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DR.E.ZAREAN
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First demonstrated by testing human blood with rabit anti sera against red cells of Rhesus monkey & classifying Rh negative & Rh positive.
However the underlying biochemical genetics
is not well understood and the genotyping & phenotyping remains little confused.
The genotype is determined by the inheritance of 3 pairs of closely linked allelic genes situated in tandem on chromosome 1 & named as D/d, C/c, E/e (Fisher- Race theory)
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Rh Negative Women Man Rh positive (Homo/Hetero)
Fetus Rh Neg Fetus No problem
Rh positive Fetus
Rh+ve R.B.C.s enter Maternal circulation
Mother previously sensitized Secondary immune response
? Iso-antibody (IgG)
Non sensitized Mother Primary immune response
Fetus unaffected, 1st Baby usually escapes. Mother gets sensitised?
Fetus
Haemolysis
?
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Chances of T.P.H/F.M.H. are only 5% in 1st trimester but 47% in 3rd trimester, many conditions can increase the risk.
Chances of primary sensitization during 1st pregnancy is only 1-2%, but 10 to 15% of patients may become sensitized after delivery.
ABO incompatibility and Rh non-responder status may protect.
Amount of antibodies that enter the fetal circulation will determine the degree of haemolysis
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HAEMOLYSIS IN UTEROAFTER BIRTH
BILLIRUBIN
ANAEMIA
MAT. LIV NO
EFFECT
HEPATIC
ERYTHROPOESIS & DYSFUNCTION
PORTAL & UMBILICAL VEIN
HYPERTNSION, HEART FAILURE
BIRTH OF AN AFFECTED INFANT - Wide spectrum of presentations. Rapid deterioration of the infant after birth. May contiune for few days to few months. Chance of delayed anaemia at 6-8 weeks probably due to persistance of anti Rh antibodies.
Jaundice
Kernicterus Hepatic Failure
DEATH
ERYTHROBLASTOSIS FETALIS
IUD
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Amniocentesis; CVS Threatened abortion, previa, abruption Trauma to abdomen External cephalic version Multiple pregnancies Cesarean delivery Fetal death Percutaneous umbilical blood sampling Manual removal of placenta Hydatidiform mole EP
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Premarital counseling? Ambitious?
Blood grouping must for every woman, before 1st pregnancy.
Rh+ve Blood transfusion- 300mcg Immunoglobulin (minimum).
Proper management of unsensitised Rh negative pregnancies.
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Blood typing at 1st visit, If negative :husband’s typing. If husband is also negative then no treatment
If husband is positive, if possible, Homo/Hetero?
Do Indirect Coomb’s test of mother – Negative-good. Repeat ICT at 28 weeks – Negative : 300mcg
Rh immunoglobulin Positive Sensitised .
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If Rh positive(neonate)- Test mother’s blood for ICT & Infant’s for DCT
• Negative or weakly reactive- 300mcg immunoglobulin.
• Positive – Sensitised–Hb & Bilirubin Estimation of the infant -Treat the infant.
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Schedules First trimester - 50 μg RhIgG Amniocentesis - 300 μg RhIgG Antepartum bleeding
• If first trimester - 50 μg RhIgG • If third trimester - 300 μg RhIgG • Postpartum <72 hr - 300 μg RhIgG; 0.1%-%1
require > 300 μg RhIgG
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Causes of sensitization- •Misinterpretation of maternal Rh type•Rh +ve blood transfusion•Unprotected preg. & labour•Inadequate dose / improper use of IgG on previous occasions
•Immunization to cross-reacting antigen
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Careful planning during antepartum, intrapartum & neonatal period
Father’s blood type & Rh antigen status
Knowledge of maternal antibody titer to the specific antigen
Intrauterine foetal monitoring with repeated ultrasound examination, cordocetesis / amniocentesis
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Fetus Rh Negative: - Observation Fetus Rh Positive: -
• Intrauterine transfusion of ‘Rh Neg’ blood as indicated
• Timely delivery any time after 32 weeks• Management of the infant up to 8 weeks
In cases of severely sensitized women, consider medical termination of pregnancy and sterilization .
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Anemia Erythroblastosis fetalis
• Ascites • Heart failure • Pericardial effusion
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Maternal antibody titer negative - do serial antibodies
If titer low - little risk of anemia If > 1:16 - perform amniocentesis and/or
Doppler assessment • ∆OD450 plot on Liley curve • Zone I - Rh negative or fetus mildly affected• Zone II - moderately affected • Zone III - high risk for IUFD
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Serial sonograms Early signs
• Thickened placenta • Liver span • Increased umbilical vein diameter • Increased blood velocities in UV, aorta and middle
cerebral artery Severe disease - scan every week if hydropic
changes. If hydropic changes, consider fetal transfusion.
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Intraperitoneal :
First done in 1963 Instill blood through needle or epidural catheter Volume to transfuse = (G.A.-20) x 10ml Generally, repeat in ~ 10 days, then every 4 wk. Risk of death about 4% per procedure Not effective in hydropic fetus Some advocate combined approach (IPT and
IVT)
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Intravascular : Goal is to have post-transfusion Hct 40-45% Can infuse about 10 ml/min Estimate requirement based on EFW and pre-transfusion
Hct Repeat in 1 wk., then about every 3 wk. Hct falls about 1%/day Goal: keep Hct > 25% Smaller volumes, therefore more procedures compared
to IPT Fetal loss about 1.5% per procedure