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, Mumbai


Background• Incidence of Rh neg individuals

varies with race

• Caucasians (whites) 15%• Afro-Carribeans (blacks) 7-8%• Asians 5%• Chinese and Japanese 1%


What is the Rhesus factor?• It is a Red blood cell

antigen• Other Red cell

antigens include -• A, B – blood groups• Duffy, Kell, Kidd


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

genotypeRh positive Rh neg


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


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


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


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


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’


Rh Sensitised Pregnancy


Middle Cerebral Artery


MCA Doppler- Rhesus isoimmunisation


MCA Doppler- IUGR


Rh Sensitised Pregnancy - 2


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


Amniotic fluid ODD 450


Intrauterine blood transfusion


Overshoot - prepathological


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


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


Neonatal Management• Commonly need

Phototherapy• May need Exchange

Transfusion• Bone marrow suppressed

if IUT• Anemia – blood transfusion • Haematinics long term• Good long term outcome


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


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


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


Profile• Total Pregnancy Care is an online guide for pregnancy, childbirth and motherhood related information.

Women wanting to conceive, pregnant women, expecting parents, and new mothers can use this pregnancy portal for a healthy pregnancy, fulfilling childbirth and joyful motherhood. With pregnancy at its core, this portal covers various important aspects and especially addresses those matters that the Indian Woman always wanted to know but did not know whom to ask.

• This website is compiled by Dr. Shantala, an Indian Obstetrician and Gynaecologist. She has over 20 years of extensive medical and diagnostics experience in areas commonly related to the Maternity and Pregnancy fields. She has studied and practiced in India as well as in the United Kingdom and thus brings about the fusion of best practices of the Oriental East and the Progressive West.

• A mother of three children, she has complete understanding of the emotional, mental and physical needs of the New Age Pregnant Woman. Her patients appreciate her empathic approach and wholeheartedly express their gratitude for her generosity and care. Dr.Shantala is presently a full time Obstetrics and Gynaecology Consultant at the Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, a premier health care initiative of the Reliance ADA Group. Dr.Shantala has a clear vision to promote a holistic pregnancy approach and her mission is to provide comprehensive maternity care. This website, www.TotalPregnancyCare.com, is her first step towards this future.


Services Offered• Pre-pregnancy counseling • Genetic counseling • Antenatal care, Labour Delivery • Specialist Ultrasound scans

– Viability scan – The First trimester scan / Nuchal translucency scans – Detailed anatomy / anomaly scans – Fetal Echocardiograph – 3D / 4D scans

• Assessment of the High risk Fetus and Mother • Amniocentesis • Chorionic Villous sampling • Cordocentesis • Intra-uterine transfusions • Embryo Reduction / Selective fetocide • Second opinion scans


Topics covered

• Pre-Conception– Working on getting pregnant or just starting to think about a family, this is

the place for you

• Pregnancy– From trying to conceive to the first trimester to labor, learn what to

expect during your pregnancy and more

• Labor Delivery– From that first contraction to the final push, here's what to expect

during labor and delivery

• Post-Pregnancy– Learn more about your diet and workouts, shopping, feeding and your

child's health


Interactive Corner

• Month by Month happenings• Articles• FAQs• Gestation Calendar


Society Memberships• British Maternal & Fetal Medicine Society • Fetal Medicine Centre• Kokilaben Dhirubhai Ambani Hospital &

Medical Research Institute• Royal College of Obstetricians and

Gynaecologists• International Society of Ultrasound in

Obstetrics and Gynecology


Contact Us

• Email: [email protected]• Mobile: +91 9324304212• KDAH Board line: +91 22 30999999


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Documents

Management of the Rhesus Negative Mother