DR.E.ZAREAN

 First demonstrated by testing human blood with rabit anti sera against red cells of Rhesus monkey & classifying Rh negative & Rh positive.  However the underlying biochemical genetics is not well understood and the genotyping & phenotyping remains little confused.  The genotype is determined by the inheritance of 3 pairs of closely linked allelic genes situated in tandem on chromosome 1 & named as D/d, C/c, E/e (Fisher- Race theory)

 Rh Negative Women Man Rh positive (Homo/Hetero)    Fetus   Rh Neg Fetus No problem Rh positive Fetus   Rh+ve R.B.C.s enter Maternal circulation  Mother previously sensitized Secondary immune response   ? Iso-antibody (IgG)  Non sensitized Mother Primary immune response  Fetus  unaffected, 1 st Baby usually escapes. Mother gets sensitised?   Fetus Haemolysis   ?

 Chances of T.P.H/F.M.H. are only 5% in 1st trimester but 47% in 3rd trimester, many conditions can increase the risk.  Chances of primary sensitization during 1st pregnancy is only 1-2%, but 10 to 15% of patients may become sensitized after delivery.  ABO incompatibility and Rh non-responder status may protect.  Amount of antibodies that enter the fetal circulation will determine the degree of haemolysis

HAEMOLYSIS  IN UTEROAFTER BIRTH  BILLIRUBIN  ANAEMIA   MAT. LIV NO EFFECT   HEPATIC ERYTHROPOESIS & DYSFUNCTION  PORTAL & UMBILICAL VEIN HYPERTNSION, HEART FAILURE       BIRTH OF AN AFFECTED INFANT - Wide spectrum of presentations. Rapid deterioration of the infant after birth.May contiune for few days to few months. Chance of delayed anaemia at 6-8 weeks probably due to persistance of anti Rh antibodies.  Jaundice Kernicterus Hepatic Failure  DEATH ERYTHROBLASTOSIS FETALIS    IUD     

 Amniocentesis; CVS  Threatened abortion, previa, abruption  Trauma to abdomen  External cephalic version  Multiple pregnancies  Cesarean delivery  Fetal death  Percutaneous umbilical blood sampling  Manual removal of placenta  Hydatidiform mole  EP

 Premarital counseling? Ambitious?  Blood grouping must for every woman, before 1st pregnancy.  Rh+ve Blood transfusion- 300mcg Immunoglobulin (minimum).  Proper management of unsensitised Rh negative pregnancies.

 Blood typing at 1st visit, If negative :husband’s typing. If husband is also negative then no treatment  If husband is positive, if possible, Homo/Hetero?  Do Indirect Coomb’s test of mother –  Negative-good.  Repeat ICT at 28 weeks – Negative : 300mcg Rh immunoglobulin  Positive  Sensitised.

 If Rh positive(neonate)- Test mother’s blood for ICT & Infant’s for DCT Negative or weakly reactive- 300mcg immunoglobulin. Positive – Sensitised–Hb & Bilirubin Estimation of the infant -Treat the infant.

Schedules  First trimester - 50 μ g RhIgG  Amniocentesis μ g RhIgG  Antepartum bleeding If first trimester - 50 μ g RhIgG If third trimester μ g RhIgG Postpartum 300 μ g RhIgG

 Causes of sensitization- Misinterpretation of maternal Rh type Rh +ve blood transfusion Unprotected preg. & labour Inadequate dose / improper use of IgG on previous occasions Immunization to cross-reacting antigen

 Careful planning during antepartum, intrapartum & neonatal period  Father’s blood type & Rh antigen status  Knowledge of maternal antibody titer to the specific antigen  Intrauterine foetal monitoring with repeated ultrasound examination, cordocetesis / amniocentesis

 Fetus Rh Negative: - Observation  Fetus Rh Positive: - Intrauterine transfusion of ‘Rh Neg’ blood as indicated Timely delivery any time after 32 weeks Management of the infant up to 8 weeks  In cases of severely sensitized women, consider medical termination of pregnancy and sterilization.

 Anemia  Erythroblastosis fetalis Ascites Heart failure Pericardial effusion

 Maternal antibody titer negative - do serial antibodies  If titer low - little risk of anemia  If > 1:16 - perform amniocentesis and/or Doppler assessment ∆OD450 plot on Liley curve Zone I - Rh negative or fetus mildly affected Zone II - moderately affected Zone III - high risk for IUFD

Serial sonograms  Early signs Thickened placenta Liver span Increased umbilical vein diameter Increased blood velocities in UV, aorta and middle cerebral artery  Severe disease - scan every week if hydropic changes. If hydropic changes, consider fetal transfusion.

Intraperitoneal :  First done in 1963  Instill blood through needle or epidural catheter  Volume to transfuse = (G.A.-20) x 10ml  Generally, repeat in ~ 10 days, then every 4 wk.  Risk of death about 4% per procedure  Not effective in hydropic fetus  Some advocate combined approach (IPT and IVT)

Intravascular :  Goal is to have post-transfusion Hct 40-45%  Can infuse about 10 ml/min  Estimate requirement based on EFW and pre-transfusion Hct  Repeat in 1 wk., then about every 3 wk.  Hct falls about 1%/day  Goal: keep Hct > 25%  Smaller volumes, therefore more procedures compared to IPT  Fetal loss about 1.5% per procedure