RHESUS ISO- Kandi

Campbell
IMMUNIZATION
 ISO-IMMUNIZATION

This is defined as the process by which antibodies

are produced in one individual in response to the
injection of antigens from another individual of the
same species
 INCIDENCE

The rate of Rh negative blood type is dependent on

the race:

Caucasians: 15-16%
Blacks: 8%
Indians/Chinese: <5%
 The most common cause of isoimmunization is feto -
maternal bleeding

The most common RBC antigen is the D

 PATHOPHYSIOLOGY

The fetal blood production begins at 3 weeks and

RBC antigens can be present as early as 38 days
after conception.

If this the first pregnancy of a Rh positive infant the

immune response may take up to 6 months to
develop.
 In subsequent pregnancies with a Rh negative
mother is the primary concern.

If the mother is sensitized her immune system will

produce IgG anti- D that has the ability to cross the
placenta and coat the fetus D positive RBC which
are then destroyed in the spleen

Haemolysis maybe: Mild, Moderate or Severe

 Severe haemolysis will result in:

Hepatic circulatory obstruction with placental

oedema (this will interfere with placental perfusion
and lead to ascites)
Hepatomegaly, increased placental thickness and
polyhydramnios which often procedes the
development of fetal hydrops
Liver damage progression can lead to decreased
production of albumin which can lead to anasarca
and effusions
 The rate of Rh negative mothers becoming sensitized
after their first pregnancy if not given anti D Ig G is
16%

In RCOG Guidelines published in March 2011, they

quoted that percentage of Rh negative women who
did not have RAADP only 1% became sensitized.

Lee D,Contreras M,Robson SC,Rodeck CH,Whittle MJ.

Recommendationsforthe use of anti-D immunoglobulin for
Rh prophylaxis.British BloodTransfusion Society and the
Royal College of Obstetricians and Gynaecologists.Transfus
Med 1999;9:937
 ABO INCOMPATIBILIT Y

ABO incompatibility is said to be protective against maternal

isoimmunization
A mother who is O blood type has naturally occuring Anti A
and Anti B antibodies.
If the fetus has blood type A the antibodies of the mother s
blood will hemolyse and this prevents the maternal
lymphocytes from getting a chance to recognize the foreign
fetal RBC and prevents iso-immunization.

Group O (maternal) : COMPLETE PROTECTION

Group A (maternal) : PARTIAL PROTECTION
Group B (maternal) : PARTIAL PROTECTION
Group AB (maternal) : NO PROTECTION
Management of the Pregnant Rh ve Mother

HISTORY
Previous pregnancies
Previous blood transfusions
Previous admission of RhoGam
Events that could have lead to fetomaternal blood
transfusion (Ectopic pregnancy, D + C, placental
abruption, placenta praevia, miscarriages,
amniocentesis)
Partner is known to be Rh +ve
INVESTIGATIONS
CBC, Blood Group, Rh Status

Indirect Coombs Test: the titre is used to determine

whether sensitization has occurred and if so the
likely effect it may have on the fetus in utero ; a titre
of 1:32 is said to be significant and suggests
sensitization
 IDCT can be done at the first booking visit and you
repeat it again at 20 weeks (for Rh ve mothers)

This test is repeated every 4 weeks up until 38

weeks provided the results remain negative

If the test is positive the frequency at which you test

increases and the fetus is monitored closely for any
complications
 ASSESSING FETAL RISK

Mother is Rh ve
Father is Rh +ve
Atypical Antibodies are present in the maternal
circulation
Antibodies associated with haemolytic diseases of
the newborn
Antibody titre of >1:32- 1:64
 MONITORING

INVASIVE
Amniocentesis
Percutaneous Blood sample

NON- INVASIVE
Ultrasound and Doppler Studies
 AMNIOCENTESIS

The aim is to look for the levels of bilirubin in the

amniotic fluid.
 This can also be used to assess for severe conditions
such as fetal ascites and hydrops fetalis.

Complications included: Amnionitis and Preterm

Labour
 SPECTROPHOTOMETRY

This is to test the optical density of the amniotic

fluid

Light is passed through the amniotic fluid at a

wavelength of 450 nm.

The less light that passes (the higher the OD)

through the higher the levels of bilirubin and vice
versa
LILEY CHART
Zone 1: No or mild anemic risk to the fetus and the
test can be repeated until every 3-4 weeks until 38
weeks gestation
Zone 2: Moderate anemic risk to the fetus; the test
should be repeated every 1- 2 weeks; delivery by 34
weeks gestation is usually indicated
Zone 3: There is HIGH anemic risk to the fetus;
interventions such as intrauterine transfusion is
usually indicated; Delivery should be undertaken once
lung maturity is assured using the
LECITHIN/SPHINGOMYELIN TESTING
 PERCUTANEOUS BLOOD SAMPLING

This is to test the fetal haematocrit.

This is a direct assessment of fetal anaemia.

The aim is to maintain fetal Hct at >25-30%

 U/S & DOPPLER STUDIES

This is used the assess the middle cerebral artery

peak systolic velocity.

This can accurately assess fetal anaemia and

decreases the number of invasive procedures such as
amniocentesis and cordocentesis

The peak increases is an indirect indicator of

anaemia.
 MANAGEMENT

Management can either be Delivery or Intrauterine

Transfusion
 CRITERIA FOR MANAGEMENT

I. Amniotic Fluid OD in Zone III

II. Fetal Hct is <25%

III. Middle Cerebral Artery peak velocity is HIGH

 If the GA is < 34 weeks we will have to proceed with
Intrauterine Transfusion.
 INTRAUTERINE TRANSFUSION

This procedure is feasible from 22-24 weeks.

Under U/S guidance a needle and cannula are
inserted via the maternal abdominal wall into the
fetal peritoneal cavity.
Between 60-120 ml of Rh negative packed red blood
cells are introduced.
IU transfusions usually need to be repeated every 1 -2
weeks with the aim of keeping the fetal Hct above
25-30%
Delivery of the fetus should take place at 34 -35
weeks
 DELIVERY

If the patient is of a GA of 34 or greater.

Delivery is indicated

The mode of delivery is preferentially via VAGINAL

delivery as C-Section may lead to a large amount of
FMH (however benefits vs the risks should be
considered)
RHOGAM
 Mechanism: passive anti D Ig ; causes Lysis of D+
RBC before maternal lymphocytes can be activated
to produce antibodies

300 micrograms of RhoGAM is said to neutralize 12-

15 ml of fetal RBC

It is recommended that before 20 weeks 250 IU of

RhoGAM be administered.
 TESTING

Kleihauer- Betke test: Can be done to identify the

extent of fetomaternal hemorrhage.

This is an acid elution technique which identifies

fetal red blood cells against a background of ghost
maternal cells

RhoGAM administration can be adjusted based on

this test.
 Flow cytometry quantifies the size of fetomaternal
hemorrhage.

The results are more accurate and reproducible

It can also detect RhD +ve cells and this is useful in

patients who have high HbF levels.
 INDICATIONS FOR RHOGAM

Antenatal Period: In cases of threatened

miscarriage, spontaneous or induced miscarriage or
ectopic pregnancy RhoGAM is given as there is an
increased risk of fetomaternal hemorrhage .
 Amniocentesis: It is administered prophylactically
due to the risk of placental trauma
Placental Abruption: The KB test is useful in these
cases.
Placenta Praevia
External cephalic version (A relatively contra -
indicated procedure in Rh ve mothers
Chorionic villus sampling
Percutaneous umbilical cord sampling
 Routine antenatal prophylaxis: There are few
patients who become sensitized in the first
pregnancy. This is preventable by the prophylactic
administration of 500 IU Rh immune globulins at
28 weeks and 34 weeks gestation.

*ACOG: 28 weeks and then again at delivery if the

fetus turns out to Rh +ve .
 Postpartum: At the time of delivery cord blood
should be taken of all Rh ve mothers to determine
the babys blood group, performing a direct coombs
test and determining bilirubin levels

If the baby turns out to be Rh +ve; 300 micrograms

of RhoGAM should be administered to the mother
and this should ideally be given up to 72 hours after
delivery.
The following are more likely to be associated with
FMH:
Traumatic delivery including C-section
Manual removal of the placenta
Stillbirths and intrauterine deaths
Abdominal trauma during the 3 rd trimester
Twin pregnancy (at delivery)
Unexplained hydrops fetalis
 DOSAGES OF RHOGAM (RCOG MAY 2011
GUIDELINES)

Prophylaxis following miscarriage, ectopic pregnancy

and TOP

250 IU up to 19+6 weeks and 500 IU thereafter

Always do a size of FMH when AntiD is given at or

after 20+0 weeks
Prophylaxis following sensitizing events before delivery

250 IU following sensitizing events up to 19+6 weeks

500 IU at or after 20 weeks and a test for size of

FMH should be done and if >4ml additional RhoGAM
should be given
Routine Antepartum Prophylaxis
Two regimens:

1. Two doses of 500 IU at 28 weeks and 34 weeks

gestation

2. A single dose of 1500 IU at 28 weeks gestation

Postpartum:

500 IU (100 micrograms) is given and you must do

testing such as the KB test to identify if there is >4
ml of fetal red blood cells and additional doses of
RhoGAM is given based on the findings

This must been given within 72 hours and if that

time as passed try to give within 10 days as it is
believed to still offer some protection.
 CONCLUSION

Only 1% of Rh ve mothers will become sensitized

without any intervention

The main concern with Rh iso-immunization is the

subsequent pregnancies of the Rh ve mother

RhoGam is a passive anti D IgG which prevents

isoimmuinization

Adequate dosage and the right circumstance in

which it is administered helps to prevent a Rh ve
mother from becoming sensitized.
 REFERENCES

http://www.rcog.org.uk/files/rcog -
corp/GTG22AntiDJuly2013.pdf