King Abdulaziz University<br />Medicine Collage<br />2009 – 2010 ( 2nd year )<br />( Rh–induced Hemolytic Disease of Newborn ) <br />Waleed Faisal Bokhari.<br />0907069 (Group One ) .<br />Definition:<br />Erythroblastosis Fetalis is a hemolytic anemia in the fetus or neonate, caused by trans-placental transmission of maternal antibodies to fetal RBCs. The disorder usually results from incompatibility between maternal and fetal blood groups, often Rh antigens.<br />Types:<br /><ul><li>ABO incompatibility ( tow deffrent blood groups are mixed together ).
Rh incompatibility discussed below.</li></ul>Rh incompatibility ( Rh–induced Hemolytic Disease of Newborn ) :<br />Rh incompatibility is that develops when a pregnant woman has Rh-Negative blood and the baby in her womb has Rh-Positive blood.<br />37216201014303During pregnancy, red blood cells from the fetus can get into the mother’s bloodstream as she nourishes her child through the placenta. If the mother is Rh-Negative blood her system cannot tolerate the presence of Rh-Positive red blood cells. In such case the, the mother’s immune system treats the Rh-Positive fetal cells as if they were a foreign substance and makes antibodies against the fetal blood cells. These anti-Rh antibodies ( Figure 1 ) may cross the placenta into the fetus, where they destroy the fetus’s circulation red blood cells ( Figure 2 ).<br />First-born infants are often not affected because it takes time for the mother to develop antibodies against the fetal blood, unless the mother has had previous mis- carriages or abortions, which could have sensitized her system for developing antibodies. Hence second children who are also Rh-Positive may be harmed.<br />Figure 1<br />19050106586<br />Figure 2<br />Symptoms: <br /><ul><li>Jaundice
Polyhydramnios ( before birth )</li></ul>Jaundice<br />3938978294754Newborn jaundice is a condition marked by high level of bilirubin in the blood. The increase bilirubin cause the infant’s and whites of eyes to look yellow ( Figure 3 ).<br />Before birth, the placenta removes the bilirubin from the infant so that it can be processed by the mother’s liver. Because the hemolytic RBCs of the fetal blood is very high, immediately after birth the baby’s own liver cannot do the normal recycling of old red blood cells, and the rate of bilirubin become higher.<br />Figure 3<br />3938978127885<br />Hypotonia ( floppy infants )<br />It’s a decreased muscle tone ( Figure 4 ) . Infants with hypotonia seem floopy and feel like a “rag doll ” does when held. They rest with their elbows and knees loosely extended, while infants with normal tone tend to have flexed elbow and knees. Head control may be poor or absent, with the head falling to the side, backward or forward.<br />Figure 4<br />3294400238604<br />Polyhydramnios<br />It’s the presence of excessive amniotic fluid surrounded the fetus. ( Figure 5 )<br />Figure 5<br />Exams and Tests: <br /><ul><li>A positive Coombs’ Test result
Fetal Blood Sampling ( FBS ) for Rh sensitization during pregnancy.
A high Level of bilirubin in the baby’s cord blood</li></ul>Coombs’ Test<br />The Coombs’ tes looks for antibodies that may bind to fetal blood cells and causes premature RBC destruction ( hemolysis). <br />The direct Coombs’ test is used to detect antibodies that are already bound to the surface of red blood cells. <br />The indirect test looks for unbound circulating antibodies against a series of standardized red blood cells it’s used to determined if the person have a reaction to blood transfusion. <br />Fetal Blood Sampling ( FBS ) for Rh sensitization<br />Fetal blood sampling (FBS) is the collecting of fetal blood directly from the umbilical cord or fetus. The fetal blood is tested for signs of anemia and other blood problems. FBS is also known as cordocentesis or percutaneous umbilical cord blood sampling. <br />FBS is used to look at a fetus's red blood cell count and oxygen level, and it also looks for signs that your immune system is destroying fetal red blood cells.<br />Prevention: <br /><ul><li>Rh immune globulin
RhoGAM</li></ul>Rh immune globulin contains antibodies to the Rh factor in blood. The antibodies come from mother’s blood stream had been sensitized to Rh factor. Giving these Rh antibodies to an Rh-Negative pregnant woman prevent her immune system from producing its own anti-Rh antibodies, which would attack the Rh-Positive red blood cells of the fetus.<br />Rh immune globulin antibodies locate any Rh-Positive of fetal red blood cells that are present. The RhoGam attach to the Rh-Positive red blood cells, making their presence from mother’s immune system. Although the Rh immune globulin antibodies destroy fetal red blood cells, also.<br />Rh immune globulin is given to all Rh-Negative women who ma be carrying an Rh-Positive fetus. While it prevent Rh Sensitization, but it cannot prevent damage to an Rh-Positive fetus if their mother is already sensitized to Rh factor.<br />Rh immune globulin should be given to an Rh-negative woman to prevent sensitization :<br />After amniocentesis, fetal blood sampling, or chorionic villus sampling. <br />When bleeding occurs in the second or third trimester of pregnancy. <br />At 28 weeks of pregnancy. <br />After an external cephalic version of a breech fetus. <br />After abdominal trauma during pregnancy. <br />Within 72 hours after delivery of an Rh-positive infant. <br />After a threatened or complete miscarriage, or an induced abortion. <br />Before or immediately after treatment for ectopic pregnancy or a partial molar pregnancy.<br />Treatment at termination of pregnancy is occasionally infective because sensitization may have occurred earlier during pregnancy.<br />Treatment:<br />Since Rh incompatibility is almost completely preventable with the use of RhoGAM, prevention remains the best treatment. But if the fetus is already affected some therapy must done for the fetus.<br /><ul><li>Aggressive hydration
Fetal Blood Transfusion</li></ul>Bilirubin Light <br />Bill light refer to a type of phototherapy that is used to treat newborn jaundice, a yellow coloring of skin and eyes related to immature liver function ( Figure 6 ).<br />Phototherapy involves the exposure of bare skin to fluorescent light. The newborn (without clothes or in a small diaper) is placed under the fluorescent lights. The eyes are covered to protect them from the bright light. The blue fluorescent "
lamps give off specific wavelengths of light that help break down bilirubin into different forms that can leave the body through the urine and stools.<br />Because dehydration may result from being under the lights, fluids may need to be given through a vein. Blood tests are done to regularly check the bilirubin level. When the levels have dropped enough, phototherapy is complete.<br />369164098914Treatment depends on three factors:<br />Birth weight <br />Concentration of bilirubin in the blood <br />Newborn's age (in hours) <br />Figure 6In severe cases of increased bilirubin in a low birth weight newborn that is less than 24 hours old, an exchange transfusion may be preferred over phototherapy.With very high bilirubin concentrations, regardless of age and weight, an exchange transfusion may be the best option.<br />3796572-123669Intraction Fetal Blood Transfusion <br />An intrauterine transfusion provides blood to an Rh-positive fetus when fetal red blood cells are being destroyed by Rh antibodies. A blood transfusion is given to replace fetal red blood cells that are being destroyed by the Rh-sensitized mother's immune system. This treatment is meant to keep the fetus healthy until he or she is mature enough to be delivered . <br />Figure 7Transfusions can be given through the fetal abdomen or, more commonly, by delivering the blood into the umbilical vein ( Figure 7 ). Umbilical cord vessel transfusion is the preferred method because it permits better absorption of blood and has a higher survival rate than does transfusion through the abdomen.<br />An intrauterine fetal blood transfusion is done in the hospital. The mother may have to stay overnight after the procedure.<br />The mother is sedated, and an ultrasound image is obtained to determine the position of the fetus and placenta. <br />After the mother's abdomen is cleaned with an antiseptic solution, she is given a local anesthetic injection to numb the abdominal area where the transfusion needle will be inserted. <br />Medicine may be given to the fetus to temporarily stop fetal movement. <br />Ultrasound is used to guide the needle through the mother's abdomen into the fetus's abdomen or an umbilical cord vein. <br />A compatible blood type (usually type O, Rh-negative) is delivered into the fetus's umbilical cord blood vessel. <br />The mother is usually given antibiotics to prevent infection. She may also be given tocolytic medicine to prevent labor from beginning, though this is unusual. <br /> <br />A sensitized mother's immune system can destroy a large amount of fetal red blood cells, causing severe anemia. Intrauterine blood transfusions are done when:<br />Doppler ultrasound of the middle cerebral artery suggests anemia. <br />The bilirubin result from amniocentesis testing shows that the fetus is moderately to severely affected by Rh sensitization. <br />Ultrasound shows evidence of fetal hydrops, such as swollen tissues and organs. <br />Fetal blood sampling (FBS) shows that the fetus has severe anemia. The transfusion may be done immediately. <br />In a severely affected fetus, transfusions are done every 1 to 4 weeks until the fetus is mature enough to be delivered safely. Amniocentesis may be done to determine the maturity of the fetus's lungs before delivery is scheduled.<br />References<br /><ul><li>http://medlineplus.gov/
http://www.medterms.com/script/main/hp.asp</li></ul>Media References <br /><ul><li>A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).