RH INCOMPATIBILITY

INTRODUCTION
In addition to the 4 main blood groups(A, B, AB and O), it is well known that, depending
on the Rh factor, a person can be Rh positive or Rh negative. Rh is an antigen that can be
found on the surface of red blood cells.

In the event that the red blood cells present such an antigen, the person is said to be
Rh positive. If, on the other hand, this antigen is absent, the person will be Rh negative.

If an Rh-negative woman becomes pregnant with an Rh-positive baby, there will be

an Rh incompatibility that can lead to serious problems, especially in a subsequent
pregnancy.

DEFINITION
Maternal isoimmunization due to Rh incompatibility can occur when an Rh-negative
woman becomes pregnant and her baby is Rh-positive (because she inherited it from the
father).
In this case, the Rh-positive red blood cells of the fetus may be recognized as foreign
by the maternal immune system. This would trigger the production of anti-Rh antibodies in
the mother, which is known as isoimmunization rh sensitization.

For this to occur, the baby's blood must come into contact with the mother's blood.
Although it can happen towards the end of pregnancy, this can happen especially at the
time of delivery. For this reason, Rh isoimmunization does not usually affect the fetus in the first
pregnancy.

However, it is important to mention that isoimmunization can occur even if the

pregnancy is terminated or is an ectopic pregnancy. Similarly, the Rh-negative woman may
become sensitized to the Rh factor for reasons unrelated to pregnancy, such as an Rh-
positive blood transfusion (which is currently very rare).

RISK FACTORS
Maternal-fetal isoimmunisation of an Rh-negative mother pregnant with an Rh-
positive fetus can occur in the third trimester of pregnancy, but occurs especially at the time of
delivery.
Other times of risk for maternal isoimmunisation to occur include:
● After an ectopic pregnancy.
● After a miscarriage or voluntary termination of pregnancy.
 ● When an invasive procedure is performed in pregnancy.
● If an external cephalic version is required.
● When vaginal bleeding occurs in pregnancy.
● If a trauma or blow to the womb occurs while pregnant.

Therefore, at 28 weeks gestation, after delivery and after all these situations, Rh-
negative women who are not isoimmunized will be administered Rh immunoglobulin to try
to prevent isoimmunisation.

SIGN AND SYMPTOMS

Rh incompatibility doesn't cause signs or symptoms in a pregnant woman. Maternal
anti-Rh antibodies can destroy Rh-positive red blood cells in the fetus, resulting in perinatal
(or newborn) hemolytic disease.
Among the main symptoms the baby may have are:
● Anemia
● Jaundice: yellowing of the skin and whites of the eyes. It is due to bilirubin produced by
the destruction of red blood cells.
● Heart failure.
● Severe edema, hydrops fetalis (fluid accumulation). - Fluid accumulates because the baby's heart
failure, caused by severe anemia, leads to increased pressure and leakage of fluid into the tissues
and cavities.
● Kernicterus: is brain damage caused by elevated bilirubin levels and its accumulation in
the brain. Affects brain = Abnormal Posture: Back arching due to muscle spasms from
neurological damage. Hypertonia: Stiff, rigid muscles. Hypotonia: Floppy, limp limbs.
Dystonia: Involuntary muscle contractions causing twisting movements. Seizures:
Abnormal movements or loss of consciousness. Hearing Loss: Bilirubin affects auditory
pathways, causing hearing loss. Developmental Delays: Delays in motor skills, speech,
and cognition. Movement Disorders: Involuntary writhing, twisting, or muscle stiffness

As mentioned, these complications can even lead to the death of the baby. Therefore, it
is essential to know if there is a risk of maternal isoimmunization and to do everything possible
to avoid it.

DIAGNOSTICS
To try to avoid Rh isoimmunization, at the first gestational consultation, the woman's
blood group, Rh factor and the presence of antibodies are determined to see if the woman is
isoimmunized by the indirect Coombs test. In addition, this test will be performed several
times throughout the pregnancy.

If the woman is Rh negative and is not sensitized for Rh, she will be given an injection
of Rh immune globulin, which is known to many as the Rh vaccine. This vaccine is
usually given in the 28th week of pregnancy, regardless of the Rh factor of the couple.
Direct Coombs Test (DAT): This test detects antibodies or complement proteins that are already
bound to the surface of red blood cells. It is primarily used to diagnose autoimmune hemolytic
anemia, hemolytic disease of the newborn, and certain drug-induced hemolytic anemias.

Indirect Coombs Test (IAT): This test detects antibodies in the plasma that have the potential to
react with red blood cells. It is commonly used in blood typing and crossmatching prior to blood
transfusions, prenatal testing to identify maternal antibodies that may cause hemolytic disease of the
newborn, and in certain autoimmune diseases like autoimmune hemolytic anemia

Anti D titer test

The anti-D titer test measures the level of anti-D antibodies in an Rh-negative mother's blood. It is
used to monitor whether she has developed an immune response to Rh-positive fetal cells. This
test helps assess the risk of hemolytic disease of the newborn in current or future pregnancies and
guides the need for interventions like additional doses of Rh immunoglobulin (RhoGAM).

However, Rh immune globulin may not be given if the infant's Rh is known (through fetal DNA
study in maternal blood or amniotic fluid) and the infant is Rh negative.

On the other hand, the vaccine will also be administered in the first 72 hours after
delivery (vaginal or cesarean section) if the baby is Rh positive and, in addition, after any of
the following situations: why 72? It times with the immunological response of the body
● Ectopic pregnancy.
● Miscarriage or voluntary termination of pregnancy.
● Amniocentesis, chorionic villus biopsy and other invasive procedures.
● External cephalic version.
● Vaginal bleeding in pregnancy.
● Trauma or blow to the abdomen while pregnant.

The purpose of this injection is to prevent the mother from producing anti-Rh antibodies.
This avoids the serious complications that could result from maternal isoimmunization and the
development of perinatal hemolytic disease.

Healthcare provider can run the following test to ensure a proper diagnosis:
● Test for Rh-positive antibodies in the mother.
● An ultrasound to view the baby for fluid build-up.
● Amniocentesis.
● Percutaneous umbilical cord sampling of the fetal blood (During this test, a blood sample
gets taken from the baby’s umbilical cord. This sample gets tested for anemia, bilirubin,
and other antibodies.)
MANAGEMENT
If the woman is isoimmunized, periodic repetition of the indirect Coombs' test will serve
to monitor the amount and increase of antibodies produced. If the antibodies reach a certain level
or critical value, there is an increased risk of hemolytic disease in the baby.

However, in these cases it is very important to know the Rh factor of the baby
through the study of fetal DNA in maternal blood (or amniocentesis if performed for another
indication), since if the baby is Rh negative, strict control is not necessary.

Evaluation of the baby for signs of anemia is often performed by Doppler ultrasound.
 If the baby should be affected by Rh incompatibility, treatment will depend on the
particular situation and severity. In a mild case, jaundice will be closely monitored after
birth and phototherapy may be applied.

In other more severe cases, when severe anemia is detected in the baby, the baby
may require intrauterine or postpartum fetal transfusions (neonatal exchange transfusion) or
may have to be delivered prematurely.

DRUG STUDY

RhO (D) IMMUNE GLOBULIN

DRUG NAME RhO (D) immune globulin (WinRho SDF, Rhophylac,

HyperRHO S/D, MICRhoGAM, RhoGAM)

CLASS Immune globulin

MECHANISM OF ACTION Suppresses the mother’s immune response and antibody

formation against the fetal Rh positive blood cells

INDICATIONS Rh-negative pregnant mothers

ROUTE(S) OF IM
ADMINISTRATION

● Headache, drowsiness, and dizziness

● Vasodilation, hypotension, hypertension
SIDE EFFECTS ● Injection site reaction: erythema, mild pain,
discomfort
● Drowsiness, pallor, fever
● Asthenia or weakness
● Diaphoresis or excessive sweating

CONTRAINDICATIONS AND ● Previous severe hypersensitivity reactions to

immune globulins
CAUTIONS
● IgA deficiency
● Rh-positive clients (futile)
 ● Review the chart and ensure there are no
contraindications
● Confirm both the maternal and newborn’s blood
type, and the maternal sensitization status
GENERAL
● Blood product: ensure informed consent
● Administer at 26–28 weeks gestation or within 72
hours of delivery, abortion, miscarriage or other
obstetrical event such as invasive testing, placental
abruption, abdominal trauma
● Match lot number and expiration date
● Administer IM in the deltoid or anterolateral thigh

● For side effects: fever, injection site soreness or

irritation, dizziness, or headache
MONITORING
● For hypersensitivity reaction: wheezing, rash,
angioedema, hypotension, or tachycardia
● Call for help and notify physician

● Why RhIG is needed

CLIENT EDUCATION ● Potential side effects
● Do not receive live vaccine within three weeks
● Future pregnancies will be evaluated for the need
for RhO (D) immune globulin administration

NURSING CARE PLAN

Priority Nursing Diagnosis: Risk for Fetal Alloimmune Hemolytic Disease
Assessment:
1. Maternal Rh status (Rh-negative)
2. Gestational age
3. Fetal Rh status (Rh-positive)
4. Maternal antibody titers (anti-Rh antibodies)
5. Signs and symptoms of fetal distress (e.g., fetal anemia, hydrops fetalis)
6. Maternal vital signs and general health status
7. Maternal emotional status and understanding of the condition

Nursing Diagnoses:
1. Risk for Fetal Alloimmune Hemolytic Disease related to maternal sensitization to
Rh-positive fetal antigens.
 2. Deficient Knowledge related to Rh incompatibility and its implications for the fetus and
newborn.
3. Anxiety related to the potential adverse outcomes for the fetus and newborn.

Interventions:
1. Monitor maternal Rh status and antibody titers
● Regularly assess maternal Rh status and antibody titers to monitor for any
increase in maternal antibodies, indicating a heightened risk for fetal
hemolysis.
2. Monitor fetal well-being
● Utilize fetal monitoring techniques such as non-stress tests, ultrasound, and
Doppler studies to assess fetal heart rate, movements, and signs of distress.
3. Administer Rh immune globulin (RhoGAM)
● Provide Rh immune globulin to the mother at appropriate intervals, typically
around 28 weeks of gestation and within 72 hours postpartum if the newborn is
Rh-positive, to prevent maternal sensitization.
4. Educate the mother
● Provide comprehensive education to the mother regarding Rh incompatibility,
including its causes, potential consequences for the fetus and newborn, and
the importance of Rh immune globulin administration.
5. Emotional support
● Offer emotional support and counseling to the mother and family members to
alleviate anxiety and concerns related to the condition and its implications for the
pregnancy and newborn.
6. Collaborate with the healthcare team
● Work collaboratively with obstetricians, neonatologists, and other healthcare
providers to develop and implement a comprehensive management plan
tailored to the specific needs of the mother and fetus.
7. Prepare for possible interventions
● Educate the mother about potential interventions for the newborn, such as
exchange transfusion or intrauterine transfusion, if fetal anemia or hydrops fetalis
develops.
Evaluation:
1. Monitor maternal antibody titers and fetal well-being regularly to assess for any signs
of worsening Rh incompatibility.
2. Assess the mother's understanding of Rh incompatibility and her ability to manage
the condition effectively.
 3. Evaluate the mother's emotional status and coping mechanisms, ensuring adequate
support is provided as needed.
4. Modify the care plan as necessary based on the patient's response to interventions
and any changes in the clinical situation.

Remember, the priority in managing Rh incompatibility is early detection, prevention

of maternal sensitization, and close monitoring of fetal well-being to prevent adverse outcomes
for the fetus and newborn.

HEALTH TEACHING

1. Rest and Sleep: Ensure adequate rest and sleep for mother. She should not be disturbed for
trivial reasons. She should be protected from undue anxiety and friends. If a mother experiences
inadequate sleep due to after pains, breast engorgement, anxiety or tiredness while caring for
the baby, she should be given appropriate medications. Mother should rest for 2 hours a day
in a horizontal position to aid in optimum healing of pelvic floor muscles. Visitors should be
restricted.

2. Early Ambulation: Encourage mother to be out of bed within the first 48 hours of the delivery
of a baby or according to her comfort level. Explain to the mother that it will prevent many
complications such as bladder complications, constipation and she will feel better after
ambulation.

3. Hygiene: Mother should be given perineal care with antiseptic lotion every 4-6 hours. If she
has episiotomy or indwelling catheter, when she is capable of self-care, advise her to
maintain her ham and perineal hygiene. Breasts should be cleaned while taking bath and
before and after feeding. Vulva pads should be changed frequently. Perineal wash-down
should be done twice daily. Hand washing should also be practiced before and after handling the
baby.

4.Care of Bladder and Bowel: Mother should pass urine within 6-8 hours of delivery.
Encourage her to avoid it frequently in order to avoid bladder distension. If constipation persists,
mothers may be given laxatives. Diet should contain sufficient roughage and fluids.

5. Diet:If mother has had normal vaginal delivery, she can be given something to eat and
drink 2 hours after delivery. The diet should contain plenty of proteins, meat, fish, fresh fruits
 and green vegetables. The total diet should have additional 400-700 K/cal to meet lactation
needs. Iron supplementation should be continued for at least 3 months after delivery.

6. Rooming in: The baby should be kept on mother's bed to allow her cuddling, fondling, kissing
and gazing at the baby. It helps to build a mother-child relationship and the mother can observe
her baby as well.

7. Postnatal Exercises: Mother should rest for 24 hours after delivery. After that, she can
gradually start exercising. Exercises are helpful in firming the figure and toning the musculature.

8. Contraception: Need for contraception should be discussed Within the first week of
delivery. Mother should be explained about the various methods of contraception available
among which she can choose according to her own needs.

9. Education: Mother should be educated about self-care and baby-care. She should be informed
about baby-Clothing, baby-bathing, breastfeeding, care of buttocks and umbilicus, weight gain of
the baby, immunization and physiological jaundice. Advise her about regular follow-up as
suggested by the physician in postnatal OPD.

10. Immunization of Mothers: Administration of anti D-gamma globulin to un-immunized Rh-

negative mother bearing Rh-positive baby and woman who is not immunized against rubella
should be given rubella vaccine in the post-partum period.

11. Emotional Needs: Mothers need support as they adjust to this experience of being mothers.
Encourage them and show confidence in mothers' ability. Don't compare others {With other
mothers. She may suffer from postpartum blues, so provide her reassurance. Observe the
symptoms of depression and need for counseling.

12. Breastfeeding and Care of Breast: Wear a well-fitting bra. Keep the breast and nipples
clean by washing with water before and after feeding the baby. Allow demand feeding and
exclusive breastfeeding for the first 6 months.

Medication: Administer Rh immunoglobulin (RhIg) injections to prevent Rh sensitization in Rh-

negative mothers.

Environment: Avoid activities that pose a risk of abdominal trauma to reduce the chance of fetal
blood mixing.

Treatment: Seek medical intervention promptly if Rh incompatibility is detected, including

intrauterine transfusions if necessary.

Hygiene: Maintain good hygiene practices to prevent infections that could complicate Rh
incompatibility.

Outpatient Care: Attend regular prenatal check-ups for monitoring and timely administration of
RhIg injections.
Diet: Follow a balanced diet to support overall maternal and fetal health during pregnancy.

Safety: Take precautions to minimize the risk of accidents or injuries during pregnancy, such as safe
physical activity practices and avoiding harmful substances.