This document discusses the management of Rh-negative pregnancies. It begins with an introduction to Rh blood types and the pathophysiology of Rh sensitization. It then discusses epidemiology and outlines the management approach for both unsensitized and sensitized Rh-negative pregnant women. Management involves screening, prophylactic Rh immunoglobulin administration, and monitoring for sensitization and fetal complications. The goals are to prevent sensitization in unsensitized women and detect issues early in sensitized pregnancies through careful history, testing, and consultation.
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
Rh Incompatibility in Pregnancy. Rh incompatibility occurs when a pregnant woman whose blood type is Rh-negative is exposed to Rh-positive blood from her fetus, leading to the mother's development of Rh antibodies
This presentation describes in detail about managing Rh negative pregnancy- to identify and manage Rh non-isommunized and Rh isoimmunized pregnancies, with recent advances
Rh Incompatibility in Pregnancy. Rh incompatibility occurs when a pregnant woman whose blood type is Rh-negative is exposed to Rh-positive blood from her fetus, leading to the mother's development of Rh antibodies
This presentation describes in detail about managing Rh negative pregnancy- to identify and manage Rh non-isommunized and Rh isoimmunized pregnancies, with recent advances
Fetal hemoglobin and rh incompatibilityrohini sane
A comprehensive presentation on fetal hemoglobin & Rh incompatibility for undergraduate medical, dental, biotechnology & pharmacology students for self-learning .Presentation has physical & chemical properties of fetal hemoglobin along with its function. Binding affinity for O₂ of HbF and oxygen dissociation curve for HbF elucidated with suitable diagrams. Molecular constitution of Embryonic Hb ( Grover I &Grover II )with electrophoretic patterns are presented here . Importance of Kleihauer staining for detection of fetal cells is described briefly.
Diagrammatic representation of Rh- incompatibility is done for complete understanding of the concept. Signs & symptoms Kernicterus are presented diagrammatically.
Direct and indirect Coomb’s Test for Rh- incompatibility for diagnosis of Erythroblastosis Fetalis is illustrated. Biochemical aspects of Hemolytic Disease of Newborn (HDN) and Physiological /Neonatal Jaundice are presented. Comparison of Causes & biochemical findings for Hemolytic Jaundice along hepatic and obstructive jaundice is done in this presentation.
Molecular mechanism involved in biosynthesis of Hb Bart and Hb H along with their electrophoretic patterns for their detection are illustrated.
Hereditary persistent fetal Hb( HPFH ) & Point mutations causing HPFH are described in lucid manner. Google images are used for intense impact of the subject.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
1. MANAGEMENT OF RHESUS
NEGATIVE PREGNANCY
OBIOKONKWO AC
(MBBS, U.PHACOURT)
DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
FEDERAL MEDICAL CENTRE, BIRNIN
KEBBI
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Introduction
The Rhesus (Rh) blood group system is one of the
35 current human blood group systems
It's the second most important system after the ABO
system
At present, the Rh system consists of 50 defined
blood group antigens (Ag), among which the five Ag
D, C, c, E, e are the most important
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... Introduction ...
The D Ag, also called the Rh factor is the most
immunogenic[1]
of them though the others are still
clinically relevant
The Rh factor is a red cell surface antigen named
after the rhesus monkey in which it was first
discovered.[1]
An individual either has or does not have the D
antigen on the surface of their red blood cells
(RBCs)
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... Introduction ...
The status is usually indicated by the suffices Rh+
for those that have, or Rh- for those who lack the D
antigen
These suffices are attached to the ABO blood type
An Rh-negative pregnant woman is one who lacks
this antigen on the surface of their red cells.
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... Introduction ...
Historical time line
− 1937: Rh blood type discovery by Karl Landsteiner &
Alexander Wiener, and noted to be distinct from ABO blood
type
− 1939: The D antigen was incidentally discovered but yet
unnamed. This followed a case of haemolytic disease of the
newborn observed in a the infant of a 25 year old G2
P1
woman,
blood group O who received O type blood
− This case was subsequently published[2]
by Philip Levine and
Rufus Stetson
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... Introduction ...
... Historical time line ...
− 1940: This unnamed factor was realised to be similar to the
earlier discovered blood type and a connection was made to
it[3]
− 1946: Exchange transfusion created by Wiener for treatment
of Rh disease
− 1960: The concept of anti-RhD for the prevention of Rh
disease was proposed by Ronald Finn
− 1963: First successful intrauterine transfusion for treatment of
Rh disease was carried out by Sir William Liley
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... Introduction
... Historical time line
− 1964: First prophylactic injection for Rh disease was given
− 1968: Immunoglobulin G antibody was first approved for use
in USA (as RhoGAM) and UK @300 mcg within 3 days
postpartum
− 1973: Reports in the USA said 50,000 babies' lives had been
saved since approval
− 1981: Rh IgG approved for routine postpartum and
antepartum administration by the US Food and Drug
Administration
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... Epidemiology
Nigerian studies
− 4.5% prevalence rate at Enugu,[5]
Southeast
− 0.7% incidence rate at Kaduna,[6]
North
− 5.5% prevalence rate at Ogbomosho,[7]
Southwest
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Pathophysiology
Two commonest systems for blood group classification:
[8]
− ABO system
− Rhesus system
ABO system: Groups A, B AB, O antigen (Ag)
Rhesus system: C, c, D, E, e and G.[4]
− There's no 'd' Ag. The letter represents absence of 'D' Ag
The D antigen is considered to be the most
immunogenic (aka Rh factor)
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... Pathophysiology ...
There are two possible alleles for each of the c or C, D
and e or E
An individual inherits one haplotype from each parent
Rh positive: presence of at least one of either C, D or E
antigens regardless of the combination (ie, homozygous
or heterozygous)
Rh negative: cde/cde genotype (always homozygous)
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... Pathophysiology ...
The D antigen
− The Rh-positive father may be homozygous (45%) or
heterozygous (55%) for D
− If homozygous for D, all children will test positive
− If heterozygous, his children will have a 50% chance of
being RhD-positive
Thus if 'D' antigen is specifically tested, its absence will
give a negative result regardless of the presence of the
other antigens (C, E)
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... Pathophysiology ...
The amount of foetal blood necessary to produce Rh
incompatibility varies, but as little as 0.1 mL of Rh+ cells
have been documented.[4]
Studies have suggested that up to 30% of persons (non-
responders) with Rh- blood never develop Rh
incompatibility even when challenged with large
volumes of Rh+ blood[1]
Rh alloimmunisation occurs by 1 of 2 mechanisms
− After incompatible blood transfusion
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... Pathophysiology ...
− After foeto-maternal haemorrhage between mother and an
incompatible foetus
Foeto-maternal haemorrhage may occur during pregnancy
(10%) or delivery (90%)[1]
Notwithstanding, foetal RBCs have been detected in the
maternal blood in all three (7, 16, 29%) trimesters without
an apparent predisposing factor[4]
The initial maternal response to Rh sensitisation is low
levels of immunoglobulin (Ig) M antibodies (Ab)
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... Pathophysiology ...
− These are confined to maternal circulation being unable to
cross the placental barrier
Within 6 weeks to 6 months, IgG Ab are formed
− These are able to cross the placenta and destroy foetal Rh-
positive cells
Therefore, first-born infants with Rh-positive blood
type are not affected
− The short period of 1st
exposure of mother to foetal RBCs is
insufficient for production of significant IgG Ab response
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... Pathophysiology ...
Subsequent pregnancies may trigger a rapid & robust
Ab response - Anamnestic response
Anamnestic theories:
– Grandmother theory
– “Sensibilization” theory
Maternal O blood type appears particularly protective
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... Pathophysiology ...
Sequence of inutero events
− Maternal IgG enters foetal circulation via placenta
− Destruction of foetal red cells occur - foetal anaemia
[HCT<30%]
− Haem is formed and converted to bilirubin – foetal
hyperbilirubinaemia
− Both are neurotoxic, but effectively cleared by placenta and
metabolised by the mother
− Extramedullary erythropoeisis is stimulated
− Immature erythroblasts are produced
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... Pathophysiology ...
When cell destruction exceeds production
− Severe anaemia occurs
− More demand on extramedullary sites to produce more red cells
– hepatosplenomegaly
− Heart failure eventually results, with ascites, oedema and
pericardial effusion – erythroblastosis foetalis
− Hydrops foetalis, occurs when the haematocrit falls below 15%.
Often results in foetal death shortly before or after birth
• Male to Female foetus = 13.1 to 1
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... Pathophysiology ...
The risk and severity of sensitisation response increases
with each subsequent pregnancy involving an ABO-
compatible foetus with Rh-positive blood
Without prophylaxis, this risk is 16% after two
deliveries;
– 1.5-2% occur antepartum
– 7% within 6 months of delivery
– 7% manifest early in 2nd
pregnancy
With prophylaxis, the risk drops to 0.1%
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... Pathophysiology
The aforementioned risk depends on the 3 main factors
− Volume of transplacental haemorrhage
− Extent of the maternal immune response
− Concurrent presence of ABO incompatibility (protective –
risk drops to 1.5-2%)[4]
Rh incompatibility is only of medical concern for
females who are pregnant, or plan to get pregnant in
future
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Management
This includes history taking, clinical examination,
appropriate investigations, and treatment
Two groups of women are catered for
– Unsensitised Rh-negative women
– Sensitised Rh-negative women
There is usually no specific finding on the history
and clinical examination for the woman that is not
sensitised
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... Management ...
For the sensitised woman, her presentation would
depend on whether or not she has a previously
affected infant. This also guides management.
Some events have been found to increase the
chances of formation of anti-D antibodies in Rh-
negative women
The goal of the history therefore, is to establish or
exclude the occurrence of such events
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... Management ...
Other aspects of the history to be explored include
− Prior blood transfusion
− Rh blood type of patient and spouse
− All previous pregnancies, outcomes, interventions
• History of hydrops = 90% chance recurrence
− Previous administration of Rh IgG
− Mechanism of injury in cases of maternal trauma during
pregnancy
− Presence of vagina bleeding
− Prior invasive procedure
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... Management ...
The objective of antenatal management is
– Prevention of Rh alloimmunisation in the Rh-
negative unsensitised woman
– Early detection and treatment of foetal anaemia in
the sensitised woman
Sensitisation is determined via the indirect Coombs
test, otherwise called antibody screen
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... Management ...
The unsensitised Rh-negative woman
History may be uneventful with patient hearing for
the first time of her Rh-negative group
First, determine husband's ABO and Rh group.
If negative, manage as any other pregnancy. No
further investigation required
If positive, screen woman for alloimmunisation at
contact.
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... Management ...
... The unsensitised Rh-negative woman
If the antibody screen is negative, repeat at 20, 24 & 28
weeks
If still negative by 28 weeks, 300 mcg of Rh IgG is given
A repeat dose is given after each invasive procedure, or
after 12 weeks of last dose if pregnancy lasts that long
If a positive result is recorded at any time, the patient is
managed as a sensitised Rh-negative woman
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... Management ...
Precautions during delivery
– Ensure consultation with neonatologist
– Don't give oxytocics at delivery of anterior shoulder
– If manual removal of placenta is required, do so gently
– If blood transfusion is indicated, use Rh-negative blood
only
– Early clamping of umbilical cord is indicated
– Leave a long length of cord, about 15 to 20 cm
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... Management ...
Postpartum management
− Involve the neonatologist
− Send cord samples for ABO/Rh typing, DCT, Hb,
bilirubin levels, peripheral smear
− If foetus is Rh-negative, no further intervention
− If foetus is Rh-positive, determine the dose of Rh IgG to
be administered by a 4-step laboratory procedure
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... Management ...
The 4-step laboratory procedure
– Rosette foetal RBC screen for FMH. If positive,
– Acid elution (Kleihauer-Betke) test to quantify the
RBCs in maternal circulation
– Estimate the volume of FMH (50 x % foetal RBCs)
– Calculate the dose of Rh IgG to be given within 72
hours of delivery
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... Management ...
For sensitised women, management is guided by the
following
– Presence or absence of history or affected foetus in
previous pregnancy (e.g. with severe anaemia or
hydrops)
– Maternal antibody titres (where no prior history)
Sensitisation may be determined by doing an
antibody screen using indirect Coombs test
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... Management ...
The sensitised Rh-negative woman
No previous history of affected foetus
– The history might include some of the previously
mentioned sensitising events
– Risk of foetal anaemia is proportional to maternal
anti-Rh antibody titre
– This relationship is lost in subsequent pregnancies
– Obtain the ABO and Rh group of the husband. If
negative, no further testing is needed. If positive,
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... Management ...
... The sensitised Rh-negative woman ...
... No previous history of affected foetus...
– Screen for alloimunisation. If positive, obtain Ab titres
– If below the critical titre, obtain monthly titres
– If still below critical level by 36th
week, pregnancy may
continue to term, but not allowed to be postdated
– If it rises beyond critical value after 34 weeks, deliver
immediately
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... Management ...
... The sensitised Rh-negative woman ...
... No previous history of affected foetus
– If it rises before 34 weeks, further testing includes
• Peak systolic velocity of the middle cerebral arteries
using Doppler
• Amniocentesis for analysis and spectrophotometry
• Ultrasound examination of foetus
• Percutaneous umbilical cord blood sampling
(cordocentesis) for HCT, Rh
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... Management ...
... The sensitised Rh-negative woman ...
Previously affected foetus
– The history may include, amongst others, that of a
stillborn neonate, one admitted for phototherapy or
exchange blood transfusion.
– One needs to be proactive to prevent recurrence, and
have a high index of suspicion
– Her Rh type should be established as well as
sensitisation
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... Management ...
... The sensitised Rh-negative woman ...
... Previously affected foetus
– Evaluation should start early – at least 4 weeks to
anniversary of prior affected foetus
– The anti-D titres cannot predict the development of foetal
anaemia, thus other tests are indicated
– Cordocentesis may be indicated to determine foetal HCT,
and Rh genotype if father is heterozygous for D
– If the foetus is determined to have the D Ag, there is a
risk of haemolytic disease and sequelae
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... Management ...
... The sensitised Rh-negative woman ...
... Previously affected foetus
– Amniocentesis may be done for amniotic fluid
spectrophotometry and assay
– Initiate middle cerebral artery Doppler (MCAD)
surveillance from 18 weeks
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... Management ...
Middle Cerebral Artery Doppler (MCAD) Velocimetry
Accurate & non-invasive screening tool for detecting
moderate to severe foetal anaemia
A sensitivity of 100% and a 12% false positive rate for
anaemia
Use has resulted in up to 80%[9]
reduction in invasive
testing (i.e., amniocentesis, cordocentesis)
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... Management ...
Middle Cerebral Artery Doppler (MCAD) Velocimetry
Not useful before 18 weeks of gestation – RES too
immature to haemolyse enough cells to cause significant
anaemia[9]
Not a reliable predictor of severe anaemia after 35 weeks
GA[10]
Found to be similar[11]
or better[12]
than amniotic fluid OD450
in prediction of anaemia
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... Management ...
Results MCAD Velocimetry[4]
Unaffected/mildly affected foetus
– Normal MCAD. Doppler is repeated monthly. Deliver at or near term after
lung maturity. Low risk of IUFD
Moderately affected
– MCAD about 1.5 multiples of median (MoM). Repeat 1-2 weekly. Deliver
after lung maturity. Enhancement of lung maturity may be necessary
Severely affected
– MCAD >1.55 MoM or has frank evidence of foetal hydrops. Foetus needs
help to attain lung maturity before delivery. High risk of IUFD
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... Management ...
Intrauterine Blood Transfusion[8]
Recommended treatment for severe (haemolytic) anaemia
inutero
Typically carried out between 18 and 35 weeks GA
May be given intraperitoneal or intravascular
O RhD negative packed cells with HCT of 80% is used
Amount to be transfused in mL is (GA-20) x 10 where
GA> 20 weeks
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... Management ...
... The sensitised Rh-negative woman
Postpartum management of the neonate
– Baby, if alive should be admitted into the neonatal
intensive care unit
– An urgent exchange blood transfusion is indicated in
moderate to severely affected neonates
– Phototherapy for mild affectation.
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... Management ...
Special foeto-maternal risk states[4]
− Abortion: Up to 5% chance of sensitisation. Fifty microgram is
recommended
− Invasive foetal procedure: Up to 11% of sensitisation. A dose
of 300 mcg is recommended
− Antepartum haemorrhage: 300 mcg stat, to be repeated 12
weeks later if pregnancy lasts that long
− External cephalic version: Up to 6% chance of sensitisation.
Dose is 300 mcg
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... Management
– Delivery with foeto-maternal haemorrhage
• The normal amount of foetal blood that enters the
maternal circulation is <0.5 mL.[13]
• Dose of Rh IgG given @ 300 mcg will neutralize nearly
30 mL whole foetal blood (or 15 mL Rh+ foetal RBCs)
• Management is guided by the estimated volume of
FMH determined by the 4-step lab tests
• Dose of Rh IgG given after sensitisation is at least 20
mcg/mL of foetal RBCs[1]
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Recent Advances
Non-invasive foetal RhD genotyping (from foetal
cell-free DNA in maternal circulation)[14]
Point-of-care-tests (POCT), i.e., rapid tests for
determining Rh status[15]
A lower 50 mcg dose preparation of Rh IgG for use
following first trimester abortions[1]
Concept of partial D and weak D antigens (usually
test positive, but can also form anti-Rh antibodies)[16]
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Take home points
1. Every woman of childbearing age should have her
ABO and Rh types done at first contact
2. Obtain the ABO/Rh types for husbands of women
found to be Rh-negative
3. Ensure ICT is done at 20, 24 and 28 weeks of
pregnancy with appropriate prophylaxis
4. A single postpartum dose may be inadequate in
cases of severe foeto-maternal haemorrhage
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Problems in our setting
• High cost of the immunoglobulin
• Lack of resources to adequately investigate and
monitor foetus inutero
• Low turnout for antenatal clinics – missed cases
• Poor documentation of prior sensitising events –
some are yet to fully grasp the import
• Loss of case notes
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Recommendations
Advocacy for partnership by Government and
NGOs to help subsidize the cost of the
immunoglobulin
Special insurance cover for Rh-negative women to
ensure ease of procurement when needed
Involvement of clergy as part of premarital
counsellors
Creation of special fora/groups for Rh-negative
people where potential Rh-negative spouses can be
met
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Conclusion
• Rhesus alloimmunisation is a real problem and real
efforts need to be made to mitigate its impact
• Although its incidence has decreased dramatically,
yet the consequences of haemolytic disease of the
newborn remain
• Great advancements have been made in the detection
and management of this condition, and many of our
Rh-negative women can now have a happy obstetric
career.
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References
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from http://emedicine.medscape.com/article/797150
2. Levine P, Stetson RE. An unusual case of intragroup agglutination. JAMA.
1939. 113:126-7.
3. Landsteiner K, Wiener AS. An agglutinable factor in human blood recognised
by immune sera for rhesus blood. Proc Soc Exp Biol Med. 43: 223-4.
4. Roman AS. Late pregnancy complications. In: Decherney AH, Nathan L, Laufer
N, Roman AS, editors. Current Diagnosis & Treatment: Obstetrics &
Gynaecology. 11th
ed. United States: McGraw-Hill Companies Inc; 2013: 250-
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5. Okeke TC, Ocheni S, Nwagha UI, Ibeghulam OG. The prevalence of Rhesus
negativity among pregnant women in Enugu, Southeast Nigeria. Niger J Clin
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6. Onwuhafua JA. Pregnancy in Rhesus Negative Women in Kaduna, Northern
Nigeria. Trop J Obstet Gynaecol. 2004; 21(1): 21-23
7. Adeyemi AS, Bello-Ajao HT. Prevalence of Rhesus D-negative blood type and
the challenges of Rhesus D immunoprophylaxis among obstetric population in
Ogbomosho, Suthwestern Nigeria. Ann Trop Med Public Health. 2016; 9(1):12-15.
8. Saxena R, editor. Bedside Obstetrics and Gynaecology. 1st
ed. New Delhi: Jaypee
Brother Medical Publishers (P) Ltd; 2010: 105-120.
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Prediction of fetal anemia in rhesus disease by measurement of fetal middle cerebral
artery peak systolic velocity. Ultrasound Obstet Gynecol. 2004; 23: 432-436.
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10. Zimmermann R, Durig P, Carpenter RJ, Jr, Mari G. Logitudinal
measurement of peak systolic velocity in the fetal middle cerebral artery for
monitoring pregnancies complicated by red cell alloimmunization: A
prospective multicentre trial with intention to treat. Br J Obstet Gynaecol.
2002; 109: 746-752
11. Bullock R, Martin WL, Coomarasamy A, Kilby MD. Prediction of fetal
anemia in pregnancies with red-cell alloimmunization: comparism of middle
cerebral artery peak systolic velocity and amniotic fluid OD450. Ultrasound
Obstet Gynecol. 2005;25:331-334
12. Pereira L, Jenkins TM, Berghalla V. Conventional management of maternal
red cell alloimmunization compared with management by Doppler
assessment of middle cerebral artery peak systolic velocity. Am J Ostet
Gynecol. 2003;189:1002-1006
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... References
13. Pessel C, Tsai MC. The Normal Pueperium. In: Decherney AH, Nathan L,
Laufer N, Roman AS, editors. Current Diagnosis & Treatment: Obstetrics &
Gynaecology. 11th ed. United States: McGraw-Hill Companies Inc; 2013:
190-213
14. Kolialexi A, Tounta G, Mavrou A. Noninvasive fetal RhD genotyping from
maternal blood. Expert Rev Mol Diagn. 2010 Apr; 10(3): 285-96
15. Rapidtest® Rh Test kit. Available from
http://nbi-sa.co.za/index.php/products/30-products/71-diagnostics
16. Gonsorcik VK, Zhou L. Rh Typing. [Updated: Nov 06 2013]. available from
http://emedicine.medscape.com/article/1731224