Rheusus iso-Immunization L2 . Management of sensitized Rh-ve pregnant : The aim of the management is to : detect the fetal affection earlier and detect its severity ( mild , moderate , severe anemia ) , it deal with it either by intrauterine therapy , or postnatally and timing the delivery to reduce fetal mortality and morbidity .

Management 1. Mildly affected fetus : we do the following : maternal plasmaphoresis , early preterm delivery (≥ 34 wks ) + intensive neonatal care ( photo therapy ,etc 2. Moderate to sever affection managed in a specialized center need follow up closely : A- If gestational age > 34 wks : ( mature lung ) by ( L/S ratio ) delivery and neonatal care ( investigation , exchange transfusion , especially if the Hb% is low ( < = 5g/dl ) . B- If GA < 34 wks gestation : especially if there is a history of previous severely affected pregnancy ( hydrops or IUD , stillbirth … etc ) intrauterine management and close follow up

Follow up 1. a non invasive methods : A- high resolution U/S : Sonographic finding predicting sever anemia and preceeding hydrops fetalis : 1. Increase amniotic fluid index . 2. Increase liver and spleen ( length and thickness 3. Increase placental thickness ( oedematous ) 4. Increase bowel echogenicity . 5. Increase cardiac biventricular diameter . B- Doppler study of fetal middle cerebral artery&CTG

Follow up 2- Invasive methods : 1. Amniotic fluid spectrophotometry - The result is potted on a spectrophotometric * The Queenan chart ( curve ) *graph called ( Liley graph ) 2- Cordocentesis

Liley chart

Management Transfusion in Rh iso- immunization ( either intra or extra-uterine ) Is life live saving in a severely anaemic fetus that is too premature for delivery to be contemplated.The aim is to restore Hb levels ,reversing or preventing hydrops or death.It will suppress fetal erythropoesis

Blood transfusion : fresh group O , Rh-ve densely packed red blood cells (Hb around 30 g/L), CMV-ve , washed , compatible to mother blood , irradiated blood ( to decrease the risk of graft versus host disease ) .

Routes A- Fetal intraperitoneal : B- Intravascular transfusion : needle inserted into the umbilical vein at the point of the cord insertion or intrahepatic vein or into the fetal heart .

Other methods of Management : Maternal plasmaphoresis Phenobarbital

New techniques for evaluation fetal Rh status Amnicocentesis : To test fetal blood types in cases of a heterozygous paternal genotype ( by polymerase chain reaction test ) Fetal blood type by chorionic villous sampling Flow cytometry

Mode of Delivery :   * If intervention is indicated > 35 wks gestation induction of labour ( if no contraindication for obstetric cause ) . * If < 32 wks C/S . * There is a low threshold for C/S All babies born to Rhesus –ve women should have cord blood taken at delivery for a blood count , blood group &indirect Coomb,s test .