Wk.2 Isoimmunization RH Incompatibility

Rh Incompatibility
(Isoimmunization)
Juvy G. Reyes, MAN, RN

Learning Objectives:
1. Describe complications of pregnancy that place a

pregnant woman and her fetus at high risk.
2. Assess a woman who is experiencing a complication of pregnancy
3. Identify expected outcomes that will contribute to a safe

pregnancy outcome when illness occurs with pregnancy.
• Rh factor Incompatibility – is a condition where
antibodies can attack Rh protein in a fetus.
• Rh factor or Rhesus factor – is an inherited

protein found on the surface of RBC
• If protein is present - Rh-positive.
• If protein not inherited - Rh-negative

RH INCOMPATIBILITY
• Antibodies – are recruited by the

immune system to identify and
neutralize foreign objects. (bacteria, virus)
• Antigen – is a substance usually a

protein, which stimulate the production
of antibodies.
RH FACTOR INCOMPATIBILITY
• occur when an Rh (-) negative mother

(one negative (-) for a D antigen or one
with a dd genotype carries a fetus with
an Rh (+) positive blood type. (DD or Dd
genotype)
• Rh (+) positive blood – have a protein factor

(D antigen), Rh negative people do not
RH (+) POSITIVE BLOOD
• Father is homozygous (DD) for the factor,

100% of the couple’s children will be Rh (+).
• If the father is heterozygous for the trait 50% of

their children can be exposed to Rh (+)positive.
RH (-) NEGATIVE MOTHER --------------------- RH (+) POSITIVE FETUS
↓
Rh (+) fetus begins to grow inside an Rh (-) negative mother who is sensitized
↓
Mother’s body reacts and form antibodies against the invading substance
↓
Maternal antibodies cross the placenta and cause destruction of fetal RBC.
(Hemolysis)
HEMOLYSIS
↓
RBC insufficiency and oxygen transport to body cell cannot maintained

↓
Hemolytic disease of the newborn
↓
Erythroblastosis Fetalis
Erythroblastosis Fetalis – is a hemolytic anemia in
fetus caused by transplacental transmission
of maternal antibodies to fetal RBC
Signs and Symptoms:
1. Comb’s test (+)

2. Elevated cord bilirubin
3. Hemolytic anemia
4. Jaundice ( skin and eyes) – occur within the

first 24 hrs. of life (Rh and ABO incompatibility)
Signs and Symptoms:
5. Thrombocytopenia
6. Kernicterus – severe jaundice due to

bilirubin builds up in the blood, cause
brain damage
7. Hydrops fetalis
Signs:
a. Heart failure
b. Enlarged liver and spleen
c. Extreme edema
RH INCOMPATIBILITY
There is no connection between fetal blood and maternal

blood during pregnancy, however:
• An occasional villus ruptures, allowing a drop or

two of fetal blood to enter the maternal
circulation.
• Procedures such as Amniocentesis or

Percutaneous umbilical blood sampling
• As the placenta separates after birth of the first child, and

an active exchange of fetal and maternal antibodies
in the first 72 hours after birth, making them a threat to a
second pregnancy
ABO Incompatibility
ABO Incompatibility – maternal blood type is O and

the fetal blood type is either A or B
• antibodies to A and B cell types naturally

antibodies are present at birth
• A or B cell are the large IgM class and do not cross

the placenta and an infant with ABO
incompatibility not born anemic
ABO Incompatibility
• Hemolysis – begins with birth, when blood and

antibodies are exchanged during the mixing
of maternal and fetal blood as the placenta
is loosened, and destruction continue for as
long as 2 wks.
Test:
1. Combs test
2. Reticulocyte count – usually elevated as the
infant attempts to replace destroyed cells
Assessment:
1. All women with Rh-negative blood should have an anti-D antibody titer done at a
first pregnancy visit
Result:
1. Normal – 0 - or titer is minimal
2. Ratio – below 1:8 - minimal
Repeated the test – 28 wks. of pregnancy (Normal results –no therapy is needed
3. Anti-D antibody titer - elevated at a first assessment (1:16 or greater), showing RH

sensitization and the well being of the fetus in this potentially toxic environment
will be monitored every 2 weeks (or more often) by Doppler velocity
Assessment:
2. Doppler velocity - a technique that can predict when anemia is present or fetal RBC are
being destroyed.
• If remains high - a fetus is not developing anemia and most likely is an Rh-negative fetus.
• Velocity is low - a fetus is in danger, and immediate birth will be carried out If not near
term, efforts to reduce the number of antibodies in the woman or replace
damaged red cells in the fetus are begun.
Assessment:
Rh incompatibility
3. Indirect Combs test – test to detect the

presence of antibodies on the fetal
erythrocytes in cord blood.
• Rising anti- Rh titer or rising level of

antibodies – result is (+)
Therapeutic Management:
1. Administered a Passive Rh D antibodies at 28 wks. of pregnancy - to reduce the

number of maternal Rh (D) antibodies being formed, RH (D) immune globulin
(RhIG or RhoGAM)
2. RhIG (RhoGAM) - is given by injection to the mother in the first 72 hrs. after
birth to prevent the woman from forming natural antibodies.
• Rh IG - is passive antibody protection, it is transient, and in 2 weeks to 2 months, the

passive antibodies are destroyed. Only those few antibodies that were
formed during pregnancy are left.
Ttherapeutic Management
3. Infant’s blood type will be determined from a sample of the cord blood.
• If it is Rh-positive Coombs’ test – negative indicates that large number of

antibodies are not present in the mother and the mother will receive
the RhIG injection.
• If the newborn’s blood type is Rh-negative - no antibodies have

been formed in the mother’s circulation during
pregnancy and none will form so passive antibody
injection is unnecessary.
THERAPEUTIC MANAGEMENT
4. Intrauterine Transfusion - to restore fetal red blood cells, blood

transfusion can be performed on the fetus in utero.
• Amniocentesis technique - directly into a vessel in the

fetal cord or depositing them in the fetal abdomen
where they migrate into the fetal circulation.
• Blood used for transfusion is either fetus own blood type or

O negative if the fetal blood type is unknown
Risk:
a. Cord blood vessel laceration by the needle
b. Irritated uterus due to invasive procedure
THERAPEUTIC MANAGEMENT
4. Intrauterine Transfusion
• From 75 to 150 ml of washed red cells are used,

depending on the age of the fetus.
• After deposition of the blood in the cord or abdomen, the

cannula is withdrawn and a woman is urged to rest for
approximately 30 minutes while fetal heart sounds and
uterine activity are monitored
RH INCOMPATIBILITY
• First Pregnancy – the effect of Rh

incompatibility is small as the placenta
separates after birth of the first child.
• Second Pregnancy – there will be a high

level of antibody circulating on the
mother’s bloodstream and this will
destroy the fetal RBC.
Wk. 2 Prelim

Wk.2 Isoimmunization RH Incompatibility

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Rh Incompatibility

Juvy G. Reyes, MAN, RN

1. Describe complications of pregnancy that place a

2. Assess a woman who is experiencing a complication of pregnancy

3. Identify expected outcomes that will contribute to a safe

• Rh factor or Rhesus factor – is an inherited

• If protein is present - Rh-positive.

• If protein not inherited - Rh-negative

• Antibodies – are recruited by the

• Antigen – is a substance usually a

• occur when an Rh (-) negative mother

• Rh (+) positive blood – have a protein factor

• Father is homozygous (DD) for the factor,

• If the father is heterozygous for the trait 50% of

RBC insufficiency and oxygen transport to body cell cannot maintained

Signs and Symptoms:

1. Comb’s test (+)

4. Jaundice ( skin and eyes) – occur within the

Signs and Symptoms:

6. Kernicterus – severe jaundice due to

There is no connection between fetal blood and maternal

• An occasional villus ruptures, allowing a drop or

• Procedures such as Amniocentesis or

• As the placenta separates after birth of the first child, and

ABO Incompatibility – maternal blood type is O and

• antibodies to A and B cell types naturally

• A or B cell are the large IgM class and do not cross

• Hemolysis – begins with birth, when blood and

3. Anti-D antibody titer - elevated at a first assessment (1:16 or greater), showing RH

3. Indirect Combs test – test to detect the

• Rising anti- Rh titer or rising level of

1. Administered a Passive Rh D antibodies at 28 wks. of pregnancy - to reduce the

• Rh IG - is passive antibody protection, it is transient, and in 2 weeks to 2 months, the

• If it is Rh-positive Coombs’ test – negative indicates that large number of

• If the newborn’s blood type is Rh-negative - no antibodies have

4. Intrauterine Transfusion - to restore fetal red blood cells, blood

• Amniocentesis technique - directly into a vessel in the

• Blood used for transfusion is either fetus own blood type or

• From 75 to 150 ml of washed red cells are used,

• After deposition of the blood in the cord or abdomen, the

• First Pregnancy – the effect of Rh

• Second Pregnancy – there will be a high

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