Management of the Rhesus Negative Mother

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Management of the Rhesus Negative Mother

  1. 1. Management of the Rhesus Negative Mother Dr Shantala Vadeyar MD, FRCOG, DM Advanced Obstetric Ultrasound (RCOG / RCR) Subspecialist Fetal & Maternal Medicine (RCOG)Consultant Obstetrician, Fetal & Maternal Medicine Kokilaben Dhirubhai Ambani Hospital, Mumbai www.totalpregnancycare.com
  2. 2. Background• Incidence of Rh neg individuals varies with race• Caucasians (whites) 15%• Afro-Carribeans (blacks) 7-8%• Asians 5%• Chinese and Japanese 1%
  3. 3. What is the Rhesus factor?• It is a Red blood cell antigen• Other Red cell antigens include -• A, B – blood groups• Duffy, Kell, Kidd
  4. 4. Genetics of Rh factor• C, D and E antigens• D antigen is the most important and determines Rh positivity• cDe is Rh positive• Two alleles – heterozygotes or homozygotes Rh positive Rh neg• Rh negative person has dd genotype
  5. 5. Pathophysiology in pregnancy• Rh negative mother• Carrying a Rh positive fetus• Some Rh positive RBCs cross over into the maternal circulation• Since the mother has not been exposed to these antigens,• She makes antibodies to this “D” antigen
  6. 6. Pathophysiology of isoimmunisation• These circulating “anti-D” antibodies enter fetus• They will attack fetal RBCs that are rhesus positive• This causes RBC destruction (hemolysis)• This leads to fetal anemia• Fetus does not get hyperbilirubimemia• Manifests as hydrops and fetal loss
  7. 7. Management of Rh negative gravida• Careful history• Previous pregnancy losses• h/o blood transfusions• Check husband‟s blood group and Rh factor• Check anti-D antibodies Coomb‟s test• If no antibodies at „booking‟, then repeat titres at 28, 36 weeks
  8. 8. Prophylactic Anti-D• Prophylactic antenatal anti D at 28, 34 weeks 300 IU injection• Following any episode of antepartum haemorrhage• Miscarriage, Ectopic pregnancy• Amniocentesis / CVS / FBS• Delivery – normal and LSCS
  9. 9. Anti – D: Mechanism of Action• The Rh positive fetal RBCs that enter the maternal circulation are destroyed by the anti D• Thus, the D antigen is not allowed to be presented to the maternal immune system• Prevents „sensitisation‟
  10. 10. Rh Sensitised Pregnancy Titres 4 weekly Titres < 1:32 till 24 wks and 2Rh antibodies wkly till term positive Serial fetal MCA Titres > 1:32 Dopplers every 1-2 wks
  11. 11. Middle Cerebral Artery
  12. 12. MCA Doppler- Rhesus isoimmunisation
  13. 13. MCA Doppler- IUGR
  14. 14. Rh Sensitised Pregnancy - 2 Fetal Blood Sampling and consider IUT MCA PSV 1.5 MoMs and aboveMCA Doppler If no facilities forVelocimtery FBS, amniocentesisPeak Systolic Velocity MCA PSV less Monitor MCA PSV than 1.5 Moms 1-2 wkly
  15. 15. Fetal assessment of hemolysis– invasive procedures • Amniocentesis and checking ODD 450 to check level of bilirubin in AF • Fetal Blood Sampling and checking fetal Haemoglobin level
  16. 16. Amniotic fluid ODD 450
  17. 17. Intrauterine blood transfusion
  18. 18. Antenatal Steroids• If preterm delivery <36 wks may be predicted, then antenatal steroids must be given to enhance fetal lung maturity• 2 doses of betamethasone 12 mg• 24 hours apart• Careful blood sugar monitoring in GDM• May also cause hyperacidity
  19. 19. Delivery• Most commonly with Rh sensitised pregnancies – LSCS• May try induction of labour• Continuous FHR monitoring• Early recourse to LSCS is any doubts• Neonatologists present at delivery
  20. 20. Neonatal Management• Commonly need Phototherapy• May need Exchange Transfusion• Bone marrow suppressed if IUT• Anemia – blood transfusion• Haematinics long term• Good long term outcome
  21. 21. Rhesus isoimmunisation-1• Mrs KC, age 38, P1, 15 yr girl• Rh negative, booking antibody screen• Anti D at 15 weeks- 11iu/ml• Scan at 20 weeks- MCA Doppler normal• Repeat Anti D titres and scans for MCA PSV every 2-3 weeks.• 26 weeks- raised titres 20iu/ml and MCA PSV raised to 1.5MoMs
  22. 22. Rh isoimmunisation-2• Amniocentesis ODD450- below action line• 29, 30 weeks- MCA Doppler normal• 30 weeks- repeat amniocentesis- slight increase in ODD 450 levels, but below action line• 31 weeks- Steroids, MCA Dopplers every week- within 1.5 MoMs- normal
  23. 23. Delivery• 32 weeks- amniocentesis- action line• Options- Intrauterine transfusion v/s delivery• 33+5 w- delivery- 2.2kg female• Exchange transfusions and phototherapy postnatally- discharged 2 weeks
  24. 24. THANK YOU
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