4th year lecture

1. Dr. Esgair Alzahra
MBBCH, DOG, ABOG
Teaching staff
Tripoli Medical Sciences
Faculty of medicine Ob. & Gy. depa
Tripoli Libya
Consultant Obstetrician and Gynecologist
Aljala teaching Maternity Hospital
Oumer Almokhtar Street
Tripoli Libya
Obstetrics & Gynecology Dept
Rhesus Isoimmunization
Scientific activity
21 – 01 - 2020
Aljala Maternity Teaching Hospital
Omer Almokhtar Street Tripoli Libya
University of Tripoli Medical Collage

2. 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

3. Rhesus Isoimmunization
Rhesus Isoimmunization occur when
a Rh – negative Pregnant patient
and her fetus is a Rh – positive
during her pregnancy
….. If a feto – maternal blood transfusion happen
….. the mother immunological system is stimulated
to produce antibodies agonist the Rh antigen on
the fetal blood cell

4. Rhesus Isoimmunization

7. Rhesus Isoimmunization
This antibodies cross the placenta and destroy
fetal red blood cells leads to fetal anemia
Usually the 1st fetus will not be affected if this is
the 1st time that the mother has been exposed to
the rhesus positive antigen
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8. Rhesus Isoimmunization
During pregnancy
while the fetus still in the uterus
The maternal antibodies “IgG” enter the fetal
circulation trans placental
In the fetal circulation the “IgG” antibodies
destroy the fetal red blood cells
The hemolyzed Fetal RBCs Led to
► Fetal Anemia
► Liberate unconjugated bilirubin
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9. The bilirubin in the fetal blood will be removed
by the placenta to the maternal circulation and
part of it inter to the liquor
The fetus will be anemic
Fetal Anemia well lead to
……. increase in the size of Placenta
with hydropic change
……. Increase in the amount of liquor
“Polyhydramnious”
……. Accumulation of fluids in the Subcutaneous
tissues under the fetal skin “fetal edema”
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10. If the degree of anemia is severe
Fetal edema increases with Accumulation of the
fluids in the fetal body cavities
…….. Peritoneal cavity “fetal ascites”
…….. Plura “plural effusion”
…….. Pericardium “pericardial effusion”
Hyper dynamic fetal heart failure
fetus may die in utero
Fetal anemia can be corrected by extrauterine
treatments otherwise deliver
and arrange for extrauterine treatment
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11. After delivery
The neonate will be affected by
The gestational age at delivery
The neonatal weight at delivery
The degree of the anemia
The amount of bilirubin
The neonatal facilities and team
experiance
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13. Causes of feto-maternal blood transfusion
Early pregnancy bleeding,
Late pregnancy bleeding,
No education during antenatal care
Inadequate prophylaxis
Wrong Blood Group Result,
External cephalic version “ECV”,
Pre eclamptic toxemia “PET”,
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14. Continue …..
Causes of feto-maternal blood transfusion
Blood and blood product
Spontaneous with no aberrant cause
Maternal abdominal trauma
Amniocenteses or Amnioinfusion
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15. Continue …..
Causes of feto-maternal blood transfusion
During Delivery,
unnecessary excessive Fundal
Pushing
Improper management of 3rd stage
of labour,
Avulsions of the cord,
Manual removal of the placenta,
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16. Management
of rhesus negative pregnant women
►Management of non sensitized Pregnancy
►Management of sensitized Pregnancy
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17. Management
of rhesus negative
non sensitized pregnant women

18. Aim
to prevent non sensitized women to become sensitized
Identifying the women at risk
Early recognition of the events of feto - maternal blood
transfusion during pregnancy and at delivery
Timing and taking the proper action of managements
Management of rhesus negative
non sensitized pregnant women
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19. Blood Group typing at 1st visit, If negative
Check husband’s Blood Group typing.
If husband is also Rhesus negative
rhesus complication in this situation is not expected, so manage as Rh
positive pregnant women
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Management
of non sensitized Pregnancy

20. 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
Management of non sensitized Pregnancy
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21. Frequent antenatal visits
In each visit:
Maternal clinical evaluation
History of pregnancy progress
inquiring specially for:-
Causes of any vag bleeding such as
“Fall Down. Direct Abd trauma vag bleed”
Routine Antenatal Examination
“Abd Tenderness, Hardness, Uterine FHt, F lie and presentation, FH
auss”
Investigation
Repeat Antibodies screen at 28 wks prior to give Anti-D prophylaxis
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22. In each visit U / S Scan for:
BPD, HC, AC, FL indices
Est. of F Wt. and F growth
Compeer the results with previous measurements
amniotic fluid amount
Placental architecture & size
Fetal structural Scan for any Signs of hydrops fetalis
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23. Fetal Movements Chart after 28 weeks gestation
C T G to be started after 30 weeks gestation.
Biophysical Profile if any risk factor weekly after 30 weeks
provided that the result reported normal
Fetal Doppler “MCA” after 32 weeks.
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24. Management of non sensitized Pregnanc
Bleeding before 20 weeks of gestation
1- Check for fetal red blood cells in
maternal circulation by Kleihauer test
2- Check for maternal antibodies ( ICT )
if negative
Give (50 mcg “half Dose”) anti D to the mother within 72 hours
from the bleeding
if Positive
Manage as sensitized patients
● If there is vaginal bleeding, then …

25. Management of non sensitized Pregnancy
Bleeding after 20 weeks of gestation
1- Check for fetal red blood cells in
maternal circulation by Kleihauer test
2- Check for maternal antibodies ( ICT )
if negative
Give (100 mcg ”Full Dose”) anti D to the mother within 72 hours
from the bleeding
● If there is vaginal bleeding, then …

26. Management of non sensitized Pregnancy
The dose should be Modified according to the result of
Kleihauer test
Appling the role of 80 cells and its multiblications
● If there is vaginal bleeding, then …

27. “Acid elution technique”
2 CC of week acid “ hydrochloric acid” + equel amount of
Maternal Blood sample
Calculate the No of Fetal Blood cells Under 50 high power field
microscope
Management of non sensitized Pregnancy
● Kleihauer test :

28. Advantage of Kleihauer test
Management of non sensitized Pregnancy
● Kleihauer test :
Diagnosis and confirmation of feto maternal blood transfusion
Detection of the severty of the bleeding
Help in the calculation of the needed amount of Anti “D”
Prophylaxis

29. Acid elution technique of Kleihauer.
Fetal RBCs stain with eosin (appear dark),
adult RBCs do not stain (appear as ghosts).
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30. Calculation of fetal red blood cells in maternal circulation by Kleihauer
test Under the 50 high power filed microscope
Each 5 fetal blood cells = 0.25 ml fetal blood
I e … Each 20 fetal blood cells = one ml
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31. Prophylactic Management of non sensitized Pregnancy
During A N period Anti “D” Dose of (500 IU or 100 mcg ) are
recommended to be given
To all negative non sensitized mothers married to Rh positive
husband
at 28 and 34 weeks to protect and overcome any asymptomatic or
un noticed antenatal feto maternal blood transfusion
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32. Indications for prophylaxis
Prophylaxis At 28 weeks and 34 weeks to a Rh –ve non sensitized woman whose
husband is Rh +ve Following:
amniocentesis
chorionic villus sampling
evacuation of a molar pregnancy or
termination of pregnancy
ectopic pregnancy
abruptio placenta
Within 72 hours Postpartum if the woman remains non sensitized and
delivers a Rhesus +ve fetus
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33. Failure of prophylaxis
Dose too small
Dose too late > 72 hours
Patient already immunized but
antibody titer too low for laboratory
recognition
Defective immune globulin given
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34. Management
of rhesus negative
non sensitized preg women
During Labour And Delivery

35. Management of non sensitized Pregnancy
No fundal pushing in 1st or 2nd stag
No uterine massage or uterine grasp and squeeze in 3rd stage
Let the placenta to be separated spontaneous
Use B A Tec. and avoid unnecessary traction force “avulsions of the cord”
Protect the vaginal and perineal wounds and laceration from being exposed to
the fetal blood spilled from cord
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Management of rhesus negative non sensitized preg women
During Labour And Delivery
During labor and vaginal delivery

36. Management of non sensitized Pregnancy
Use abdominal packs in the sides of the uterus
before opening the lower segment to prevent
blood from the placenta to inter the
peritoneal cavity.
Don’t be in harry
Wat the uterus to contract and let the placenta to
start spontaneous separation. Using same idea
of B A tec, push the uterus up and use control
cord traction without squeezing the uterus
A void avulsions of the cord
● During Cesarean Section

37. Maternal blood sample for
indirect Comb's test ( ICT ) antibodies detection
Kleihauer test ( detection and counting fetal red blood cells
in maternal circulation )
Management of non sensitized Pregnancy
● After delivery:

38. antibodies detection
Direct Comb's test ( DCT )
Neonatal blood group
Neonatal bilirubin level
Neonatal Hb & Hct level
Management of non sensitized Pregnancy
● After delivery:
Neonatal blood sample
(Cord blood sample ) for

39. Don’t give Anti D
If fetal blood group is rhesus
negative
If Antibodies detected
Management of non sensitized Pregnancy
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40. If the neonate blood group is rhesus
positive and No antibodies detected
Give full dose of Anti D ( 500 IU / 100
mcg ) to the mother within 72 hours
after delivery
The dose can be corrected according to
the number of fetal red blood cells
present in the maternal circulation
Management of non sensitized Pregnancy
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41. Management
Of sensitized rhesus negative
pregnant women

42. Causes of sensitization
Misinterpretation of maternal Rh type
Rh positive blood transfusion
Unprotected pregnancy & labour
Inadequate dose Anti D on previous
occasions
Sensitized Rh Negative mothers●

43. Factors affecting immunization
Strength of the antigen ..…. antigenicity
Amount of Antigen …… ( amount of fetal RBCs)
Host factors …… Integrity of Maternal Immune System
Influence of ABO typing
ABO-incompatible Rh- positive cells will be
hemolyzed before Rh antigen can be
recognized by the mother’s immune system
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44. Management of Sensitized Pregnancy
… Check quantitative antibodies level @ 1st visit
… Recheck the level every 2 weeks
… Serial U/S Scan monitoring every 2 weeks
… If antibodies level continuo at the same level
and no fetal compromise … deliver at term
Sensitized Rh Negative mothers●

45. Management of Sensitized Pregnancy
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 will beings
… Use LILY’ s Curve to determine the fetal
condition
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46. Help in fetal monitoring and timing of first intervention if
anti-D level is ≥ 10 IU/mL
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 status)
Ultrasound scan (USS)
Management of Sensitized Pregnancy
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47. ●

48. ●

51. 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

52. Amniocentesis
Where optic density of the fluid
changes according to the amount of
the bilirubin concentration
Increasing of the OD as pregnancy
advance shows worsening of the
fetal hemolytic disease

53. Amniocentesis
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54. 100
200
450
300
0.1
0.4
0.8
1
1.2
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55. Liley’s chart
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56. Zone I
Zone II
Zone III
Liley’s
chart

57. Term pregnancy ( mild or Severely affected )
…………………………………. …Deliver
Suitability of the place and its facility
Experience of the team
Type of Delivery
Extra uterine Blood exchange
Photo therapy
Medication
Management of Sensitized Pregnancy
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58. Preterm fetus < 36 weeks with Zone I
Cordocentesis
blood sample Hb > 10g/dl
U / S Scan
No evidence of Hydropic changes
Consider conservative management
with regular follow up of fetal and maternal
conditions till the fetal lung maturity is assured
…. Then deliver
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59. Daily maternal clinical assessments
Fetal Movements Chart
Daily C T G
Serial U / S Scan for fetal growth and
amniotic fluid
Biophysical Profile
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60. Regular cheek of the amniotic fluid bilirubin
level by repeated amniocentesis every 2
weeks until the lung maturity reached
Regular cheek of the fetal Hb and Hct
values if the facilities available

61. Preterm fetus < 36 weeks with Zone II or III
Cordocentesis
blood sample Hb less than 10g/dl
Ultrasound
evidence of Hydropic changes
Consider
Transfer to suitable place
Intra uterine therapy
Delivery + extra uterine mang
Management of Sensitized Pregnancy
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62. Dexamethasone to enhance lung maturity
Clinical assessments +
C T G +
U / S Scan +
B P P
If Intrauterine B T was Successful
Consider repeating the intrauterine BT after
3 weeks from the previous one
Lung maturity ….. If certain … deliver
Management of Sensitized Pregnancy●

63. Intra peritoneal blood transfusion
Through umbilical vein “ Cordocentesis”
80 % of packed cell “ O “ rhesus
negative Blood Cross matched
against maternal blood group
Fresh
Free of infection
Intra uterine therapy
Management of Sensitized Pregnancy
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64. Infant with kernicterus: note spasticity and opisthotonos
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65. Thank you all
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66. Thank you
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