UNIVERSITY OF THE ASSUMPTION

College of Nursing
City of San Fernando, Pampanga

SCIENTIA, VIRTUS et COMMUNITAS

R.L.E. - 106
ACUTE BIOLOGIC CRISIS

RH & ABO
INCOMPATIBILITY
SUBMITTED BY:
Shiela Marie A. Ng
Camille Louise S. Sunglao
BSN 4A
A1

SUBMITTED TO:
Mr. Ulysses N. Rengel, R.N., M.A.N.©

27 September 2011
 ABO INCOMPATIBILITY

 ABO incompatibility is a reaction of the immune system that occurs if two different and
not compatible blood types are mixed together.
 Occurs in about 20% to 25% of all pregnancies, but only one in 10 cases of ABO
incompatibility result HDN.

CAUSES

A, B, and O are the three major blood types. The types are based on small substances
(molecules) on the surface of the blood cells. In people who have different blood types, these
molecules act as immune system triggers (antigens).

Each person has a combination of two of these surface molecules. Type O lacks any molecule.
The different blood types are:

 Type A (AA or AO molecules)

 Type B (BB or BO molecules)
 Type AB
 Type O

People who have one blood type form proteins (antibodies) that cause their immune system to
react against other blood types. Being exposed to another type of blood can cause a reaction.
This is important when a patient needs to receive blood (transfusion) or have an organ
transplant. The blood types must be matched to avoid an ABO incompatibility reaction.

For example:

 A patient with type A blood will react against type B or type AB blood
 A patient with type B blood will react against type A or type AB blood
 A patient with type O blood will react against type A, type B, or type AB blood

Because type O lacks any surface molecules, type O blood does not cause an immune response.
This is why type O blood cells can be given to patients of any blood type. People with type O
blood are called "universal donors." However, people with type O can only receive type O blood.

Since antibodies are in the liquid part of blood (plasma), both blood and plasma transfusions
must be matched to avoid an immune reaction.
 PATHOPHYSIOLOGY

Contact between two incompatible blood

(ex. Mother and child through birth)

Blood cannot be attached together

because of different surface antigen

One blood determines the other as

a foreign substance in the body

The immune system forms antibodies

The antibodies attack the other blood type and

destroy as if it is a foreign substance

Hemolytic reactions occur antibodies

contact the unmatched blood type

S/Sx become prevalent

 SIGNS AND SYMPTOMS

 Back pain
 Blood in urine
 Feeling of "impending doom"
 Fever
 Yellow skin (jaundice)

LABORATORY TEST

 Bilirubin level is high

 Complete blood count (CBC) shows damaged red blood cells, may also show
mild anemia
 Lab testing of patient's and donor's blood shows that they are not compatible
 At birth, the cord blood is taken to determine the blood type of the newborn and the
antibody titer (Direct Coombs test).
 The newborn is carefully screened for jaundice, which indicates hyperbilirubinemia.

MEDICAL MANAGEMENT

 Drugs used to treat allergic reactions (antihistamines)

 Drugs used to treat swelling and allergies (steroids)
 Fluids given through a vein (intravenous)
 Medicines to raise blood pressure if it drops too low
 Exchange transfusion - is a potentially life-saving procedure that is done to counteract
the effects of serious jaundice or changes in the blood. The procedure involves slowly
removing the patient's blood and replacing it with fresh donor blood or plasma.

COMPLICATIONS

 Kidney failure
 Low blood pressure needing intensive care ( Hypotension )
 Death

NURSING MANAGEMENT
 1. Anticipatory guidance: assessment of maternal and fetal status. These include
psychosocial factors that may place stress on the family.
2. Providing atmosphere for open communication allows the woman to express feelings
and gain knowledge about self-care demand.

PREVENTION

 Careful testing of donor and patient blood types before transfusion or transplant can
prevent this problem.
 Preventive care obtained through regular visits is the key to improve outcomes and
possible complications.

References:

Maternal and Child Nursing by Emily Slone Mckinney et.al, 1st edition

Pathophysiology. The Biologic Basis for Disease in Adults and Children, 2nd Edition by Kathryn L.
McCane

http://www.nlm.nih.gov/medlineplus/ency/article/001306.htm
 RH INCOMPATIBILITY

Rh incompatibility is a condition which develops when a pregnant woman has an Rh-negative

blood type and the fetus she carries has Rh-positive blood type.

CAUSES

During pregnancy, red blood cells from the unborn baby can cross into the mother's
bloodstream through the placenta.

If the mother is Rh-negative, her immune system treats Rh-positive fetal cells as if they were a
foreign substance and makes antibodies against the fetal blood cells. These anti-Rh antibodies
may cross back through the placenta into the developing baby and destroy the baby's
circulating red blood cells.

When red blood cells are broken down, they make bilirubin. This causes an infant to become
yellow (jaundiced). The level of bilirubin in the infant's bloodstream may range from mild to
dangerously high.

Because it takes time for the mother to develop antibodies, firstborn infants are often not
affected unless the mother had past miscarriages or abortions that sensitized her immune
system. However, all children she has afterwards who are also Rh-positive may be affected.

Rh incompatibility develops only when the mother is Rh-negative and the infant is Rh-positive.
Thanks to the use of special immune globulins called RhoGHAM, this problem has become
uncommon in the United States and other places that provide access to good prenatal care.

PATHOPHYSIOLOGY

Fetus Rh (+) blood

Mother Rh (-) blood

Rh antibodies form in mother’s blood within

72 hours after delivery or abortion of Rh (+)
baby
 Fetus in subsequent
pregnancy
Hemolysis of RBC

Destroy RBC

production of immature RBC (erythroblasts) serum bilirubin

Jaundice
Enlarged liver and Unconjugated bilirubin pass to brain
spleen

Kernicterus
Erythroblastosis fetalis

CLINICAL MANIFESTATIONS

Mild Rh incompatibility:
• Positive direct Coombs
• Evidence of hemolysis in the infant’s blood
• Elevated cord blood bilirubin

Hydrops fetalis:
• Severe anemia
• Heart failure (cardiac failure)
• Enlarged liver (hepatomegaly)
• Respiratory distress
• Bruising or purplish bruise-like lesions on the skin (purpura)

Kernicterus — Early:
• High bilirubin level (greater than 18 mg/cc)
• Extreme jaundice
• Absent Moro (startle) reflex
• Poor breast-feeding or sucking
• Lethargy

Kernicterus — Mid:
• High-pitched cry
• Arched back with neck hyperextended backwards (opisthotonos)
• Bulging fontanel (soft spot)
• Seizures
 Kernicterus — Late (full neurological syndrome):
• High-frequency hearing loss
• Mental retardation
• Muscle rigidity
• Speech difficulties
• Seizures
• Movement disorder

DIAGNOSTIC TESTS

Early Diagnosis – Pregnancy for Rh incompatibility

 H/O previous blood transfusions
 Blood group and Rh status of pregnant woman
 Rh antibody titer for Rh negative woman at the first pregnancy visit and repeat at 32-38
weeks of pregnancy (ICT)
 Normal titer is 0
 Minimal ratio 1:8
 Chorionic villus sampling in early pregnancy.
 Amniocentesis and amniotic fluid spectrophotometry for biliribin
 Regular ultrasound from 14-18 weeks onwards – look for fetal ascites and subcutaneous
edema (hydrops fetalis)

Early Diagnosis – After Birth for Rh incompatibility

 Determination of fetal blood group and test for alloimmunization (DCT) from cord blood
at the time of delivery.

MEDICAL MANAGEMENT

Since Rh incompatibility is almost completely preventable with the use of RhoGAM, prevention
remains the best treatment. Treatment of the already affected infant depends on the severity of
the condition.

Mild:
 Aggressive hydration
 Phototherapy using bilirubin lights

Hydrops fetalis:
 Amniocentesis to determine severity
 Intrauterine fetal transfusion
 Early induction of labor
 A direct transfusion of packed red blood cells (compatible with the infant’s blood) and
also exchange transfusion of the newborn to rid the blood of the maternal antibodies
that are destroying the red blood cells
 Control of congestive failure and fluid retention
Kernicterus:
 Exchange transfusion (may require multiple exchanges)
 Phototherapy

NURSING MANAGEMENT

During Phototherapy:

1. Remove clothing to proper skin exposure.

2. Turn infant frequently to expose all skin area.
3. Record and report jaundice and blood levels of bilirubin.
4. Record and report if any change in body temperature
5. Cover and check eyes with eye patches to prevent eye injury.
a. Be sure the eyes close before applying eye patch to prevent corneal irritation
b. Should be loose enough to avoid pressure.
c. Eye patches should be changed every 8houly and eye care given.
6. Nurse should expect the infant’s stools to be green and the urine dark because of
photodegradation products.
7. Serum bilirubin and hematocrit should be monitored during therapy and for 24 hours
following therapy.
8. In case of breast milk jaundice stop breast feeding temporarily.
9. Maintain feeding intervals to prevent dehydration.

PREVENTION

 Screening for the blood group of all pregnant women.

 Arrange for further investigations if the woman is Rh negative.
 Anti D (RhoD or RhoGAM) injection 300µg IM for the mother at 28 weeks of gestation.
 Anti D (RhoD or RhoGAM) injection 300µg IM for the mother within 72 hours of an
abortion, delivery of Rh positive baby or after procedures like amniocentesis or chorionic
villus sampling.

References:

Stoll BJ. Blood disorders. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson
Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 103.

Davidson, Susan. Diseases Causes & Diagnosis Current Therapy Nursing Management Patient
Education (Educational Publishing House. 1990)

Kumar. Robbins & Cotran Pathologic Basis of Disease (Elsevier Saunders Inc. 7th edition. 2005)

http://www.nursing-lectures.com/2011/02/rh-incompatibility-and-nursing-care.html