1. RHESUS HAEMOLYTIC DISEASE OF THE NEWBORN (RhDN)
Dr Graeme Woodfield
Hon. Clinical Assoc. Professor
Molecular Medicine and Pathology
The University of Auckland
NEW ZEALAND
Salaam. I want to talk about a disease which was one of our biggest worries in the 50’s and 60’s.

2. FROM WOE TO WONDER!
Alternative title. Woe indicates sadness that even affected those of us who were laboratory based. As we did the many tests required we became familiar with the names of the women who were in very difficult situations with regard to Rh disease.

3. FROM WOE TO WONDER
The diagnosis, treatment and prevention of Rhesus HDN represents a major advance in neonatal medicine.
Still much to learn and do.
Particularly in countries where there are many Rhesus negative women..such as Iran.
In Western countries Rh disease has been largely controlled through immunization but not eliminated.
In India and parts of the Middle East there is still much to do. In Libya where I worked for 3 years , many cases of “viral hepatitis in newborn”…was actually unrecognized Rh disease!

4. I must be almost a dinosaur by now as I have lived through the entire era of woe and wonder of Rh disease.
DINOSAURS

5. 80
It is 80 years , this year from where we started the journey from discovery to prevention of Rh (D) Disease.
Years

6. 1937-2017 1937..Discovery of Anti-Rh 1939..First report of RhDN
1946..First exchange transfusion for RhDN
Coombs Test (antihuman globulin test)
Let me take you through this interesting history with some key dates

7. HISTORY of discovery of the Rhesus blood type
1937. Rhesus monkey cells injected into a rabbit to produce an antibody (Landsteiner and Wiener). Named the Rhesus factor (anti LW).
1939 First patient noted with haemolytic disease of the newborn later to be shown to be very similar to the 1937 Anti-Rh.
Landsteiner and Wiener , the former having discovered the ABO groups in 1902, made key observations on what would be the Rh System. Almost got called the LW system.

8. Rhesus Monkey
The hero who started it all

9. History
1960 Foetal cells recognized in maternal blood (Finn). Antibody designated as Anti-D.
Other antibodies in Rhesus system identified (C,c. E, e)
Antibodies outside Rhesus system could also cause HDN (Kell, Duffy, M, Kidd)
Not clear in early days what the process of immunisation was due to . Not until FINN developed an elaborate method to identify foetal cells that the mechanism became evident. Th eCoombs test was the key in identifying many more antibodies that could cause HDN. Fortunately not many of these antigens are strongly immunogenic. But they can occur particularly in women who seem to be ”high responders” to immune stimulation.

10. History
1960 Use of Anti-D Immunoglobulin as an immunoprophylaxis against RHDN proposed. (Pollack)
1963 First Intrauterine transfusion (Liley)
1964 First use of Anti-D IG (Gorman), followed by international trial.
1968 Final approval of vaccine.
This was a novel approach but it was not until 1964 that it was used clinically for the first time. In 1963 Liley first used IUT and we are honoured to have his daughter here today who now knows much more about this subject than I do !

11. Rh(D) HDNB
In Rh (Rh D) negative women, with Rh(D) positive husband or partner. Child will be Rh D positive.
Anti-D antibodies develop in the mother due to transfusion, injection or leakage of Rh positive red cells into the maternal circulation.
Antibodies cross placenta and attack foetal Rh(D) positive cells.
Hardly need to explain this to you . Except to point out the dangers of inappropriate transfusions in any female, even the very young. Mistakes still happen . My own experience with technical staff indicates that even in well-run blood services mistakes occur that can be very serious for women..

12. Erythroblastosis foetalis
Haemolysis
Anaemia
Heart failure (Hydrops foetalis)
Erythroblasts (immature red cells) in circulation
Hepato-splenomegaly
The title is forbidding but very descriptive

13. BlOOD GROUP CAUSES OF HDNB
ABO HDNB (Common)
Anti-D
More than 50 different blood group antibodies implicated in HDNB
Anti-c, anti-e, anti-E, anti-Kell, anti Duffy, Anti Kidd, anti M, all can cause HDNB but uncommon.
ABO HDN will be the commonest form of HDN in Iran , Fortunately , seldom serious, often overlooked.

14. Complications in infant with RhDNB
Heart failure and death in utero
Hyperbilirubinaemia
Kernicterus with brain damage
Hepato-splenomegaly
May be neutropenia and thrombocytopenia
First pregnancy spared. Progressively more severely affected infants but not inevitable. Desperation of some women to have a baby and this is why IUT was such a landmark discovery .

15. Auckland, New Zealand
Not as big as Milad Tower. Population 1.5 million. 1/3 population of NZ.

16. National Womens’ Hospital Auckland
Reference Centre for New Zealand on Womens’ health

17. Antenatal Screening for blood group antibodies in NZ
All women screened in early pregnancy .
More frequent testing if an antibody detected.
Indentification and level of antibody measured.
Mixed antibodies are a problem requiring specially typed units of blood for the infant.

18. Rhesus Committee
History of Rh (D) negative mothers, Rh group of father
Measurements of maternal antibody titre
Amniocentesis with evaluation of amniotic fluid by spectrophotometer.
Decision as to when to induce delivery of the baby.
This committee was the key to co-ordinating all specialists involved with the disease..obstetricians, paediatricians, nursing, blood transfusion, researchers, physiologists, pathologists. Management was individualised with many meetings to discuss patients situation in detail.

19. Dr.William Liley Many publications.
Use of Liley curve in determining when to induce Rh affected infants.
Expert in neonatal and perinatal medicine.
Had travelled widely
Decisions on Management made based on type of antibody and its concentration, exchange transfuions at birth. Early induction of delivery. Liley introduced spectrophotometric analysis of amniotic fluid to assess degree of anaemia of the infant. Amniocentesis carried out frequently which was not without risks

20. 1963 My story!
Training in Pathology. Training in blood group serology.
Autopsies at NWH, Auckland.
Many hydropic babies.
Rhesus and perinatal Committees
AS a trainee I was learning the different aspects of Rh disease. Assigned to do autopsies

21. Autopsy room August 1963
Dr ‘Bill’ Liley arrives with other Doctors (2 occasions)
Minute examination of liver, spleen and bowel for any damage
Puzzle for me!
First successful intra-uterine transfusion performed with live baby, Sept 1963
I was Trainee Pathologist and allocated to carry out autopsies on infants who had died because of Rh disease. Not popular job.

22. Intrauterine Transfusion (IUT)
Concentrated Rh negative red cells injected into peritoneal cavity of baby while it is still in the uterus, under radiographic guidance; red cells are absorbed by lymphatics into circulatory system
Correction of anaemia..prolongation of pregnancy until infant can be delivered safely. Multiple transfusions often needed.
Now intravascular umbilical cord transfusion (1981)
Major changes. Amazing that transfusion can now be given directly into developing baby through a blood vessel.

23. . Sir William Liley’s original procedures
1963
First successful Intra peritoneal (uterine) transfusion
Sir Willian or Bill as we knew him was a private man but an enthusiastic researcher and charismatic teacher who was not afraid to try things and wasnot fetted by the complexities of todays bureacratic grant and ethics application procedures.
His experimental work and approach to the fetus changed the course of fetal medicine and surgery
Professor Sir William Liley

24. How did Liley develop the idea of an intra-uterine transfusion?
A geneticist visited NWH in early 1960’s and outlined her experience of intra peritoneal transfusion of red cells in neonates with sickle cell disease. Also intra peritoneal transfusions are not uncommon in young children in some tropical countries where malaria is prevalent.
Liley considered he could try the same procedure with infants in utero.
Association and amalgamation of ideas.

25. History of foetal transfusion
Procedure fraught with technical difficulties
Gradually improved procedures
Much later high resolution ultrasound guided transfusion through the intrahepatic portion of the foetal umbilical vein.
Astonishing procedure with good safety margin. Now reserved for a very small minority of Rh affected babies

26. SIR WILLIAM (Bill)LILEY (1929-83)
Distinguished career in NZ schools and Universities
Became physiologist
Professor in Perinatal Physiology, National Womens Hospital, Auckland
Development of Liley Curve using spectroscopy of amniotic fluid
1963 IUT development
Improved perinatal mortality in NZ
1973 Knighthood
Friend of many including myself

27. Another major advance in 1964
Development of Rhesus AntiD hyperimmune immunoglobulin(RhDIg).
Revolutionary in prevention of Rh(D) immunization if used appropriately.
Excitement remembered.

28. ANTI-D Ig First used in 1964 In Canada
Widespread use in USA and UK in 1968
Used first in NZ in Scotland in 1967.
Antenatal use in some countries eg Australia.
Commercial availability from USA and Canada.
Supply programme . Australian source from one highly immunized donor

29. ANTI-D HYPERIMMUNE IMMUNOGLOBULIN
Plasma obtained from Rh negative Anti-D immunised mothers or from RH negative men immunized with Rh(D) positive red cells.
Plasmapheresis of immunized donors often performed
Pools of plasma fractionatedby Cohn alcohol process to produce immunoglobulin.
Supply problems with decrease of suitable donors

30. 1966-67 EDINBURGH (my story!) Pilot fractionation plant in laboratory
Production of Anti-D Immunoglobulin
Eventual formation of Scottish blood fractionation facility
We did plasma fractionation in large glass carboys (bottles) in the cold rooms of the laboratory . Really was pilot fractionation programme for the development of a Scottish blood Fractionation facility.

31. Auckland
Extensive plasmapheresis of immunized blood donors to provide sufficient Anti-D containing plasma for fractionation to Anti-D Immunoglobulin.
Contract processed for NZ by CSL in Melbourne Australia
NZ self sufficient for plasma products.
Back in Auckland, recruitment of previously immunized female and male donors. Contract processing by very large fractionation facility.

32. RhDNB Still remains a problem despite immunoprophylaxis.
Missed or too lower dose of RHDIG, red cell immunization during pregnancy.
Prenatal administration of RhDIG in some countries is useful,restricted by cost and availability of IG.
Commercial supply used extensively from paid donors. Cost high. Dose disputed . 20 micrograms /ml of foetal cells. We used 125 microgram doses…some failures.

33. Countries with an Rh negative population
ALL pregnant women should be screened at least once in early pregnancy, for blood group antibodies.
Rh(D) negative women should be screened early in pregnancy and then again regularly throughout gestation.
Husband Rh typed, if Rh negative, child will not be affected.
AVOID transfusing Rh(D) positive blood to Rh(D) negative females of any age.

34. Countries with a population of Rh(D) negative women
High quality Rh laboratory testing with good quality control.
Referral of immunized women to Rhesus specialist centre for advice as to management.
Widespread availability of Rhesus Immunoglobulin for prophylaxis

35. Countries with a population of Rh(D) negative women
Staff training will be needed at all levels.
On-going surveillance of programme with evaluation of situations where women have become sensitized.
Information available for pregnant women.

36. WONDER A DISEASE VIRTUALLY CONQUERED
Still needs vigilance and an active surveillance programme.
Challenge for Iran where about 7 % of females are Rh (D) negative

37. THE PRESENT AND FUTURE
Foetal DNA in maternal blood to confirm Rh type. All women?
Improved post delivery treatment of infants. Use of steroids..etc
Better treatment and prevention of HDNB caused by other blood group antibodies

38. OK, THAT’S ALL FROM ME!
But the story is not yet finished….Over to you!

39. We can be thankful for those who have gone before us.