Rh Sensitization during Pregnancy

In Rh-negative, the red blood cells do not have a marker called Rh factor on them. Rh-positive
blood does have this marker. If blood mixes with Rh-positive blood, the immune system will react to
the Rh factor by making antibodies to destroy it. This immune system response is called Rh
sensitization.
Rh sensitization during pregnancy can only happen if a woman has Rh-negative blood and
only if her baby has Rh-positive blood.
❑ If the mother is Rh-negative and the father is Rh-positive, there is a good chance the baby will
have Rh-positive blood. Rh sensitization can occur.
❑ If both parents have Rh-negative blood, the baby will have Rh-negative blood. Since the
mother's blood and the baby's blood match, sensitization will not occur.

Cause: Rh sensitization can occur during pregnancy if the mother is Rh-negative and pregnant
with a developing baby (fetus) who has Rh-positive blood. In most cases, the mothers blood will
not mix with the baby's blood until delivery. It takes a while to make AB that can affect the baby,
so during first pregnancy, the baby probably would not be affected.
But if the mother gets pregnant again with an Rh-positive baby, the AB already in the
mothers blood could attack the baby’s RBC. This can cause the baby to have anemia, jaundice,
or more serious problems called Rh disease.
DIAGNOSTIC:
If with Rh-negative blood but are not sensitized:
❑ The blood test may be repeated between 24 and 28 weeks of pregnancy. If the test still
shows that there is no sensitization, probably will not need another AB test until delivery.
(might need to have the test again if there is an amniocentesis, if the pregnancy goes
beyond 40 weeks, or if there is a problem such as abruptio p., which could cause bleeding in
the uterus.)
❑ The baby will have a blood test at birth. If the newborn has Rh-positive blood, the mother will
have an AB test to see if she were sensitized during late pregnancy or childbirth.
If Rh-sensitized, the doctor will monitor the pregnancy carefully and have the ff:
❑ Fetal blood sampling (cordocentesis)- done to assess fetus's health & used on a limited basis,
usually for monitoring known sensitization problems (as when a mother has had previous fetal
deaths, or when other testing has shown signs of fetal distress).
❑ Fetal Doppler UTZ, to check blood flow to the baby's brain. This can show anemia and how
severe it is (can give the same anemia information as amniocentesis, without the risks)
❑ Amniocentesis after 15 weeks, done to check AF for signs of fetal problems or to learn the
fetus's blood type and Rh factor.
❑ Electronic fetal heart monitoring (NST)- done in the third trimester to check fetus's condition.
Unusual FHR detected during a NST may be a sign that the fetus has anemia related to the
sensitization.
Indirect Coombs test – A test to determine whether a woman has
Rh-positive or Rh-negative blood (Rh antibody titre) & is done early
in pregnancy (periodically during pregnancy to see if mothers Rh-
positive AB levels are increasing). This is the typical course of
treatment for most sensitized women during pregnancy.
An abnormal (positive) result means that the mother has
developed antibodies to the fetal red blood cells and is sensitized.
However, a positive Coombs test only indicates that an Rh-positive
fetus has a possibility of being harmed.

There are two types of Coombs tests:

Direct Coombs test- looks for AB that are stuck to RBC
Indirect Coombs test- looks for AB floating in the liquid part of
the blood, called serum.
PREVENTION:
If Rh-negative blood but are not Rh-sensitized, the doctor will give one or more shots of
Rh immune globulin (such as WinRho). This prevents Rh sensitization in nearly all women
who use it.
A shot of Rh immune globulin will be given:
If with a test such as an amniocentesis or chorionic villus sampling (CVS).
If bleeding occurs during pregnancy.
At time of miscarriage, induced abortion, ectopic or molar pregnancy.
Trauma to the abdomen during pregnancy.
Around week 26-28 of pregnancy.
After delivery if newborn is Rh-positive.
The shots only work for a short time, so there is a need to repeat the treatment each
time of pregnancy. (To prevent sensitization in future pregnancies, Rh immune globulin is
also given when an Rh-negative woman has a miscarriage, abortion, or ectopic
pregnancy). The shots won't work if the mother is already Rh-sensitized.
TREATMENT:
Treatment of the baby is based on how severe the loss of RBC (anemia)
is.
If the baby's anemia is mild – there will be more testing than usual
during pregnancy. The baby may not need any special treatment after
birth.
If anemia is getting worse, it may be safest to deliver the baby early.
After delivery, some babies need a blood transfusion or treatment for
jaundice. For severe anemia, a baby can have a blood transfusion
while still in the uterus. This can help keep the baby healthy until he or
she is mature enough to be delivered (an early C-section, and the baby
may need to have another blood transfusion right after birth).
In the past, Rh sensitization was often deadly for the baby. But
improved testing and treatment mean that now most babies with Rh
disease survive and do well after birth.
 MATERNAL-FETAL BLOOD GROUP INCOMPATIBILITY

Mother is type O and Baby is A, B or AB

Blood types A, B, & AB contain antigen not present in type
O blood
Blood type O have anti A/ anti B antibodies
If exchange occurs, maternal AB attack fetal blood cells,
causing rapid lysis of RBC’s
Lysis of RBC’s → byproduct bilirubin → “Jaundice”
TREATMENT:
* Phototherapy ( if with increased bilirubin levels in the
blood)
PREGNANCY-INDUCED HYPERTENSION
(PIH, PREECLAMPSIA AND ECLAMPSIA )
Magnesium Sulfate (MgSO4)
 Bronchodilating effects that prevents seizures / lowers BP
 Delivered via infusion pump (infuse slowly) or IVP to the mainline IVF
before, during labor and 24H post delivery

Nursing Considerations:
a. Assess the baseline VS and UO before therapy (RR @ least 16bpm)/
check VS prior to administration/ VS esp. RR monitoring every hour during
treatment course/ Fetal Status monitoring every hour
b. Contraindicated for patients with Renal disease and other drugs (Dilantin
& Valium)
c. Check patellar reflex together with the VS/ Magnesium level q2h (4-
6meq/liter is therapeutic)
d. UO monitoring every hour during the treatment course (FBC)
MAGNESIUM TOXICITY based on Clinical Signs:
1.SHARP DROP IN BP
2.RESPIRATORY PARALYSIS
3.DISAPPEARANCE OF PATELLAR REFLEX

Nursing Considerations:
*Stop the infusion
*Give O2
*Administer Ca Gluconate ASAP
 HYDRAMNIOS
POLYHYDRAMNIOS - more than 2L of AF (Excessive AF)
OLIGOHYDRAMNIOS – less than 500 ml of AF
Management:
✓Maintain bed rest to reduce pressure on cervix
and to prevent PTL
✓Monitor for rupture or Uterine contraction
✓Avoid constipation (will increase intrauterine
pressure) by bulk in the diet
✓Amniocentesis (slow to prevent premature
separation of the placenta)
guided by UTZ