What is Rh sensitization during pregnancy. How does it occur. Who is at risk for Rh sensitization. How is Rh sensitization diagnosed. What are the prevention methods for Rh sensitization. How is Rh sensitization treated during pregnancy.

Understanding Rh Sensitization: A Crucial Aspect of Pregnancy

Rh sensitization is a critical issue that can affect pregnant women with Rh-negative blood type. This condition occurs when an Rh-negative woman’s immune system reacts to the Rh factor present in Rh-positive blood, potentially causing complications in future pregnancies. To fully grasp the importance of this topic, we need to delve deeper into its causes, risks, and management strategies.

The Mechanism Behind Rh Sensitization

Rh sensitization is fundamentally an immune response. When an Rh-negative individual’s blood comes into contact with Rh-positive blood, their immune system identifies the Rh factor as a foreign substance. In response, it produces antibodies to destroy this perceived threat. This process is particularly significant during pregnancy, as it can have serious implications for the developing fetus.

How does Rh sensitization occur during pregnancy?

During pregnancy, Rh sensitization typically happens when an Rh-negative mother carries an Rh-positive fetus. Although the mother’s and baby’s blood usually don’t mix until delivery, certain circumstances can lead to blood mixing earlier in the pregnancy. These situations include:

• Miscarriage
• Ectopic pregnancy
• Abdominal trauma
• Invasive prenatal testing procedures like amniocentesis or chorionic villus sampling (CVS)

It’s important to note that the first pregnancy with an Rh-positive fetus is usually not affected, as it takes time for the mother’s body to produce enough antibodies. However, subsequent pregnancies with Rh-positive fetuses can be at risk if the mother has been sensitized.

Identifying Those at Risk for Rh Sensitization

Understanding who is at risk for Rh sensitization is crucial for proper prenatal care and prevention. The primary risk factor is having Rh-negative blood type, but other factors come into play as well.

Who is most likely to experience Rh sensitization?

Rh sensitization during pregnancy can only occur under specific circumstances:

1. The mother must have Rh-negative blood
2. The baby must have Rh-positive blood
3. The mother’s and baby’s blood must come into contact

If both parents have Rh-negative blood, the baby will also be Rh-negative, eliminating the risk of sensitization. However, if the father is Rh-positive or his blood type is unknown, doctors typically treat the pregnancy as if the baby could be Rh-positive to err on the side of caution.

Diagnosing Rh Sensitization: Early Detection is Key

Early diagnosis of Rh sensitization is crucial for proper management and prevention of complications. Healthcare providers use specific tests to identify Rh status and potential sensitization.

What tests are used to diagnose Rh sensitization?

All pregnant women undergo blood tests at their first prenatal visit. These tests determine:

• The mother’s blood type (Rh-positive or Rh-negative)
• The presence of Rh antibodies (indicating sensitization)

For Rh-negative women who are not sensitized, additional tests may be performed:

• Repeat antibody test between 24 and 28 weeks of pregnancy
• Antibody test at delivery if the newborn has Rh-positive blood

For women who are Rh-sensitized, more intensive monitoring is required:

• Regular blood tests to check antibody levels
• Doppler ultrasound to assess blood flow to the baby’s brain
• Amniocentesis after 15 weeks to check the baby’s blood type and look for potential problems

Preventing Rh Sensitization: A Proactive Approach

Prevention is the cornerstone of managing Rh sensitization. Modern medical interventions have significantly reduced the incidence of this condition.

How can Rh sensitization be prevented?

The primary preventive measure for Rh sensitization is the administration of Rh immune globulin (such as WinRho). This treatment is highly effective when given at the appropriate times:

• Around the 28th week of pregnancy
• After delivery if the newborn is Rh-positive
• Following any event that could cause maternal-fetal blood mixing (e.g., amniocentesis, miscarriage, abdominal trauma)

It’s important to note that Rh immune globulin shots are only effective for a short period, so they must be repeated with each pregnancy. Additionally, they are not effective if sensitization has already occurred.

Treatment Options for Rh Sensitization

When Rh sensitization occurs, the focus shifts to managing the pregnancy and protecting the baby from potential complications.

What treatments are available for Rh sensitization during pregnancy?

Treatment approaches depend on the severity of the fetal anemia caused by Rh sensitization:

• Mild anemia: Close monitoring throughout pregnancy with more frequent testing
• Moderate to severe anemia: May require early delivery or intrauterine blood transfusions
• After birth: Some babies may need blood transfusions or treatment for jaundice

In all cases, pregnancies affected by Rh sensitization require specialized care, often involving a perinatologist (a doctor specializing in high-risk pregnancies).

The Impact of Rh Sensitization on Future Pregnancies

Understanding the long-term implications of Rh sensitization is crucial for family planning and managing subsequent pregnancies.

How does Rh sensitization affect future pregnancies?

Once a woman becomes Rh-sensitized, all future pregnancies with Rh-positive fetuses are at risk. The severity of complications tends to increase with each subsequent Rh-positive pregnancy. Potential issues include:

• Hemolytic disease of the newborn (HDN)
• Severe anemia in the fetus
• Jaundice in the newborn
• In extreme cases, stillbirth or neonatal death

However, with proper management and close monitoring, many women with Rh sensitization can still have successful pregnancies and healthy babies.

Advancements in Rh Sensitization Management

Medical science continues to make strides in understanding and managing Rh sensitization, offering hope for affected women and their families.

What new developments are emerging in Rh sensitization treatment?

Recent advancements in the field include:

• Improved non-invasive testing methods for fetal anemia, reducing the need for amniocentesis
• Refined techniques for intrauterine blood transfusions
• Research into more effective and longer-lasting Rh immune globulin formulations
• Exploration of gene therapy approaches to prevent Rh sensitization

These developments promise to further reduce the incidence and impact of Rh sensitization in the future.

Rh sensitization remains a significant concern in obstetric care, but with increased awareness, early detection, and proper management, its impact can be minimized. Pregnant women should discuss their Rh status with their healthcare providers early in pregnancy to ensure appropriate care and prevention strategies are implemented. By understanding the mechanisms, risks, and treatment options associated with Rh sensitization, expectant mothers can make informed decisions and take proactive steps to protect their health and the health of their babies.

As research continues and medical practices evolve, the outlook for managing Rh sensitization continues to improve. With ongoing advancements in prenatal care and fetal medicine, the goal of eliminating the complications associated with Rh sensitization becomes increasingly attainable. This progress not only benefits individual families but also contributes to overall improvements in maternal and fetal health outcomes worldwide.

It’s crucial for all pregnant women to receive comprehensive prenatal care, including blood type testing and appropriate Rh immune globulin administration when indicated. By following medical recommendations and staying informed about their Rh status, women can play an active role in preventing Rh sensitization and ensuring the best possible outcomes for their pregnancies.

The management of Rh sensitization exemplifies the importance of preventive care in obstetrics. It demonstrates how a relatively simple intervention – the timely administration of Rh immune globulin – can prevent a potentially serious complication. This approach serves as a model for other areas of prenatal care, emphasizing the value of proactive, evidence-based interventions in promoting maternal and fetal health.

As our understanding of Rh sensitization continues to grow, so too does our ability to manage this condition effectively. The collaboration between obstetricians, perinatologists, hematologists, and other specialists has led to a multidisciplinary approach to care that addresses all aspects of Rh sensitization. This comprehensive care model not only improves outcomes for affected pregnancies but also provides valuable insights that can be applied to other areas of maternal-fetal medicine.

Education plays a crucial role in managing Rh sensitization. Healthcare providers must ensure that all pregnant women understand their Rh status, the potential risks associated with Rh incompatibility, and the importance of following recommended preventive measures. This knowledge empowers women to make informed decisions about their care and to seek appropriate medical attention promptly if concerns arise.

The success in managing Rh sensitization also highlights the importance of ongoing research in obstetrics and fetal medicine. Continued investigation into the mechanisms of sensitization, improved diagnostic techniques, and novel treatment approaches will further enhance our ability to prevent and manage this condition. This research not only benefits those directly affected by Rh sensitization but also contributes to our broader understanding of maternal-fetal immunology and blood disorders.

As we look to the future, the goal of completely eliminating the complications of Rh sensitization seems increasingly achievable. With continued advancements in prenatal screening, preventive treatments, and fetal interventions, we can envision a time when Rh incompatibility no longer poses a significant threat to maternal and fetal health. This progress serves as a testament to the power of medical research and the importance of applying scientific knowledge to clinical practice.

In conclusion, Rh sensitization represents a unique challenge in obstetric care, but one that modern medicine has made significant strides in addressing. Through a combination of early detection, preventive measures, and advanced treatment options, the risks associated with Rh incompatibility have been dramatically reduced. As we continue to refine our approach to managing this condition, we move closer to ensuring that every pregnancy, regardless of Rh status, has the best possible chance for a healthy outcome.

Rh Sensitization During Pregnancy | HealthLink BC

Topic Overview

What is Rh sensitization during pregnancy?

If you are Rh-negative, your red blood cells do not have a marker called Rh factor on them. Rh-positive blood does have this marker. If your blood mixes with Rh-positive blood, your immune system will react to the Rh factor by making antibodies to destroy it. This immune system response is called Rh sensitization.

What causes Rh sensitization during pregnancy?

Rh sensitization can occur during pregnancy if you are Rh-negative and pregnant with a developing baby (fetus) who has Rh-positive blood. In most cases, your blood will not mix with your baby’s blood until delivery. It takes a while to make antibodies that can affect the baby, so during your first pregnancy, the baby probably would not be affected.

But if you get pregnant again with an Rh-positive baby, the antibodies already in your blood could attack the baby’s red blood cells. This can cause the baby to have anemia, jaundice, or more serious problems. This is called Rh disease. The problems will tend to get worse with each Rh-positive pregnancy you have.

Rh sensitization is one reason it’s important to see your doctor in the first trimester of pregnancy. It doesn’t cause any warning symptoms, and a blood test is the only way to know you have it or are at risk for it.

• If you are at risk, Rh sensitization can almost always be prevented.
• If you are already sensitized, treatment can help protect your baby.

Who gets Rh sensitization during pregnancy?

Rh sensitization during pregnancy can only happen if a woman has Rh-negative blood and only if her baby has Rh-positive blood.

• If the mother is Rh-negative and the father is Rh-positive, there is a good chance the baby will have Rh-positive blood. Rh sensitization can occur.
• If both parents have Rh-negative blood, the baby will have Rh-negative blood. Since the mother’s blood and the baby’s blood match, sensitization will not occur.

If you have Rh-negative blood, your doctor will probably treat you as though the baby’s blood is Rh-positive no matter what the father’s blood type is, just to be on the safe side.

How is Rh sensitization diagnosed?

All pregnant women get a blood test at their first prenatal visit during early pregnancy. This test will show if you have Rh-negative blood and if you are Rh-sensitized.

If you have Rh-negative blood but are not sensitized:

• The blood test may be repeated between 24 and 28 weeks of pregnancy. If the test still shows that you are not sensitized, you probably will not need another antibody test until delivery. (You might need to have the test again if you have an amniocentesis, if your pregnancy goes beyond 40 weeks, or if you have a problem such as abruptio placenta, which could cause bleeding in the uterus. )
• Your baby will have a blood test at birth. If the newborn has Rh-positive blood, you will have an antibody test to see if you were sensitized during late pregnancy or childbirth.

If you are Rh-sensitized, your doctor will watch your pregnancy carefully. You may have:

• Regular blood tests, to check the level of antibodies in your blood.
• Doppler ultrasound, to check blood flow to the baby’s brain. This can show anemia and how severe it is.
• Amniocentesis after 15 weeks, to check the baby’s blood type and Rh factor and to look for problems.

How is Rh sensitization prevented?

If you have Rh-negative blood but are not Rh-sensitized, your doctor will give you one or more shots of Rh immune globulin (such as WinRho). This prevents Rh sensitization in nearly all women who use it.

You may get a shot of Rh immune globulin:

• If you have a test such as an amniocentesis or chorionic villus sampling (CVS).
• If bleeding occurs during pregnancy.
• At time of miscarriage, induced abortion, ectopic or molar pregnancy.
• Trauma to the abdomen during pregnancy. 
• Around week 28 of your pregnancy.
• After delivery if your newborn is Rh-positive.

The shots only work for a short time, so you will need to repeat this treatment each time you get pregnant. (To prevent sensitization in future pregnancies, Rh immune globulin is also given when an Rh-negative woman has a miscarriage, abortion, or ectopic pregnancy. )

The shots won’t work if you are already Rh-sensitized.

How is it treated?

If you are Rh-sensitized, you will have regular testing to see how your baby is doing. You may also need to see a doctor who specializes in high-risk pregnancies (a perinatologist).

Treatment of the baby is based on how severe the loss of red blood cells (anemia) is.

• If the baby’s anemia is mild, you will just have more testing than usual while you are pregnant. The baby may not need any special treatment after birth.
• If anemia is getting worse, it may be safest to deliver the baby early. After delivery, some babies need a blood transfusion or treatment for jaundice.
• For severe anemia, a baby can have a blood transfusion while still in the uterus. This can help keep the baby healthy until he or she is mature enough to be delivered. You may have an early C-section, and the baby may need to have another blood transfusion right after birth.

In the past, Rh sensitization was often deadly for the baby. But improved testing and treatment mean that now most babies with Rh disease survive and do well after birth.

Cause

Rh sensitization can occur when a person with Rh-negative blood is exposed to Rh-positive blood. Most women who become sensitized do so during childbirth, when their blood mixes with the Rh-positive blood of their fetus. After being exposed, a mother’s immune system produces antibodies against Rh-positive red blood cells.

The minimum amount of blood mixing that causes sensitization is not known. Fortunately, Rh sensitization can almost always be prevented with the Rh immune globulin injection.

When an Rh-negative person’s immune system is first exposed to Rh-positive blood, it takes several weeks to develop immunoglobulin M, or IgM, antibodies. IgM antibodies are too large to cross the placenta. So the Rh-positive fetus that first triggers maternal sensitization is usually not harmed.

A previously Rh-sensitized immune system rapidly reacts to Rh-positive blood, as during a second pregnancy with an Rh-positive fetus. Usually within hours of Rh-positive blood exposure, smaller immunoglobulin G, or IgG, antibodies are formed. IgG antibodies can cross the placenta and destroy fetal red blood cells. This causes Rh disease, which is dangerous for the fetus.

Some Rh-negative people never become sensitized, even after exposure to large amounts of Rh-positive blood. The reason for this is not known.

Symptoms

If you are already Rh-sensitized or become Rh-sensitized while pregnant, you will not have any unusual symptoms.

Fetal problems from Rh sensitization are detected with Doppler ultrasound testing and sometimes with amniocentesis. It is possible, though, that a fetus with severe Rh disease will move less frequently than it did earlier in the pregnancy.

Other conditions with symptoms similar to Rh sensitization include other blood type incompatibility problems and fetal infections.

What Happens

If you are Rh-negative

Unless you are given Rh immune globulin just before or after a high-risk event, such as miscarriage, amniocentesis, abortion, ectopic pregnancy, or childbirth, you have a chance of becoming sensitized to an Rh-positive fetus’s blood.

If you have been Rh-sensitized in the past

If you have been Rh-sensitized in the past, you must be closely watched during any pregnancy with an Rh-positive partner, because your fetus is more likely to have Rh-positive blood. In response to an Rh-positive fetus, your immune system may quickly develop IgG antibodies, which can cross the placenta and destroy fetal red blood cells. Each subsequent pregnancy with an Rh-positive fetus may produce more serious problems for the fetus. The resulting fetal disease (called Rh disease, hemolytic disease of the newborn, or erythroblastosis fetalis) can be mild to severe.

• Mild Rh disease involves limited destruction of fetal red blood cells, possibly resulting in mild fetal anemia. The fetus can usually be carried to term and requires no special treatment but may have problems with jaundice after birth. Mild Rh disease is more likely to develop in the first pregnancy after sensitization has occurred.
• Moderate Rh disease involves the destruction of larger numbers of fetal red blood cells. The fetus may develop an enlarged liver and may become moderately anemic. The fetus may need to be delivered before term and may require a blood transfusion before (while in the uterus) or after birth. A newborn with moderate Rh disease is watched closely for jaundice.
• Severe Rh disease (fetal hydrops) involves widespread destruction of fetal red blood cells. The fetus develops severe anemia, liver and spleen enlargement, increased bilirubin levels, and fluid retention (edema). The fetus may need one or more blood transfusions before birth. A fetus with severe Rh disease who survives the pregnancy may need a blood exchange. This procedure replaces most of the infant’s blood with donor blood (usually type O, Rh-negative).
• A history of pregnancy with Rh disease is a sign that you will need special treatment when you are pregnant with an Rh-positive fetus.

If you have been Rh-sensitized in the past, an Rh-negative fetus cannot trigger an immune reaction.

What Increases Your Risk

Rh sensitization can occur when a person with Rh-negative blood is exposed to Rh-positive blood. During pregnancy, an Rh-negative woman can become sensitized if she is carrying an Rh-positive fetus.

Things that increase the risk of blood mixing and sensitization during pregnancy include:

• Delivery.
• Abdominal trauma, such as from a car crash.
• Abdominal surgery, such as a caesarean section.
• Abruptio placenta or placenta previa, both of which can cause placental bleeding.
• External cephalic version for a breech fetus.
• Obstetric procedures such as amniocentesis, fetal blood sampling, or chorionic villus sampling (CVS).
• Miscarriage (spontaneous abortion), ectopic pregnancy, or elective abortion (medical or surgical abortion) after 8 weeks of fetal age (when fetal blood cell production begins).
• Partial molar pregnancy involving fetal growth beyond 8 weeks.

Although rare, Rh sensitization has been known to occur after needle sharing between intravenous drug users. Transfusing Rh-positive blood in an Rh-negative person can also trigger sensitization. But this is extremely rare, because blood is always tested prior to transfusion.

When should you call your doctor?

If you are already Rh-sensitized and are pregnant

Your pregnancy will be closely watched. Discuss possible symptoms early in pregnancy with your doctor. You’ll need repeated tests to watch the fetus.

Call your doctor now if you note a decrease in your fetus’s movement after 24 to 26 weeks of pregnancy.

If you are Rh-negative

Call your doctor now if you:

• Think you may have been pregnant and miscarried.
• Are pregnant and may have injured your belly.

Examinations and Tests

If you are pregnant, you will have your first prenatal tests during your first trimester. Every woman has her blood tested at the first prenatal visit to see what her blood type is. If your blood is Rh-negative, it will also be tested for antibodies to Rh-positive blood. If you have antibodies, that means that you have been sensitized to Rh-positive blood. The antibodies can now kill Rh-positive red blood cells.

If you are Rh-negative and your partner is Rh-positive, your fetus is likely to be Rh-positive.

If you are pregnant or have miscarried, or if you have had an elective abortion, a partial molar pregnancy, or an ectopic pregnancy, you will need testing to see if you have been sensitized to Rh-positive blood.

If you are Rh-negative

All pregnant women have an indirect Coombs test during early pregnancy.

• At the first prenatal visit, your blood is tested to see if you have been previously sensitized to Rh-positive blood. If you are Rh-negative and test results show that you are not sensitized, a repeat test may be done between 24 and 28 weeks.
• If test results at 28 weeks show that you have not been sensitized, no additional tests for Rh-related problems are done until delivery (barring complications such as abruptio placenta). You will also have a shot of Rh immune globulin. This lowers your chances of being sensitized during the last weeks of your pregnancy.
• If your newborn is found to be Rh-positive, your blood will be screened again at delivery with an indirect Coombs test to see if you have been sensitized during late pregnancy or childbirth. If you have not been sensitized, you will have another shot of Rh immune globulin.

If you are sensitized to the Rh factor

If you are already Rh-sensitized or become sensitized while pregnant, close monitoring is important to determine whether your fetus is being harmed.

• If possible, the father will be tested to see if the fetus could be Rh-positive. If the father is Rh-negative, the fetus is Rh-negative and is not in danger. If the father is Rh-positive, other tests may be used to learn the fetus’s blood type. In some medical centres, the mother’s blood can be tested to learn her fetus’s blood type. This is a new test that is not widely available.
• An indirect Coombs test is done periodically during your pregnancy to see if your Rh-positive antibody levels are increasing. This is the typical course of treatment for most sensitized women during pregnancy.
• Fetal Doppler ultrasound of blood flow in the brain shows fetal anemia and how bad it is. At a medical centre with Doppler experts, this test can give you the same anemia information as amniocentesis, without the risks.
• Amniocentesis may be done to check amniotic fluid for signs of fetal problems or to learn the fetus’s blood type and Rh factor.
• Fetal blood sampling (cordocentesis) may be done to directly assess your fetus’s health. This procedure is used on a limited basis, usually for monitoring known sensitization problems (as when a mother has had previous fetal deaths, or when other testing has shown signs of fetal distress).
• Electronic fetal heart monitoring(non-stress test) may be done in the third trimester to check your fetus’s condition. Unusual fetal heart rhythms detected during a non-stress test may be a sign that the fetus has anemia related to the sensitization.
• Fetal ultrasound testing can be used as a pregnancy progresses to detect sensitization problems, such as fetal fluid retention (a sign of severe Rh disease).

Treatment Overview

If you are sensitized to the Rh factor

If your blood is Rh-negative and you have been sensitized to Rh-positive blood, you now have antibodies to Rh-positive blood. The antibodies kill Rh-positive red blood cells. If you become pregnant with an Rh-positive baby (fetus), the antibodies can destroy your fetus’s red blood cells. This can cause anemia.

If you are already Rh-sensitized and are pregnant, your treatment will focus on preventing or minimizing fetal harm and on avoiding early (preterm) delivery.

Treatment options depend on how well or poorly the fetus is doing.

• If testing shows that your fetus is Rh-positive but is only mildly affected by your Rh factor antibodies, you will be closely watched until your pregnancy reaches term. Your fetus will be delivered early only if his or her condition gets worse.
• If testing shows that your fetus is moderately affected by your Rh antibodies, your fetus’s condition will be closely watched until his or her lungs are mature enough for a preterm delivery. A caesarean section may be used to deliver the baby quickly or to avoid the difficulty of inducing labour before term. A moderately affected newborn sometimes needs a blood transfusion immediately after birth.
• If testing shows that your fetus is severely affected by your Rh factor antibodies, a blood transfusion may be given before birth (intrauterine fetal blood transfusion). This can be done through the fetus’s abdomen or directly into the fetus’s umbilical cord. A preterm delivery is likely to be needed. Multiple blood transfusions are sometimes needed to keep a fetus healthy until the fetal lungs mature enough to function after birth. Often a caesarean section is done to deliver the baby quickly. A blood transfusion is sometimes needed immediately after birth.

Prevention

If you are Rh-negative and pregnant

If you are an Rh-negative woman and you have conceived with an Rh-negative partner, you are not at risk of Rh sensitization during pregnancy. (Most health professionals treat all Rh-negative pregnant women as though the father might be Rh-positive.)

If you are already sensitized to the Rh factor, your pregnancy will need to be closely monitored to prevent fetal harm. For more information on fetal and newborn treatment, see Treatment Overview.

If you are unsensitized Rh-negative, treatment focuses on preventing Rh sensitization during pregnancy and childbirth. Rh immune globulin (such as WinRho) is a highly effective treatment for preventing sensitization.

• To prevent sensitization from occurring late in the pregnancy or during delivery, you must have a shot of Rh immune globulin around week 28 of your pregnancy. This treatment prevents your immune system from making antibodies against your fetus’s Rh-positive red blood cells.
• Rh immune globulin injection is also necessary if you have had an obstetric procedure such as amniocentesis or external cephalic version.
• If your newborn is Rh-positive, you are given Rh immune globulin again within 72 hours after delivery. By preventing Rh sensitization from delivery, you are protecting your next Rh-positive fetus.
• If your newborn is Rh-negative, sensitization cannot happen, and no treatment is needed.

Rh immune globulin is also needed within 72 hours after vaginal bleeding, a miscarriage, partial molar pregnancy, ectopic pregnancy, or abortion.

Medications

Use of Rh immune globulin is effective in preventing Rh sensitization. Rh immune globulin contains Rh antibodies that have been purified from human donors. This treatment prevents an unsensitized Rh-negative mother from making antibodies against her fetus’s Rh-positive blood.

If an affected fetus younger than 34 weeks needs to be delivered, corticosteroid medicine (betamethasone or dexamethasone) may be given to the mother to speed fetal lung development before a premature birth.

Other Treatment

An intrauterine fetal blood transfusion is sometimes used to supply healthy blood to a fetus with severe hemolytic disease of the newborn (also called Rh disease or erythroblastosis fetalis).

A blood transfusion or exchange transfusion is sometimes given to a newborn to treat severe anemia or jaundice related to Rh disease.

References

Other Works Consulted

• Fung K, Eason E (2003). Prevention of Rh alloimmunization. SOGC Clinical Practice Guidelines No. 133. Journal of Obstetrics and Gynaecology Canada, 25(9): 765–773. Also available online: http://www.sogc.org/guidelines/documents/133E-CPG-September2003.pdf.
• Moise KJ Jr (2008). Management of rhesus alloimmunization in pregnancy. Obstetrics and Gynecology, 112(1): 164–176.
• Roman AS (2013). Late pregnancy complications. In AH DeCherney et al., eds., Current Diagnosis and Treatment Obstetrics & Gynecology, 11th ed., pp. 250–266. New York: McGraw-Hill.

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Rh sensitization!

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1. What is Rh sensitization?
2. Treatment and prevention of Rh sensitization in pregnancy
3. Treatment of a child with Rh sensitization
4. Conclusion

1.

What is Rh sensitization?

If you are Rh negative, it means that your red blood cells do not have a special marker (Rh) on them. A positive Rh factor means you have it. If blood with different Rh factors is mixed, then blood with a negative Rh factor begins to produce antibodies. This immune reaction is called Rh sensitization.

Rh sensitization during pregnancy is a possible but uncommon problem. Rh sensitization occurs when an Rh-negative mother has an Rh-positive fetus. In most cases, the blood of the mother and child does not mix before delivery, however, in some cases this can happen. It takes time for the mother’s blood to develop antibodies, so the first child is usually relatively safe. If a mother is already carrying a second child with a positive Rh blood factor, then he is more likely to be negatively affected.

Rh sensitization during pregnancy can cause anemia, jaundice and even more serious problems in the baby. Therefore, all women are advised to visit a doctor in the first trimester of pregnancy to find out the risks associated with Rh sensitization.

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2. Treatment and prevention of Rh sensitization during pregnancy

Remember that Rh sensitization during pregnancy can always be prevented. If sensitization has already begun, then appropriate treatment will protect the child.

If the child’s mother is Rh negative and the father is Rh positive, the child is more likely to be Rh positive. If both parents are Rh negative, the child will also be Rh negative.

All pregnant women should have their blood type tested on their first pregnancy visit. If the mother has an Rh-negative blood type, and Rh sensitization has not begun, then the blood test will be repeated at 24-28 weeks of pregnancy. Additional analysis may also be needed after amniocentesis, if this procedure was performed. The child is tested for a blood type at birth, and if he has a positive Rh factor, then the mother is given an additional test for sensitization.

If Rh sensitization has already begun, the doctor will prescribe the following procedures for you:

• Regular blood tests to check for antibodies;
• Doppler sonography, to check the blood flow of the child’s brain. Doppersonography can reveal anemia;
• Amniocentesis at 15 weeks gestation to determine the baby’s Rh factor.

If you have Rh negative blood, your doctor may give you one or more injections containing Rh antibodies (Rh immune globulin). It prevents Rh sensitization during pregnancy at 99% of cases.

The shot only works for a short time, so it is given in the following cases:

• Before amniocentesis;
• At 28 weeks pregnant;
• After delivery, if you have an Rh-positive baby.

Rh antibodies will not work if Rh sensitization has already begun.

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3.

Treatment of a child with Rh sensitization

Treatment of a child depends on damage to red blood cells – anemia:

• If the anemia is mild, the child may not need special treatment;
• If the anemia is severe, the child is given a blood transfusion immediately after delivery, or even in utero.

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4.Conclusion

In the past, Rh sensitization was often fatal to a child. But at present, the level of medicine is such that Rh sensitization rarely occurs, and if it does, it is successfully treated. Prevention of Rh sensitization requires mandatory tests and frequent visits to the doctor.

Rhesus conflict. What is Rhesus conflict?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Rh-conflict – immunological incompatibility of the blood Rh factor of an Rh-negative mother and a Rh-positive fetus, characterized by sensitization of the mother’s organism. The cause of the Rh conflict is the transplacental penetration of fetal erythrocytes carrying a positive Rh factor into the bloodstream of an Rh-negative mother. Rhesus conflict can cause intrauterine fetal death, miscarriage, stillbirth and hemolytic disease of the newborn.

• Causes of Rh conflict
• Mechanism of development of Rhesus conflict
• Rh incompatibility symptoms
• Diagnosis of Rhesus conflict
• Treatment of Rh conflict
• Prevention of Rh conflict
• Prices for treatment

General

Rh-conflict can occur in women with a negative Rh during pregnancy or during childbirth, if the child has inherited a positive father’s Rh. The Rh factor (Rh) of human blood is a special lipoprotein (D-agglutinogen) in the Rh system, located on the surface of red blood cells. It is present in the blood of 85% of the human population who are Rh-positive Rh (+), and 15% of those without Rh factor belong to the Rh-negative Rh (-) group.

Rhesus conflict

Causes of Rh conflict

Isoimmunization and Rh-conflict are caused by the entry of Rh-incompatible blood of the child into the mother’s bloodstream and largely depend on the outcome of the first pregnancy in Rh (-) women. Rhesus conflict during the first pregnancy is possible if a woman has previously had a blood transfusion without taking into account Rh compatibility. The occurrence of the Rhesus conflict is facilitated by previous abortions: artificial (abortions) and spontaneous (miscarriages).

The entry of the baby’s umbilical cord blood into the mother’s bloodstream often occurs during childbirth, making the mother’s body susceptible to the Rh antigen and creating a risk of Rh conflict in the next pregnancy. The likelihood of isoimmunization increases with delivery by caesarean section. Bleeding during pregnancy or childbirth due to detachment or damage to the placenta, manual separation of the placenta can provoke the development of the Rhesus conflict.

After invasive prenatal diagnostic procedures (chorionic biopsy, cordocentesis or amniocentesis), Rh-sensitization of the mother’s body is also possible. In a pregnant woman with Rh (-), suffering from preeclampsia, diabetes, who had influenza and acute respiratory infections, there may be a violation of the integrity of the chorionic villi and, as a result, activation of the synthesis of anti-Rh antibodies. The cause of the Rh-conflict can be a long-term intrauterine sensitization of the Rh (-) woman, which occurred at her birth from the Rh (+) mother (2% of cases).

Mechanism of Rhesus conflict development

The Rh factor is inherited as a dominant trait, therefore, in Rh (-) mother with homozygosity (DD) Rh (+) of the father, the child is always Rh (+), which is why the risk of Rh conflict is high. In the case of heterozygosity (Dd) of the father, the chances of having a child with a positive or negative Rh are the same.

The formation of fetal hematopoiesis begins from the 8th week of intrauterine development, at this time, fetal erythrocytes in a small amount can be detected in the mother’s bloodstream. At the same time, the Rh antigen of the fetus is foreign to the mother’s Rh (-) immune system and causes sensitization (isoimmunization) of the mother’s body with the production of anti-Rh antibodies and the risk of Rhesus conflict.

Rh (-) sensitization of a woman during her first pregnancy occurs in isolated cases and the chances of her bearing with an Rh conflict are quite high, since the antibodies (Ig M) formed in this case have a low concentration, poorly penetrate the placenta and do not pose a serious danger to the fetus.

The likelihood of isoimmunization during delivery is greater, which can lead to Rh conflict in subsequent pregnancies. This is due to the formation of a population of long-lived immune memory cells, and in the next pregnancy, upon repeated contact with even a small amount of Rh antigen (no more than 0.1 ml), a large number of specific antibodies (Ig G) are released.

Due to the small size of IgG, they are able to penetrate the bloodstream of the fetus through the hematoplacental barrier, cause intravascular hemolysis of Rh (+) erythrocytes of the child and inhibition of the hematopoiesis process. As a result of the Rhesus conflict, a severe, life-threatening condition for the unborn child develops – hemolytic disease of the fetus, characterized by anemia, hypoxia and acidosis. It is accompanied by damage and an excessive increase in organs: the liver, spleen, brain, heart and kidneys; toxic damage to the central nervous system of the child – “bilirubin encephalopathy”. Without timely preventive measures taken, the Rh conflict can lead to intrauterine fetal death, spontaneous miscarriage, stillbirth, or the birth of a child with various forms of hemolytic disease.

Rh symptoms

Rhesus conflict does not cause specific clinical manifestations in a pregnant woman, but is detected by the presence of antibodies to the Rh factor in her blood. Sometimes the Rhesus conflict can be accompanied by functional disorders similar to preeclampsia.

Rhesus conflict is manifested by the development of hemolytic disease of the fetus, which, at an early onset, can lead to intrauterine death from the 20th to the 30th week of pregnancy, miscarriage, stillbirth, premature birth, as well as the birth of a full-term baby with an anemic, icteric or edematous form of this disease. Common manifestations of Rh-conflict in the fetus are: anemia, the appearance of immature erythrocytes in the blood (reticulocytosis, erythroblastosis), hypoxic damage to important organs, hepato- and spelenomegaly.

The severity of the manifestations of the Rh conflict can be determined by the amount of anti-Rhesus antibodies in the mother’s blood and the degree of maturity of the child. The edematous form of hemolytic disease of the fetus can be extremely difficult with an Rhesus conflict – with an increase in the size of the organs; pronounced anemia, hypoalbuminemia; the appearance of edema, ascites; thickening of the placenta and an increase in the volume of amniotic fluid. With an Rhesus conflict, fetal dropsy, edematous syndrome of the newborn, an increase in the weight of the child by almost 2 times can develop, which can lead to death.

A small degree of pathology is observed in the anemic form of hemolytic disease; the icteric form is expressed by icteric coloration of the skin, enlargement of the liver, spleen, heart and lymph nodes, hyperbilirubinemia. Bilirubin intoxication in Rhesus conflict causes damage to the central nervous system and is manifested by the lethargy of the child, poor appetite, frequent regurgitation, vomiting, reduced reflexes, convulsions, which can subsequently lead to a lag in his mental and mental development, hearing loss.

Diagnosis of Rhesus conflict

Diagnosis of Rh-conflict begins with determining the Rh-affiliation of a woman and her husband (preferably even before the onset of the first pregnancy or at its earliest possible date). If the future mother and father are both Rh negative, there is no need for further examination.

For the prediction of Rh-conflict in Rh (-) women, data on blood transfusions performed in the past without taking into account Rh-affiliation, previous pregnancies and their outcomes (the presence of spontaneous miscarriage, honeybort, intrauterine fetal death, the birth of a child with hemolytic disease) are important, which may indicate possible isoimmunization.

Diagnosis of the Rh conflict includes the determination of the titer and class of anti-Rh antibodies in the blood, which is carried out during the first pregnancy for women who are not sensitized for Rhesus – every 2 months; sensitized – up to 32 weeks of gestation every month, from 32-35 weeks – every 2 weeks, from 35 weeks – weekly. Since there is no direct relationship between the degree of damage to the fetus and the titer of anti-Rh antibodies, this analysis does not give an accurate idea of ​​the state of the fetus in Rhesus conflict.

To monitor the condition of the fetus, an ultrasound examination is performed (4 times in the period from 20 to 36 weeks of pregnancy and immediately before childbirth), which makes it possible to observe the dynamics of its growth and development. In order to predict the Rh conflict, ultrasound evaluates the size of the placenta, the size of the fetal abdomen (including the liver and spleen), reveals the presence of polyhydramnios, ascites, and dilated veins of the umbilical cord.

Conducting electrocardiography (ECG), fetal phonocardiography (FCG) and cardiotocography (CTG) allows the gynecologist who manages pregnancy to determine the degree of fetal hypoxia in Rh conflict. Important data are provided by prenatal diagnosis of Rhesus conflict using the methods of amniocentesis (examination of amniotic fluid) or cordocentesis (examination of umbilical cord blood) in dynamics under ultrasound control. Amniocentesis is carried out from 34 to 36 weeks of pregnancy: in the amniotic fluid, the titer of anti-Rh antibodies, the sex of the unborn child, the optical density of bilirubin, and the degree of maturity of the lungs of the fetus are determined.

Accurately determine the severity of anemia in Rhesus conflict allows cordocentesis, which helps to determine the blood type and Rh factor by the cord blood of the fetus; levels of hemoglobin, bilirubin, serum protein; hematocrit, reticulocyte count; antibodies fixed on fetal erythrocytes; blood gases.

Treatment of Rh conflict

To alleviate the Rh conflict, all Rh (-) pregnant women at 10-12, 22-24 and 32-34 weeks of gestation are given courses of non-specific desensitizing therapy, including vitamins, metabolic agents, calcium and iron preparations, antihistamines, oxygen therapy. At a gestational age of more than 36 weeks, in the presence of Rh-sensitization of the mother and a satisfactory condition of the fetus, self-delivery is possible.

If a serious condition of the fetus is noted during the Rhesus conflict, a planned caesarean section is performed for a period of 37-38 weeks. If this is not possible, an intrauterine blood transfusion through the umbilical vein is performed under ultrasound control, which makes it possible to partially compensate for the effects of anemia and hypoxia and prolong the pregnancy.

With Rhesus conflict, it is possible to prescribe pregnant plasmapheresis in the second half of gestation in order to reduce the titer of antibodies to Rh (+) erythrocytes of the fetus in the mother’s blood. With a severe degree of hemolytic damage to the fetus, immediately after childbirth, the child undergoes a replacement transfusion of one-group Rh-negative blood or plasma or group I erythrocyte mass; begin treatment of hemolytic disease of the newborn.

Within 2 weeks after birth, breastfeeding of a child with signs of hemolytic disease is not allowed, so as not to worsen the condition of the baby. If, with a Rh-conflict, the newborn does not have symptoms of this disease, then after an injection of anti-Rhesus immunoglobulin to the mother, breastfeeding is carried out without restrictions.

Prevention of Rh conflict

To avoid very serious consequences for a child with an Rh-incompatible pregnancy, the primary task in gynecology is to prevent the development of Rh-immunization and Rh-conflict. Of great importance for the prevention of Rh – conflict in Rh (-) women is taking into account Rh compatibility with a donor during blood transfusion, the obligatory preservation of the first pregnancy, and the absence of a history of abortions.

An important role in the prevention of Rh-conflict is played by pregnancy planning, with the examination of a woman for a blood group, Rh-factor, for the presence of anti-Rh antibodies in the blood. The risk of developing a Rh conflict and the presence of antibodies to Rh in a woman’s blood is not a contraindication to pregnancy and a reason for its termination.

Specific prevention of Rh conflict is an intramuscular injection of anti-Rhesus immunoglobulin (RhoGAM) from donor blood, which is given to women with Rh (-) who are not sensitized to the Rh antigen. The drug destroys Rh (+) erythrocytes, which may have entered the woman’s bloodstream, thereby preventing her isoimmunization and reducing the likelihood of Rh conflict. For the high effectiveness of the preventive action of RhoGAM, it is necessary to strictly observe the timing of the drug administration.

The introduction of anti-Rh immunoglobulin Rh (-) to women for the prevention of Rhesus conflict is carried out no later than 72 hours after transfusion of Rh (+) blood or platelet mass; artificial termination of pregnancy; spontaneous miscarriage, surgery associated with ectopic pregnancy. Anti-Rh immunoglobulin is prescribed to pregnant women at risk of Rhesus conflict at 28 weeks of gestation (sometimes again at 34 weeks) to prevent fetal hemolytic disease. If a pregnant woman with Rh (-) had bleeding (with placental abruption, abdominal trauma), invasive manipulations were performed with the risk of developing an Rh conflict, anti-Rhesus immunoglobulin is administered at the 7th month of gestation.

In the first 48 – 72 hours after delivery, in the case of the birth of a Rh (+) child and the absence of antibodies to Rh in the mother’s blood, the injection of RhoGAM is repeated. This avoids Rh sensitization and Rh conflict in the next pregnancy. The effect of immunoglobulin lasts for several weeks, and with each subsequent pregnancy, if there is a chance of the birth of an Rh (+) child and the development of an Rh conflict, the drug must be administered again. For Rh (-) women already sensitized to the Rh antigen, RhoGAM is not effective.

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Sources

1. self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests.