Rh negative

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THE MANAGEMENT OF RH NEGATIVE
PREGNANCY
Dr Simi J

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Introduction
● The purpose of this guideline is to provide guidance on
the management of pregnant women with red cell
antibodies predating the pregnancies or those
developing antibodies during pregnancy
● Anti-D is the most commonly encountered antibody
during pregnancy
● The presence of red cell antibodies signifies
alloimmunisation that has occurred as a result of
previous pregnancy, transfusion or transplantation

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Rh-Iso Immunization
Definition
Known as:
Rhesus incompatibility, Rhesus disease
RhD Hemolytic Disease of the newborn.
When Rh- mother gets pregnant to Rh+fetus
-she may be sensitized to Rh antigen and develop
antibodies. These will cross the placenta and cause
hemolysis of fetal red blood cell

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Pathophysiology
● Rh- isoimmunization is due to D antigen in more than
90% of cases
● Occasional result of other than Rh group like anti-Kell
and anti-Duffy

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Development of Rhesus antibodies
depends on:
1) Inborn inability to respond to Rh-antigenic stimulus
2) Protection if ABO incompatible 110
3) Strength of Rh antigen stimulus (CDe=R1)
4) Volume of leaking feta blood(0.1 ml)
5) Immunological nonresponders found in 30% of Rh-
negative women

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Feto-maternal hemorrhage as a reason of
Rh- isoimmunization has been documented
in:
● 6.7% in the first trimester
● 13.9% in the second trimester
● 29% in the third trimester

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CAUSE OF FMH
Feto-maternal haemorrhage: during pregnancy leakage of fetal
cells in the maternal circulation(Rh+fetal cells in Rh – maternal
circulation)
Examples:
1. Abortion
2. APH
3.E.C.V
4.Cordocentesis
5. CVS
6. Amniocentesis
7.Severe pre eclampsia
8. Ectopic pregnancy

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Amount needed for sensitization 0.1ml

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Complications
●Hydrops fetails and stillbirth
●Icterus gravis neonatorum
●Neonatal Jaundice
● Complications of Neonatal Kernicterus
(Lethargy,Hypertonicity,Hearing Loss,Cerebral Palsy and
Learning Disability

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MANAGEMENT
● Rh negative women categorized in two groups
1) Rh-negative non immunized women
2) Rh-negative immunized women
● Immunized against -D antigen
● -nonD Rh antigen
● -other blood group system

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Objectives
● Non immunized women – prevention of alloimmunization
● Immunized women – a. early detection
● b. adequate treatment of fetal
anemia and timely delivery

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Rh- negative non immunized

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RH-NEGATIVE IMMUNIZED WOMEN

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Management based on
a) First affected pregnancy
b)Previous affected pregnancy

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First affected pregnancy
➢ Should have antibody triter every 4 weeks
A)If triter>critical level→
B)-amniocentasis
C)-MCA-PSV
D)If triter< critical level up-to 36wks of gestation, should
delivered between38-40 weeks

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PREVIOUS AFFECTED PREGNANCY
a) Maternal anti-D titre not predict the fetal anemia
b) MCA-PSV to determine the anemia
c) Serial amniocentasis

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Previous affected pregnancy
a)Maternal anti-
D triter not
predict the fetal
anemia
b)MCA-PSV to
determine the
anemia
c)Serial
amniocentasis

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Transfusion therapy can be given intraperitoneal or
intravascular
● Other therapies
a)Plasmapheresis: tried to remove several liters of
maternal plasma with anti-D antibodies
b)High dose I.v immunoglobulin: 1000mg/kg weekly

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Guidelines
● Women with red cell antibodies,particularly if there is a
risk of fetal anemia or if compatible donor red cells for
transfusion may be difficult to obtain, should attend for
prepregnancy counselling with a clinician with
knowledge and expertise of this condition.(RCOG)
● All women should have their blood group and antibody
status determined at booking and at 28 weeks of
gestation.(RCOG)

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● Prophylactic anti-D immune globulin should be offered to
unsensitized Rh D- negative women at 28 weeks of
gestation. Following birth, if the infant is confirmed to be
Rh D positive, all Rh D- negative women who are not
known to be sensitized should receive anti-D immune
globulin within 72 hours of delivery.(ACOG)
● Invasive testing is not contraindicated if alloimmunisation
has occurred.(RCOG)
● Anti-D prophylaxis should be given to cover invasive
testing if the mother is rhesus D (RhD)negative and is
not sensitized.(RCOG)

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● Referral to a fetal medicine specialist should occur when
there are rising antibody levels/titres, a level/titre above
a specific threshold or ultrasound features suggestive of
fetal anemia
● The cause of the alloimmunisation, relevant past history
and pregnancy outcomes should be ascertained in order
to generate an assessment of risk of HDFN
● Referral to a fetal medicine specialist for consideration of
invasive treatment should take place of the MCA PSV
rises above the 1.5 multiples of the median(MoM)
threshold or if there are other signs of fetal anemia

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● If maternal transfusion required : Red cell component of
same ABO group and the RhD type, and that are K
negative and CMV negative, should be selected
● A women with a history of a pregnancy or infant affected
by HDFN should be referred for early assessment to a
fetal medicine specialist in all further pregnancies

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INTRAPARTUM MANAGEMENT

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Intrapartum management
● Cesarean section only for obstetric indication
● Undergo delivery in the term of 37-38 weeks of gestation
● Induction of labour is performed by prostaglandin(in the
case of “unripe” uterine cervix) or by intravenous
oxytocin infusion administration(in the case of “ripe”
uterine cervix)

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In vaginal delivery
● No fundal pushing
● With hold inj methergin after ant. shoulder delivery
● Early cold camping and no milking
● No uterine massage or squeeze in 3rd stage
● Let the placenta to be delivered spontaneous to avoid
avulsions of the cord
● Protect the vaginal and perineal wounds and laceration
from being exposed to the fetal blood spilled from the

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●At birth
● Maternal blood
a) Antibodies by indirect Comb’s test(ICT)
b) Fetal red blood cells in maternal circulation
● Cord blood sample (neonatal blood sample) for
a) Antibodies by Comb’s test (DCT)
b) Infant blood group and rh-typing
c) Infant bilirubin level
d) Infant Hb and Hct level

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Anti-D Immunoglobulin

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Take Home Messages
● All Rh negative pregnant women should have a
prepregnancy counseling regarding antibody testing
and need for blood arrangement as its difficult to
find a donor at need
● Close collaboration between maternity ,neonatolgy
and haematology staff is essential
● All women should have blood grouping and
antibody testing at booking,28 weeks and 34 weeks
● All women with ict negative should be offered anti D
injection if possible at 28 weeks and 34 weeks or

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● Inj Anti D is advised in case of Ectopic pregnancy and
molar pregnancy in Rh negative mother
● In case of any APH in the 2nd and 3rd trimester inj Anti D
300mcg to be given
● Anti D to be given when iud is confirmed irrespective of
delivery
● Any case ict positive is considered to be immunized and
should not give Anti D

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● All cases of Rh immunized pregnancy should be
managed in a tertiary care centre where a fetal medicine
expertise is there
● Serial titre monitoring once reach critical titre 1;16 to
1;32 need either non invasive monitoring with MCA
doppler peak systolic velocity or invasive amniocentesis
● Intrauterine transfusion advised in case of severe fetal
anemia
● Cesarean only for obstetric indication. IUT is not an
indication for cesarean,

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● Timing of delivery depend on the period of
gestation,severity of fetal anemia and fetal lung
maturity.
● In severe case termination by 34 weeks after giving
corticosteroids for lung maturity
● Continous electronic fetal heart monitoring is advised
during labour.
● Inj methergin is with held in active management of 3rd
stage.
● Postpartum inj Anti D 300mcg is given to all Rh negative

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● NIPT can be offered to Rh negative women if they can
afford it. If baby is Rh negative then further testing and
Anti D can be avoided
● There is no clinical evidence that ART increases the risk
of red cell alloimmunization,however if donor eggs are
used for a mother with an alloantibody and the donor red
cell antigen status is not known fetal genotyping may be
done.

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Reference
1. Williams obstetrics-25th edition
2. High risk pregnancy 5th addition-James, Steer, Weiner,
Gonik, Crowther, Robson
3. RCOG Green-top Guideline No :65-2014
4. ACOG Practice Bulletin 2017
5. NICE Guideline -2008
4. BCSH Guideline- 2014
5. BMJ- 2005
6. Fogsi Guideline- 2009