DR.SURENDRA NATH BERA
DR. MITALI DASH
M K C G MEDICAL COLLEGE , ORISSA
A process by which immune
antibodies are produced in a
person by the entry of an antigen of
another individual of same species,
the former lacking the antigen.
Rh- Iso imunization
Rhesus incompatibility ,Rhesus disease
RhD Hemolytic Disease of the Newborn.
-When Rh– mother gets pregnant to Rh+ fetus
—she may be sensitized to Rh antigen and
develop antibodies. These will cross the
placenta and cause hemolysis of fetal red
1609-description of hydrops fetalis.
1939-Levine and Stetson discovered
1940-Landsteiner and wiener Rh-antigen.
1941-Levine discover Rh-antidody.
Rhesus factor (1940):
Agglutinogen (C,D,E) - mainly D
C,D,E - dominant antigen
c,e - recessive antigen
Person lack D-antigen called Rh-ve
- Rh positive (85%) - homozygous (DD) (35%),
or heterozygous (Dd) (50%)
- Rh negative (15%)
- Incidence of Rh-ve in far east is about 1%
Examples of Rh factor: (CDe=R1) , (Cde=r)
Kell is most common of minor gr.
Responsible for 10% of cases of
severe antibody-mediated anemia
Only anti-Fy(a) antibody associated
with HDFN- may range from mild to
INCIDENCE OF Rh-ve
Chinese and Japanese 1%
North American Indian 1—2%
African American 4 - 8%
Caucasian 15 - 16%
Basque 30 - 35%
A. Mismatched blood transfusion.
B. Rh-negative women bearing Rh-
positive fetous with feto-maternal
CAUSE OF FMH
Feto-maternal haemorrhage: during pregnancy
leakage of fetal cells in the maternal circulation (Rh+
fetal cells in Rh- maternal circulation)
CAUSE OF FMH
10.Manual removal of placenta
11.Silent feto-maternal hage
Rh-isoimmunization is due to D antigen in
more than 90% of cases.
Occasionally result of other than Rh group
like anti- Kell and anti- Duffy
Following feto-maternal hemorrhage.
Initial response is forming IgM antibodies for
the short period (6wks-6month)
o Followed by production of IgG on subsequent
pregnancy which crosses placenta.
IgG antibodies adhere to the antigen site on
the surface of erythrocytes causing hemolysis.
The excessive removal of circulatory RBCs
leads to severe anemia and hypoxia.
1. Cleared by
•6 wks to 6 M.
Anti - D
T- helper cell
Antibodies Coated Red Cells
Destruction of Fetal Cells by Fetal RES
Fetal Hypoxia and Stimulate of Erythropoitin
Extra Medullary red Cells Synthesis
Hepatic Cell Failure
Hypoproteinemia, Increased Intrahepatic
Pressure, Portal hypertension
Ascetic, Edema, hypoxia, Placental
Thickness, Polyhydramnios, Pericardial
Development of Rhesus antibodies:
depends on :
1- Inborn inability to respond to Rh-antigenic
2- Protection if ABO incompatible 110
3- Strength of Rh antigen stimumlus (CDe=R1)
4- Volume of leaking feta blood (0.1ml)
5- Immunological nonresponders found in 30%
of Rh-negative women.
1- If ABO is incompatible:
Red blood cells is easily destroyed, so
not reaching enough immunological
component to cause antibody
response and reaction.
The risk of sensitization after ABO
incompatible pregnancy is only 2%.
- If ABO is compatible:
Rh+ fetal cells remain in circulation
(life span) until removed by (R.E.S)
destroyed liberating antigen (D)
Anti - A Anti - B
A Rh positive B Rh
Positive“O” Rh positive
Group “O” Rh Negative
Fetomaternal hemorrhage as a reason
of Rh –isoimmunization has been
6.7% in the first trimester.
13.9% in the second trimester
29% in the third trimester.
Hydrops fetalis And Stillbirth.
Icterus gravis neonatorum.
Compilations Of Neonatal Kernicterus
(Lethargy, Hypertonicity, Hearing Loss,
Cerebral Palsy And Learning Disability)
Congenital Anemia of newborn.
ICTERUS GRAVIS NEONATORUM
Less severe form of hemolytic
Baby born alive without jaundice but
soon develops within 24 hrs of birth.
Concentration of bilirubin in the
newborn blood exceeds
in-term fetus – > 342 mmoll/L
in pre-term fetus – >205 mmoll/L,
Billirubin crosses the BBB and
damage the basal nuclei of brain.
Screening and diagnosis
Maternal blood grouping, Rh-typing
and antibody screening at their 1st
Presence of anti-D antibodies in
serum is diagnostic of maternal Rh-
Antibody screening in mother
Should be done in….
I. Rh-negative women who have
received anti-D immune globulin.
II. Rh-positive mother who have…
--unexplained fetal loss.
--infant with unexplained jaundice.
Gold Standard Test
-mix Rh(D)+ cells with maternal serum
-anti-Rh(D) Ab will adhere
-RBC’s then washed & suspended in
Coombs serum (antihuman globulin)
-RBC’s coated with Ab will be agglutinated
-mix infant’s RBC’s with Coombs serum
-maternal Ab present if cells agglutinate
If indirect coombs test
is positive, the father’s
Rh should be tested.
Serial maternal Anti D
titers should be done
every 2- 4 weeks.
If titer is less than 1/16
the fetus is not at risk.
If titer is more than
1/16 then severity of
condition should be
Confirmation of gestational age.
Early detection of hydrops when finding one or
more of the following:
Ascites, pleural effusion,
pericardial effusion, skin edema.
Increase placental size,
Middle Cerebral Artery peak systolic velocity
B = moderate-severe
A = mild anaemia
C = no anaemia
To know fetal Rh genotype.
Advantage: early detection.
--increase severity of
alloimmunization if baby Rh +
Methode of choice for detection of Rh factor of
fetous and amniotic fluid bilirubin.
Critical titre/previous affected infant.
Bilirubin correlates with fetal hemolysis.
Spectophotometric analysis optical density of
amniotic fluid @ ▲OD 450nm.
Data plotted on Liley curve.
More complicated procedure..
Fetal Rh phenotype can be known
rapidly by blood bank serology.
Gold standard for detection of fetal
Greater morbidity and mortality
2.7% total risk of fetal loss
Diagram of cordocentesis procedure
Rh-negative women categorized in two
I. Rh-negative non-immunized women.
II. Rh-negative immunized women.
-non D-Rh antigens
-other blood group system
The aim of antenatal
To predict which pregnancy is
To predict whether or not the
fetus is severely affected.
To correct anemia and reverse
hydrops by intrauterine
To deliver the baby at the
appropriate time, weighing the
risks of prematurity
against these of intrauterine
A. Non immunized women– prevention
B. Immunized women—
a. early detection.
b. adequet treatment of
Rh-negative non immunized
of Ab screening at
20,24,28 wks GA.
Antibody screening at
20,24& 28wks ga
No anti-Ab detected
Pt should received
at 28wks of GA.
If anti-D antibodies
Manage as Rh-negative
At times of delivery to determine the
mother’s eligibility for a second dose of
Management based on---
A. First affected prenancy.
B. Previous affected pregnancy.
FIRST AFFECTED PREGNANCY
Should have antibody triter every 4 wks.
A. If triter≥critical level
B. If triter<critical level upto 36 wks of
gestation,should deliverd between 38-40wks.
Sudden elevation of Ab-triter
when GA>34WKS <37WKS
if bilirubin<0.05 with
weekly Lung maturity
PREVIOUS AFFECTED PREGNANCY
a. Maternal anti-D triter not predict the fetal
b. MCA-PSV to determine the anemia.
c. Serial amniocentasis.
PREVIOUS AFFECTED PREGNANCY
a. Maternal anti-D
predict the fetal
b. MCA-PSV to
TRITER LEVEL PAST
% OF IUD
<64 NEGATIVE 4%
<64 POSITIVE 32%
>64 NEGATIVE 17.2%
>64 POSITIVE 68.7%
Suggested management after amniocentesis for ΔOD 450
Lily zone I
Lower Zone II
Upper Zone II Zone III
Hydramnios & Hydrops
Delivery at OR near term
Repeat Amniocentesis in 7
days or FBS
Hct < 30% Hct > 30%
7 to 14 days
Follow with fetal
Fetal blood sampling
First done in 1963
Instill blood through needle or epidural catheter
Volume to transfuse = (G.A.-20) x 10ml.
Generally, repeat in ~ 10 days, then every
Risk of death about 4% per procedure.
Not effective in hydropic fetus.
Some advocate combined approach (IPT and
Goal is to have post-transfusion Hct 40-45%
Can infuse about 10 ml/min
Estimate requirement based on EFW and pre-
Repeat in 1 wk., then about every 3 wkly.
Fetal loss about 1.5% per procedure
Pregnant women undergo cesarean
section in isoimunization:
Severe form of hemolytic
infant disease in the term
or 34-35 weeks after
prevention of fetal hyaline
Measures to be taken
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
… A void avulsions of the cord.
undergo delivery in
the term of 37-38
weeks of gestation.
Induction of labor is
prostaglandin (in the
case of “unripe”
uterine cervix) or by
administration (in the
case of “ripe” uterine
Vaginal delivery in Rh-isoimmunization
Vaginal delivery in Rh-isoimmunization
No fundal pushing in 1st or 2nd stage of labor.
With hold inj methergin after ant. shoulder delivery.
Early cord clamping and no milking.
No uterine massage or squeeze in 3rd stage.
Let the placenta to be delivered spontaneous to
avoid avulsions of the cord.
Protect the vaginal and perineal wounds and
laceration from being exposed to the fetal blood spilled
a. antibodies by indirect Comb's test ( ICT )..
b. fetal red blood cells in maternal circulation
Cord blood sample ( Neonatal blood sample ) for
a. antibodies by Direct Comb's test ( DCT )
b. Infant blood group and rh-typing.
c. Infant bilirubin level
d. Infant Hb & Hct level
Rh- Iso imunization
- Screening of all pregnant mothers to Rh D
antigen and antibody screening for Rh D
Word of Vincent Freda
the rule of thumb should be to administer
anti-D immunoglobin when in doubt
rather than to withhold it.
Prophylactic anti D immunoglobulin
To be given
All Rh – mothers after delivery if the fetus
At 28, 32 weeks of pregnancy or after
40wks if pregnancy contineued
After abortion, amniocentesis, abruption,
Rh- Iso imunization
Prevention The standard dose of anti D is
0.3 mg —will eradicate 15 ml of
fetal red blood cells (routine for
all Rh –ve pregnancies) within 3
days of delivery.
-If more feto-maternal bleeding is
suspected as in abruption or
ante partum hemorrhage-Do
Kleihauer –Betke test to
estimate the amount of fetal
red cells in maternal
circulation and re-calculate the
dose of the anti-D.
measure amount of feto-maternal haemorrhage.
PRINCIPLE: Adult hemoglobin, but not fetal hemoglobin, is soluble in a
citrate buffer with pH 3.2 and will elute out of the red cell.
(critical volume) isoimmunization represented by 5
fetal cells in 50 low power microscopic field of
peripheral maternal blood.
So 1 ml is represented by 20 fetal cells
Prepare patient blood smears
Fix smears in 80% ethanol
Incubate slides in citrate buffer
Stain smears with erythrosine
Count fetal cells on patient slid
Red cells containing Hgb F stain bright
pink due to erythrosin stain ,Negative
staining, adult red cells that contained Hgb
A,appear as pale, ghost cells.
%Fetal red cells = fetal cell counted in total slids x 100
total maternal cell
%fetal red cell x 5000ml(MBV)
volume of FMH =
MBV – maternal blood volume (usually 5000ml)
volume of FMH
VIAL REQUIRS =
positive cells on the
Post-partum mothers following a
• Newborns/infants less than 6 months
• Hereditary persistence of hemoglobin F
• Disorders that compensate with
hemoglobin F such as beta thal major or
sickle cell disease
Other test: to detect FMH
Enzyme linked antiglobulin test
Spon.abortionBefore 12wks –
RCOG,UK- no dose require
Austalian soc.- 50 μg RhIgG
Canadian soc.- 120 μg RhIgG
2nd trimester abortion- 50 μg RhIgG
1st trimester - not requir
2nd trimester- 50 μg RhIgG
(should be repeated 6wkly if heavy bleeding)
A minimum dose of 50 μg RhIgG is
recomendate upto 19wks+6days GA.
After 20wks minimum dose 125 μg
Two dose 500IU at 28 and 34wks GA.
Single dose 1500IU at 28 wks GA.
Postpartum <72 hr - 300 μg RhIgG;
IT can be given upto 28 days of delivery
0.3% require > 300 μg RhIgG
patrial mole-anti-D to be given.
women wants new partner desire
In future if major accident occurs
and Rh- blood not available at
300 μg anti-D neutralizes 30 mL fetal
Rh-positive blood (15 mL packed fetal
Management of sensitized
Mild anemia (Hb <14gm/dl,
cord bilirubin>4 mg/dl)---
-Moderate to severe----
-Mild Hydrops improves in
88% of cases
mannage as Rh-negative immunized women
At times of delivery to determine the mother’s eligibility for a second dose of anti-D immunoglobin