Red Cell Alloimmunization in

Pregnancy

Dr. Shahi Farzana Tasmin

Professor & HOD
Department of Gynaecology and Obstetrics
Prime Medical college
Introduction:
In spite of advances in medical science, Rh
alloimmunisation remains one of the leading causes
of preventable neuro-morbidities and significant
neonatal hyperbilirubinemia in lower-middle income
countries, despite availability of effective antenatal
preventive strategy (Anti-D).
Its uptake in antenatal period is low due to ignorance
and it is not cost effective.
Further, once diagnosed, there is lack of adequate
antenatal follow up in health care facility. Some of
these cases even remain undiagnosed in antenatal
period only to present as a case of severe
hyperbilirubinemia and kernicterus in late neonatal
period causing neuro morbidities, hydrops fetalis,
high output cardiac failure.
Rh system

 Rh blood group is the most complex human blood group.

 Rh antigens are lipoproteins that are confined to the red cell
membrane.
 The Rh antigens are D C,c E,e and G.
 The most important is the D gene, which confers to the
individual the characteristic of being Rh-positive.
 When the Father is Rh positive , 2 possibilities exists:
 He is either homozygous( 45%) or heterozygous (55%).
 Where as a Rh(-ve) person may only be homozygous,


Cont.

 This has practical importance, because a

homozygous Rh-positive father(DD), if mated with
Rh-negative mother, passes to his offspring a
dominant D gene as a result, the offspring is
Rh(+ve) in 100% cases.
 If the father is heterozygous, the chances of a
child being Rh-positive are only 50% cases.
 In heterozygous cases fetal Rh typing is mandated
either by cell free fetal DNA or invasive testing
like cordocentesis.
Incidence

 Basque population have the highest incidence (30- 35%).

 White populations in general have a higher incidence than
other ethnic groups (15-16%).
 African Americans have a rate of 8%.
 African blacks 4%.
 Indoeuresians 2%.
 Pathogenesis:
 A fetus receives half of its genetic material from its mother
and half from its father; therefore, the fetus may have red
cell antigen different from its mother.
 Some blood group may act as an antigens in individuals
not possessing those blood groups.
 The antigens resides on RBC .
 If enough cell cross maternal blood , a maternal antibody
response may be provoked.
 If these maternal antibodies cross the placenta, they then
can enter the fetal circulation and destroy the fetal
erythrocytes causing haemolytic anaemia
.
 Approximately 97% of all cases of Erythroblastosis
fetalis are caused by maternal antibodies
directed against the RhD antigen.
 The remaining cases are caused by maternal
antibodies directed against other fetal antigenic
blood groups such as C,c E, e ( Rh system nonD),
K,k ( Kell) Fya (Duffy), M(MNS) and Jka ( Kidd)
 Alloimmunization (Isoimmunization)

Production of immune antibodies in

an individual in response to an
antigen derived from another
individual of the same species
provided the first one lacks the
antigen.
Methods :

1)Transfusion of mismatched blood: In ABO group incompatibility, there

are naturaly occurring anti-A & anti-B isoagglutinins, which result in
immediate adverse reaction.
 In case of Rh group, there is no such naturally occurring antibody
and as such there is no immediate reaction but the red cells carrying
the Rh antigen sensitise the immunologically competent cells in the
body, provided the amount is sufficiently large .This takes at least
one week.
 Following a subsequent exposure to the antigen, the cells are
stimulated to produce more specific anti-D antibody. The women
may suffer a severe haemolytic reaction to the subsequent
mismatched transfusion.
2)As a result of pregnancy (Rh-negative women
bearing a Rh-positive fetus).
Normally, the fetal red cells containing the Rh
antigen rarely enter the maternal circulation.
The following are the conditions where the risk
of feto-maternal bleed is present:

1. Miscarriage.
2. MTP.
3. Genetic amniocentesis.
4. Ectopic pregnancy.
5. Hydatidiform mole.
6. CVS, Cordocentesis.
Placenta praevia with bleeding
Placental abruption, IUFD,
External cephalic version,
Abdominal trauma
Multiple pregnancy
Manual removal of the placenta and
Delivery of a Rh-D positve infant to a Rh negative mother.( either delivery per
vaginaly or by cesarean section)
 With no apparent predisposing factors, fetal red
cells have been detected in maternal blood in
6.7% of women the during first trimester, 15.9%
during the second trimester and 28.9% during the
third trimester
Passage of fetal blood into the maternal circulation at the time of
parturition is almost universal, but only 10-15% of Rh –ve mother
get sensitized at delivery.
Factor influencing Rh Isoimmunisation:

 Size of the inoculum : The greater the number of fetal cells

entering maternal circulation, greater the possibility of maternal
sensitization, as little as 0.1 mL of Rh +ve cell can cause sensitization.

 Coexistence of ABO Incompatibility

between mother and fetus: Because maternal anti A or
Anti B antibodies destroy fetal red cells carrying the Rh antigen before
they can elicit an immune response.

 Approximately 30% of Rh- ve women are

nonresponder.
Mechanism of development of Rh
Isoimmunisation.

 If an immune response is elicited during pregnancy

incidence less than 1% or at delivery incidence is 10% to
15%

 An Rh-ve mother carrying a Rh +ve baby the response will

be the development of anti Rh antibodies (IgM) with a
molecular wt too large to cross the placenta
 This is followed by the synthesis of anti Rh
antibodies IgG that do cross the placenta
because of small molecular wt and stick to the
fetal red cells accelerating their destruction by
RE system.
 Within 6 weeks to 6 months ,IgG antibodies
become detectable.
The general rules of Rh inheritance have exceptions.
Some red cells react weakly with anti-D antibodies
because they contain a gene that produces only a
part of the D antigen. This variant is called Du and
should be absent (Du negative) in a given individual
to be considered Rh –ve.
 Some individuals have a rare state termed Rh-null
in which their red cells lack Rh antigens.
 Some individuals of African and Asian ancestry
have parts of non-functioning Rh genes that
produce false positive Rh determinations with the
polymerase chain reaction technology(PCR).
Other blood groups
Alloimmunization:
Of the other blood groups that may evoke an Immunoglobulin
capable of crossing the placenta ( often called atypical or
irregular immunizing antibodies), those that may cause severe
fetal haemolysis are, Kell, Duffy, Kidd, MNSs and Diego.
P. Lutheran and Xg groups may Also causes fetal haemolysis,
but it usually is less severe.
 Another antigen frequently found in antenatal
testing is the Lewis group (Le-a and Le-b).
 The Lewis antigens do not cause fetal haemolytic
disease and differ from all other red cell antigens
in that they are not synthesized by the red cell
membrane but are absorbed onto it.
 Pregnancies affected by alloimmunization to one
of these antigens are typically managed similar to
pregnancies affected by Anti-D alloimmunization.
 However, because anti-kell antibodies target both
circulating red blood cells and erythrocytes
progenitors in the bone marrow, those
pregnancies followed with middle cerebral arterial
Doppler .
Manifestation of the haemolytic disease of
Fetus and Newborn (HDFN)

Clinical manifestation of the haemolytic disease of the fetus

and neonates are:
 Hydrops fetalis.
 Icterus gravis neonatorum.
 Congenital anaemia of the newborn.
Hydrops fetalis

This is the most serious form of Rh haemolytic disease.

Execssive destruction of the fetal red cells leads to severe
anaemia, tissue anoxaemia and metabolic acidosis.

These have got adverse effects on the fetal heart and brain
and on the placenta. Hyperplasia of the placental tissue
occurs in an effort to increase the transfer of oxygen but the
available fetal red cells (oxygen carrying cells) are
progressively diminished due to haemolysis.
.
 As a result of fetal anoxaemia, there is damage to the liver
leading to hypoprotenaemis which is responsible for
generalized oedema(Hydrops fetalis), ascites and hydrothorax.
 Fetal death occurs sooner or later due to cardiac failure. The
baby is either still birth or macerated and even if born alive,
dies soon after delivery.
fetalis

Maternal Criteria :
 Mother is Rh-negative
 Serological examination reveals presence of Rh antibody.
 There may be presence of polyhydramnions.
 Previous history of affection of s baby due to haemolytic disease.

Investigations:
 Sonography- to detect oedema in the skin, scalp and pleural or pericardial
effusion and echogenic bowel.

 Straight X-ray abdomen showing-”Buddha position” of the fetus with a

halo around the head due to oedematous scalp.
Retrospective diagnosis of Hydrops Fetalis:
The baby at birth looks pale and oedematous with an enlarged
abdomen due to ascities.

Placenta:
Placenta is large , pale and edematous.
The placental weight may be increased to about half or even almost
equal to the fetal weight.
There is undue persistence of Langerhan’s layer with marked
swelling of the villi. If the fetus is not hydropic, the placenta usually
looks normal
Icterus gravis neonatorum.

 The clinical entity is the effect of lesser of fetal haemolysis. The baby is
born alive without evidence of jaundice but soon develops it within 24
hours of birth.
Congenital Anaemia of the Newborn :
This is the mildest form of the disease where haemolysis is
going on slowly.
Anaemia develops slowly within first few weeks of life, jaundice
is not usually evident.The destruction of the red cells continue
upto 6weeks afterwhich antibodies are not available for
haemolysis.
Prevention of Rh Alloimmunization

 To prevent active immunization.

 To prevent or minimize feto-maternal bleed.
 To avoid mismatched transfusion.
 To prevent active immunization
Administration of anti-D plays a corner stone in prevention of
Rh alloimmunization.
.

Anti-D Prophylaxis:
 The incidence of Rh alloimmunization without any anti-D
prophylaxis after two deliveries is approximately 16% which
decreases to less than 1% with antenatal anti-D prophylaxis
 Of these 1.5% -2% will occur antepartum,and 7%
within 6 months of delivery ; the remainder 7%
manifest early in the second pregnancy, most
likely as a result of amnestic response
 Cont:
 Further decreases to 0.1–0.3% following anti-D in
immediate post-partum period .

 Hence, it is the most effective strategy in

preventing Rh alloimmunisation.
Mode of action:

The possible mechanisms are:

The anti D antibody when injected, blocks the Rh-antigen
of the fetal cells.

• Macrophage induced clearance of anti-D coated RBCs

• Down regulation of antigen specific B cells and
antigen masking

Figure:
When to administer-

There are different protocols regarding the timing and doses of

Antibody:

ACOG recommends administering anti –D at 28weeks of pregnancy routinely provided

antibody screening is negative,

The recommended antenatal dose is a single 300 microgram intramuscular

(IM) dose given to all Rh negative non-alloimmunised
pregnant women once at 28 which takes care of small
FMH happening during pregnancy.

The same amount is again

repeated soon after delivery within 72 h (if missed, then up to 28
d) for combatting the FMH happening during parturition.
 NICE routinely offersroutine ant –D prophylaxis
toall unsensitised Rh –ve mother in ( 28 – 34
weeks)
 Blood tests for other atypical antibodies should be
done at 28 weeks prior to administration of anti –
D globulin.
There are three recommended regimes:
1. Two doses of 500 IU of anti –D immune globulin
at 28 weeks and 34 weeks.
2. A single dose of 1500 IU at 28 weeks
3. Two doses of 1000-1650 IU at 28 and 34 weeks
Special fetomaternal risk states:
All Rh-negative unsensitised women should received
5o microgram of Rh-immune globulin I.M. within 72
hours of induced or spontaneous abortion, ectopic or
molar Pg or CVS in the first trimester, cordocentesis.
Women with pregnancy beyond 12 weeks should
have full dose of 300 microgram.
 . Abortion—Sensitization will occur in 2% of spontaneous
abortions and 4–5% of induced abortions.
 In the first trimester, because of the small amount of fetal
blood, 50 μg of RhIgG apparently is sufficient to prevent
sensitization.
 However, because the cost of Rh IgG has dropped, a full
300-μg dose is usually given. The same dose is
recommended for exposure after the first trimester. The risk
of
 Rh alloimmunization after threatened abortion is less well
understood, but many experts agree that RhIgG should also
be given to these patients.
 If more than 12 weeks have elapsed since anti-D
immunoglobulin administration, consideration
 should be given to administering 300 μg of anti-D
immunoglobulin at 40 weeks of gestation.
 Full dose shoulbe given after External Cephalic
Version.
 Antepartum Bleeding—In cases of antepartum
vaginal bleeding or when there is evidence of a
subchorionic hematoma or placenta abruption on
ultrasound, administration of 300 μg of RhIgG is
recommended.
 If the pregnancy is carried more than 12 weeks
from the time of RhIgG administration, a repeat
prophylactic dose is recommended
Kleihauer-Betke (KB) Test:

 KB test or acid dilution test is done to quantify the

amount of FMH.
 It is based on the principle that fetal hemoglobin
is acid
resistant as compared to adult’s.
 After treatment with acid, the maternal blood
smear slide (contaminated with fetal blood
following FMH) is subjected to staining where fetal
RBCs appear rose pink in contrast to ghost cells of
maternal RBCs.
 The percentage of fetal cells in a field of two
thousand RBCs are counted for estimating exact
FMH.
 Grossly fetal blood volume (ml ) = % fetal cells ×
50
 In general, 1 vial of 300 microgram of anti-D is
sufficient to protect against 15 ml of FMH (as is
the case in most pregnancies).

 However, in suspected cases of severe FMH,

additional
10 microgram of anti-D should be considered for
each 0.5 ml of FMH (as determined by KB test)
 While in heterozygous cases fetal Rh typing is
mandated either by cell free fetal DNA or invasive
testing like cordocentesis
.
Administration of anti-D plays a corner stone in
prevention of Rh alloimmunisation.

 The incidence of Rh alloimmunisation without any

anti-D prophylaxis after two deliveries is
approximately 15% which decreases to less than
1% with antenatal anti-D prophylaxis.
Diagnosis :
Rhesus typing and an antibody
screen should be performed at
the first prenatal visit.
The presence of D antibodies in
the maternal serum is diagnostic
of maternal Rh alloimmunization.
The test most commonly used for
diagnostic purposes is the indirect
Coombs test.
 It should be remembered every Rh(-ve)
patient who has received anti-D
immunoglobulin in a previous pregnancy
should have antibody screening in all
subsequent pg.

 Antibody screening should also be

obtained who have had previous blood
transfusion, unexplained fetal losses, or
infants with unexplained jaundice during
the pervious pg.
 The concentration of anti D
antibodies will be determined by a
tritation procedure in which double
dilutions of maternal serum will
progressively be incubated with
group O positive erythrocytes and the
agglutination of the erythrocytes will
be used as the end point of the
reaction .
 For example , a titre of 32 indicates
that the tube with the greatest
dilution where agglutination was
detected had a dilution of 1:32 .
 There are variations between the
different laboratories , the
obstretician managing an immunized
pregnancy should use the same
laboratory for all antibody titre
determinants of a given patient .
 For most laboratories , the critical
anti –D value is between 8 and 32.
The gel micro column assay (GMa) card
is a promising alternative to traditional
tube agglutination tests for determining
anti-D antibody titres.

The main advantage is that it is less

susceptible to inter and intra-laboratory
sources of variability, furthermore, it
yields clear objective results and takes
less time and it is compatible with
automation.
Management

 Rh-negative women presenting for

obstetrical care can be categorized in
two different groups:

a) Rh-negative non-immunized
women and
b) Rh-negative immunized women.
The last group can be divided into two
further subgroup:(b)

 Rh –ve immunized women.

 Rh +ve women immunized against
non- D Rhesus antigens or against
other blood group systems
These two sets of patients are managed
differently. In Rh-non-immunized
women, the primary aim of care is the
prevention of alloimmunization.
In already immunized women, it is the
early detection and adequate treatment
of fetal anaemia.
 The management of Rh-negative
women immunized in a prior
pregnancy or with immunization
secondary to the administration of
incompatible blood products requires,
as a first step the determination of
the paternal and fetal Rh phenotype
and genotype.
 Maternal antibody titres are most
useful in the first sensitised
pregnancy.
When a clinically significant antibody
capable of causing haemolytic disease
of the fetus and newborn (HDFN),
particularly anti-D, anti-c and anti-K, is
present in a maternal sample,
determination of the Rhesus phenotype
of the baby's father is important as it
provides useful information to predict
the likelihood of a fetus carrying the
relevant red cell antigen.
A fetus can only be affected by
maternal alloantibodies if its red cells
express the antigen. If the father is Rh
negative, the fetus will be Rh-negative
too and is therefore not at risk.
If the father is homozygous the baby
has a 100% chance of being Rh-positive
and if he is heterozygous the chances
are 50%.
DNA testing has become available and
techniques such as multiplex
quantitative polymerase chain reaction
(PCR) can reliably determine paternal
zygosity.
 If the father is heterozygous for the
antigen in question, it becomes
important to determine the fetal
antigen status as soon as possible.
 This used to be done by invasive
procedures, such as chorionic villus
sampling (CVS), amniocentesis or
fetal blood sampling.
 CVS had the advantage that it could
be done early in pregnancy but it had
the potential disadvantage of
increasing the severity of
alloimmunization if the fetus was Rh-
positive.
 Amniocentesis seemed to be the safest
and most reliable option and was the
investigation of choice in most centres.
 It used to be carried out after 15 weeks
gestation and amniocytes were used to
obtain the fetal genotype using PCR. There
was a false-positive rate of 1.5%.
 Fetal rhesus-D status can be determined
reliably by PCR analysis of cell-free fetal
DNA from maternal plasma or serum.
A meta-analysis re ported accurate
fetal-D determination in 98.7-100% of
fe 27 tuses in four studies, including at
least 200 cases.
"These techniques have superseded
invasive testing for the assessment of
fetal blood group. They are not only
reliable but also enable women to avoid
invasive procedures to determine fetal
genotype.
All women should have their ABO blood
group and rhesus types determined at
their booking appointment in the first
trimester, along with screening for
atypical antibodies using the direct
Coombs test.
This should be repeated at 28 weeks.
A. Management of the Rh-Negative
Patient with Anti-D
Alloimmunization

 Management of the pregnancy

complicated by alloimmunization is
guided by 2 factors: Whether the
patient has a history of an affected
fetus in a previous pregnancy(ie.
fetus with severe anemia or hydrops)
and
 Maternal antibody titers.
1. No history of previous fetus
affected by Rh (D)
alloimmunization-

 Once the antibody screen is positive

for alloimmunization, these patients
should be followed up with antibody
titers at intake, 20 weeks EGA, and
then every 2-4 weeks.
 As long as antibody titers remain
below the critical titer (< 1: 16 )but
each laboratory must establish its
own norms, there is no indication for
further intervention.
Once antibody titers reach 1:16,
additional surveillance should be
performed because a titer of 1:16 place
the fetus at significant risk of hydrops
and demise before 37 weeks.
Fetal monitoring:

 1) Ultrasound assessment
 2)Middle Cerebral Artery –Peak
Systolic Velocity (MCA-PSV)
Ultrasound Assesment :
High resolution ultrasound is a valuable
in the modern management of
sensitized Rh- negative patients.
The dating scan establish an accurate
estimation of the gestational age.
This influences management decisions
such as the interpretations of
laboratory values and timing of
delivery.
Ultrasonography also allows early
diagnosis of fetal hydrops .
MCA-PSV

Ultrasound assessment of blood flow in

he fetal middle cerebral artery (MCA)
by Doppler has been shown to be a
reliable and noninvasive screening tool
for detecting moderate to severe fetal
anemia.
It is based in the concept that the fetus
preserves oxygen delivery to the brain
in the low viscosity blood.
Ultrasound is performed to identify the
circle of Willis, and blood flow in the
proximal third of the MCA can be
estimated using Doppler.
 This tests can be performed at 2
weeks intervals in these patients , so
more invasive diagnostic interventions
can be avoided by 70% until evidence
of severe anemia is observed.
Interpretation of MCV -PSV

High peak velocity blood flow in this

area(> 1.5 multiples of the median)
correlates well with severe fetal
anemia.
Timing of test:
It can be used reliably from 18 -36
weeks.
After 35 weeks the false positive rate of
MCA-PSV in predicting fetal anaemia
rises considerably.
2. History of a prior fetus
affected by Rh(D)
alloimmunization-
In general, after a first affected
pregnancy, further pregnancies tend to
manifest with more severe disease and
at an earlier gestational age.
Antibody titers need not be followed
in these pregnancies.
Amniocentesis may be performed to
determined the fetal genotype if the father of the
fetus is determined to be heterozygous for D.
If the fetus is determined to have the D antigen,
that fetus is considered to be at risk of hemolytic
disease and severe anemia regardless of
maternal antibody titers.
For this reason, MCA Doppler surveillance should
be initiated at 18 weeks and repeated every 1-2
weeks. Treatment of these patients is dictated
by MCA Doppler results.
Once it is determined that a patient
should be followed with MCA Dopplers,
the results of the MCA Dopplers will
place the fetus into 1 of 3 categories:
A) Unaffected or mildly affected
fetus: the fetus that has normal
MCA Doppler studies is considered to
be unaffected or mildly affected.
Testing should be repeated every 2
weeks, and delivery should be
entertained at term or near term and
after the fetus has archived pulmonary
maturity.
B)Moderately affected fetus: the
fetus that has MCA Doppler studies
nearing 1.5 multiples of the median
should be required before term, and the
fetus is delivered as soon as pulmonary
maturity is reached.
In some cases, enhancement of
pulmonary maturity by use of
corticosteroids may be necessary.
C) Severly affected Fetus:
The severely affected fetus has MCA
Doppler studies>1.55 multiples of the
median or has frank evidence of
hydrops ( eg,ascites,pleural or
pericardial effusion,subcutaneous
edema)
Intervention usually is needed to allow
the fetus to reach a gestational age at which
delivery and neonatal risks are fewer than
the risks of in utero therapy.
If the fetus is preterm, cordocentesis or
percutaneous umbilical cord blood sampling
is recommended at this stage to directly
asses the fetal haematocrit.
Intrauterine transfusion are generally
performed between 18 and 35 weeks
gestation.
Before 18 weeks, access to the umbilical vein
is limited due to the small caliber of the
vessel. After 35 weeks, the risk or benefit
ratio favors delivery of a fetus with evidence
of severe anemia.
Once severe anemia is confirmed,
intrauterine transfusion can be performed
directly into the umbilical vein. The
transfusion is performed using O-negative,
cytomegalovirus-negative, washed,
leukocyte depleted, irradiated packed red
cells.
After transfusion, repeat transfusion or
delivery usually will be necessary, as timing
of these transfusion may be assisted by
ultrasonic determination of MCA Doppler
studies.
Delivery should take place when the fetus
Fetal Blood Sampling (FBS)
and Intrauterine Transfusion
(IUT)
 Fetal blood sampling is also called
cordocentesis or percutaneous umbilical
sampling. It was introduced by Daffos in
1983 and dramatically changed the
management and therapy of Rh-sensitized
patients.
 It is the only definitive means of confirming
fetal anaemia by giving a precise
measurement of the fetal haematocrit and
haemoglobin concentration to determine
the need for intrauterine transfusion.
During fetal blood sampling and in-utero
transfusion, the placental insertion of the
umbilical cord is found using high-resolution
ultrasound and colour flow mapping.
Then, still under ultrasound guidance, a
needle is introduced into the umbilical vein
and fetal blood is drawn to determine the
fetal blood group, Rh status, haemoglobin
and haematocrit. A haematocrit of less than
30% (=Hb 8 g/dl) is an indication for in-
utero transfusion.
Cordocentesis requires a degree of
expertise and has the potential for
serious complications, most commonly
bleeding, which is normally transient but
also feto-maternal haemorrhage, fetal
loss (1-2% after 24 weeks gestation),
placental abruption, thrombosis of the
umbilical vessels, fetal distress and
amnionitis.
It also allows the adequate assessment
before and after transfusion.
Cordocentesis carries an increased risk of
fetal death that may be as high as 5% in
performed before 24 weeks. It can be
performed as early as at 16-20 weeks.
In-utero transfusion has been
performed since 1963 and intravenous
in-utero transfusions have now largely
replaced intraperitoneal transfusions
because they are associated with less
procedure-related morbidity and
mortality.
Most operators aim to transfuse to
supranormal haemoglobin levels
enabling long intervals of 2-4 weeks
between transfusions.
Some studies have shown that on an
average three transfusions are required
but sometimes more than 10 might be
needed during pregnancy.
These will be carried out until 34 weeks
gestation. After 34 weeks, the risk of
the procedure outweighs the benefits
and delivery is preferable if severe
anaemia is suspected.
Once an invasive procedure has been
carried out, use of antibody titre as a
marker for disease severity is no longer
valid, because the titres invariably rise
after FBS.
Care at Delivery:
Timing of the delivery depends on:
Gestational age, severity of fetal
anaemia and fetal maturity. If fetal
surveillance is reassuring, labour can
often be induced between 37 and 38
weeks.
This has the advantage that a vaginal
delivery can be allowed.
However delivery by caesarean section is
common delivery before when the fetal
condition necessitates a 34 weeks.
If delivery is anticipated before 36 weeks,
the use of steroids for lung maturation is
recommended. A direct agglutinin test is
recommended on a sample of cord blood
in alloimmune women.
During delivery, these measures should
be followed:
 Keep cross-matched blood ready
before induction of labour;
 Clamp cord immediately;
 Keep cord long for possible
catheterization.
 Collect cord blood for blood group,
bilirubin and direct agglutinin test.
 Exchange transfusions may be
needed soon after birth.
Neonatal management

Despite the huge improvement in

neonatal care, the principles for the
treatment of haemolytic disease of the
newborn are the same.
Early anaemia and hyperbilirubinemia
mia are treated with exchange or top-
up infusions and milder cases with
phototherapy.
 Neonates from severely affected pregnancies
are less likely to show signs of haemo lytic
disease because they will have received in-
utero transfusions.
and at the time of birth nearly all their blood
volume consist of adult donor Rh-negative
blood cells, Recombinant erythropoietin has
shown to reduce the need for top-up infusions.
The role of intravenous gamma globulin still
remains unclear.
Management of Rh-negative
patients
 Management should be grouped as follows-
I. The Rh(-ve) non-immunized patient.
II. The Rh(-ve) immunized patient.

 Rh(-ve) non-immunized patient-

1. Primigravida
2. Multigravida patient who are Rh(-ve) and
do not have detectable iso antibodies in
the initial prenatal evaluation.
If the patient is Rh(-ve) the problems for
obstetrician are---
a) To assess the chances for the patient to become iso
immunized.
b) To take measures to detect iso-immunization if it actually
occurs during the present pg, and
c) To use adequate prophylaxis antepartum and in the
immediate postpartum period.
To assess the possibility of iso-immunization following
steps should be taken-
a. Blood grouping and Rh-typing of the father.
b. If the father is Rh(-ve),no need further testings.
 If father Rh(+ve), then genotype of father should be done
because the infant has a 50% chance, If the father is
heterozygous
 If the father is homozygous, 100% chance
Next step to detect iso-immunization
Detection of Rh antibody titre:

 Antibody screening should be done at booking then should

be repeated at 28 wks of gestation.
 If screening reveal anti-D antibodies the patient should be
managed as Rh(-ve) immunized pregnancy.
 If the screening(-ve) patient should receive anti-D
immunoglobulin at 28 wks of gestation.
 Further antibody screening will be unnecessary.
 At the time of delivery it will be necessary to determine the
mothers eligibility to receive a 2nd dose od anti-D
immunoglobulin in the immediate post partum period.
D Immunoglobulin should be given under
the following circumstances---

 The infant is Rh-positive.

 The direct Coombs test on umbilical cord blood is (-ve)

N.B.-
 The maximum protective effects is obtained. If the antibody
is administered within 72 hrs after delivery.
Fetal monitoring-

 By serial USG.
Plan of delivery

Unimmunized mothers: In cases where there is no

detectable antibody found during Pg, an expectant attitude
is followed till term. Tendency of Pg to overrun the
expected date should not be allowed.
Plan of delivery---
Antibodyscreening
Antibody screeningbecomes
at negative
booking and 28 wks.

Give D-Ig at 28wks and

Fig:- Mx of
Determine the Rh-vefor
eligibility non-immunized
2nd dose of preg
D-Ig at
delivery
Methods of delivery-

1. Amniotomy (low rupture of the

membrane) is quite effective, If Bishops
scoring is good, no other obstetric or medical
complications vaginal delivery may be allowed.
Short trial of labour should be given. Vaginal
prostaglandin gel (PGE2) could be used to
make the cervix ripe.
2. Caesarean section: If cervix is unfavorable
and other obstretic & medical complications ,
Caesarean section is a safe procedure.
 To prevent or minimize feto-maternal bleed:
• Precaution during caesaren section:
1. To prevent blood spilling into the peritoneal cavity
2. Manual removal of placenta should not be done as a routine.
• Prophylactic ergometrine with the delivery of the anterior shoulder
should preferably be withheld, as it may facilitate more feto-
maternal bleed.
• Amniocentesis should be done after sonographic localization of the
placenta to prevent its injury.
• Forcible attempt to perform external version under anaesthesia
should be avoided
• Manual removal of placenta should be done gently.
• To refrain from abdominal palpation as far as possible in
abruption placentae.
To avoid mismatched transfusion

• To avoid giving Rh-positive blood to one Rh-negative female

from her birth to the manupause.
To prevent active immunization.

To prevent active immunization of Rh-negative yet

unimmunized, Rh anti-D immunoglobulin(IgG) is administered
intramuscularly to the mother following child birth. The other
conditions that the Rh anti-D immunoglobulin should be given.
 It should be given provided the baby born is Rh-
positive and the direct Coombs’ test is negative.
 During Pragnancy
• In spite of postpartum Rh immune globulin prophylaxis, failure rate
is about 1-2 present. This is due to antepartum feto-maternal
haemorrhage and sensitization (1-2 per cent). If the women is Rh-
negative & has no antibody, she should have one dose of 300
microgram Rh immune globulin as prophylaxis at around 28
weeks(ACOG-1996) & again after birth(within 72 hours).
 Management
of
Rh-immunized patient
Management based on the
adequate use of four diagnostic
procedures-
1. Maternal serum antibody titres.
2. Fetal assessment by USG.
3. Amniotic fluid bilirubin determination.
4. Fetal blood sampling.
Management of Rh-negative
immunized women
 The management of Rh-negative women immunized in a
prior pg or with immunization secondary to the
administration of incomplete blood products requires, as a
first step, the determination of the paternal and fetal Rh
phenotype and genotype.
Paternal Rh phenotype and
genotype
 Determination of the paternal Rh phenotype is the first step.
If the father of the baby is Rh negative the fetus will not be
affected and further tests are unnecessary. If the father is Rh
positive it is necessary to determine if he is homozygous or
heterozygous for the RHD gene.
 If the father is heterozygous, the fetus has a 50% probability
of being Rh negative and determination of the fetal Rh
becomes mandatory to avoid unnecessary testing in the
50% fetuses that will be Rh negative. If the father is
homozygous, the fetus will be Rh positive and amniocentesis
to determine the fetal Rh will be unnecessary.
Fetal Rh determination
 The fetal Rh genotype can be determined using cells
collected by chronic villous sampling (CVS) or
amniocentesis. The fetal Rh phenotype can be determined
by serologic testing using fetal blood.
 Amniocentesis is the method of choice to obtain fetal tissue
for Rh factor determination because of its simplicity and
safety.
 The fetal cells contained in the amniotic fluid are cultured in
order to obtain an adequate amount of DNA. The genomic
DNA is used for genetic amplification by PCR.
 The management of sensitized Rh-negative women with an
Rh-positive fetus is different if the pregnancy is the first
affected one or not.
1. First affected pregnancy

 The first affected pregnancy is the only pregnancy in which

maternal anti-Rh antibody titers can be used to determined
the risk of fetal anemia.
 In the majority of first immunized pregnancies the anti-Rh
antibody concentration is low and rarely exceeds the critical
level of most laboratories. The critical level means that no
death due to fetal hemolytic disease has occurred within 1
week of delivery when the antibody titer was at that level or
lower.
Serum antibody titers
 Patients in the course of their sensitized pg should have
antibody titers every 4 weeks unless the following occur:
1. The titer is found to be at or above the critical level
(usually 32) on the initial evaluation.
2. The titer reaches or exceeds the critical level at any time
during gestation.
3. There is a significant rise in titer (two-tube dilution)
between two consecutive samples, even if the upper
dilution dose not reach the critical level(e.g. an increase
from 4 to 32 with a critical level of 64).
 If any of these conditions occur, there is no further use for
antibody titers for following the first sensitized pregnancy
and further management will be based on fetal assessment
using the mid-cerebral artery peak systolic velocity (MCA
PSV) and the concentration of bilirubin in amniotic fluid.
 If the antibody titer remains under the critical level up to 36
weeks of weeks of gestation, the patient with a first
sensitized pg should be delivered by elective induction of
labor between 38 and 40 weeks, and the birth of a non
affected (Rh-negative) or mildly affected Rh-positive infant
should be anticipated.
 Women with a first sensitized pg followed with antibody
titers that have a sudden antibody titer elevation when they
are more than 34 and less than 37 weeks gestation should
have amniocentesis and delivered if the fetal lung maturity
is adequate. If the fetal lung maturity tests indicate
pulmonary immaturity and the bilirubin level is low(less than
0.05), the pregnancy should be allowed to continue as long
as weekly amniocentesis shows fetal pulmonary immaturity
and a low bilirubin concentration. These babies usually have
mild hemolytic disease and should be delivered as soon as
their lungs reach adequate maturation.
2. Women with previous affected Pg

 After the first affected pg, the ability to predict fetal anemia
from the maternal anti-D titers is lost and different methods
are necessary to evaluate the likelihood of fetal anemia. In
these cases the past obstetric history is the predominant
indicator of the outcome.
 Since titers are not predictive of outcome, women with prior
affected pregnancies should be followed with serial
determinations of the PSV of the middle cerebral artery
(MCA PSV) and with amniocentesis to determine the
concentration of bilirubin in the amniotic fluid.
1. Meddle cerebral artery peak velocity

 the MCA PSV is an accurate noninvasive method for the

diagnosis of fetal anemia. The correlation between the MCA
PSV and fetal anemia become stronger as the fetal
hemoglobin decreases. Also, MCA peak velocity values can
be used to predict the fetal hemoglobin concentration.
 Ultrasound assessment of blood flow in the fetal
middle cerebral artery (MCA) by Doppler has been
shown to be a reliable and noninvasive screening
tool for detecting moderate to severe fetal
anemia.

 It is based on the concept that the fetus

preserves oxygen delivery to the brain in the
setting of anemia by increasing flow to the brain
of the low viscosity blood.
Ultrasound is performed to identify
the
circle of Willis, and blood flow in the
proximal third of the MCA can be
estimated using Doppler.
High peak velocity blood flow in this
area (>1.5 multiples of the median)
correlates well with severe fetal
anemia.
2. Amniotic fluid bilirubin
 Spectrophotometric analysis of the amniotic fluid to
determine the concentration of bilirubin is the traditional
method for evaluating the severity of the fetal hemolytic
process and for determining the optimal time for IUT or for
delivery of the infant. Usually the first amniocentesis is
performed at 20wks but in women who start off with a high
titer, who have had a baby that was hydropic or died in
uterus, or whose ultrasound evaluation demonstrates early
signs of fetal hydrops, the first amniocentesis may be done
at 18 wks.
 About 5-10 ml of amniotic fluid is required for
spectrophotometric analysis. The fluid should be kept in a
brown bottle to protect it from exposure to the sunlight,
which destroys some of the bilirubin and causes false low
reading. The fluid is centrifuged at 4000rpm for 20 minutes
and analyzed by spectrophotometry. When normal amniotic
fluid is examined in a spectrophotometry using water as a
blank, the optical density(OD) readings between 350 and
650 nm form an almost straight line. If the amniotic fluid
contains bilirubin, the OD readings will show a peak at 450
nm, and the size of the peak will be proportional to the
amount of pigment in the fluid.
3. Ultrasound assessment
 High- resolution ultrasound is a valuable tool in the
management of sensitized Rh-negative patients. Modern
equipment allows a clear visualization of the fetal structure
and early diagnosis of the presence of fetal ascites,
pericardial effusion, liver enlargement, and placental
swelling.
 There are two important caveats in the use of ultrasound as
the main indicator of fetal hemolytic disease. In the first
place, fetal hydrops usually develops when the fetal
hematocrit is below 20% and ultrasound will only detect
advanced degrees of fetal anemia. Secondly, in many
patients the onset of fetal hydrops is rather sudden and its
detection by ultrasound will require the performance of
frequent evaluations.
 Once fetal ascites is detected, the fetus is anemic and IUT is
necessary.
4. Fetal blood sampling
 The introduction of cordocentesis by Daffos et al.(1983)
dramatically changed the management and the therapy of
the Rh-sensitized patient. Umbilical cord blood sampling
allows a precise measurement of the fetal hematocrit and
hemoglobin concentration to determine the severity of the
hemolytic process and the need for IUT. Also, the same
technique may be used for direct intravascular transfusion
to the fetus, a technique that has successfully allowed “in
utero” treatment of hydropic fetuses unresponsive to
transfusions into the peritoneal cavity.
 For fetal blood sampling or transfusion the placental
insertion of the umbilical cord is found using high resolution
ultrasound and color flow mapping. Then, under ultrasound
guidance a needle is introduced into the umbilical vein and
fetal blood is drawn for determination of fetal blood group
and Rh, direct Coombs’ test, hemoglobin and hematocrit. A
hematocrit of less than 30% is an indication for IUT.
Intrauterine transfusion
 There are two types of IUT: intraperitoneal and intravascular.
In both methods, the procedure is carried out under visual
control with real-time ultrasound. In intraperitoneal IUT the
blood is injected into the peritoneal cavity and transported
by the lymphatic system into the fetal blood-stream. In
intravascular transfusion, the blood is injected directly into
the umbilical circulation.
 IUT has a potential for serious complication. Peritoneal death
approximately 11.0%
 Infection, rupture of membranes, and emergency delivery
occur occasionally. The procedure-related complication rate
is 3.1% per procedure
 Intrauterine transfusions are generally performed
between 18 and 35 weeks of gestation. Before 18
weeks, access to the umbilical vein is limited due
to the small caliber of the vessel. After 35 weeks,
the risk/benefit ratio favors delivery of a fetus
with evidence of severe anemia.
 Once severe anemia is confirmed, intrauterine transfusion
can be performed directly into the umbilical vein.
 The transfusion is performed using O negative,
cytomegalovirus-negative, washed, leukocyte-depleted,
irradiated packed red cells. After transfusion, repeat
transfusions or delivery usually will be necessary, as production
of fetal blood markedly decreases or ceases.
 Timing of these transfusions may be assisted by ultrasonic
determination of MCA Doppler studies
 .Delivery should take place when the fetus has documented
pulmonary maturity.

 .
Early delivery and glucocorticoids
 If delivery before 36 wks is necessary, the use of steroids to
accelerate the maturation of the fetal lungs is
recommended. Betamethasone 12mg IM daily for 2
consecutive days or dexamethasone 6mg every 12 hrs for 4
doses are equally effective.
 Corticosteroids cause a decrease in OD450 values.
Other treatment modalities
 There are treatment modalities for women with Rh
alloimmunization which have been used in cases of severe
immunization with high initial titers and history of pregnancy
losses due to fetal hydrops. They include plasmapheresis
and administration of promethazine and IgG.
Thank
you