management of the rhesus negative mother
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Management of the Rhesus Negative Mother
Dr Shantala VadeyarMD, FRCOG, DM
Advanced Obstetric Ultrasound (RCOG / RCR)Subspecialist Fetal & Maternal Medicine (RCOG)
Consultant Obstetrician, Fetal & Maternal Medicine
Kokilaben Dhirubhai Ambani Hospital, Mumbaiwww.totalpregnancycare.com
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• Incidence of Rh neg individuals varies with race
• Caucasians (whites) 15%• Afro-Carribeans (blacks) 7-8%• Asians 5%• Chinese and Japanese 1%
Background
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What is the Rhesus factor?
• It is a Red blood cell antigen
• Other Red cell antigens include -
• A, B – blood groups• Duffy, Kell, Kidd
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Genetics of Rh factor
• C, D and E antigens• D antigen is the most
important and determines Rh positivity
• cDe is Rh positive• Two alleles –
heterozygotes or homozygotes
• Rh negative person has dd genotype
Rh positive Rh neg
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Pathophysiology in pregnancy
• Rh negative mother• Carrying a Rh positive fetus• Some Rh positive RBCs cross over
into the maternal circulation• Since the mother has not been
exposed to these antigens, • She makes antibodies to this
“D” antigen
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Pathophysiology of isoimmunisation
• These circulating “anti-D” antibodies enter fetus
• They will attack fetal RBCs that are rhesus positive
• This causes RBC destruction (hemolysis)
• This leads to fetal anemia• Fetus does not get
hyperbilirubimemia • Manifests as hydrops and
fetal loss
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Management of Rh negative gravida
Coomb’s test
• Careful history• Previous pregnancy
losses• h/o blood transfusions• Check husband’s blood
group and Rh factor• Check anti-D antibodies • If no antibodies at
‘booking’, then repeat titres at 28, 36 weeks
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Prophylactic Anti-D
• Prophylactic antenatal anti D at 28, 34 weeks 300 IU injection
• Following any episode of antepartum haemorrhage
• Miscarriage, Ectopic pregnancy
• Amniocentesis / CVS / FBS• Delivery – normal and LSCS
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Anti – D:Mechanism of Action
• The Rh positive fetal RBCs that enter the maternal circulation are destroyed by the anti D
• Thus, the D antigen is not allowed to be presented to the maternal immune system
• Prevents ‘sensitisation’
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Rh Sensitised PregnancyRh antibodies positive
Titres < 1:32
Titres 4 weekly till 24 wks and 2 wkly till term
Titres > 1:32
Serial fetal MCA Dopplers every 1-2 wks
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Middle Cerebral Artery
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MCA Doppler- Rhesus isoimmunisation
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MCA Doppler- IUGR
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Rh Sensitised Pregnancy - 2MCA Doppler VelocimteryPeak Systolic Velocity
MCA PSV 1.5 MoMs and above
Fetal Blood Sampling and consider IUT
If no facilities for FBS, amniocentesis
MCA PSV less than 1.5 Moms
Monitor MCA PSV 1-2 wkly
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Fetal assessment of hemolysis– invasive procedures
• Amniocentesis and checking ODD 450 to check level of bilirubin in AF
• Fetal Blood Sampling and checking fetal Haemoglobin level
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Amniotic fluid ODD 450
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Intrauterine blood transfusion
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Antenatal Steroids
• If preterm delivery <36 wks may be predicted, then antenatal steroids must be given to enhance fetal lung maturity
• 2 doses of betamethasone 12 mg• 24 hours apart• Careful blood sugar monitoring in
GDM• May also cause hyperacidity
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Delivery
• Most commonly with Rh sensitised pregnancies – LSCS
• May try induction of labour• Continuous FHR monitoring• Early recourse to LSCS is any doubts• Neonatologists present at delivery
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Neonatal Management
• Commonly need Phototherapy
• May need Exchange Transfusion
• Bone marrow suppressed if IUT
• Anemia – blood transfusion • Haematinics long term• Good long term outcome
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Rhesus isoimmunisation-1• Mrs KC, age 38, P1, 15 yr
girl• Rh negative, booking
antibody screen• Anti D at 15 weeks- 11iu/ml• Scan at 20 weeks- MCA
Doppler normal• Repeat Anti D titres and
scans for MCA PSV every 2-3 weeks.
• 26 weeks- raised titres 20iu/ml and MCA PSV raised to 1.5MoMs
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Rh isoimmunisation-2
• Amniocentesis ODD450- below action line
• 29, 30 weeks- MCA Doppler normal
• 30 weeks- repeat amniocentesis- slight increase in ODD 450 levels, but below action line
• 31 weeks- Steroids, MCA Dopplers every week- within 1.5 MoMs- normal
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Delivery
• 32 weeks- amniocentesis- action line
• Options- Intrauterine transfusion v/s delivery
• 33+5 w- delivery- 2.2kg female
• Exchange transfusions and phototherapy postnatally- discharged 2 weeks
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THANK YOU