Rh-isoimmunization and & abo incompatibility

Август 8, 2022

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Rh-isoimmunization and & abo incompatibility

Содержание

2. Rh- Iso imunization Definition known as: Rhesus incompatibility, Rhesus disease RhD Hemolytic Disease of the Newborn.
3. Pathophysiology The rhesus system which comprises number of antigens C, D, E, c, e. A person
4. Pathophysiology Initial response is forming IgM antibodies for short period followed by production of IgG which
5. IGM antibodies 1. Cleared by Macrophage 2. Plasma stem cells Fetal Anaemia Mother Placental Primary Response
6. Anti - D Macroph. antigen Presenting cell T- helper cell B cell Fetal Anaemia Mother Placental
7. Macroph. Antigen Presenting Cell T-Hellper B-cell Anti-D Anti - A Anti - B Mother Infant A
9. Fetomaternal hemorrhage as a reason of Rh –isoimmunization has been documented in: 7% in the first
10. Rh Antibodies Antibodies Coated Red Cells Destruction of Fetal Cells by Fetal RES Fetal Anemia Fetal
11. Complications of Fetal-Neonatal anemia: Fetal Hydrops And Stillbirth Hepatosplenomegaly Neonatal Jaundice Compilations Of Neonatal Kernicterus (Lethargy,
12. Kernicterus Concentration of bilirubin in the newborn blood exceeds in-term fetus – 307,8 – 342 mkmoll/L
13. Natural History 50% of affected infants have no or mild anemia, requiring either phototherapy or no
14. Hydrops fetalis
15. The aim of antenatal management To predict which pregnancy is at risk To predict whether or
16. Recognition of pregnancy at risk First ante-natal visit check blood group, antibody screening. If indirect coombs
17. Prediction of the severity of fetal hemolysis History of previous affected pregnancies The levels of maternal
18. Amniocentesis – at 16 weeks - There is an excellent correlation between the amount of bilirubin
19. Amniocentesis
20. Amniocentesis Normally Bilirubin In Amniotic Fluid Decreases With Advanced Gestation. It Derives From Fetal Pulmonary And
21. Ultrasound detection of Rh Sensitization - Placental size and thickness and hepatic size. - Fetal hydrops
22. Ultrasonographic investigation
23. Rh- Iso imunization Body wall edema hydropic fetus
24. Rh- Iso imunization Fetal Ascites
25. Biophysical surveillance Middle cerebral artery peak velocity
26. Biophysical surveillance Middle Cerebral Artery peak systolic velocity C Median 80 70 60 50 40 30
27. Diagram of cordocentesis procedure Cordocentesis -
28. Percutaneous Fetal Blood Sampling - allows measurement of fetal Hb, Hct, pH, reticulocytes
29. Is the gold standard for detection of fetal anemia. Reserved for cases with: - With an
30. Suggested management of the RhD-sensitized pregnancy Monthly Maternal Indirect Coombs Titre Below Critical Titre Complicated History
31. Suggested management after amniocentesis for ΔOD 450 Serial Amniocentesis Lily zone I Lower Zone II Upper
32. Direct fetal intravascular transfusion
33. Pregnant women undergo cesarean section in isoimunization: Severe form of hemolytic infant disease in the term
34. Vaginal delivery in Rh-isoimmunization In the second stage of labor pudendal block and episiotomy are indicated
35. Rh- Iso imunization Prevention - Screening of all pregnant mothers to Rh D antigen and antibody
36. Rh- Iso imunization Prevention The standard dose of anti D is 0.3 mg —will eradicate 15
37. Management of sensitized newborn Mild anemia (Hb 4 mg/dl)---Phototherapy -Moderate to severe----Exchange transfusion. -Mild Hydrops improves
38. Indications to exchange blood transfusion in infants :
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Rh- Iso imunization Definition
known as:
Rhesus incompatibility, Rhesus disease RhD Hemolytic Disease of

the Newborn.
-When Rh– mother gets pregnant to Rh+ fetus —she may be sensitized to Rh antigen and develop antibodies. These will cross the placenta and cause hemolysis of fetal red blood cells.
- The risk of sensitization after ABO incompatible pregnancy is only 2%

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Pathophysiology
The rhesus system which comprises number of antigens C, D, E,

c, e.
A person who lacks D antigen is called Rh negative.
15% of Caucasians, 5% African Americans and 2 % of Asians are Rh negative.
Rh isoimmunisation is due to D antigen in more than 90% of cases.
Occasionally hemolytic disease of the newborn is a result of maternal immunization to Irregular RBC antigens other than Rh group like anti- Kell and anti- Duffy

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Pathophysiology
Initial response is forming IgM antibodies for short period followed by

production of IgG which crosses placenta
IgG antibodies adhere to the antigen site on the surface of erythrocytes causing hemolysis.
The excessive removal of circulatory RBCs leads to severe anemia and hypoxia.
Erythropoiesis results in hepatosplenomegaly.
Tissue hypoxia and hypoproteinemia results in cardiac and circulatory failure, with generalized odema and hydrops

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IGM antibodies
1. Cleared by Macrophage
2. Plasma stem cells
Fetal Anaemia
Mother
Placental
Primary Response
6 wks

to 6 M.
IGM.

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Anti - D
Macroph. antigen
Presenting cell
T- helper cell
B cell
Fetal Anaemia
Mother
Placental
Secondary Response
Small amount
Rapid

IgG

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Macroph. Antigen
Presenting Cell
T-Hellper
B-cell
Anti-D
Anti - A
Anti - B
Mother
Infant
A Rh positive
B Rh Positive
“O”

Rh positive

Group “O” Rh Negative

Placenta

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Fetomaternal hemorrhage as a reason of Rh –isoimmunization has been documented

in:

7% in the first trimester.
16% in the second trimester
29% in the third trimester
Risk of fetromaternal hemorrhage is increased in abruption placenta, threatened abortion, toxemia, after cesarean section, ectopic pregnancy, amniocentesis, intrauterine fetal transfusion.
And it occur during normal delivery

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Rh Antibodies
Antibodies Coated Red Cells
Destruction of Fetal Cells by Fetal RES
Fetal

Anemia
Fetal Hypoxia and Stimulate of Erythropoitin
Extra Medullary red Cells Synthesis
Hepatomegally
Hepatic Cell Failure
Hypoproteinemia, Increased Intrahepatic Pressure, Portal hypertension
Ascetic, Edema, hypoxia, Placental Thickness, Polyhydramnios, Pericardial effusion

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Complications of Fetal-Neonatal anemia:
Fetal Hydrops And Stillbirth
Hepatosplenomegaly
Neonatal Jaundice

Compilations Of Neonatal Kernicterus (Lethargy, Hypertonicity, Hearing Loss, Cerebral Palsy And Learning Disability)
Neonatal Anemia

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Kernicterus
Concentration of bilirubin in the newborn blood exceeds
in-term fetus

– 307,8 – 342 mkmoll/L
in pre-term fetus – 153-205 mkmoll/L,

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Natural History
50% of affected infants have no or mild anemia,

requiring either phototherapy or no treatment.
25% have some degree of hepatosplenomegaly and moderate anemia and progressive jundice culminating in kernicterus, neonatal death or severe handicap.
25% are hydropic and usually die in utero or in the neonatal period ( half of these the hydrops develops before 34 weeks gestation

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Hydrops fetalis

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The aim of antenatal management
To predict which pregnancy is at risk
To

predict whether or not the fetus is severely affected.
To correct anemia and reverse hydrops by intrauterine transfusion.
To deliver the baby at the appropriate time, weighing the risks of prematurity against these of intrauterine transfusion.

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Recognition of pregnancy at risk
First ante-natal visit check blood group, antibody

screening.
If indirect coombs test is positive, the father’s Rh should be tested.
Serial maternal Anti D titers should be done every 2- 4 weeks.
If titer is less than 1/16 the fetus is not at risk.
If titer is more than 1/16 then severity of condition should be evaluated.

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Prediction of the severity of fetal hemolysis
History of previous

affected pregnancies
The levels of maternal hemolytic antibodies
Amniocentesis
Biophysical surveillance
Fetal blood sampling

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Amniocentesis – at 16 weeks
- There is an excellent correlation between

the amount of bilirubin in amniotic fluid and fetal hematocrit.
- the optical density deviation at 450 nm measures the amniotic fluid unconjugated bilirubin.

Ultrasound image of amniocentesis at 16 weeks of gestation

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Amniocentesis

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Amniocentesis
Normally Bilirubin In Amniotic Fluid Decreases With Advanced Gestation.
It

Derives From Fetal Pulmonary And Tracheal Effluents.
Its Level Rises in Correlation With Fetal Hemolysis.

Determination Of Amniotic Fluid Bilirubin:
By The Analysis Of The Change In Optical Density Of Amniotic Fluid At 450 nm On The Spectral Absorption Curve (delta OD450)
Procedures Are Undertaken At 10-15 Days Intervals Until Delivery Data Are Plotted On A Normative Curve Based Upon Gestational Age.

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Ultrasound detection of Rh Sensitization
- Placental size and thickness and hepatic

size.
- Fetal hydrops is easy to diagnose when finding one or more of the following: Ascites, pleural effusion, pericardial effusion, or skin edema.
- Doppler assessment of peak velocity of fetal middle cerebral artery proved to valuable in predicting fetal anemia

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Ultrasonographic investigation

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Rh- Iso imunization
Body wall edema hydropic fetus

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Rh- Iso imunization
Fetal Ascites

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Biophysical surveillance Middle cerebral artery peak velocity

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Biophysical surveillance Middle Cerebral Artery peak systolic velocity
C Median
80
70
60
50
40
30
20
20 25 30 35
A

1.5 MOM

B 1.29 MOM

Gestational Age (wks)

MCA peak velocity cm/sec

from Mari et al, NEJM 2000; 342:9-14

A = moderate-severe anaemia
B = mild anaemia
C = no anaemia

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Diagram of cordocentesis procedure
Cordocentesis -

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Percutaneous Fetal Blood Sampling - allows measurement of fetal Hb, Hct,

pH, reticulocytes

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Is the gold standard for detection of fetal anemia.
Reserved for

cases with: - With an increased MCA-PSV

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Suggested management of the RhD-sensitized pregnancy
Monthly Maternal Indirect Coombs Titre
Below

Critical Titre

Complicated History and / or Exceeds Critical Titre

Paternal Rh Testing

Rh Positive

Rh-negative

Amniocentesis for RhD antigen status

Routine Care

Fetus RhD positive

Fetus RH D Negative

Serial Amniocentesis

Weekly MCA-PSV

< 1.50 MOM

Cordocentesis or Deliver

> 1.50 MOM

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Suggested management after amniocentesis for ΔOD 450
Serial Amniocentesis
Lily zone I
Lower

Zone II

Upper Zone II

Zone III
Hydramnios & Hydrops

Repeat Amniocentesis every 2-4 weeks

Delivery at or near term

Repeat Amniocentesis in 7 days or FBS

Hct < 25%

Hct > 25%

Intrauterine
Transfusion

Repeat Sampling
7 to 14 days

< 35 to 36 weeks
And Fetal lung immaturity

> 35 to 36 weeks Lung maturity present

Intrauterine
Transfusion

Delivery

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Direct fetal intravascular transfusion

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Pregnant women undergo cesarean section in isoimunization:
Severe form of hemolytic infant

disease in the term 34-35 weeks after previous antenatal prevention of fetal hyaline membranes syndrome;
Hydrops fetalis in any gestation term because of interm pregnancy would provoke antenatal fetal death.

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Vaginal delivery in Rh-isoimmunization
In the second stage of labor pudendal block

and episiotomy are indicated (they decreasing fetal trauma).
In the all others cases pregnant women with the diagnosis of Rh- disease undergo delivery in the term of 37-38 weeks of gestation.
Induction of labor is performen by prostaglandin (in the case of “unripe” uterine cervix) or by intravenous oxytocin infusion administration (in the case of “ripe” uterine cervix).

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Rh- Iso imunization Prevention
- Screening of all pregnant mothers to Rh D

antigen and antibody screening for Rh D negative mothers.
-Prophylactic anti D immunoglobulin to all Rh – mothers after delivery if the fetus is Rh+ or( at 28, 36 weeks of pregnancy) and after abortion, amniocentesis, abruption.

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Rh- Iso imunization Prevention
The standard dose of anti D is 0.3 mg

—will eradicate 15 ml of fetal red blood cells (routine for all Rh –ve pregnancies) within 3 days of delivery.
-If more feto-maternal bleeding is suspected as in abruption or ante partum hemorrhage-Do Kleihauer –Betke test to estimate the amount of fetal red cells in maternal circulation and re-calculate the dose of the anti-D.

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Management of sensitized newborn
Mild anemia (Hb <14gm/dl, cord bilirubin>4 mg/dl)---Phototherapy
-Moderate to

severe----Exchange transfusion.
-Mild Hydrops improves in 88% of cases
-Severe hydrops—Mortality is 39%

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Rh-isoimmunization and &amp; abo incompatibility

Содержание

Rh- Iso imunization Definitionknown as:Rhesus incompatibility, Rhesus disease RhD Hemolytic Disease of

PathophysiologyThe rhesus system which comprises number of antigens C, D, E,

PathophysiologyInitial response is forming IgM antibodies for short period followed by

IGM antibodies1. Cleared by Macrophage2. Plasma stem cellsFetal AnaemiaMotherPlacentalPrimary Response6 wks

Anti - DMacroph. antigenPresenting cellT- helper cellB cellFetal AnaemiaMotherPlacentalSecondary ResponseSmall amountRapid

Macroph. AntigenPresenting CellT-HellperB-cellAnti-DAnti - AAnti - BMotherInfantA Rh positiveB Rh Positive“O”

Fetomaternal hemorrhage as a reason of Rh –isoimmunization has been documented

Rh AntibodiesAntibodies Coated Red CellsDestruction of Fetal Cells by Fetal RESFetal

Complications of Fetal-Neonatal anemia:Fetal Hydrops And Stillbirth Hepatosplenomegaly Neonatal Jaundice

Kernicterus Concentration of bilirubin in the newborn blood exceeds in-term fetus

Natural History 50% of affected infants have no or mild anemia,

Hydrops fetalis

The aim of antenatal managementTo predict which pregnancy is at riskTo

Recognition of pregnancy at riskFirst ante-natal visit check blood group, antibody

Prediction of the severity of fetal hemolysis History of previous

Amniocentesis – at 16 weeks- There is an excellent correlation between

Amniocentesis

Amniocentesis Normally Bilirubin In Amniotic Fluid Decreases With Advanced Gestation. It

Ultrasound detection of Rh Sensitization- Placental size and thickness and hepatic

Ultrasonographic investigation

Rh- Iso imunizationBody wall edema hydropic fetus

Rh- Iso imunizationFetal Ascites