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I. DEFINITION
ABO incompatibility is an immune system reaction that occurs when
blood from two different and incompatible blood types are mixed together.
1. Hemolytic disease of the fetus and newborn is an immune reaction of the
mothers blood against the blood group factor on the fetus RBCs.
2. When RhoGAM (Rh immune globulin) became available in the 1960s to
treat isoimmunization in Rh-negative women, the incidence of hemolytic
disease in the fetus and newborn dropped significantly.


II. ASSESSMENT
1. Clinical manifestations
The hemolytic response in ABO incompatibility usually begins at birth with
a resulting newborn jaundice.
Rh incompatibility may lead to:
o Hydramnios in the mother
o Excess bilirubin levels in the amniotic fluid.
o Varying degrees of hemolytic anemia (erythroblastosis) in the fetus.
If the condition is left unmanaged, 25% of affected infants may die
or suffer permanent brain damage.

III. PATHOPHYSIOLOGY
1. This disorder occurs when the fetus has a blood group antigen that the
mother does not possess. The mothers body forms an antibody against
that particular blood group antigen, and hemolysis begins. The process of
antibody formation is called maternal sensitization.
2. The fetus has resulting anemia from the hemolysis of blood cells. The fetus
compensates by producing large numbers of immature erythrocytes, a
condition known as erythroblastosis fetalis, hemolytic disease of the
newborn, or hydrops fetalis. Hydrops refers to the edema and fetalis refers
to the lethal state of the infant.
3. In Rh incompatibility, the hemolysis usually begins in utero. It may not
affect the first pregnancy but all pregnancies that follow will experience
this problem. In ABO incompatibility, the hemolysis does not usually does
not usually begin until the birth of the newborn.


IV. LABORATORY RESULTS
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Laboratory and diagnostic study findings
The indirect Coombs test can aid in the search for agglutination of Rh-
positive RBCs to determine if antibodies are present.
Amniocentesis is used to determine optical density and estimate fetal
hemolysis. Spectrophotometer readings are made of the amniotic fluid
collected. The readings are obtained to determine fluid density. They are
plotted on a graph and correlated with gestational age. The amount of
bilirubin resulting from the hemolysis of red blood cells can then be
estimated.
An antibody titer should be drawn at the first prenatal visit on all Rh-
negative women. It should also be drawn at 28 and 36 weeks of
pregnancy and again at delivery or abortion. The normal value is 0. The
result is usually reported as a ratio; normal is 1:8. If the titer is absent or
minimal (1:8), no therapy is needed. A rising titer indicates the need for
RhoGAM and vigilant monitoring of fetal well-being.

V. MEDICAL MANAGEMENT
1. Phototherapy
2. Possible exchange transfusion
3. Administration of intravenous immunoglobulin


VI. NURSING MANAGEMENT

1. Administer RhoGAm to the unsensitized Rh-negative client as appropriate

Administer RhoGAM at 28 weeks gestation, even when titers are
negative, or after any invasive procedure, such as amniocentesis.
RhoGAM protects against the effects of early transplacental hemorrhage
(as recommended by the American College of Gynecologists).
When the Rh-negative mother is in labor, crossmatch for RhoGAM, which
must given within 72 hours of delivery of the newborn.


2. Provide management for the sensitized Rh-negative mother and Rh-
positive fetus.

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Focus management of the sensitized Rh-negative mother on close
monitoring of fetal well-being, as reflected by Rh titers, amniocentesis
results, and sonography.
If there is evidence of erythroblastosis, notify the perineal team of the
possibility for delivery of a compromised newborn.

3. Provide management for ABO incompatibility.

Phototherapy usually can resolve the newborn jaundice associated with
ABO incompatibility.
In addition, initiation of early feeding and exchange blood transfusions
may be immediate measures required to reduce indirect bilirubin levels.
Provide client and family teaching.


VII. NURSING DIAGNOSIS
1. Interrupted breast feeding r/t excessive bilirubin levels secondary to
breast milk jaundice
2. Risk for injury r/t effects of exchange transfusion
3. Pain r/t frequent heel sticks


VIII. 2 NURSING THEORIES W/ RATIONALE
1. Dorothea Orem - Self Care Deficit According to Orem, nurses have to supply care when the
patients cannot provide care to themselves. In relation to this, the infant affected by ABO
incompatibility is very vulnerable especially to jaundice. The nurse's provide phototherapy to the
infant.
2. Virginia Henderson Henderson's theory is defined as, "Assisting the individual, sick or well,
in the performance of those activities contributing to health or its recovery (or to peaceful death)
that an individual would perform unaided if he had the necessary strength, will or knowledge"
In this case, the nurse assists the mother and educates her on how to care for her child. Teach her
how to provide phototherapy independently, encourage breastfeeding, and provide health
education to the client and the family.