RH Isoimmunization

Dr Elfalet Fekadu
JAN 27,2023 G.C
 General Considerations
Over 400 red cell antigens have been identified to date.
RH antigen detected in human erythrocytes at day 30.
Many are so rare as to be of little clinical significance.
Blood banks do not routinely test for any red cell antigen other than
the Rhesus and ABO antigens.
There are RH antigens(Dd, Cc, Ee) identified on human RBCs.
• Locus on the short arm of Chromosome 1.
• If enough RH positive fetal cells cross into the RH negative maternal
blood, a maternal antibody response will be provoked.
• This clinical condition is termed as RH-isoimmunization
• If these maternal antibodies cross the placenta, they can enter the
fetal circulation and destroy the fetal erythrocytes, causing hemolytic
anemia.
• The changes in the fetus and newborn are called Erythroblastosis
Fetalis.
• The RH antigens are grouped in 3 pairs: Dd, Cc, and Ee. The major
antigen in this group, Rh(D), or Rh factor, is of particular concern and
the remaining are less immunogenic but still can cause
erythroblastosis.
• Such sensitization is suggested by a Positive indirect Coombs test
performed to screen for abnormal antibodies in maternal serum.
• Other minor antigens include; kell, duffy, lewis, kidd….
 Incidence
• Depends on the incidence of RH negativity in the population ( African
blacks 4%) .
• In mothers who do not receive prophylaxis, the overall risk of
isoimmunization for an Rh-positive ABO-compatible infant with an
Rh-negative mother is about 16%.
• 10% of sensitizations occur antepartum & 90% during labor and
delivery.
• ABO incompatibility between an RH-positive fetus and an RH-negative
mother provides some protection against RH isoimmunization.
• In mothers who receive prophylaxis with RH immunoglobulin, the risk
 Pathogenesis
For RH Alloimmunization to occur:
o Fetus must be RH positive & mother RH negative
o Sufficient number of erythrocytes must enter maternal Blood
o Mother should have immunogenic capacity to D antigen
• RH Isoimmunization may occur by 2 or 3 mechanisms:
o Following Incompatible blood transfusion
o Following Fetomaternal hemorrhage
o From the Grandmother of index pregnancy

‘ Grandmother Theory ‘
 Fetomaternal hemorrhage may occur during pregnancy or delivery

- 7% of women during the First trimester,

- 16% during the Second trimester, and
- 29% during the Third trimester.
 The Rh-positive cells necessary to cause isoimmunization of the
RH - negative pregnant woman is unknown, as little as 0.1 ml of
RH-positive cells can cause sensitization.
 Predispositions to FMH
o Spontaneous or induced abortion

o Amniocentesis

o Chorionic villus sampling

o Abdominal trauma (motor vehicle accidents or external cephalic

version)
o Placenta previa

o Abruptio placentae

o Fetal death

o Multiple pregnancy

o Manual removal of the placenta

• About 30% of RH-Negative persons never become sensitized
(Non responders) when given RH-Positive blood.
• The initial maternal immune response to RH sensitization is low
levels of Immunoglobulin M.
• Within 6 weeks to 6 months, IgG antibodies become detectable.
• In contrast to IgM, IgG is capable of crossing the placenta and
destroying fetal RH - positive cells.
 Diagnosis of Isoimmunization
= Maternal Antibody Determination ( Ig G )

= Fetal Blood Typing:

- Uses free fetal DNA in maternal plasma for determination of the fetal blood type

= Fetal Blood Sampling

- Ultrasound-directed fetal blood sampling (FBS; also percutaneous umbilical

blood sampling, cordocentesis, and funipuncture) allows direct access to the
fetal circulation to obtain important laboratory values such as fetal blood
type, hematocrit, direct Coombs' test, reticulocyte count, and total bilirubin.

= Ultrasound

= Amniocentesis
Maternal Antibody titer
Once the Indirect Coombs’s test becomes positive, then
determine the antibody titer .
The human antiglobulin titer (Indirect Coombs' test) is used
to determine the degree of alloimmunization as it
measures the maternal IgG response.
Most titer values in the obstetric literature are reported as
dilutions (i.e., 1:32).
In the same laboratory, the titer should not vary by more
than one dilution if the two samples are run in tandem.
A critical titer is defined as the anti–red cell titer
associated with a significant risk for hydrops fetalis.
This value will vary with institution and methodologies;
however, in most centers, a critical titer for anti-D
between 8 and 32 is usually used.
Levels of < 4 IU/ml are rarely associated with HDFN;
level of 4 -15 IU/ml cause only mild fetal anemia
Ultrasound ; helps detection of
1.Gestational Age
2. Hydrops fetalis is defined as the presence of extracellular fluid in at least
two fetal compartments.
Fetal ascites is the first sign of impending hydrops, with scalp edema and
pleural effusions noted with worsening anemia.
Hydrops indicates End-stage state of fetal anemia.
3. Doppler ultrasound peak velocity in the fetal MCA ( Middle cerebral
artery) to predict fetal anemia.
A value of greater than 1.5 multiples of the median (MoMs) for the
corresponding gestational age predicts moderate to severe fetal anemia
MCA Doppler studies
 Amniocentesis
Helps to follow the Severity of Hemolytic Disease of the Fetus and
Newborn (HDFN).
The spectral analysis of amniotic fluid has been used in
alloimmunized pregnancies to determine the level of bilirubin, an
indirect indicator of the degree of fetal hemolysis.
 The “Liley” curve has proven extremely useful in monitoring the
alloimmunized pregnancy.
Currently amniocentesis is replaced by MCA peak velocity .
Liley graph used to depict severity of fetal hemolysis with red cell isoimmunization
Doppler peak velocities based on gestational age
 Sign of sever anemia on the fetus are full filled;

 Edema of the fetus

 Increased optical density of the amniotic fluid at OD450

 Increased Middle cerebral artery Doppler Velocimetry

( >1.5Mom)
 Fetal anemia (Cordiocentesis)
 Fetal Effects

Fetal anemia results;

o Stimulating extramedullary erythropoietic sites to
produce high levels of nucleated red cell elements.
o Fetal hepatosplenomegaly
o Increased cardiac output
o Hemolysis produces heme, which is converted to
bilirubin; neurotoxic.
o When severe anemia occurs; heart failure, edema,
ascites, and pericardial effusion.
o Tissue hypoxia and acidosis may result.
o Normal hepatic architecture and function may be
disturbed by extensive liver erythropoiesis, which may
lead to decreased protein production, portal
hypertension, and ascites.
Severe erythroblastosis Fetalis Hydropic, macerated stillborn infant
 Neonatal Effects

• In the immediate neonatal period, the primary problem

may relate to anemia.
• Hyperbilirubinemia may also pose an immediate risk as
further red cell breakdown occurs. The immature liver,
with its low levels of glucuronyl transferase, is unable
to conjugate the large amounts of bilirubin.
• This results in a high serum bilirubin level, with
resultant bilirubin deposition in the basal ganglia
(kernicterus ) and cerebral palsy.
Prevention of Hemolytic disease of the fetus and newborn

Indications for Anti – D administration

All pregnant clients should have blood type & an antibody
screen at the first prenatal visit.
If there is no evidence of Anti-D alloimmunization in RHD -
negative woman ( confirmed by Negative maternal Indirect
coomb’s test ), administer 300 µg of RhIG at 28 weeks .
Some experts recommend that a second dose of RHIG be
given if the patient has not delivered by 40 weeks.
Other indications for the antepartum administration of
RHIG is abortion, a dose of 50 µg of RHIG is effective until
13 weeks owing to the small volume of red cells in the
fetoplacental circulation.
Administer 300 µg of RHIG within 72 hours of delivery if
umbilical cord blood typing reveals a RhD-positive infant.
This dose protects from sensitization due to a FMH of
30 ml of fetal whole blood.
ACOG recommends routine screening of all women at the
time of delivery for excessive FMH.
Indications for Administration of Rhesus Immune Globulin
Spontaneous abortion[*] Suspected abruption[‡]

Elective abortion Intrauterine fetal demise

Threatened abortion Blunt trauma to the abdomen

Ectopic pregnancy At 28 weeks, unless father of fetus is RhD-negative

Hydatidiform mole Amniocentesis for fetal lung maturity

Genetic amniocentesis External cephalic version

Chorion villus sampling After 72 hours of delivery of RhD-positive infant

Fetal blood sampling After transfusion of RhD-positive blood

Placenta previa with bleeding

 Management
Unsensitized Pregnancy
• First Prenatal Visit: all pregnant women should be screened for
the ABO blood group and the RH group. They should also undergo
antibody screening (Indirect Coombs' test) if RH negative.
• Unless the father of the baby is known to be RH-Negative, all RH-
negative mothers should receive prophylaxis according to the
following protocol.
 Visit at 28 Weeks;
• Antibody screening (Indirect coomb’s test) is performed. If negative, 300
microgram of RHIgG is given. If positive, managed as RH-sensitized.
• If pregnancy continues beyond 40 wks, second dose could be considered.

Postpartum
• If the infant is RH-positive, 300microgram of RHIgG is administered to the
mother (provided maternal antibody screening is negative).
• Although RHIgG should generally be given within 72 hours after delivery,
it has been shown to be effective in preventing isoimmunization .
• If the antibody screen is positive, the patient is managed as if she will be
RH-sensitized during the next pregnancy.
 Special Fetomaternal Risk States

1. Abortion
• Sensitization occurs in 2% of spontaneous abortions and 5% of
induced abortions.
• In the first trimester, because of the small amount of fetal
blood, 50microgram RHIgG is sufficient to prevent sensitization.
• The same dose as term pregnancy is recommended for exposure
after the first trimester.
2. Amniocentesis, Chorionic Villus Sampling, and Cord Blood
Sampling
• If the placenta is traversed by the needle, 11% chance of
sensitization; 300microgram of RHIgG is recommended.
3. Antepartum Hemorrhage
• In placenta previa or abruptio placentae, administration of
300microgram of RHIgG is recommended. If more than 12
weeks from the time of RHIgG administration, a repeat
prophylactic dose is recommended.
• External Cephalic Version; Fetomaternal hemorrhage
occurs in 2– 6% of ECV, whether failed or successful;
these patients should receive 300microgram of RHIgG.

 Isoimmunized pregnancy

 No Previous Fetal Affection

• Once the antibody screen is positive , patients should

be followed by antibody titers starting at 28 weeks, and
then every 2 weeks.
• Antibody Critical titer is 1:32
o < 1:32 ………... there is no indication for further
intervention.
o >1:32 ……….. Amniocentesis……….. MCA Doppler
Velocimetry - High peak velocity blood flow > 1.5 multiples
of the median correlates well with severe fetal anemia.
 With a Prior Fetus Affection
• Antibody titers need not be followed in these pregnancies
and amniocentesis should be performed 4–8 weeks earlier
than when RH-associated morbidity was first identified.
• The alternative of MCA Doppler peak velocity
assessment by Ultrasound is now more widely used.
• In addition, ultrasound also plays an important role in
evaluating the Isoimmunized patient for hydrops and
its complications.
 Management of Affected Pregnancy
 Mildly Affected Fetus
• Zone 1 on the Liley curve or has normal MCA Doppler
studies.
• Testing repeated every 2-3 weeks,
• Delivery near term after the fetal pulmonary maturity.
 Moderately Affected Fetus

• Zone 2 on Liley or zone A on MCA Doppler studies

• Tested every 1–2 weeks

• Delivery as soon as pulmonary maturity is reached, enhancement

of pulmonary maturity by use of corticosteroids.
 Severely Affected Fetus

• Zone 3 on the Liley curve or MCA Doppler studies > 1.5 multiples
of the median (Zone -B) on MCA Doppler.
• Has evidence of hydrops ( ascites, pleural or pericardial effusion,
subcutaneous edema).
• If preterm, intrauterine transfusion
Thank you