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Rh-ve mother

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by

Dr.Ahmed Sameh

on 24 September 2013

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Transcript of Rh-ve mother

You requested the routine Rh from a 26 years old, 16 weeks pregnant patient @ her first visit. An Rh negative result had come. what's the first step in management?:
1- say " you must take the anti-D after delivery"
2- Request for indirect Coomb's test for anti-D antibodies
3- Request for paternal Rh group
4- say "you will probably take the anti-D after delivery"
+VE
Rh-VE mother
D protein
C/c protein
E/e protein
The Rh Complex
E
e
Dominant allele
Recessive allele
Carrier

C
c
Dominant allele
Recessive allele
Carrier

D
One Dominant allele
Recessive D allele has not been identified to date
No carrier
D allele present = Rh+ve
D allele = Rh-ve
Foreign Antigen
Anti-D IgG= maternal sensitization

Increased hematopoesis from the liver
Immature erythroblasts enter circulation (EBF)
Decreased albumin synthesis
Decreased oncotic pressure
Hemolytic Anemia
Hyperbilirubinemia
High output heart failure
Incraesed hydroststic pressure
Decreased oncotic pressure
Increased hydrostatic pressure
EDEMA
Sensitized or not?
( Enemy is present or not?)
Who is @ high risk?
who has the enemy target
Who has the "D" antigen?
what 's the fetal Rh?
we need to know if our
ENEMY
is present?
even if no history of:
pregnancy related bleeding in current or in past pregnancies
Mismatched blood transfusion
takes about 2 to 5 days to form
This is our
ENEMY
we will fight !!!
This means that every Rh-ve woman should have:
Indirect
coombs test
searches for the presence / abscence of the

Negative
Positive
D
D
Anti-D IgG
ENEMY!!
Reassessment @
28 weeks
Negative
Positive
Not taken the RhoGAM
Taken the RhoGAM
in first trimester
for any reason
Give the standard dose of RhoGAM:
Now
After any condtion of bleeding
Postpartum
Protection against sensitization and formation of the anti-D IgG
Prevent the ENEMY creation
The standard dose of RhoGAM
Eevery 10 mcg -> neutralize 1cc of fetal blood
In first trimester: 50 mcg for 5 cc of fetal blood
In second trimester: 300 mcg for 30 cc of fetal blood
accurate dosage: Kleihauer–Betke test
Critically Sensitized mother ...
all fetuses @ risk?
Obtain the Paternal Rh
Rh-ve
Rh+ve
The fetus is safe
and happy
and so are we
Is it definite that an Rh-ve mother and Rh +ve father MUST have an Rh+ve baby?
HELP THE
ENEMY
IS PRESENT
RhoGAM would help?
then who?
An Rh+ve fetus
Ok .. then how'd we know?
Amniocentesis?
Fetal blood sampling?
Invasive ... leave them to the end
we will do something less invasive, trying to guess what the fetal blood type is...
IgG crosses the plcenta after 20 weeks
NO
OK .. end of the story ....
start management?
NO
D
D
D
Homozygous
Heterzygous
Obtain paternal Rh genotype
The fetus MUST be Rh+ve
The fetus has 50% chance of being Rh+ve
Managment of at risk
Early detection of the ENEMY hits (Anemia)

Amniocentesis
(Fetal genotype RH)
Fetal Genotype Rh-ve
Fetal Genotype Rh+ve
Genotype/Phenotype discrepancies
Genotype dose NOT definitely represent the phenotype
Fetus could have:
Genotypic is read as Rh-ve
but it still produces Rh+ve RBCS that could make him a target of Anti-D IgG
Loci Rearrangment
Pseudogene Rh
The same sequence
Different sequence
Rh-ve fetus
Rh+ve fetus
Pseudogene is read as positive, while it doesn't produce the D antigen
we want to exclude the +ve
Compare with the +ve
(paternal Genotype)
we want to exclude the -ve
Compare with the -ve
(maternal Genotype)
Pseudogene analysis in the mother
PG-ve in mother
=phenotypically Rh-ve mother
=phenotypically Rh+ve fetus
PG+ve in mother
=phenotypically Rh-ve mother as the PG cannot produce the D antigen
In this case the fetus could be PG +Ve with phenotypic Rh-ve
or could be PG-ve with Rh+ve .... how'd we know?
Check for PG in fetus
PG+ve in fetus= phenotypically Rh-ve
PG-ve in fetus= phenotypically Rh+ve
PG+ve=Rh-ve
PG-ve=Rh+ve
Rh+ve fetus
Rh-ve mother
No we are sure that the fetus is Rh+ve
Critically sensitized mother
Fetal Blood Sampling
Strenght of sensitization
Enemy can cause harm?
Follow up maternal serum titre
Titre increases by 4X
or reaced 1:16
Critical titre reached
Detialed US scan:
accurate dating
detection of Edema
Fetla assessment
NST
BPPs
UADWF
Anemia
Serial Amniocentesis
MCA PSV
Spectrophotometer of Bilirubin
Liley Curve
Queenan curve (before 28 weeks)
>1.5 MoM Anemic
100% sensitivity
Management of fetal anemia
Reconstruction of Enemy hits
Obtain FBS for Hct
If less than 30 -> IUBT

Worried about her next pregnancy
Maternal titre XX
Amniocentesis and try to ID the fetal Rh
Repeat in 14 days
Fetal anemia
Thnak you
Full transcript