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RH Incompatibility

The document discusses isoimmunization which occurs when a pregnant mother's blood is Rh negative and the fetus's blood is Rh positive. This can cause the mother's immune system to produce antibodies against the fetus's Rh positive blood. The summary outlines the process, effects on the fetus including hemolytic anemia, and ways to prevent isoimmunization through Rh immunoglobulin administration.

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Sagun lohala
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104 views38 pages

RH Incompatibility

The document discusses isoimmunization which occurs when a pregnant mother's blood is Rh negative and the fetus's blood is Rh positive. This can cause the mother's immune system to produce antibodies against the fetus's Rh positive blood. The summary outlines the process, effects on the fetus including hemolytic anemia, and ways to prevent isoimmunization through Rh immunoglobulin administration.

Uploaded by

Sagun lohala
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Isoimmunization

Moderator: Presented By:


Dr. Rojina Manandhar Sagun Lohala
Objectives
At the end of the session participants will be able to

• explain terminologies

• explain flow chart mating of Rh

• define isoimmunization

• describe pathogenesis of isoimmunization

• elucidate types of antibodies

• explain effect of Rh antibody in fetus

• determine ways to prevent isoimmunization

• Identify indications for RhoGAM


Terminology
Antigen and antibody
Cont´d…
Rh factor

• First demonstrated in rhesus monkey

• Rh factor are protein found in Red blood cells of human being.


• Blood groups are classified as Rh positive and Rh negative

• The Rh factor , Rh+ and Rh- usually refers specially to the


presence or absence of antigen-D
• There are two genetic variants, of this antigen: D and d

• A person who is Rh- has two recessive traits, dd. Anyone who has
at least one D either DD or Dd-is Rh+
Cont´d…
Rh incompatibility

A condition which develops when there is a


difference in Rh blood type between that of the
pregnant mother (Rh negative) and that of fetus (Rh
positive).
Blood Group Typing

• Describes the characteristics of blood cells in a


particular person.

• Describes the kinds of proteins, or lack of proteins


that a person has on their red blood cells.
• Blood is typed as ABO, but also by Rh factor.

• These are two proteins, known as antigens,


represented by A and B
Isoimmunization

Isoimmunization is defined as a production of


immune antibodies in an individual in response to an
antigen derived from another individual of the same
species provided

This is in contrast to ABO group, where there are


naturally occurring isoimmune anti-A anti-B
antibodies
Pathophysiology

• Fetomaternal hemorrhage of Rh positive cells enter into maternal circulation and


will produce anti-D antibodies IgM type initially called sensitization

• After a minimum period of 3 months IgG antibodies are produced which are
capable of crossing placental barrier

• IgG antibodies attack and destroy fetal RBCs in spleen and produce Hemolytic
anemia

• Anemia will produce erythropoiesis in liver leading to erythroblast production


called Eryblastosis fetalis.
Cont’d…

• In a mother who is already sensitized, fetus will have a very


severe hemolytic anemia and hyperbilirubinemia called Icterus
Gravis Neonatrum
• If this unconjugated bilirubin crosses blood brain barrier it will
stain basal ganglia called Kernicterus

• And hypo-proteinemia which will lead to changes in


hemodynamics results in accumulation of fluid all over the body
and also in body cavities called Hydrops fetalis.
Causes of Rhesus Isoimmunization

1. Mismatched blood transfusion


2. Feto maternal hemorrhage following delivery ,
ectopic pregnancy, abortions.
3. Invasive procedures like Chorionic villous
sampling , Amniocentesis in pregnant mother
4. APH-Placenta Previa, Abruption of placenta
5. External cephalic version
6. Intrauterine fetal death
Effect of Rh antibody in fetus

• The antibody formed in the maternal system IgG crosses


the placental barrier and enters into the fetal circulation.

• If the fetus is Rh positive , the antibodies become attached


to the antigen site on the surface of the fetal erythrocytes.

• The affected cells are rapidly removed from the


circulation by the reticuloendothelial system
Cont’d…

• Depending upon the degree of agglutination and


destruction of the fetal red cells, various types of
fetal hemolytic disease appears.

• These are loosely termed as erythroblastosis.


Prevention of Rh immunization

1. Prevent active immunization

2. Prevent or immunize feto-maternal bleed

3. Avoid mismatched transfusion


Prevention of Iso- Immunization
• Antenatal- at 28 and 34 weeks Anti D Immunoglobulin
of 300 micrograms should be given

• Anti D immunoglobulin of 300 micrograms should given


within 72 hours called RhoGAM(following delivery)
• Following all invasive procedures also it should be given

• 300 micrograms can protect from 30 ml of bleed


Indications for RhoGAM

Miscarriage:
 All therapeutic termination (medical or surgical)

All surgical evacuation


Threatened miscarriage>12 weeks (300mcg)

Threatened miscarriage< 12 weeks with heavy or


repeated bleeding , abdominal pain(50mcg)
Cont’d…

• Ectopic pregnancy
• An induced or spontaneous abortion

• Conditions to feto-maternal hemorrhage:


a. Antepartum hemorrhage
b. Falls or closed abdominal trauma
c. Intrauterine death
d. External cephalic version
e. Invasive prenatal diagnosis(e.g.amniocentesis,
chrionic villus sampling)
Sign and Symptom of Rh Incompatibility:

• Rh incompatibility can cause symptoms ranging from


very mild to fatal
• Mildest form –Rh incompatibility :

1. Hemolysis(Destruction of the red blood cells ) with the


release of free hemoglobin into the infant’s circulation.

2. Jaundice (Hemoglobin is converted into, bilirubin


which causes an infant to become yellow)
Neonatal jaundice
Severe form –Rh incompatibility

1. Hydrops fetalis(Massive fetal


red blood cell destruction)

2. It causes severe anemia


Fetal heart failure Death of
the infant shortly after delivery
Management:-

The management will be done under:-


I. The Rh negative unsensatized patient
II. The Rh negative sensitized patients.
Rh Negative unsensitized patient:-
i. All pregnant women should be screened for blood
ABO and Rh groups at first antenatal visit

ii. If the mother is Rh negative, she is advice to


obtained husbands ABO Rh group and has her
blood screened for presence of antibodies.
[ Indirect Comb’s Test]
iii. Collect previous obstetric history

iv. At 35 weeks, repeat maternal blood for Rh


Unsensitized patient contd…

v)At birth, collect cord blood of the baby and sent it for testing
for direct combs test, Hb, and ABO /Rh group of newborn

vi)Administer 300microgram Rh anti-D immunoglobulin


following abortion within 72hours or preferably earlier.

vii)Check the condition of baby carefully for any abnormalities


closely observe the baby within 24 hours because hemolytic
jaundice may develops
Management of Rh negative sensitized patients:-
a. USG at around 16 weeks is recommended to
confirm gestational maturities, location of the
placenta and detect anomalies if present.

b. Amniotic fluid analysis at 28 weeks of gestation,


which provide information for further prenatal
management of the current pregnancy.

c. The mildly affected fetus is good and maturity is


achieved moderately affected fetus may need to
Sensitized patient
Cont..

d)Exchange transfusion may need for fetus and


neonate.

e)The baby may need to keep under phototherapy for


jaundice so care need to taken for this.
Prevention and management

• During antenatal , delivery and after delivery


During antenatal

• Investigation protocol of Rh- negative mothers

• Obstetric history

• Antibody detection
Plan of delivery

• Unimmunized mothers
• Immunized mothers
Care during delivery

• Careful fetal monitoring is to be done to detect at the


earliest , evidence of distress
• Gentle handling of the uterus in third stage
• To take care of postpartum hemorrhage
• Quickly clamping the umbilical cord
• Kept long cord
• Collection of cord blood for investigation( clotted
blood: ABO and Rh ,reticulocytes, direct comb’s test
and serum bilirubin; oxalated blood: Hb and blood
smear for presence of immature RBC)
Intrauterine fetal transfusion

1. Intraperitoneal transfusion

2. Intravascular transfusion

3. Plasmapheresis

4. High-dose intravenous immunoglobulin

5. Exchange transfusion in the newborn


REFERENCES

• Dutta D.C.(2018). Textbook of obstetrics(9th ed.).New


Delhi; Replika Press Pvt.Ltd.
• Raman A V. (2014).Maternity Nursing (19th ed.).New
Delhi;Wolters Kluwer Pvt.Ltd.
• Myers, J. L. (2003).Mosby’s Nursing Care. Fifth Edition
• http://www.healthline.com/health/Rh incompatibility
• Williams OBSTETRICS Part A,24th edition
• https:/coloringpage wiki.com/m/abo-iso immunization
• Prasai Durga. (2016).Midwifery Nursing (3rd
ed.).Kathmandu medhavi publiation

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