Rhesus negative in pregnancy guideline

1. RHESUS
NEGATIVE IN
PREGNANCY
NURAFIQAH BINTI
MUHAMMAD ALI AKBAR
SUPERVISOR: DR NURUL
IZZA BINTI MOHAMED
RUSDI

2. What is Rhesus factor?
- The Rhesus factor is a protein that can be found on the
surface of red blood cells. If your blood cells have this
protein you are Rh positive, and if you don’t you are Rh
negative

3. How does a person get the Rhesus factor?
- The Rh factor is inherited, meaning it is passed from parent
to child through genes. The fetus can inherit the Rh factor
from the father or mother.

4. • Having an Rh negative blood type is not an illness, and it
usually does not affect your health. But it can affect
pregnancy. Your pregnancy needs special care if you're
Rh negative and your baby is Rh positive. That's called Rh
incompatibility.

5. Rh incompatibility
• Rh incompatibility, also known as Rh disease, is a
condition that occurs when a woman with Rh-negative
blood type is exposed to Rh-positive blood cells, leading
to the development of Rh antibodies.

9. Complications
• Hydrops fetalis and stillbirth
• Icterus gravis neonatorum
• Neonatal jaundice
• Congenital anemia in newborn

11. Hydrops fetalis
Sonography(combined with pulse
Doppler)
• Oedema in skin and scalp
• Pleural effusion
• Pericardial effusion
• Echogenic bowel

13. Baby at birth
• Pale
• Oedematous
• Enlarge abdomen due to ascites

14. Placenta
• Large,Pale,Edematous with fluid oozing from it
• Increase weight may be equal to fetal weight
• Swelling of villi

16. History
• Obtain the following history:
1 . History of prior blood transfusion
2. Rh blood type of the mother
3. Rh blood type of the father (55% of Rh-positive men are
genetically heterozygous for the Rh antigen and, therefore,
produce Rh-negative offspring when mating with Rh-negative
women 50% of the time.)
4. History of fetal hydrops
5. History of hemolytic disease of newborn
6. History of prolonged jaundice/phototherapy

17. 7. Previous pregnancies, including spontaneous and elective
abortions
8. Previous administration of Rh IgG (RhoGAM)
9. Mechanism of injury in cases of maternal trauma during
pregnancy
1 0. Presence of vaginal bleeding and/or amniotic discharge
1 1 . Previous invasive obstetric procedures, such as
amniocentesis, cordocentesis, chorionic villous sampling, or
ectopic pregnancy

18. MANAGEMENT OF
RHESUS
ISOIMMUNISATION
IN PREGNANCY
Page 169-170

19. Antenatal Management
At booking:
• screening of all pregnant mothers to Rh D antigen
and antibody screening for Rh D negative mother by indirect coombs
test.
-to detect prior sensitization
-at first antenatal visit for known case of rhesus negative
- After diagnosis of new cases
• Husband need to be screened

20. Antenatal management

21. • Indirect Coomb's can be done in mothers to look for
circulating antibodies.
• Direct Coomb's test can be done using baby umbilical
cord blood to look for presence of antibodies adhering to
the RBCs (agglutination)

23. RCOG guideline
for antibody screening

24. Subsequent antenatal follow up
• If Indirect Coomb’s test / indirect agglutination test is
positive, refer to MFM or O&G
• If initial Indirect Coomb’s test / indirect agglutination is
negative, repeat test is required at 24-26 weeks
• For MO Klinik Kesihatan to call MO at Blood Bank in the
Hospital to inform the details of the mother with rhesus
negative- to reserve rhesus negative blood.

25. Role of Anti-D Prophylaxis
• Anti-D Prophylaxis:
1) Routine – Routine Antenatal Anti-D Prophylaxis (RAADP)
& postnatal prophylaxis
2) Any potentially sensitising events

26. Routine Antenatal Anti-D Prophylaxis (RAADP)
• Routine Antenatal Anti-D Prophylaxis (RAADP) for non-
sensitised patient, either one of these regimes:
⮚ 2-dose regime: IM Anti-D Immunoglobulin 500iu at 28
weeks and 34 weeks
⮚ Single dose regime: IM Anti-D Immunoglobulin 1500iu
between 28-34 weeks
* RAADP may be administered in a health clinic if Anti-D
immunoglobulin is available

27. Prophylactic anti D immunoglobulin
(RhoGAM)

28. Potentially sensitising events requiring
anti-D Ig prophylaxis
• Amniocentesis, chorionic villus biopsy and cordocentesis
• APH/PV bleeding in pregnancy
• External cephalic version
• Abdominal trauma (sharp/blunt, open, closed)
• Ectopic pregnancy
• Evacuation of molar pregnancy
• IUD and stillbirth
• In-utero therapeutic interventions (transfusion, surgery, insertion shunts, laser)
• Miscarriage, threatened miscarriage
• Therapeutic termination of pregnancy
• Delivery – normal, instrumental or caesarean section
• Intra-operative cell salvage

29. BCSH Guideline for Anti-D immunoglobulin

30. • Prior to availability of anti-D Ig – incidence of alloimmunisation in D-
ve women following 2 deliveries of D+ve, ABO compatible infants
was ~16%, haemolytic disease of newborn was a significant cause of
morbidity and mortality
• Following routine post-partum anti-D – rate of alloimmunisation
dropped to ~2%
• Further reduction in sensitisation rate ranging from 0.17 to 0.28%
achieved by RAADP during 3rd trimester reduction n in mortality
a/w HDN from 46/100 000 to 1.6/100 000 births

31. If already
sensitized,
No need for
antiD

32. Continuous
bleeding :
Anti D 500IU every
6 weeks
FMH test
requested every 2
weeks

33. In IUD : 72 hours starts from
the diagnosis of IUD and
not from delivery

34. Except if heavy
bleeding/severe pain : 250IU

35. Management by RCOG guideline

36. 1)Management of
non sensitized
mother

37. • Follow up at tertiary centre
• Routine antenatal prophylaxis at 28 weeks
• Timing and mode of delivery depending on obstetric
indication
• Routine prophylaxis 72 hours within delivery

38. 2)Management of
sensitize mother

39. • Anti-D antibodies may cause severe hemolytic disease of
fetus and newborns as a result of feto-maternal
hemorrhage in RH negative women with RH positive fetus.

40. When antibodies D are detected
• Ultrasound should be done to look for features suggestive of fetal
anaemia.
• Sign of fetal anemia
• Ascites
• Pericardial effusion
• Circulatory velocity increased ( DOPPLER OF MIDDLE CEREBRAL ARTERY)
• Fetal heart enlarged
• Polyhydramnious
• Reduced fetal movement
• Abnormal ctg

41. Follow up
FOLLOW UP WITH MATERNAL FETAL MEDICINE CONSULTANT
• Antibodies levels/titres should be done
• Serial anti-D antibody levels should be done every 4 weeks
till 28 weeks and then 2 weekly till delivery.
• If level is > 4 iu/ml moderate risk of haemolytic disease of
the fetus and neonate (HDFN)
• If level is > 15 iu/ml- severe risk of HDFN

42. Kleihauer-Betke test
MEASURE THE 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 fetal cells in 50 low power
microscopic field of peripheral maternal
blood.
SO 1ml is represented by 20 fetal cells.

43. MCA PSV
• To detect fetal anemia
• MCA PSV rises above the 1.5
multiples of the median
(MoM) threshold.
• MCA PSV monitoring is
predictive of moderate or
severe fetal anaemia with
100% sensitivity and a false
positive rate of 12%

45. Timing of delivery
• Depends on antibody levels/titre rate of rise and whether
fetal therapy has been instituted:
• if anti-D levels have been stable deliver between
37 and 38 weeks
• if there is rising anti-D levels but no intrauterine transfusion
(IUT) consider early delivery

46. Timing of delivery
• If IUT has been performed, This will depend on the
gestation that the last IUT was performed as well as the
estimated rate of drop of fetal haemoglobin/haematocrit
• Prior IUT is not in itself an indication for elective caesarean
section
• The timing mode and delivery birth must be timed so that
the fetus doesn't have significant anaemia at birth.

47. Admission for delivery
• To prepare GXM 1 pint
• Update MO Blood bank regarding patient admission- to
ask regarding blood availability
• if admission for induction of labour, to ensure blood is
available prior to IOL.

48. Intrapartum
• Although the National Institute for Health and Care Excellence
(NICE) guideline on intrapartum care contains no specific
recommendation for fetal monitoring in pregnancies complicated
by red cell antibodies, these pregnancies are generally considered
to be ‘high risk’ and intrapartum continuous electronic fetal heart
monitoring is therefore advised.
• Alert paeds team for standby if baby have complication from
sensitizing mother.
• PPH prophylaxis

49. Postpartum management
• Refer baby to Paediatrics
• Administer IM Anti-D immunoglobulin 500iu within 72 hours if baby is
Rh positive
• IM Anti-D immunoglobulin 500iu is also required for IUD >20 weeks at
diagnosis and again after delivery, unless delivery is soon after IUD is
diagnosed

50. Postpartum management
• If baby’s direct Coomb’s test / direct agglutination test is
positive, baby is at risk of haemolytic disease of newborn
(HDN) and Kleihauer test for the mother should be
performed to quantify the foetal maternal haemorrhage
(FMH). Further Anti-D required if FMH >4ml.
• Contraceptive advice.

51. Anti-D detectable in samples from pregnant D-ve
women
• Antibody screens may be positive following anti-D Ig injection
• Detectable anti-D may be passive or immune – no serological
method for distinguishing the two
• Even if measured at the pharmacokinetic peak, passive anti-D
rarely exceeds 0.4 IU mL.
• Regardless any prior anti-D Ig injection, any anti-D detected at
28weeks should be quantified – results recorded in the woman’s
hand-held and hospital records.
• if no clear conclusion can be reached as to the origin of anti-D,
then prophylaxis should be continue to be administered in
accordance to guideline.

52. Prepregnancy counselling
• Women with red cell antibodies, particularly if there is a risk
of fetal anaemia or if compatible donor red cells for
transfusion may be difficult to obtain, should attend for
prepregnancy counselling with a clinician with knowledge
and expertise of this condition.

53. References
• Perinatal care manual 4th Edition, MOH 2022
• BCSH Guideline for The Use of Anti-D immnumoglobulin for
The Prevention of Haemolytic Disease of Fetus and
Newborns, Nov 2013
• The Management of Red Cell Antibodies during
Pregnancy, GTG No. 65 May 2014.