice in the newborn, and elevated
bilirubin level in the newborn.
What causes ABO incompatibility ?
ABO incompatibility can occur between the mother and fetus under
three scenarios.
The blood types are: A, B, and O.
The most common incompatibility occurs when the mother has O type
blood and the fetus has B, A, or AB.
The other combinations that cause ABO incompatibility are: the mother
has A type blood and the fetus has B or AB type blood, or the mother
has B type blood and the fetus has A or AB type blood. Both these last
combinations are highly unlikely to occur.
CONT…ED
• How is ABO incompatibility diagnosed?
• ABO incompatibility is diagnosed by: (1) cord blood test for
incompatibility, (2) a complete blood count (CBC) that shows
damaged and hemolyzed blood cells, and (3) elevated bilirubin levels.
• How is ABO incompatibility treated?
• ABO incompatibility is treated in newborns by light therapy
(phototherapy). On rare occasions an exchange transfusion may be
necessary. Full recovery usually occurs with no lasting repercussions.
