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Isoimmunisation
And Hemolytic Disease of the Newborn
Rhesus Isoimmunization
Rhesus (Rh) factor is an antigenic protein
located on RBCs in Rh- individuals.
Transmission is autosomal dominant. When
fetal RBCs leak into maternal circulation,
maternal anti-Rh IgG antibodies can form.
These antibodies can cross the placenta
hemolysis of fetal Rh- RBCs (erythroblastosis
fetalis)
Hemolytic disease usually occurs during the
second pregnancy owing to rapid production of
anti-Rh IgG antibodies by memory plasma cells.
Pathophysiology
Pathophysiology
Rh Sensitisation Requirements
1)
2)
3)
Mother must be Rh ve
Fetus must be Rh +ve which means father
must be Rh +ve
Adequate fetal RBCs must cross over into
maternal circulation to stimulate her
lymphocytes to produce antibodies to the
fetal RBC antigens
Rh Sensitisation Etiologies
- delivery
- prenatal diagnosis (CVS; amniocentesis,
cordocentesis)
- blunt trauma to the gravid abdomen
- antenatal hemorrhage
- external cephalic version
- ectopic pregnancy
- spontaneous abortion
- hydatidiform mole
- vaginal bleeding
- inadvertent transfusion Rh+ blood
Diagnosis - Maternal
On initial visit, test for ABO and Rh
blood groups and perform antibody
screening (indirect Coombs test). If
ve, repeat Coombs test at 2628 weeks. If
+ve, test serially for critical titers of
maternal anti-Rh IgG (> 1:16 to > 1:32).
Diagnosis - Fetal
Diagnosis - Fetal
Middle Cerebral Artery Doppler
When the critical titer is reached or exceeded
and the fetus isRHD-positive, Doppler
velocimetry of the middle cerebral artery
(MCA) peak systolic velocity (PSV) is
performed to identify fetuses that may be
severely anemic. Doppler assessment of the
fetal MCA-PSV is based on the principle that
the fetal hemoglobin level determines blood
flow in the MCA: MCA-PSV increases as fetal
hemoglobin level falls.
MCA
Immunoprophylaxis
Current recommendations for immunoprophylaxis from the Royal
College of Obstetricians and Gynaecologists and NICE are as
follows:
After delivery, irrespective of the dose of antenatally administered
anti-D immunoglobulin, postnatal prophylaxis must be given and
include a screening test to identify women with a large
fetomaternal haemorrhage who need additional immunoglobulin
Anti-D immunoglobulin should be given after sensitising events
before delivery and after abortion
Anti-D immunoglobulin is no longer necessary in women with
threatened miscarriage with a viable fetus and cessation of
bleeding before 12 weeks' gestation
At least 500 IU of anti-D immunoglobulin should be given to nonsensitised RhD negative women at 28 weeks and 34 weeks of
pregnancy.
Kumar, S. "Management Of Pregnancies With Rhd Alloimmunisation". BMJ 330.7502 (2005): 12551258. Web.
RhoGAM
Treatment
If the baby is Rh +ve , give RhoGAM postpartum as well.
Give RhoGAM to Rh- mothers who undergo abortion
(therapeutic or spontaneous) or who have had an ectopic
pregnancy, amniocentesis, vaginal bleeding, or placenta
previa/placental abruption.
Sensitized Rh- mothers with titers > 1:16 should be closely
monitored
with serial ultrasound and amniocentesis for evidence of
fetal hemolysis.
In severe cases, initiate preterm delivery when fetal lungs
are mature.
Prior to delivery, intrauterine blood transfusions may be
given to correct a low fetal hematocrit.
Summary of Management
Appendix
Management of HDN