Rhesus (rh) isoimmunization

Август 10, 2022

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Rhesus (rh) isoimmunization

Содержание

2. Blood groups (1900): Antigens: Antibodies: O (45%) AntiA+Anti B A (40%) Anti B B (10%) Anti
3. Rhesus factor (1940): Agglutinogen (C,D,E) - mainly D C,D,E - dominant antigen d,e - recessive antigen
4. Rh positive (85%) - homozygous (DD) (35%), or heterozygous (Dd) (50%) Rh negative (15%) Incidence of
5. Rh ISOIMMUNIZATION So in response to introduction of foreign protein (antigen) ? production of antibody to
6. Rh ISOIMMUNIZATION Feto-maternal haemorrhage: during pregnancy leakage of fetal cells in the maternal circulation (Rh+ fetal
7. Rh ISOIMMUNIZATION Development of Rhesus antibodies: depends on factors: 1- Inborn ability to respond 2- protection
8. 1- If ABO is incompatible: Red blood cells is easily destroyed, so not reaching enough immunological
9. IgM antibodies 1. Cleared by Macrophage 2. Plasma stem cells The First Pregnancy is NOT Affected
10. Anti-D Macroph. antigen Presenting cell T- helper cell B cell Fetal Anemia Mother Placental Secondary Response
11. 2 - If ABO is compatible: Rh+ fetal cells ? remain in circulation (life span) until
13. Mild Cases: fetal (RBC) destruction ? from anti-D (IgG): ? anaemia ? compensating haemopoiesis ? excess
14. Rh ISOIMMUNIZATION Kleihauer-Betke technique: (acid elution test) - measure amount of feto-maternal haemorrhage If 0,1-0,25 ml
15. Rh ISOIMMUNIZATION Fetal and Neonatal Effects: Haemolytic anaemia of newborn Hb=14-18g/dl Icterus gravis neonatorum Hb=10-14g/dl Hydrops
16. MANAGEMENT OF Rh ISOIMMUNIZATION I) PROPHYLAXIS 1 - Prevention of Rhesus isoimmunization: Anti D (RhoD IgG)
17. MANAGEMENT OF Rh ISOIMMUNIZATION K-B test if large amount of leaking ? another SD if mother
18. MANAGEMENT OF Rh ISOIMMUNIZATION II) 1- Antibody Screening: for all pregnant women in ANC for irregular
19. MANAGEMENT OF Rh ISOIMMUNIZATION 2 - Management following detection of Rh antibodies Should be treated in
20. 3 - Amniocentesis: Should be performed under ultrasound guidance if titre > 1\16 = 0.5-1 ugm
21. CORDOCENTESIS
22. IU transfusion (cordocentesis, in the past intraperitoneal transfusion) versus delivery of the baby: Using Liley’s chart
23. LILEY’S CHART
24. WHITEFIELD’ ACTION LINE
25. MANAGEMENT OF Rh ISOIMMUNIZATION Alternatively follow up with Doppler study for the fetal middle cerebral artery
26. Intensive plasmaphoresis: when severe cases anticipated, using continous flow cell separator, as early as 12 wks
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Blood groups (1900):
Antigens: Antibodies:
O (45%) AntiA+Anti B
A (40%) Anti B
B (10%)

Anti A
AB (5%)
A and B : dominant
O : recessive

Rh ISOIMMUNIZATION

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Rhesus factor (1940):
Agglutinogen (C,D,E) - mainly D
C,D,E - dominant antigen
d,e -

recessive antigen

Rh ISOIMMUNIZATION

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Rh positive (85%) - homozygous (DD) (35%), or heterozygous (Dd) (50%)
Rh

negative (15%)
Incidence of Rh-ve in far east is about 1%
Examples of Rh factor: (CDe=R1) , (Cde=r) (cDE=R2)
Other systems:
kell-antikell,
luther,
Duffy, etc.

Rh ISOIMMUNIZATION

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Rh ISOIMMUNIZATION
So in response to introduction of foreign protein (antigen) ?

production of antibody to neutralize the antigen
In ABO and other non Rh-incompatibility: It usually causes mild anaemia, mainly as there is no intrapartum boosting
In Rhesus isoimmunization: mainly (D), but C, E can produce antibodies

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Rh ISOIMMUNIZATION
Feto-maternal haemorrhage: during pregnancy leakage of fetal cells in the

maternal circulation (Rh+ fetal cells in Rh- maternal circulation
Examples:
- Spontaneous abortion
- Induced abortion
- APH
- E.C.V.
- Cordocentesis, CVS, amniocentesis
- Severe preeclampsia
- Ectopic pregnancy
- Caesarean section
- Manual removal of placenta
- Silent feto-maternal hage

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Rh ISOIMMUNIZATION
Development of Rhesus antibodies: depends on factors:
1- Inborn ability to

respond
2- protection if ABO incompatible 1\10
3- Strength of Rh antigen stimumlus (CDe=R1)
4- Volume of leaking feta blood (0.25ml)
IgM (7 days) doesn’t cross placenta, then IgG 21 days - crosses placenta

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1- If ABO is incompatible:
Red blood cells is easily destroyed, so

not reaching enough immunological component to cause antibody response and reaction

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IgM antibodies
1. Cleared by Macrophage
2. Plasma stem cells
The First Pregnancy is

NOT Affected

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 Anemia
Mother
Placental
Secondary Response
Small amount
Rapid

IgG

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2 - If ABO is compatible:
Rh+ fetal cells ? remain in

circulation (life span) until removed by (R.E.S) ? destroyed ? liberating antigen (D) ? isoimmunization
It takes time:
1st pregnancy is almost always not affected:
1% - during labour or 3rd stage)
10% - 6 months after delivery
15% by the 2nd pregnancy

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Mild Cases:
fetal (RBC) destruction ? from anti-D (IgG): ? anaemia

? compensating haemopoiesis ? excess of unconjugated bilirubin
Severe Cases:
excessive destruction of fetal (RBC) ? severe anaemia ? hypoxia the tissues ? cardiac or circulatory failure ? generalized edema ? (H. failure) ? ascitis ? IUFD
When excess of unconjugated bilirubin > (310-350 mol/L) ? It passes brain barrier ? (kernicterus) ? permanent neurological and mental disorders

Rh ISOIMMUNIZATION

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Rh ISOIMMUNIZATION
Kleihauer-Betke technique:
(acid elution test) - measure amount of feto-maternal haemorrhage
If

0,1-0,25 ml of fetal blood leakes (critical volume) ? isoimmunization represented by 5 fetal cells in 50 low power microscopic field of peripheral maternal blood
So 1 ml is represented by 20 fetal cells

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Rh ISOIMMUNIZATION
Fetal and Neonatal Effects:
Haemolytic anaemia of newborn Hb=14-18g/dl
Icterus gravis neonatorum

Hb=10-14g/dl
Hydrops fetalis (Erythroblastosis fetalis)

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MANAGEMENT OF Rh ISOIMMUNIZATION
I) PROPHYLAXIS
1 - Prevention of Rhesus isoimmunization:

Anti D (RhoD IgG)
Standard dose for > 20 wks, and ½ standard dose for < 20 wks - given within 72hours of the incident
SD: i.m. injection: 500 iu = 100 ugm (UK),
1500iu = 300 ugm (USA)
1500iu = 300 ugm ? neutralize 15ml
500 iu = 100 ugm ? neutralize 5ml (4ml+1ml)
4ml = 4x20 f.cells = 80 fetal cells

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MANAGEMENT OF Rh ISOIMMUNIZATION
K-B test if large amount of leaking ?

another SD if mother is Rh-, baby Rh+ with no isoimmunization (checked by indirect or direct Coombs test)
2 - A.P. administration of anti-D
SD at 28 wks or at 28 and 36 wks will reduce Rh isoimmunization

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MANAGEMENT OF Rh ISOIMMUNIZATION
II) 1- Antibody Screening:
for all pregnant women in

ANC for irregular antibodies (mainly for Rh- women), then start at 20 wks , and every 4 weeks

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MANAGEMENT OF Rh ISOIMMUNIZATION
2 - Management following detection of Rh antibodies
Should

be treated in specialized centres
Quantitative measures of antibodies + husband genotype
Repeat titration (indirect Coombs, detecting of antibodies) titre or specific enzymes for antibodies IU
Amniocentesis once necessary
Obstetrical management based on timing of I.U. transfusion (now cordocentesis + fetoscopy) versus delivery

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3 - Amniocentesis:
Should be performed under ultrasound guidance if titre >

1\16 = 0.5-1 ugm ? 2.5-5 I.U
Timing: 1st amniocentesis - 10 weeks before previous IUFD
Start from 20-22 weeks, 2-4 weekly or more frequent if needed
Amniotic fluid analysis - spectrophotometry: optical density at the height of optical density deviation at wave length 450 nM

MANAGEMENT OF Rh ISOIMMUNIZATION

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CORDOCENTESIS

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IU transfusion (cordocentesis, in the past intraperitoneal transfusion) versus delivery of

the baby:
Using Liley’s chart
Prediction chart (Queenan curve)
Whitefield’s action line

MANAGEMENT OF Rh ISOIMMUNIZATION

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LILEY’S CHART

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WHITEFIELD’ ACTION LINE

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MANAGEMENT OF Rh ISOIMMUNIZATION
Alternatively follow up with Doppler study for the

fetal middle cerebral artery
Prognosis depends on:
obstetrical history
paternal genotype
maternal history (blood transfusion, antibody titre)
amniocentesis results
Delivery: Vaginal versus C-Section

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Intensive plasmaphoresis: when severe cases anticipated, using continous flow cell separator,

as early as 12 wks
Postnatal management: for the neonate:
Direct Coombs test, blood group, Rh type, Hb, bilirubin
Mild cases: phototherapy - correction of acidosis
Severe cases: exchange transfusion

MANAGEMENT OF Rh ISOIMMUNIZATION

Rhesus (rh) isoimmunization

Содержание

Blood groups (1900):Antigens: Antibodies:O (45%) AntiA+Anti BA (40%) Anti BB (10%)

Rhesus factor (1940):Agglutinogen (C,D,E) - mainly DC,D,E - dominant antigend,e -

Rh positive (85%) - homozygous (DD) (35%), or heterozygous (Dd) (50%)Rh

Rh ISOIMMUNIZATIONSo in response to introduction of foreign protein (antigen) ?

Rh ISOIMMUNIZATIONFeto-maternal haemorrhage: during pregnancy leakage of fetal cells in the

Rh ISOIMMUNIZATIONDevelopment of Rhesus antibodies: depends on factors:1- Inborn ability to

1- If ABO is incompatible: Red blood cells is easily destroyed, so

IgM antibodies1. Cleared by Macrophage2. Plasma stem cellsThe First Pregnancy is

Anti-DMacroph. antigenPresenting cellT- helper cellB cellFetal AnemiaMotherPlacentalSecondary Response Small amount Rapid

2 - If ABO is compatible:Rh+ fetal cells ? remain in

Mild Cases: fetal (RBC) destruction ? from anti-D (IgG): ? anaemia

Rh ISOIMMUNIZATIONKleihauer-Betke technique:(acid elution test) - measure amount of feto-maternal haemorrhageIf

Rh ISOIMMUNIZATIONFetal and Neonatal Effects:Haemolytic anaemia of newborn Hb=14-18g/dlIcterus gravis neonatorum

MANAGEMENT OF Rh ISOIMMUNIZATIONI) PROPHYLAXIS 1 - Prevention of Rhesus isoimmunization:

MANAGEMENT OF Rh ISOIMMUNIZATIONK-B test if large amount of leaking ?

MANAGEMENT OF Rh ISOIMMUNIZATIONII) 1- Antibody Screening:for all pregnant women in

MANAGEMENT OF Rh ISOIMMUNIZATION2 - Management following detection of Rh antibodiesShould

3 - Amniocentesis:Should be performed under ultrasound guidance if titre >

CORDOCENTESIS

IU transfusion (cordocentesis, in the past intraperitoneal transfusion) versus delivery of

LILEY’S CHART

WHITEFIELD’ ACTION LINE

MANAGEMENT OF Rh ISOIMMUNIZATIONAlternatively follow up with Doppler study for the

Intensive plasmaphoresis: when severe cases anticipated, using continous flow cell separator,

Похожие презентации

Blood groups (1900):
Antigens: Antibodies:
O (45%) AntiA+Anti B
A (40%) Anti B
B (10%)

Rhesus factor (1940):
Agglutinogen (C,D,E) - mainly D
C,D,E - dominant antigen
d,e -

Rh positive (85%) - homozygous (DD) (35%), or heterozygous (Dd) (50%)
Rh

Rh ISOIMMUNIZATION
So in response to introduction of foreign protein (antigen) ?

Rh ISOIMMUNIZATION
Feto-maternal haemorrhage: during pregnancy leakage of fetal cells in the

Rh ISOIMMUNIZATION
Development of Rhesus antibodies: depends on factors:
1- Inborn ability to

1- If ABO is incompatible:
Red blood cells is easily destroyed, so

IgM antibodies
1. Cleared by Macrophage
2. Plasma stem cells
The First Pregnancy is

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

2 - If ABO is compatible:
Rh+ fetal cells ? remain in

Mild Cases:
fetal (RBC) destruction ? from anti-D (IgG): ? anaemia

Rh ISOIMMUNIZATION
Kleihauer-Betke technique:
(acid elution test) - measure amount of feto-maternal haemorrhage
If

Rh ISOIMMUNIZATION
Fetal and Neonatal Effects:
Haemolytic anaemia of newborn Hb=14-18g/dl
Icterus gravis neonatorum

MANAGEMENT OF Rh ISOIMMUNIZATION
I) PROPHYLAXIS
1 - Prevention of Rhesus isoimmunization:

MANAGEMENT OF Rh ISOIMMUNIZATION
K-B test if large amount of leaking ?

MANAGEMENT OF Rh ISOIMMUNIZATION
II) 1- Antibody Screening:
for all pregnant women in

MANAGEMENT OF Rh ISOIMMUNIZATION
2 - Management following detection of Rh antibodies
Should

3 - Amniocentesis:
Should be performed under ultrasound guidance if titre >

MANAGEMENT OF Rh ISOIMMUNIZATION
Alternatively follow up with Doppler study for the