Management of the Rhesus Negative Mother

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www.totalpregnancycare.com
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Management of the Rhesus Negative Mother

• Dr Shantala Vadeyar
• MD, FRCOG, DM
• Advanced Obstetric Ultrasound (RCOG / RCR)
• Subspecialist Fetal Maternal Medicine (RCOG)
• Consultant Obstetrician, Fetal Maternal
  Medicine
• Kokilaben Dhirubhai Ambani Hospital, Mumbai

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Background

• Incidence of Rh neg individuals varies with race
• Caucasians (whites) 15
• Afro-Carribeans (blacks) 7-8
• Asians 5
• Chinese and Japanese 1

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What is the Rhesus factor?

• It is a Red blood cell antigen
• Other Red cell antigens include -
• A, B blood groups
• Duffy, Kell, Kidd

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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 genotype

Rh positive
Rh neg
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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

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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

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Management of Rh negative gravida

• Careful history
• Previous pregnancy losses
• h/o blood transfusions
• Check husbands blood group and Rh factor
• Check anti-D antibodies
• If no antibodies at booking, then repeat titres
  at 28, 36 weeks

Coombs test
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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

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Anti DMechanism 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

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Rh Sensitised Pregnancy
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Middle Cerebral Artery
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MCA Doppler- Rhesus isoimmunisation
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MCA Doppler- IUGR
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Rh Sensitised Pregnancy - 2
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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

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Amniotic fluid ODD 450
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Intrauterine blood transfusion
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Overshoot - prepathological
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Antenatal Steroids

• If preterm delivery lt36 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

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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

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Neonatal Management

• Commonly need Phototherapy
• May need Exchange Transfusion
• Bone marrow suppressed if IUT
• Anemia blood transfusion
• Haematinics long term
• Good long term outcome

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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

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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

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Delivery

• 32 weeks- amniocentesis- action line
• Options- Intrauterine transfusion v/s delivery
• 335 w- delivery- 2.2kg female
• Exchange transfusions and phototherapy
  postnatally- discharged 2 weeks

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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.

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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

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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

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Interactive Corner

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

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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

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Contact Us

• Email shantala_at_totalpregnancycare.com
• Mobile [phone]
• KDAH Board line 91 22 30999999

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