4. ffDNA - Testing from maternal serum
Rh–Positive – At Risk pregnancy
Investigation
5. Serial Antibody Quantification or indirect Coombs test
At Risk pregnancy
Genotype of father-Homozygous ff-DNA Rh-Positive
Positive Negative
6. No Antibody
Primigravida Multigravida
Repeat indirect
Coombs’ Test at
36 Weeks - negative
Deliver at Term
Repeat indirect
Coombs’ Test at
monthly intervals upto
24 weeks and every 2
weeks thereafter
7. Antibody Present
Titer <1:16 Present titer >1:16
Deliver at Term
•Shift the patient to an
equipped centre
•Serial fetal MCA PSV
•Serial ultrasonography
Continue monitoring the
titer
8. •Rising Antibody titer
•MCA PSV >1.5 MoMs
•Abnormal USG
Yes No
Cordocentesis for fetal
hematocrit <30%
•Serial fetal MCA PSV every 1 or
2
weeks
•To start antenatal fetal
Surveillance by 32 weeks
Deliver By Term
IUFT to Continue
pregnancy till 34
weeks
9. In case of Severe Affection Before 34weeks
Terminate pregnancy after Confirming
Fetal lung maturation by L:S ration
Intrauterine Fetal transfusion is Done
to continue pregnancy Till 34 weeks
When to Deliver? - Severe Affection (>1:16)
Terminate Pregnancy around 34weeks after maternal steroid
administration
When to Deliver? - Mild Affection titer (<1:16)
Pregnancy Can be Continued up to 38weeks and can be Terminated
10. Vaginal delivery can be Done if the
termination of pregnancy is near
Term.
Amniotomy is Quite Effective. Vaginal
prostraglandin gel (PGE2) can be Used for
cervical ripening.
Careful fetal monitoring,prophylatic
methergine during Second stage Should
be withheld,gentle Handling of Uterus
11. Caesarian Section can be Done if the
termination of pregnancy is Done
prematurely.
Cervix will be Unfavorable and considering
the Severity of Affection and urgency.
Avoid spillage of blood into the peritoneal
Cavity, Routine manual removal of
placenta should be withheld
12. • As quickly as possible to minimize
the antibodies to cross to the
fetus
• Cord should be kept Long for
exchange transfusion if necessary
in future.
Clamping of
Umbilical
Cord
• 2 x 4ml of blood Collected in
Red vacutainer.
(contains Serum)
• 2 x 3ml of blood is collected in
Lavender vacutainer.
(contains EDTA)
Collection of
cord Blood
for
investigation
13. • Bilirubin level – Biochemistry.
• DCT – Blood Bank
Red Vacutainer
• Blood grouping and Rh typing –
Blood
Bank
• Hemoglobin, Reticulocyte Count -
Pathology
Lavender
Vacutainer
14. Methods
Intraperitoneal transfusion
Intravascular transfusion
Indications
Severe affection of the uterus in utero before 34weeks.
Advantages
Correction of fetal anemia and improves oxygenation.
Improved fetal hepatic function.
15. Indication
Severe and early onset of hemolysis where the
umbilical vein is too small to puncture.
Principle
Under ultrasound guidance blood is transfused into
the peritoneal cavity and the erythrocytes are taken up
by the sub diaphragmatic lymphatics.
Timing of transfusion
Blood can be transfused as Early as 18weeks and
repeated in intervals of 1-3 weeks up to 34 weeks
16. Quality of blood
Blood group – O, Rh- Negative, cross matched with the
mother is to be transfused. The Blood should be
relatively fresh, irradiated and screened.
Quantity of blood
For every 10% increase in hematocrit the volume of
blood (with 78% hematocrit) to be transfused is =
Estimated fetal weight(g) x 0.02
Procedure
Blood is to be infused slowly(5-10ml/min) through a
polythene tube that has been threaded, through an
introducing needle inserted into the fetal abdomen
under ultrasound guidance.
17. Transfusion is made through the Umbilical vein near its
insertion into the placenta under real time ultrasound
using a 20gauge needle
Blood group – O, Rh –negative blood with hematocrit of
90% is to be Transfused.
Hematocrit level is checked at intervals during the
procedure
Goal – 50% hematocrit
Repeat transfusion is given after 2 weeks
Betamethasone should be given 24hrs before transfusion
from 26weeks to increase pulmonary maturity in case
delivery becomes necessary during
transfusion.
18. Plasmapheresis
This procedure has been tried to remove several liters of maternal anti D
antibodies, maternal titer should be reduces to 50%
Then IVIG can be used
Due to its lack of definite benefit it is not used
High Dose intravenous immunoglobulin
It blocks placental transport of antibodies or to destroy anti D coated
erythrocytes in fetal spleen or liver.
A Dose of 1000mg/kg IVIG weekly has been used
Monoclonal anti–D blocking antibodies
These are to be used to prevent anti–D response
And thereby to prevent HDFN
