Rh INCOMPATIBILITY

Presented by –
Dr.Minal M. Patil (3rd Year B.A.M.S.)
Under guidance of
Dr. Jyotsna P. Patil
(MD-Gynac)
 Rh INCOMPATIBILITY
Index

- Introduction.

- Rh Blood group

- Heamolytic Disease of newborn

- Management
INTRODUCTION-
 Fetal Circulation :
Normally, there is no direct mixing of material & fetal blood
because all exchange occur by diffusion through capillary walls.
Blood
[Fetus Placenta]
Umbilical Artery
 Blood System :
- ABO System
- Rh System
Blood Plasma contain antibodies called agglutinins.
RBC’s contain antigen
 Landsteiner’s Law :-
If particular antigen present on RBC, corresponding antibody must be
absent in serum.
If Antigen is absent on RBC’s the corresponding antibody mustn't be
present in serum.

Group Antigen on RBC Antibody in Serum

A A Anti B (β)
B B Anti B (α)
AB A and B No antibody
O No antigen Anti A and Anti B
 Rh blood group :-
It named because antigen was discovered in blood of Rhesus
monkey.
- Rh factor is an antigen present in RBC’s
- There are many Rh antigens but only the D is more antigenic.
Person having ‘D’ antigen  Rh+ve
Person without ‘D’ antigen  Rh-ve
a) Rh blood group system differ from ABO system antigen ‘b’ does not
have corresponding natural antibody (anti D) Rh-ve person is
exposed of Rh +ve blood group for first time, then anti ‘D’ is formed
in that person.
b) Rh +ve person receive Rh-ve blood without the risk of developing
complication.
 Defn :- Incompatibility means not suitable for
combinations.
 Inheritance of Rh antigen
 Transfusion reactions due to Rh incompatibility
Rh -ve persons received Rh+ve blood at first time, not affected.
Reaction not occur immediately But, the Rh agglutinitis develop within one
month.

Transfused RBC’s which are still present in receipent’s blood, are

agglutinated.

These agglutinated cells are lysed by macrophages. So delayed

transfusion reaction occurs. But usually mild & does not after the recipent.
agglutinins developed in recepient body remain forever

Dectable antibody usually develop after 6 months following large

volume of feto-maternal bleed. Antibodies once formed remain throught life.

But, when person receive Rh+ve blood for 2nd time. Severe
transfusion reaction occur.
Hemolytic Disease of Newborn
When Rh-ve mother carries Rh+ve foetus.

Usually at first time child escapes the complications of Rh

incompability. This is becoz Rh antigen cannot pass from fetal
blood into mother’s blood through the placental barrier.

However, at time of parturation (delivery of the child) the Rh

antigen from fetal blood leaks into mother’s blood becoz of
serveranced of Umbilical cord.

During PPH period i.e. within a month after delivery, the mother
develops Rh antibody in her blood.
 When mother conceives for IInd time & if the fetus happens to
be Rh+ve again, antibody from mother’s blood crosses placental
barrier & enters the fetal blood.

Thus only Rh antigen can’t cross the placental barrier whear as

Rh agglutin can cross it.

The Rh agglutinins which enter the fetus causes agglutination

of fetal RBC’s resulting in hemolysis (i.e. Reputure of RBC’s)

Severe hemolysis in fetus causes Jaundice. To componsate

the hemolysis of more & more number of RBC’s, there is rapid
production of RBC’s not only from bone, but also from spleen &
liver.
 Now many large & immature cells in proerthyroblastic stage are
released into circulation. Becoz of this, disease called
Erythroblastosis fetalis.
 Hydrops Fetalis :-
Hemolysis is very severe leads to IUD to fetus.
death occur due to oedema, enlargement of liver & spleen &
cardiac failure.
 Kernicterus :-
Brain damage in infants caused by Severe Jaundice.
by Anemia [in erythrocyte fetalis]

Increased bilirubin content

[Because in children, blood-
brain barrier is not developed
well so it can pass through this Bilirubin enters
barrier and cause damage]
Brain

Permanent brain damage.

 A portion of bilirubin enters the
While in fetus in utero amniotic fluid
destruction red cells Perhaps

From fetal long or through skin or

Liberation of unconjugate
across the surface of placenta or cord.
bilrubin
excreted
So this reason not directly born with
through
Jaundice
Placenta
as soon as

Material system Umbilical Cord clamp

Hemolysis

Bilirubin

So baby become Jaundice

 Coomb’s tests :-
[R.R.A. Combs Briton immunologist 1921]

Postnatal test of a sample of umbilical cord blood for maternal

antibodies against the fetal blood type.

An abscences of agglutination signifies a normal negative

finding & qualifies Rh-ve mother of administration of Rh Gamma to
protect subsequent pregnancy.
Management
 MANAGEMENT IN TWO TYPES
1) Rh –ve non – immunized patient

2) Rh –ve immunized patient.

 Management of Rh- negative non immunized patient.
Non
immunized group is formed by primigravida, multigravida patient who are Rh
negative.
Father Rh factor mother Rh (-ve)

Negative (i.e. Rh-ve) Positive (Rh+ve)

Antibody Screening at 20, 24, 28 wks

No need for testing manage Antibody Screening Antibody

treat at normal pregnancy becomes +ve Screening
remains - ve
manage as
sensitized Give D-immunoglobulin
pregnancy at 28th Wks & determing
eligibility for IInd does of
D-immunoglobulin at
delivery.
 Indication for D-immunolobulin :

- Infants is Rh+ve
- Direct coombs test on Umbilical cord blood is
negative
Test reveals Whether infants red cells are
covered by irregular antibodies.
- Cross match between anti-D immunoglobulin &
mother’s red cells is compactible.
 DOSE
Anti-D gamma globalin is administered IM to the mother 300 µg
following delivery.

 TIME
 immunoglobulin given any time upto 4 wks after delivery.

 Maximum protective effect is obtained if antibody administered

with in 72 hrs after delivery.
 Management of Rh-ve immunized patient:
Immonized Rh-ve patient Depends upon
the 4 diagnostic techniques

1) Maternal serum antibody titre

2) fetal assesment by ultrasound

3) Amniotic fluid bilrubin determination

4) Fetal blood sampling.

 Maternal Serum antibody titer :-
- Useful for follw-up of patients in their first immonized
pregnancy.
- Patient in the course of their first sentisized pregnancy
should have antibody liters every 4 wks.
Fetal assesment by Ultrasound :-
- High resolution Ultrasound is valuable in management
of sensitized Rh negative Pt.
- Modern equipment allows a clear visulasation of the
fetal structures & early diagnosis of the presence of fetal
ascites, pericardial effussion, liver management &
placental swelling.
 Amniotic Fluid analysis :-
If pregnancy affected by presence of irregular
antibodies capable of producing erythroblastosis fetalis
spectro- photometric analysis of amniotic fluid is reliable
method for evaluating severity of fetal hemolytic process
& for determining optimal time for IUT [Intrauterine
transfusion]

- Ist amniocentesis is carried out at 26 wks.

 Fetal blood sampling or transfusion –
The site of placental insertion of umbilical cord is
found using high resolution USG needle is introduced
into umbilical vein & fetal blood is drawn for
determination of fetal blood group

- Rh +ve / -ve

- Fetal Hb.

- Haemocrit value.
 Prognosis :-
Prognosis of the baby depends on
1) Genotype of fetus
2) Maternal antibody level
3) History of Previous affection of the baby due to hemolytic
disease
4) availability of diagnostic & therapeutic facilities for the affected
babies.

Advice :-
An immunised mother who has anti-D level more than 400 IU/L
should be advised for anti-D donation.
 Care During Delivery :- C4

* Careful Vaginal delivery :-

1) Fetal monitoring is to be detect at the earliest evidence of distress.

2) Prohylatic ergometrine during second stage should be withheld.
3) Gentle handling of uterus in the third stage.
4) Care of PPH.

* Cesarean Section :-

- To avoid spillage of blood into peritoneal cavity.

- Routine manual removal of placenta should be with held.
* Clamping the umbilical cord :-

1) Cord is clamp as quaickly as possible.

2) Cord should be kept long for exchange transfusion is required.

• Collection of cord blood for investigation :-

1) Collected 5ml of blood (2 ml oxalated)

(3 ml clotted)

2) Clotted blood - Rh grouping

- direct coomb’s test

3) Oxalated blood - Hb% estimation.