What is Rh sensitization during pregnancy?

If you are Rh-negative, your red blood cells do not have a marker called Rh factor on
them. Rh-positive blood does have this marker. If your blood mixes with Rh-positive blood, your
immune system will react to the Rh factor by making antibodies to destroy it. This immune
system response is called Rh sensitization.

What causes Rh sensitization during pregnancy?

Rh sensitization can occur during pregnancy if you are Rh-negative and pregnant with a
developing baby (fetus) who has Rh-positive blood. In most cases, your blood will not mix with
your baby's blood until delivery. It takes a while to make antibodies that can affect the baby, so
during your first pregnancy, the baby probably would not be affected.

But if you get pregnant again with an Rh-positive baby, the antibodies already in your
blood could attack the baby's red blood cells. This can cause the baby to have anemia, jaundice,
or more serious problems. This is called Rh disease. The problems will tend to get worse with
each Rh-positive pregnancy you have.

Rh sensitization is one reason it's important to see your doctor in the first trimester of
pregnancy. It doesn't cause any warning symptoms, and a blood test is the only way to know you
have it or are at risk for it.

If you are at risk, Rh sensitization can almost always be prevented.

If you are already sensitized, treatment can help protect your baby.

Who gets Rh sensitization during pregnancy?

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.

If you have Rh-negative blood, your doctor will probably treat you as though the baby's blood
is Rh-positive no matter what the father's blood type is, just to be on the safe side.

How is Rh sensitization diagnosed?

All pregnant women get a blood test at their first prenatal visit during early pregnancy.
This test will show if you have Rh-negative blood and if you are Rh-sensitized.

If you have 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 you are not sensitized, you probably will not need another antibody test until
delivery. (You might need to have the test again if you have an amniocentesis, if your
pregnancy goes beyond 40 weeks, or if you have a problem such as placenta abruptio,
which could cause bleeding in the uterus.)

Your baby will have a blood test at birth. If the newborn has Rh-positive blood, you will
have an antibody test to see if you were sensitized during late pregnancy or childbirth.

If you are Rh-sensitized, your doctor will watch your pregnancy carefully. You may have:

Regular blood tests, to check the level of antibodies in your blood.

Doppler ultrasound, to check blood flow to the baby's brain. This can show anemia and
how severe it is.

Amniocentesis after 15 weeks, to check the baby's blood type and Rh factor and to look
for problems.

How is Rh sensitization prevented?

If you have Rh-negative blood but are not Rh-sensitized, your doctor will give you one or
more shots of Rh immune globulin (such as RhoGAM). This prevents Rh sensitization in about
99 women out of 100 who use it.1

You may get a shot of Rh immune globulin:

If you have a test such as an amniocentesis.

Around week 28 of your pregnancy.

After delivery if your newborn is Rh-positive.

The shots only work for a short time, so you will need to repeat this treatment each time
you get pregnant. (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 you are already Rh-sensitized.

How is it treated?
If you are Rh-sensitized, you will have regular testing to see how your baby is doing. You
may also need to see a doctor who specializes in high-risk pregnancies (a perinatologist).

Treatment of the baby is based on how severe the loss of red blood cells (anemia) is.

If the baby's anemia is mild, you will just have more testing than usual while you are
pregnant. 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. You will
most likely have 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.

Frequently Asked Questions

Learning about Rh sensitization during
pregnancy:

What is Rh sensitization during pregnancy?

What causes it?

What are the symptoms of Rh sensitization?

What tests are done during pregnancy to look for

Rh sensitization?

What medicines are used to prevent Rh

sensitization during pregnancy?

How is Rh sensitization treated?

What increases my chance of getting Rh

sensitization?

If I am Rh-sensitized, what happens if I get

pregnant again?

Being diagnosed:

Getting treatment:

Ongoing concerns:

Living with Rh sensitization:

Cause

Rh sensitization can occur when a person with Rh-negative blood is exposed to Rhpositive blood. About 90% of women who become sensitized do so during childbirth,
when their blood mixes with the Rh-positive blood of their fetus. 1 After being exposed, a
mother's immune system produces antibodies against Rh-positive red blood cells.

The minimum amount of blood mixing that causes sensitization is not known. But many
women become sensitized during pregnancy or childbirth after being exposed to as little
as 0.1 mL of Rh-positive fetal blood.1 Fortunately, Rh sensitization can almost always be
prevented with the Rh immune globulin injection.

When an Rh-negative person's immune system is first exposed to Rh-positive blood, it

takes several weeks to develop immunoglobulin M, or IgM, antibodies. IgM antibodies
are too large to cross the placenta. So the Rh-positive fetus that first triggers maternal
sensitization is usually not harmed.

A previously Rh-sensitized immune system rapidly reacts to Rh-positive blood, as during

a second pregnancy with an Rh-positive fetus. Usually within hours of Rh-positive blood
exposure, smaller immunoglobulin G, or IgG, antibodies are formed. IgG antibodies can
cross the placenta and destroy fetal red blood cells. This causes Rh disease, which is
dangerous for the fetus.

Some Rh-negative people never become sensitized, even after exposure to large amounts
of Rh-positive blood. The reason for this is not known.

Symptoms

If you are already Rh-sensitized or become Rh-sensitized while pregnant, you will not
have any unusual symptoms.

Fetal problems from Rh sensitization are detected with Doppler ultrasound testing and
sometimes with amniocentesis. It is possible, though, that a fetus with severe Rh disease
will move less frequently than it did earlier in the pregnancy.

Other conditions with symptoms similar to Rh sensitization include other blood type
incompatibility problems and fetal infections.

What Happens
If you are Rh-negative

Unless you are given Rh immune globulinjust before or after a high-risk event, such as
miscarriage, amniocentesis, abortion, ectopic pregnancy, or childbirth, you have a chance of
becoming sensitized to an Rh-positive fetus's blood.
If you have been Rh-sensitized in the past

If you have been Rh-sensitized in the past, you must be closely watched during any
pregnancy with an Rh-positive partner, because your fetus is more likely to have Rh-positive
blood. In response to an Rh-positive fetus, your immune system may quickly develop IgG
antibodies, which can cross the placenta and destroy fetal red blood cells. Each subsequent
pregnancy with an Rh-positive fetus may produce more serious problems for the fetus. The
resulting fetal disease (called Rh disease, hemolytic disease of the newborn, or erythroblastosis
fetalis) can be mild to severe.

Mild Rh disease involves limited destruction of fetal red blood cells, possibly resulting
in mild fetal anemia. The fetus can usually be carried to term and requires no special
treatment but may have problems with jaundice after birth. Mild Rh disease is more
likely to develop in the first pregnancy after sensitization has occurred.

Moderate Rh disease involves the destruction of larger numbers of fetal red blood cells.
The fetus may develop an enlarged liver and may become moderately anemic. The fetus
may need to be delivered before term and may require a blood transfusion before (while
in the uterus) or after birth. A newborn with moderate Rh disease is watched closely for
jaundice.

Severe Rh disease (fetal hydrops) involves widespread destruction of fetal red blood
cells. The fetus develops severe anemia, liver and spleen enlargement,
increased bilirubin levels, and fluid retention (edema). The fetus may need one or more
blood transfusions before birth. A fetus with severe Rh disease who survives the
pregnancy may need a blood exchange. This procedure replaces most of the infant's
blood with donor blood (usually type O, Rh-negative).

A history of pregnancy with Rh disease is a sign that you will need special treatment
when you are pregnant with an Rh-positive fetus.

If you have been Rh-sensitized in the past, an Rh-negative fetus cannot trigger an immune
reaction.
Symptoms

If you are already Rh-sensitized or become Rh-sensitized while pregnant, you will not
have any unusual symptoms.

Fetal problems from Rh sensitization are detected with Doppler ultrasound testing and
sometimes with amniocentesis. It is possible, though, that a fetus with severe Rh disease
will move less frequently than it did earlier in the pregnancy.

Other conditions with symptoms similar to Rh sensitization include other blood type
incompatibility problems and fetal infections.

What Increases Your Risk

Rh sensitization can occur when a person with Rh-negative blood is exposed to Rhpositive blood. During pregnancy, an Rh-negative woman can become sensitized if she is
carrying an Rh-positive fetus.
Things that increase the risk of blood mixing and sensitization during pregnancy include:

Delivery.

Abdominal trauma, such as from a car accident.

Abdominal surgery, such as a cesarean section.

Placenta abruptio or placenta previa, both of which can cause placental bleeding.

External cephalic version for a breechfetus.

Obstetric procedures such as amniocentesis, fetal blood sampling, or chorionic villus

sampling (CVS).

Miscarriage (spontaneous abortion), ectopic pregnancy, or elective abortion (medical or

surgical abortion) after 8 weeks of fetal age (when fetal blood cell production begins).

Partial molar pregnancy involving fetal growth beyond 8 weeks.

Although rare, Rh sensitization has been known to occur after needle sharing between
intravenous drug users. Transfusing Rh-positive blood in an Rh-negative person can also trigger
sensitization. But this is extremely rare because blood is always tested prior to transfusion.
When To Call a Doctor
If you are already Rh-sensitized and are pregnant

Your pregnancy will be closely monitored. Discuss possible symptoms early in

pregnancy with your doctor. Repeated diagnostic testing will be needed to watch the fetus.
Call your doctor immediately if you note a decrease in your fetus's movement after 24 to
26 weeks of pregnancy.
If you are Rh-negative

Call your doctor immediately if you:

Think you may have been pregnant and miscarried.

Are pregnant and have had an accident that may have injured your abdomen.

Who to see

A woman who may have problems with Rh incompatibility or sensitization can be treated by:

A family medicine doctor, for mild fetal Rh disease.

An obstetrician, for mild to moderate Rh disease.

A perinatologist, for moderate to severe fetal Rh disease (hydrops).

If you test positive for Rh sensitization, your health care system or health professional may want
you to be followed and treated by a perinatologist or an obstetrician who can easily call in a
perinatologist.
Exams and Tests
If you are pregnant, you will have your first prenatal tests during your first trimester. Every
woman has her blood tested at the first prenatal visit to see what her blood type is. If your blood
is Rh-negative, it will also be tested for antibodies to Rh-positive blood. If you have antibodies,
that means that you have been sensitized to Rh-positive blood. The antibodies can now kill Rhpositive red blood cells.

If you are Rh-negative and your partner is Rh-positive, your fetus is likely to be Rhpositive.
If you are pregnant or have miscarried, or if you have had an elective abortion, a partial molar
pregnancy, or an ectopic pregnancy, you will need testing to see if you have been sensitized to
Rh-positive blood.
If you are Rh-negative

All pregnant women have an indirect Coombs' test during early pregnancy.

At the first prenatal visit, your blood is tested to see if you have been previously
sensitized to Rh-positive blood. If you are Rh-negative and test results show that you are
not sensitized, a repeat test may be done between 24 and 28 weeks.

If test results at 28 weeks show that you have not been sensitized, no additional tests for
Rh-related problems are done until delivery (barring complications such as placenta
abruptio). You will also have a shot of Rh immune globulin. This lowers your chances
of being sensitized during the last weeks of your pregnancy.

If your newborn is found to be Rh-positive, your blood will be screened again at

delivery with an indirect Coombs' test to see if you have been sensitized during late
pregnancy or childbirth. If you have not been sensitized, you will have another shot of
Rh immune globulin.

If you are sensitized to the Rh factor

If you are already Rh-sensitized or become sensitized while pregnant, close monitoring is
important to determine whether your fetus is being harmed.

If possible, the father will be tested to see if the fetus could be Rh-positive. If the father
is Rh-negative, the fetus is Rh-negative and is not in danger. If the father is Rh-positive,
other tests may be used to learn the fetus's blood type. In some medical centers, the
mother's blood can be tested to learn her fetus's blood type. This is a new test that is not
widely available.

An indirect Coombs' test is done periodically during your pregnancy to see if your Rhpositive antibody levels are increasing. This is the typical course of treatment for most
sensitized women during pregnancy.

Fetal Doppler ultrasound of blood flow in the brain shows fetal anemia and how bad it
is. At a medical center with Doppler experts, this test can give you the same anemia
information as amniocentesis, without the risks.3

Amniocentesis may be done to check amniotic fluid for signs of fetal problems or to
learn the fetus's blood type and Rh factor.

Fetal blood sampling (cordocentesis) may be done to directly assess your fetus's health.
This procedure is 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).

Electronic fetal heart monitoring (nonstress test) may be done in the third trimester to
check your fetus's condition. Unusual fetal heart rhythms detected during a nonstress
test may be a sign that the fetus has anemia related to the sensitization.

Fetal ultrasound testing can be used as a pregnancy progresses to detect sensitization

problems, such as fetal fluid retention (a sign of severe Rh disease).

Treatment Overview
If you are sensitized to the Rh factor

If your blood is Rh-negative and you have been sensitized to Rh-positive blood, you now
have antibodies to Rh-positive blood. The antibodies kill Rh-positive red blood cells. If you
become pregnant with an Rh-positive baby (fetus), the antibodies can destroy your fetus's red
blood cells. This can cause anemia.
If you are already Rh-sensitized and are pregnant, your treatment will focus on
preventing or minimizing fetal harm and on avoiding early (preterm) delivery.
Treatment options depend on how well or poorly the fetus is doing.

If testing shows that your fetus is Rh-positive but is only mildly affected by your Rh
factor antibodies, you will be closely watched until your pregnancy reaches term. Your
fetus will be delivered early only if his or her condition gets worse.

If testing shows that your fetus is moderately affected by your Rh antibodies, your
fetus's condition will be closely watched until his or her lungs are mature enough for a
preterm delivery. A cesarean section may be used to deliver the baby quickly or to avoid
the difficulty of inducing labor before term. A moderately affected newborn sometimes
needs a blood transfusion immediately after birth.

If testing shows that your fetus is severely affected by your Rh factor antibodies, a blood
transfusion may be given before birth (intrauterine fetal blood transfusion). This can be
done through the fetus's abdomen or directly into the fetus's umbilical cord. A preterm
delivery is likely to be needed. Multiple blood transfusions are sometimes needed to
keep a fetus healthy until the fetal lungs mature enough to function after birth. Often a
cesarean section is done to deliver the baby quickly. A blood transfusion is sometimes
needed immediately after birth.

Prevention
If you are Rh-negative and pregnant

If you are an Rh-negative woman and you have conceived with an Rh-negative partner,
you are not at risk of Rh sensitization during pregnancy. (Most health professionals treat all Rhnegative pregnant women as though the father might be Rh-positive.)
If you are already sensitized to the Rh factor, your pregnancy will need to be closely
monitored to prevent fetal harm. For more information on fetal and newborn treatment,
see Treatment Overview.

If you are unsensitized Rh-negative, treatment focuses on preventing Rh sensitization during

pregnancy and childbirth. Rh immune globulin (such as RhoGAM) is a highly effective
treatment for preventing sensitization.

To prevent sensitization from occurring late in the pregnancy or during delivery, you
must have a shot of Rh immune globulin around week 28 of your pregnancy. This
treatment prevents your immune system from making antibodies against your fetus's
Rh-positive red blood cells.

Rh immune globulin injection is also necessary if you have had any vaginal bleeding or
an obstetric procedure such as amniocentesis or external cephalic version.

If your newborn is Rh-positive, you are given Rh immune globulin again within 72
hours of delivery. By preventing Rh sensitization from delivery, you are protecting your
next Rh-positive fetus.

If your newborn is Rh-negative, sensitization cannot happen, and no treatment is

needed.

Rh immune globulin is also needed after a miscarriage, partial molar pregnancy, ectopic
pregnancy, or abortion.
Home Treatment
There is no home treatment for Rh sensitization.
Medications
Use of Rh immune globulin is 99.8% effective in preventing Rh sensitization. 1 Rh
immune globulin contains Rh antibodiesthat have been purified from human donors. This
treatment prevents an unsensitized Rh-negative mother from making antibodies against her
fetus's Rh-positive blood.
If an affected fetus younger than 34 weeks needs to be delivered, corticosteroid medicine
(betamethasone or dexamethasone) may be given to the mother to speed fetal lung development
before a premature birth.
Surgery
There is no surgical treatment for Rh sensitization during pregnancy.
Other Treatment
An intrauterine fetal blood transfusion is sometimes used to supply healthy blood to a
fetus with severe hemolytic disease of the newborn (also called Rh disease or erythroblastosis
fetalis).
A newborn blood transfusion or exchange transfusion is sometimes given to treat
severe anemia or jaundice related to Rh disease.

References
Citations
1. American College of Obstetricians and Gynecologists (1999, reaffirmed 2010).
Prevention of Rh D alloimmunization. ACOG Practice Bulletin No. 4. Obstetrics and
Gynecology, 93(5): 17.
2. Branch DW, et al. (2008). Immunologic disorders in pregnancy. In RS Gibbs et al., eds.,
Danforth's Obstetrics and Gynecology, 10th ed., pp. 313339. Philadelphia: Lippincott
Williams and Wilkins.
3. American College of Obstetricians and Gynecologists (2006, reaffirmed 2010).
Management of alloimunization during pregnancy. ACOG Practice Bulletin No. 75.
Obstetrics and Gynecology, 108(20): 457464.
Other Works Consulted

Moise KJ Jr (2008). Management of rhesus alloimmunization in pregnancy. Obstetrics

and Gynecology, 112(1): 164176.

Roman AS, Pernoll ML (2007). Rh isoimmunization and other blood group

incompatibilities section of Late pregnancy complications. In AH DeCherney et al., eds.,
Current Diagnosis and Treatment Obstetrics and Gynecology, pp. 282287. New York:
McGraw-Hill.

U.S. Preventive Services Task Force (2004). Screening for Rh (D) incompatibility:
Agency

for

Healthcare

Research

and

Quality.

Available

online:

http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrhi.htm

http://www.emedicinehealth.com/rh_sensitization_during_pregnancyhealth/article_em.htm#Topic Overview

Definition
Rh incompatibility is a condition which develops when a pregnant woman has an Rhnegative blood type and the fetus she carries has Rh-positive blood type.
The Rh factor (ie, rhesus factor) is an red blood cell surface antigen that was named after
the monkeys in which it was first discovered. Rh incompatibility, also known as Rh disease, is a
condition that occurs when a woman with Rh-negative blood type is exposed to Rh-positive
blood cells, leading to the development of Rh antibodies.
Rh incompatibility can occur by two main mechanisms. The most common type occurs
when an Rh-negative pregnant mother is exposed to Rh-positive fetal red blood cells secondary
to fetomaternal hemorrhage during the course of pregnancy from spontaneous or induced
abortion, trauma, invasive obstetric procedures, or delivery. Rh incompatibility can also occur
when an Rh-negative female receives a blood transfusion that contains Rh antigens. In part, this

is the reason that blood banks prefer using blood type O-negative or type-O, Rh negative, as
the universal donor type, especially in females.
The most common cause of Rh incompatibility is exposure to an Rh-negative mother by Rhpositive fetal blood during pregnancy or delivery, whereby red blood cells from the fetal
circulation leak into the maternal circulation. After a significant exposure, sensitization occurs
and maternal antibodies are produced against the foreign Rh antigen.
Once produced, maternal Rh immunoglobulin G (IgG) antibodies may cross freely from
the placenta to the fetal circulation, where they form antigen-antibody complexes with Rhpositive fetal erythrocytes and eventually are destroyed, resulting in a fetal alloimmune-induced
hemolytic anemia. Although the Rh blood group systems consist of several antigens (eg, D, C, c,
E, e), the D antigen is the most immunogenic; therefore, it most commonly is involved in Rh
incompatibility.
Causes, incidence, and risk factors
During pregnancy, red blood cells from the fetus can get into the mothers bloodstream as
she nourishes her child through the placenta. If the mother is Rh-negative, her system cannot
tolerate the presence of Rh-positive red blood cells.
In such cases, the mothers immune system treats the 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 the placenta into the fetus, where they destroy the fetuss circulating red
blood cells.
First-born infants are often not affected unless the mother has had previous miscarriages or
abortions, which could have sensitized her system as it takes time for the mother to develop
antibodies against the fetal blood. However, second children who are also Rh-positive may be
harmed.
Rh incompatibility can cause symptoms ranging from very mild to fatal. In its mildest
form, Rh incompatibility causes hemolysis (destruction of the red blood cells) with the release of
free hemoglobin into the infants circulation.
Hemoglobin is converted into bilirubin, which causes an infant to become yellow
(jaundiced). The jaundice of Rh incompatibility, measured by the level of bilirubin in the infants
bloodstream, may range from mild to dangerously high levels of bilirubin.
Hydrops fetalis is a complication of a severe form of Rh incompatibility in which massive fetal
red blood cell destruction (a result of the Rh incompatibility) causes a severe anemia resulting in
fetal heart failure, total body swelling, respiratory distress (if the infant has been delivered), and
circulatory collapse. Hydrops fetalis often results in death of the infant shortly before or after
delivery.
Kernicterus is a neurological syndrome caused by deposition of bilirubin into the brain
(CNS) tissues. Kernicterus develops in extremely jaundiced infants, especially those with severe
Rh incompatibility.
It occurs several days after delivery and is characterized initially by loss of the Moro (startle)
reflex, poor feeding, and decreased activity. Later, a high-pitched shrill cry may develop along
with unusual posturing, a bulging fontanel, and seizures. Infants may die suddenly of kernicterus.
If they survive, they will usually later develop decreased muscle tone, movement
disorders, high-pitched hearing loss, seizures, and decreased mental ability.
Rh incompatibility develops only when the mother is Rh-negative and the infant is Rhpositive. Special immune globulins, called RhoGAM, are now used to prevent this sensitization.
In developed countries such as the US, hydrops fetalis and kernicterus have decreased markedly
in frequency as a result of these preventive measures.

Pathophysiology
The amount of fetal blood necessary to produce Rh incompatibility varies. In one study,
less than 1 mL of Rh-positive blood has been shown to sensitize volunteers with Rh-negative
blood. Conversely, other studies have suggested that 30% of persons with Rh-negative blood
never develop Rh incompatibility, even when challenged with large volumes of Rh-positive
blood. Once sensitized, it takes approximately one month for Rh antibodies in the maternal
circulation to equilibrate in the fetal circulation. In 90% of cases, sensitization occurs during
delivery. Therefore, most firstborn infants with Rh-positive blood type are not affected because
the short period from first exposure of Rh-positive fetal erythrocytes to the birth of the infant is
insufficient to produce a significant maternal IgG antibody response.
The risk and severity of sensitization response increases with each subsequent pregnancy
involving a fetus with Rh-positive blood. In women who are prone to Rh incompatibility, the
second pregnancy with an Rh-positive fetus often produces a mildly anemic infant, whereas
succeeding pregnancies produce more seriously affected infants who ultimately may die in utero
from massive antibody-induced hemolytic anemia.
Risk of sensitization depends largely upon the following 3 factors:
1. Volume of transplacental hemorrhage
2. Extent of the maternal immune response
3. Concurrent presence of ABO incompatibility
The incidence of Rh incompatibility in the Rh-negative mother who is also ABO
incompatible is reduced dramatically to 1-2% and is believed to occur because the mothers
serum contains antibodies against the ABO blood group of the fetus. The few fetal red blood
cells that are mixed with the maternal circulation are destroyed before Rh sensitization can
proceed to a significant extent.
Rh incompatibility is only of medical concern when transfusion is needed and during
pregnancy. Rh positive antibodies circulating in the bloodstream of an Rh-negative woman have
no adverse effect in the nonpregnant state.

Coombs Test
If you have been feeling fatigued, have shortness of breath, cold hands and feet, and very
pale skin, you may have an insufficient amount of red blood cells. This condition is called
anemia, and there are many causes. If its confirmed that you have a low red blood cell count, the
Coombs test is one of the blood tests that your doctor may order to help find out what kind of
anemia you have.
Why Is the Coombs Test Done?
The Coombs test checks the blood to see if it contains certain antibodies. Antibodies are
proteins that your immune system makes when it detects that something may be harmful to your
health. These antibodies will destroy the harmful invader. If the immune systems detection is
wrong, it will make antibodies that dont destroy the invader. This can cause many kinds of
health problems.

The Coombs test will help your doctor determine if you have antibodies in your
bloodstream that are causing your immune system to attack and destroy your own red blood
cells. If your red blood cells are being destroyed, this can result in a condition called hemolytic
anemia.
There are two types of Coombs tests: the direct Coombs test and the indirect Coombs
test. The direct test is more common and checks for antibodies that are attached to the surface of
your red blood cells. The indirect test checks for unattached antibodies that are floating in the
bloodstream. It is also administered to determine if there was a potential bad reaction to a blood
transfusion.
How Is the Coombs Test Done?
A sample of your blood will be needed to perform the test. The blood is tested with
compounds that will react with antibodies in your blood.
The blood sample is obtained through venipuncture, in which a needle is inserted into a
vein in your arm or hand. The needle draws a small amount of blood into tubing, and the sample
is stored in a test tube.
This test is often done on infants who may have antibodies in their blood because their
mother has a different blood type. To do this test in an infant, the skin is pricked with a small
sharp needle called a lancet, usually on the heel of the foot. Blood is collected into a small glass
tube, on a glass slide, or on a test strip.
How Do I Prepare for the Coombs Test?
No special preparation is necessary. Your doctor will have you drink a normal amount of
water before going to the laboratory or collection site.
You may have to stop taking certain medications before the test is performed, but only if
your doctor tells you to do so.
What Are the Risks of the Coombs Test?
When the blood is collected, you may feel moderate pain or a mild pinching sensation,
though this is usually for a very short time and very slight. After the needle is removed, you may
feel a throbbing sensation, and you will be instructed to apply pressure to the site at which the
needle entered your skin. A bandage will be applied, and it will need to remain in place typically
for 10 to 20 minutes. You should avoid using that arm for heavy lifting for the rest of the day.
Very rare risks include:

lightheadedness or fainting
hematoma, a bruise in which blood accumulates under the skin
infection, usually prevented by the skin being cleaned before the needle is
inserted
excessive bleeding (bleeding for a long period after the test may indicate a more
serious bleeding condition and should be reported to your doctor)

What Are the Results for the Coombs Test?

Normal Results
Results are considered normal if there is no clumping of red blood cells.

Abnormal Results in a Direct Coombs Test

Its an abnormal result if there is clumping of the red blood cells during the test.
Clumping (agglutination) of your blood cells during a direct Coombs test means that you have
antibodies on the red blood cells and that you may have a condition that causes the destruction of
red blood cells by your immune system (hemolysis). The conditions that may cause you to have
antibodies on red blood cells are:

autoimmune hemolytic anemia (your immune system reacts to your red blood
cells)
drug toxicity where you develop antibodies to your red blood cells; drugs that can
cause this include cephalosporins (an antibiotic), levodopa (for Parkinsons
disease), dapsone (antibacterial), nitrofurantoin (antibiotic), NSAIDs such as
ibuprofen, and quinidine (heart medication)
transfusion reaction where your immune system attacks donated blood
different blood types between mother and infant (erythroblastosis fetalis)
chronic lymphocytic leukemia and some other leukemias
lupus (systemic lupus erythematosus), an autoimmune disease
mononucleosis
infection with mycoplasma (a type of bacteria that many antibiotics cant kill)
syphilis
Sometimes, especially in older adults, a Coombs test will have an abnormal result
even without any other disease or risk factors.

Abnormal Results in an Indirect Coombs Test

An abnormal result to an indirect Coombs test means you have antibodies circulating in
your bloodstream that could cause your immune system to react to any red blood cells that are
considered foreign to the body, particularly regarding those that may be present during a blood
transfusion. Depending on your age and circumstances, this could mean a mother and infant have
different blood types (erythroblastosis fetalis), an incompatible blood match for a blood
transfusion, or hemolytic anemia due to an autoimmune reaction or drug toxicity.
Infants with erythroblastosis fetalis may have very high levels of bilirubin in their blood,
which leads to jaundice. This reaction occurs when the infant and mother have different blood
types (Rh factor positive or negative, or ABO type differences), and the mothers immune system
attacks the babys blood during labor. This condition must be watched carefully because it can
result in death of the mother and child. A pregnant woman is often given an indirect Coombs test
to check for antibodies during prenatal care, before labor.