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Rhesus Isoimmunization

1. A (surface antigen A)
2. B (surface antigen B)
3. AB (antigens A and B)
4. O (neither A nor B)
4 Basic Blood Types
ABO System & Pregnancy
hemolytic diseases of the newborn
may be due to ABO incompatibility
O + O = O,
O + A = O or A,
O + B = O or B,
O + AB = O or A B
Fetus inherits one gene from each parent.
Rhesus Blood Group System
First demonstrated in Rhesus
monkey
Blood group are classified as
Rh negative or Rh positive
Rhesus Blood Group System
The genotype is determined by the inheritance
of 3 pairs of closely linked allelic genes
situated on chromosome 9 named as
D/d,
C/c,
E/e
.. (Fisher- Race theory)
Rhesus Blood Group System
The gene ( d ) is an amorph & has no antigenic
expression. So there are only five effective antigens
Weiner postulates a series of allelic genes at a
single locus Rh (D), Rh (C), Rh (E), Rh (c) & Rh (e)
The updated system of Rosenfield refers
these antigens as Rh1, Rh2, Rh3, Rh4, Rh5
Rhesus Blood Group System
The fetus inherits one gene from each group as a
haplotype such as sets of Cde, cde etc from each parent
12 sets of combinations & 78 genotypes are possible.
Most frequent genotypes are
Cde / cde (33%), Cde / cDe (18%), cde / cde
(15%),
Cde / cDE (12%) cDE / cde (11%),
cdE / cde (1%), Cde / cde (1%)
Rhesus Blood Group System
Incidence of Rh negative
varies in different races:
Mongoloids > 1,
Chinese & Japanese 1-2%,
Indians 5%,
Africans 5-8%,
Caucasians 15-17% &
Basques 30-35%.
Rhesus Isoimmunization
Rhesus Iso immunization is an immunologic disease
that occurs in pregnancy resulting in a serious
complication affecting the fetus / or the neonate
ranging from

mild neonatal jaundice

to intra uterine loss or neonatal death
Rhesus Isoimmunization
This immunologic disease occur when
a Rh negative patient carrying a Rh positive fetus

.. had a feto maternal blood transfusion

.. the mother immunological system is stimulated
to produce antibodies to the Rh antigen on the
fetal blood cell

.. This antibodies cross the placenta and destroy
fetal red blood cells leads to fetal anemia

. Usually the 1
st
fetus will not be affected if this is
the 1
st
time that the mother has been exposed to
the rhesus positive antigen
During pregnancy while the fetus still in the uterus
The bilirubin in the fetal blood will be removed by the
placenta to the maternal circulation and part of it go to
the liquor
The fetus will be anemic
.. If the degree of anemia is severe
fetus may die in utero because of heart failure
After delivery
The neonate will affected by
The degree of the anemia
The amount of bilirubin
Rh Negative Women

Fetus
Rh Neg Fetus
No problem
Rh positive
Fetus



Rh+ve R.B.C.s enter
Maternal circulation

previously sensitized
2
nd
immune response

IgMIgG
antibodies

Non sensitized Mother
Primary immune
response

1
st
Baby usually
escapes. Mother gets
sensitized?

Fetus
Haemolysis

Pathogenesis Of Rh Iso - immunisation
Man Rh positive
(Hetero)
Antigen-Antibody reaction on the RBCs
surface Hemolysis
IN UTERO
Anemia
Hepatic erythropoesis & dysfunction

Portal & Umbilical Vein Hypertension Heart
Failure
Erythroblastosis
fetalis

IUD


Polyhydramni
os
After birth

Anemia Jaundice
Kernicterus
Neonatal death
Hemolysis


Antigen-Antibody reaction on the RBCs surface
Management
of rhesus negative pregnant women
Management of non sensitized Pregnancy
Management of sensitized Pregnancy
Non sensitized Rh Neg. mothers married to a Rh Pos. husband
If husband is Rh Positive then
Check Husband being Homozygous or Heterozygous
.... Check for maternal antibodies
by indirect Comb's test ( ICT )
if antibodies detected treat as sensitized
If no antibodies Repeat ( ICT )
at 28 and 32 weeks provided that no bleeding.
If there is bleeding then ..
Management of non sensitized Pregnancy
Management of non sensitized Pregnancy
Bleeding after 20 weeks of gestation
.. Check for fetal red blood cells in
maternal circulation by Kleihauer test
.. Check for maternal antibodies ( ICT ) if negative
.. Give ( 500 IU / 100 mcg ) anti D to the mother
within 72 hours from the bleeding
.. The dose should be doubled or tripled if fetal
RBCs are more than 80 cells in maternal circulation
Prophylactic Management of non sensitized Pregnancy
During antenatal period
Prophylactic (500 IU / 100 mcg ) Anti D
are recommended to be given to all
negative non sensitized mothers married to
Rh positive husband at
28weeks and 34 weeks to protect and
overcome any asymptomatic or un noticed
antenatal feto maternal blood transfusion
Management of non sensitized Pregnancy
Precaution should be taken to prevent the
possibility of increased chance of feto - maternal
blood transfusion At birth
During labor
No fundal pushing in 1
st
or 2
nd
stage of labor
No uterine massage or uterine grasp and squeeze
in 3
rd
stage
Let the placenta to be delivered spontaneous
A void avulsions of the cord
Protect the vaginal and perineal wounds and laceration
from being exposed to the fetal blood spilled from cord
Management of non sensitized Pregnancy
During cesarean section

Use abdominal packs in the sides of the uterus
before opening the lower segment to prevent
spilled blood from the placenta to inter the
peritoneal cavity.

Let the placenta to be delivered spontaneous using
control cord traction without squeezing the uterus

A void avulsions of the cord
Management of non sensitized Pregnancy
At birth
. Maternal blood sample for
.. antibodies by indirect Comb's test ( ICT )
.. fetal red blood cells in maternal circulation
. Cord blood sample ( Neonatal blood sample ) for
.. antibodies by Direct Comb's test ( DCT )
.. Infant blood group
.. Infant bilirubin level
.. Infant Hb & Hct level
Management of Sensitized Pregnancy
Sensitized Rh Negative mothers
If antibodies level start to increase
Arrange for amniocenteses
Spectrophotometer to study the optical density
of the amniotic fluid
( i.e. bilirubin level which reflect RBCs haemolysis )
U/S Scan evaluation of the fetal well beings

USS can detect
... Fetal Skin and scalp edema,
... Fetal Ascites,
... Fetal Pericardial or pleural effusion
.. Polyhydramnios
.. Fetal hepatosplenomegaly
.. Fetal Cardiomegaly
.. Placental hypertrophy and enlargements
.. Abnormal fetal posture (Buddha stance)
Ultrasound scan (USS)
Amniocentesis
Is an Indirect method to measure the degree of haemolysis of
the fetal red blood cells by measuring the Concentration of
bilirubin in the amniotic fluid.
Amniocentesis
Amniotic fluid sample taken and sent for Spectrophotometer
Where optic density of the fluid changes according
to the amount of the bilirubin concentration
Amniocentesis
Cordocentesis
Fetoscopy
The first pregnancy with a Rhesus positive baby is
significant for a rhesus negative woman because she
can be sensitized to the Rh positive antigen. about
13% of Rhesus negative mothers are sensitized by
their first pregnancy with a rhesus positive baby.
about 5% of the second Rhesus positive infants of
Rhesus negative woman, would result in still
births or extremely sick babies and many babies
who managed to survive would be severely ill
If no prevention measures were taken during antenatal
period
By using anti-RhD immunoglobulin (Rho(D) Immune
Globulin) the incidence is massively reduced .
Rh disease sensitization is about 10 times less likely to
occur if the fetus is ABO incompatible with the mother
than if the mother and fetus are ABO compatible.




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