- This is a case presentation of a 24-year-old woman, Mrs. Ranjani, who is 34 weeks and 1 day into her pregnancy. She has an Rh negative blood type while her husband's is Rh positive, making this an Rh incompatible pregnancy. - Her past obstetric history includes one full-term vaginal delivery. During her current pregnancy she received regular antenatal checkups and her tests have been normal. She is being referred for a tertiary care opinion due to the Rh incompatibility. - On examination, she appears well with normal vital signs. The fetus is in a cephalic presentation with a heart rate of 146 beats per minute. Further tests and monitoring are planned to

1. CASE
PRESENTATION
Rh NEGATIVE
PREGNANCY
OGSSI PG REVISION COURSE
WEBINAR

2. 24 year old Mrs. Ranjani, resident of Podanur, Coimbatore, belonging to middle socioeconomic status, studied
upto higher secondary class, a homemaker
G2 P1 L1, LMP 23.08.2021 and EDD on 30.05.2022, 34 +1 day GA
Regular cycles, sure of dates, booked and immunized, came for a routine AN checkup as she was advised to get a
tertiary care opinion in view of her Rh negative pregnancy.

3.  Able to perceive fetal movements well
 No c/o abdomen pain/draining pv/ bleeding pv/ discharge pv.
 No h/o headache/vomiting/ visual disturbance/ swelling of legs
 No h/o breathing difficulty/ palpitation
 No h/o fever, cold, cough
 No h/o trauma

4. PRESENT PREGNANCY
 First trimester:
 Pregnancy was confirmed following 10 days of missed periods by a urine pregnancy test at home.
 Visited nearby PHC soon
 Blood investigations- normal
 Her blood group was B negative
 Spouse B positive
 Other blood tests and scans were said to be normal.
 No h/o excessive vomiting, no h/o fever
 Started on folic acid tablets, got first dose of vaccination.
 No h/o radiation exposure.
 No h/o blood transfusions/ drug intake
 No h/o bleeding pv

5. SECOND TRIMESTER
 Quickening felt after complete 5 months
 Get second dose of vaccination
 Started on calcium and iron tablets
 Blood and urine investigations were done and said to be normal
 Bp was recorded and said to be normal
 Anomaly scan- apparently normal
 No h/o abdomen pain/ bleeding pv/ draining pv/ fever
 ICT was done at complete 6 months and said to be negative
 No h/o Anti D administration
 No h/o hypertensive disorders of pregnancy/ Gestational Diabetes

6. THIRD TRIMESTER
 Continued to perceive movements as usual
 Continued calcium and iron tablets
 No c/o pain, draining, bleeding pv
 Blood investigations were done and USG said to be normal.
 BP was monitored and said to be normal.
 No H/O hypertensive disorders of pregnancy/Gest Diabetes
 No h/o anti D injections

7. MENSTRUAL HISTORY
 Attained menarche at 12 years
 Had regular cycles thereafter 3 to 5/ 28 to 30 cycles, moderate flow,
 No h/o menstrual disturbances
 Last menstrual period: 23.08.2021
 Edd: 30.05.2022

8. MARITAL HISTORY
 Married for 5 years, non consanguineous,
 spouse BSc, Bank employee
 No h/o contraceptive use
 Blood group B positive

9. OBSTETRIC HISTORY
 G2 P1 L1
 First pregnancy:
 Spontaneous conception after 6 months of marriage,
got regular antenatal checkups, booked and immunized, scans and blood tests were done periodically- normal, and
she was informed that her blood group- B negative.
 No h/o hypertensive disorders of pregnancy, gestational diabetes,
 No h/o blood transfusions, no h/o obstetric interventions antenatally.
 Full term normal vaginal delivery at Theni GH, alive Boy baby ,B. wt: 2.9kg, cried soon after birth, breastfeeding
initiated soon after birth, uneventful.
 Baby blood group was B positive.
 Got Anti D injection on 2nd postnatal day, and discharged home on 3rd postnatal day.
 Puerperium uneventful, no contraceptive method was adopted, breastfed upto 1 year (exclusively 5 months)
 Now 3 years of age, normal milestones.
 Present pregnancy: Booked and immunized at PHC, history elaborated already.

10. PAST HISTORY
 Not a case of HT/DM/TB/BA/ Thyroid/ Heart disease/ Epilepsy
 No H/o previous surgeries
 No H/o previous hospitalisations
 No h/o blood transfusions
 No h/o long term drug intake
 No h/o allergies

11. FAMILY HISTORY
 Nuclear family, with 3 members
 No h/o medical illnesses in family members
 No h/o unexplained fetal deaths in family
 No h/o congenital anomalies in family
 No family h/o twins
 No smokers in family
 Blood group of pt’s mother: unaware

12. PERSONAL HISTORY
 Takes veg and non veg diet
 Bowel and bladder habits normal
 Good appetite and good sleep
 No addictive habits

13. DIET HISTORY
 Takes a total of 2300 calories as against 2500 required
 Takes 65 g of protein in her avg diet as against 70g as required
 Has nuts, egg and greens in her diet

14. SUMMARY
 24 year old G2 P1 L1, LCB 3 years, LMP on 23.08.2021, EDD on 30.05.2022, regular cycles, excellent dates,
booked and immunized, with no other comorbidities, Rh negative blood group with Rh incompatible
pregnancy.

15. EXAMINATION
 Moderately built, adequately nourished
 No pallor
 No pedal edema
 No icterus/cyanosis/clubbing/ generalized lymphadenopathy
 Ht: 150cm Prepregnancy wt: 39kg BMI 17.3
 Present weight: 48kg

16.  Breasts, Spine, Thyroid, Gait- clinically normal
 BP: 110/70mmHg measured in Right arm in sitting position
 Pulse rate: 84/min, regular, normal volume and character, measured in right radial artery, no radioradial/
radiofemoral delay
 Respiratory rate 16/min
 Temp: normal
 CVS: s1 S2 heard normally, no murmur
 RS: NVBS heard
 CNS clinically normal

17. OBSTETRIC EXAMINATION
 Inspection:
 Abdomen longitundinally enlarged, umbilicus flushed with surface,
 Linea nigra, stria gravidarum +
 No scars, sinuses, dilated veins

18. PALPATION
 After correcting dextrorotation,
 Fundal height corresponds to 34 to 36 weeks of gestation ( below xiphisternum)
 SFH: 35cm
 Leopold maneuvers:
 Fundal grip: a broad smooth mass, not independently ballotable felt in fundus suggestive of breech
 Lateral grip: a smooth uniform curved resistance on maternal left- suggesting spine, irregular knob like structures
towards right- suggesting limbs
 First pelvic grip: a hard, round, regular, independently ballotable mass in lower pole- suggestive of head.
 Second pelvic grip: Finding of first pelvic grip confirmed.
 Liquor clinically appears adequate

19. AUSCULTATION:
 Fetal heart sound heard along the left spino umbilical line, 146 beats per minute, regular.

20. SUMMARY
 24 yr old G2 P1 L1, previous FTNVD, LCB 5 years, LMP 23.08.2021, EDD 30.05.2022, booked and immunized,
with a singleton fetus of 34 weeks 1 day gestation in cephalic presentation with good FHR, adequate liquor,
with Rh incompatible, non alloimmunised pregnancy.

21. DIAGNOSIS
 24 year G2 P1 L1,, with a singleton fetus of 34 weeks 1 day GA in cephalic presentation with good FHR, with Rh
incompatible, non alloimmunised pregnancy for tertiary care opinion.

22. INVESTIGATIONS
 CBC
 HIV 1 and 2 for patient and spouse
 HBsAg, VCTC
 Urine R/E
 ICT
 USG obstetrics with fetal doppler
 BPP/NST

23. MANAGEMENT PLAN
ICT
POSITIVE
<
CRITICAL
TITRE
REPEAT
EVERY 2
WEEKS
>
CRITICAL
TITRE
USG
MCA PSV
MCA PSV
< 1,5Mom
FOR GA
REPEAT
EVERY
WEEK
MCA PSV
>1.5 MoM
>35WKS <35 WKS
FBS/
CONSIDER
IUT
NEGATIVE
REPEAT
AFTER 3 TO 4
WEEKS
IF NEG,
DELIVER AT
TERM

24. THANK YOU…