Rhesus Isoimmunization

By : Salah Eswaysi

4 Basic Blood Types

1. 2.

3.
4.

A B AB O

(surface antigen A) (surface antigen B) (antigens A and B) (neither A nor B)

ABO System & Pregnancy hemolytic diseases of the newborn may be due to ABO incompatibility

Fetus inherits one gene from each parent.

O+O O+A O+B O + AB = = = = O, O or A, O or B, O or A B

Rhesus Blood Group System

First demonstrated in Rhesus monkey

Blood group are classified as Rh negative or Rh positive However the underlying biochemical genetics is not well understood and the genotyping & phenotyping remains little confused

Rhesus Blood Group System

The genotype is determined by the inheritance of 3 pairs of closely linked allelic genes situated on chromosome 9 named as D/d, C/c, E/e
.. (Fisher- Race theory)

Rhesus Blood Group System Weiner postulates a series of allelic genes at a single locus Rh (D), Rh (C), Rh (E), Rh (c) & Rh (e) The gene ( d ) is an amorph & has no antigenic expression. So there are only five effective antigens The updated system of Rosenfield refers these antigens as Rh1, Rh2, Rh3, Rh4, Rh5

Subsequently less common antigens Cw, Du, Es have been found

Rhesus Blood Group System The fetus inherits one gene from each group as a haplotype such as sets of Cde, cde etc from each parent 12 sets of combinations & 78 genotypes are possible.

Most frequent genotypes are

Cde / cde (33%), (15%), Cde / cDE (12%) cdE / cde (1%), Cde / cDe (18%), cDE / cde (11%), Cde / cde (1%) cde / cde

Rhesus Blood Group System Incidence of Rh negative varies in different races: Mongoloids Chinese & Japanese Indians Africans Caucasians Basques > 1, 1-2%, 5%, 5-8%, 15-17% & 30-35%.

Rhesus Isoimmunization

Rhesus Iso immunization is an immunologic disease that occurs in pregnancy resulting in a serious complication affecting the fetus / or the neonate ranging from
mild neonatal jaundice to intra uterine loss or neonatal death

Rhesus Isoimmunization

This immunologic disease occur when a Rh negative patient carrying a Rh positive fetus
.. had a feto maternal blood transfusion .. the mother immunological system is stimulated to produce antibodies to the Rh antigen on the fetal blood cell .. This antibodies cross the placenta and destroy fetal red blood cells leads to fetal anemia . Usually the 1st fetus will not be affected if this is the 1st time that the mother has been exposed to the rhesus positive antigen

During pregnancy while the fetus still in the uterus The bilirubin in the fetal blood will be removed by the placenta to the maternal circulation and part of it go to the liquor The fetus will be anemic .. If the degree of anemia is severe fetus may die in utero because of heart failure After delivery The neonate will affected by The degree of the anemia The amount of bilirubin

Antigens Anything that can trigger an immune response Most are protein

Surface Antigens

cell surface proteins that identify cells to immune system Normal cells are ignored and foreign cells attacked

Antigens

Controlled by genes at chromosomal loci.

Appearance by 40 days of I.U. Life unchanged till death. Also present in tissues & tissue fluids

Blood cell Types Blood group system: A group of antigens controlled by a locus having a variable no of allele genes. Are genetically determined By the presence or absence of RBC surface antigens the blood group can be named A, B, AB, or O Rh positive or Rh negative

Blood cell Antigens Blood Group type- means.. Individual antigen phenotype which is the serological expression of the inherited genes

15 blood group systems are recognized : ABO, Rh, Kell, Duffy, MN, P, Lewis, . These blood group antigens have been found to be associated with hemolytic disease. However ABO & Rh account for 98%

Antibodies

Natural IgM

Iso / Immune antibodies IgG Formed in response to foreign R.B.C.

Natural Antibodies: Antibodies are formed against most of the major group antigens & present in almost all individuals when the antigen is absent.

In most other minor systems, natural antibodies to the antigens are found occassionally but as their anitgenicity is low, the immune antibodies are also rare ( except Kell & Duffy)
Mostly of them are IgM type. React poorly at body temp. ( except anti-A & anti-B), but agglutinate R.B.C.s at 5-20C Usually do not cross placenta.

Immune Antibodies: In contrast the immune or isoantibodies are IgG. Best react at body temp. & readily cross placenta

Most antibodies are complement binding notable exceptions being Rh & MN Antibodies may be Complete / Incomplete

Antibodies Can Be Detected by:

Saline agglutination test (SAT).

b Tests using cells suspended in colloid media.

c Tests using enzyme-treated cellsRh & occasional antobodies. Indirect antiglobulin ( Coombs test) - wide spectrum.

IgG Detected by IgM Detected by

SAT b, c, d

W.B.C. & Platelet

ANTIGEN

R.B.C.

Plasma
ANTIBODY

>400 Agglutinogens on the cell membrane

Antigen-Antobody reaction on the cell surface Hemolysis

ABO Blood Group System ABO system is controlled by allelic genes A1, A2, B, O located on the long arm of chromosome 9

The loci of ABO & H are not genetically linked

A1 & A2 genes perform same function but have a different rate constant

ABO Blood Group System

The O gene is an amorph & functionaly silent The H antigen is a precursor to A & B Secretors & non secretors Se & se genes control the production of a flucosyl transferase, which controls the production of H, A & B antigens in tissues

ABO Blood Group System

Genotype (Genes) A1 A1 , A1 A2 A2 A2, A2 O BB, BO Phenotype (Blood type) A1 (23-25%) A2 (6-10%) B(8-17%) Antigens in R.B.C. A1, (H) A2, (H) B,(H) Antibody In plasma anti-B, anti-H Anti-B, anti-A1 Anti-A/A1

A1B A2 B
O,O H,h

A1B(3%) A2B(1%)
O(43-50%) Oh Bombay

A,A1,B A,B,H
H None

Anti-H Anti-A1
Anti-A,-A1,-B Anti-A,-A1,-B,-H

ABO System & Pregnancy There is a 20% chance of ABO incompatibility of mother & fetus if feto maternal Hemorrhage occur Less than 5% chance of developing noticeable hemolytic disease ( milder forms )
It is more prominent in type A & B infants of type O mothers

In fetus & newborn, RBCs have a decreased No. of H, A & B reactive sites

ABO System & Pregnancy The fetal immunoglobulin production is low, so the plasma contains very little of anti-A & B agglutinins Anti-A & B produced in the mother being natural are IgM molecules & so do not cross placenta.

In some type O adults, much of the anti-A & B and anti-AB (a cross reacting antibody, also called anti-C) isoagglutinins are of IgG class.

ABO System & Pregnancy There is no adequate method of antenatal diagnosis

Direct Coombs antiglobulin test may be negative in ABO haemolytic disease ABO haemolytic disease is frequently seen in infants of primigravidae & the chance of recurence is 87%. The risk of stillbirth is not increased & no antenatal treatment is necessary Only 67% of affected infants will need any treatment

Rhesus Blood Group System

The antigenic expressions of these genes are dependent on an interaction between R.B.C. membrane protein & phospholipid molecules resulting in a set of antithelical epitopes, the coresponding antigens, consisting of C/c, D/d, E/e The antigenic determinants form an intrinsic part of the red cell membrane protein structure

C/c & E/e are weak antigens and impractical to match

Rhesus Blood Group System

D is by far the most immunogenic in the Rh system

There is a rare type of Rh negative called Rh null who lack all known Rh antigens

D antigen has no natural antibody while C & E have the corresponding natural antibodies, though weak & found infrequently.

D is by far the most immunogenic in the Rh system

A single transfusion of Rh positive (+ ve )blood to an Rh negative ( - ve ) person has a 50% chance of forming anti Rh D antibodies (IgG) Anti Rh antibodies are of three categories1st order saline / bivalent / complete antibodies 2nd order - albumin active / univalent / incomplete antibodies 3rd order atypical / antiglobulin active / incomplete antibodies

Pathogenesis Of Rh Iso - immunisation

Rh Negative Women Man Rh positive (Homo) (Homo/Hetero) Fetus Rh positive Fetus previously sensitized 2nd immune response

Rh+ve R.B.C.s enter Maternal circulation

IgMIgG antibodies Fetus

Non sensitized Mother Primary immune response

Haemolysis

1st Baby usually escapes. Mother gets sensitized?

Pathogenesis Of Rh Iso - immunisation

Rh Negative Women Man Rh positive (Hetero) Rh Neg Fetus No problem

Fetus

Rh positive Fetus
Rh+ve R.B.C.s enter Maternal circulation

previously sensitized 2nd immune response IgMIgG antibodies Fetus

Non sensitized Mother Primary immune response 1st Baby usually escapes. Mother gets sensitized?

Haemolysis

IN UTERO Antigen-Antibody reaction on the RBCs surface Hemolysis Anemia

Hepatic

erythropoesis & dysfunction

Portal & Umbilical Vein Hypertension Heart Failure

IUD

Erythroblastosis fetalis

Polyhydramni os

After birth Antigen-Antibody reaction on the RBCs surface

Hemolysis

Anemia Jaundice Kernicterus

Neonatal death

Management of rhesus negative pregnant women

Management of non sensitized Pregnancy Management of sensitized Pregnancy

Management of non sensitized Pregnancy

Non sensitized Rh Neg. mothers married to a Rh Pos. husband

Blood Group typing at 1st visit, If negative Check husbands Blood Group typing. If husband is also Rhesus negative then no rhesus complication and manage as other pregnant women

Management of non sensitized Pregnancy

If husband is Rh Positive then Check Husband being Homozygous or Heterozygous .... Check for maternal antibodies by indirect Comb's test ( ICT ) if antibodies detected treat as sensitized If no antibodies Repeat ( ICT ) at 28 and 32 weeks provided that no bleeding. If there is bleeding then ..

Management of non sensitized Pregnancy

Bleeding before 20 weeks of gestation .. Check for fetal red blood cells in maternal circulation by Kleihauer test

.. Check for maternal antibodies ( ICT ) if negative

.. Give ( 250 IU / 50 mcg ) anti D to the mother within 72 hours from the bleeding

Management of non sensitized Pregnancy Bleeding after 20 weeks of gestation .. Check for fetal red blood cells in maternal circulation by Kleihauer test .. Check for maternal antibodies ( ICT ) if negative .. Give ( 500 IU / 100 mcg ) anti D to the mother within 72 hours from the bleeding .. The dose should be doubled or tripled if fetal RBCs are more than 80 cells in maternal circulation

Prophylactic Management of non sensitized Pregnancy

During antenatal period Prophylactic (500 IU / 100 mcg ) Anti D are recommended to be given to all
negative non sensitized mothers married to Rh positive husband at 28weeks and 34 weeks to protect and overcome any asymptomatic or un noticed antenatal feto maternal blood transfusion

Prophylactic Management of non sensitized Pregnancy Indications for prophylaxis

At 28weeks to a Rhesus ve non sensitized woman whose husband is Rhesus +ve

Postpartum if the woman remains non sensitized and delivers a Rhesus +ve fetus Following amniocentesis or chorionic villus sampling Following evacuation of a molar pregnancy or termination of pregnancy Following an ectopic pregnancy Following abruptio placenta or undiagnosed uterine bleeding

Prophylactic Management of non sensitized Pregnancy

Failure of prophylaxis

Dose too small

Dose too late >72 hours

Patient already immunized but antibody titer too low for laboratory recognition
Defective immune globulin given

Management of non sensitized Pregnancy

Precaution should be taken to prevent the possibility of increased chance of feto - maternal blood transfusion At birth
During labor No fundal pushing in 1st or 2nd stage of labor No uterine massage or uterine grasp and squeeze in 3rd stage Let the placenta to be delivered spontaneous A void avulsions of the cord Protect the vaginal and perineal wounds and laceration from being exposed to the fetal blood spilled from cord

Management of non sensitized Pregnancy

During cesarean section

Use abdominal packs in the sides of the uterus before opening the lower segment to prevent spilled blood from the placenta to inter the peritoneal cavity.

Let the placenta to be delivered spontaneous using control cord traction without squeezing the uterus A void avulsions of the cord

Management of non sensitized Pregnancy

At birth . Maternal blood sample for .. antibodies by indirect Comb's test ( ICT ) .. fetal red blood cells in maternal circulation

. Cord blood sample ( Neonatal blood sample ) for .. antibodies by Direct Comb's test ( DCT ) .. Infant blood group .. Infant bilirubin level .. Infant Hb & Hct level

Management of non sensitized Pregnancy

. If fetal blood group is rhesus positive . No antibodies detected

Give full dose of Anti D ( 500 IU / 100 mcg ) to the mother within 72 hours after delivery The dose should be corrected according to the number of fetal red blood cells present in the maternal circulation Dont give Anti D . If fetal blood group is rhesus negative . If Antibodies detected

Sensitized Rh Negative mothers

Causes of sensitization
Misinterpretation of maternal Rh type Rh positive blood transfusion Unprotected pregnancy & labour Inadequate dose Anti D on previous occasions

Factors affecting immunization and severity

Amount of Antigen ( amount of fetal RBCs) Host factors ..
Integrity of Maternal Immune Sys antigenicity

Strength of the antigen ... Influence of ABO group

ABO-incompatible Rh- positive cells will be hemolysed before Rh antigen can be recognized by the mothers immune system

Management of Sensitized Pregnancy

Sensitized Rh Negative mothers

Check quantitative antibodies level @ 1st visit Recheck the level every 2 weeks Serial U/S Scan monitoring every 2 weeks If antibodies level continuo at the same level and no fetal compromise deliver at term

Management of Sensitized Pregnancy Sensitized Rh Negative mothers

If antibodies level start to increase Arrange for amniocenteses Spectrophotometer to study the optical density of the amniotic fluid ( i.e. bilirubin level which reflect RBCs haemolysis ) U/S Scan evaluation of the fetal will beings Use LILY s Curve to determine the fetal condition

Ultrasound scan (USS)

Help in fetal monitoring and timing of first intervention if anti-D level is 10 IU/mL
USS can detect ... Fetal Skin and scalp edema, ... Fetal Ascites, ... Fetal Pericardial or pleural effusion

.. Polyhydramnios .. Fetal hepatosplenomegaly .. Fetal Cardiomegaly .. Placental hypertrophy and enlargements .. Abnormal fetal posture (Buddha stance)

Fetal Ascites

Amniocentesis Amniocentesis Is an Indirect method to measure the degree of haemolysis of the fetal red blood cells by measuring the Concentration of bilirubin in the amniotic fluid. Amniotic fluid sample taken and sent for Spectrophotometer Where optic density of the fluid changes according to the amount of the bilirubin concentration Increasing of the OD as pregnancy advance shows worsening of the fetal hemolytic disease

Amniocentesis

1.2 1
0.8

0.4
0.1

100

200

450

300

Lileys chart

Lileys chart Zone III

Zone II

Zone I

Management of Sensitized Pregnancy

Term pregnancy ( mild or Severely affected ) Deliver Suitability of the place and its facility Experience of the team Type of Delivery Medication Photo therapy Extra uterine Blood exchange

Preterm fetus with Zone I in .. Cordocentesis blood sample Hb > 10g/dl No U / S Scan evidence of Hydropic changes Consider conservative management with regular follow up of fetal and maternal conditions till the fetal lung maturity is assured . Then deliver

Daily maternal clinical assessments Fetal Movements Chart Daily C T G Serial U / S Scan for fetal growth and amniotic fluid Biophysical Profile Regular cheek of the amniotic fluid bilirubin level by repeated amniocentesis every 2 weeks until the lung maturity reached Regular cheek of the fetal Hb and Hct values if the facilities available

Management of Sensitized Pregnancy

Preterm fetus with

Zone II or III
Cordocentesis blood sample Hb less than 10g/dl Ultrasound evidence of Hydropic changes Consider Transfer to suitable place Intra uterine therapy Delivery + extra uterine mang.

Management of Sensitized Pregnancy

Dexamethazone to enhance lung maturity Clinical assessments + C T G + U / S Scan + B P P

Consider repeating the intrauterine blood transfusion

Lung maturity .. If certain deliver

Management of Sensitized Pregnancy

Intra uterine therapy

Intra peritoneal blood transfusion

Through the umbilical vein Cordocentesis 80 % of packed cell o rhesus negative Blood Cross matched against maternal blood group Free of infection Fresh

Thank you all