Skaidre Brown

May 17, 2018

Evaluation and management of Infant/Mother Blood Incompatibility in Pregnancy

1. Definition or Key Clinical Information: There are four blood types A, B, AB, and O there is also a
Rhesus factor of positive or negative. Rh (D) antigen is a protein that may or may not be present on the
blood cells. Rh- status means that the Rh (D) antigen is not present on the mother’s blood cells. When the
father of the baby is Rh+ there is a chance that the baby can be Rh+. When the baby is Rh+ and the
mother’s blood and baby’s blood mix the Rh- blood produces antibodies against the Rh (D) antigen. This
usually does not affect the current pregnancy but can affect subsequent pregnancy because those
antibodies are small enough to cross the placenta and attack Rh+ blood causing hemolysis,
erthroblastosis fetalis, and still birth. The risk of the bloods mixing is rare unless there is some sort of
abdominal trauma, then there is a 2% risk of isoimmunization (Delaney, 2017). When the client is Rh-
and the baby is Rh+ and prophylactic Rh (D) immunoglobin is not taken there is a 17% risk of
isoimmunization (Delaney, 2017). All clients coming in to the practice for care should have blood type
and Rh status test. When the client’s blood type is Rh- and the father’s blood is Rh+ or unknown, the
client should be counselled about her options to reduce sensitization.
Another incompatibility possible is ABO incompatibility. It is more common but less severe. Type
O mother’s that have type A or B comprise 50% of the cases with A being more common but B being
more severe. Other babies affected can be type B or AB born to type A mothers and type A or AB born to
type B mothers. These babies can have symptoms such as jaundice within the first 24 hours after birth
with “varying degrees of anemia, reticulocytosis, and RBC destruction who have a positive direct
antiglobulin (Coombs) test; and for whom other causes of hemolysis can be ruled out” (Frye, 2007, p.
130).
2. Assessment
i. Risk Factors
Client is Rh- and father of baby is Rh+ or unknown
There is a history of miscarriages or abortions
History of repeated miscarriages
History of client having a blood transfusion
History of client having a baby that had neonatal jaundice or anemia
History of client having a baby needing a blood transfusion
Client is Rh- and elects to have invasive diagnostic testing, amniocentesis and CVS
ii. Subjective Symptoms
History of repeated miscarriages
History of having a baby that had neonatal jaundice or anemia
History of having a baby that needed a blood transfusion
 iii. Objective Signs
Blood work shows client is Rh-
Antibody screen (indirect Coombs) is positive
Titer is > 1:16
iv. Clinical Test Considerations
Type and factor and indirect Coombs at initial visit
Repeat at 28-30 weeks before Rh(D) immunoglobin administration
Repeat at 36 weeks or every 4 weeks as indicated
Type and factor of baby’s cord blood after delivery
3. Management plan
i. Therapeutic measures to consider
Prophylactic Rh(D) immunoglobin (RhoGAM) 300mcg at 28 weeks
Repeat in 12 weeks if client has not delivered.
RhoGAM 300mcg within 72 hours after delivery if baby is Rh+
RhoGAM 50mcg with SAB/TAB < 12 weeks
RhoGAM 300mcg with abdominal trauma, vaginal bleeding in pregnancy, abruption,
placenta previa, multiples, amniocentesis/CVS, and external version.
ii. Complementary measures to consider
Reduce risk of sensitization by having excellent nutrition to support a healthy placenta
attachment.
Avoid invasive procedures.
Gentle delivery of the placenta.
iii. Considerations for pregnancy, delivery and breastfeeding
If there is trauma there is a 2% risk of isoimmunization during pregnancy.
If client is Rh- and baby is Rh+ and RhoGAM is not administered during pregnancy, there
is a 17% risk of isoimmunization.
Current pregnancy should not be affected.
Subsequent pregnancies run the risk of hemolysis, erythroblastosis fetalis, and stillbirth if
baby is Rh+
iv. Client and family education
Education about risks (see section 3. iii.)
Counsel about her options to reduce risk of isoimmunization (see section 3. i.)
Informed consent for RhoGAM administration
Concerns for RhoGAM:
Thimerosal is no longer used so no longer a concern.
Theoretical risk of Creutzfeldt-Jakob disease – blood product infection by prions
that infect the brain.
It is a blood product, clients may have religious or philosophical objections.
v. Follow-up
Have parents report jaundice in the first 24 hours immediately.
Collect cord blood on all babies.
Direct Coombs test on cord blood either routinely or if newborn is Rh+.
Maternal antibody screen after birth, either routinely or if newborn is Rh+.
 If newborn is Rh+ and client declined RhIG prophylaxis, recommend antibody screen at 3
months postpartum.
Consider Kleihauer-Betke testing with a maternal blood draw after the birth to
determine amount of fetal blood in maternal circulation.
4. Indications for Consult, Collaboration or Referral
Referal when titer is > 1:16 – indicates possible sensitization.
When there is a large fetomaternal bleed.
When there is a positive Direct Coombs.
5.References
Delaney, S. (2017). Rh (D) Negative Pregnancy. Prenatal Care I, Live session.

Frye, A. (2007). Understanding diagnostic tests in the childbearing year. Portland, OR: Labrys Press.

Frye, A. (2008). Holistic midwifery volume I: Care during pregnancy. Portland, OR: Labrys

Press

King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C. & Varney, H. (2015). Varney’s Midwifery. Burlington,

MA: Jones & Bartlett Learning.