3.1. Hemolytic Dse- Rh Sensitization ABO.pdf

3.1. Hemolytic Dse- Rh Sensitization ABO.pdf

1. Source: Maternal & Child Care by Pillitteri; Part of Chapters 21 & 26
MCH by Sia
Hemolytic Disease:
ABO & RH Incompatibility (Sensitization)
Prepared by:
Yvette M. Batar, RN, MAN, DM

2. Objectives
After mastering the contents of this topic, SNs should be able to:
1.Describe hemolytic disease that place a pregnant woman and her fetus at high risk.
2.Use critical thinking to analyze ways that nurses can help prevent complications of
hemolytic disease while keeping care family centered.
3. Assess a pregnant woman who is experiencing hemolytic disease.
4.Formulate nursing diagnoses that address the needs of a pregnant woman and her family
experiencing hemolytic disease.
5.Identify expected outcomes to minimize the risks to a pregnant woman and her fetus when
a hemolytic disease occurs.
6.Plan nursing interventions to meet the needs and promote optimal outcomes for a woman
and her family during a complication of pregnancy.


3. ABO Incompatibility
1.Every person has a BT: Type O,
A, B or AB
2.ABO incompatibility occurs when
maternal blood is O & fetus is:
Type A – most common
Type B – most serious
Type AB - rare
3. Mother has antibodies against
Blood Type A & B even before
pregnancy that circulates in her
body.
4. It is uncommon for maternal blood to
enter fetal circulation & v/v coz
antibodies (IgM) are large type w/c
cannot cross placental barrier.
5. During placental separation,
placental barrier is broken resulting to
mixture of maternal & fetal blood.
Maternal antibodies that entered
infant’s circulation begin to destroy
the infant’s RBC after baby’s birth.
Baby will be normal at birth & will
manifest signs of hemolytic dse
several hours after.

4. Rh Incompatibility (Sensitization)
1.Rh Factor
A.Rh factor – a distinct CHON antigen
found on RBC
B.Rh + is incompatible w/ Rhˉ
C.The immune system assume that all
antigens are potentially harmful to the
body
D.85% of people are Rh +(dominant); 15%
are Rhˉ
E.Rh factor is genetically determined
Genes ++ = Rh+
Genes +- = Rh+
Genes - - = Rh-
2. Rh Sensitization/Rh
Isoimmunization
A.Is the exposure of Rhˉ blood to an
Rh+ blood & the resultant
production of antibodies by the
immune system of the person
having Rhˉ against Rh+ blood.
Occurs through:
Sensitization from previous
pregnancy
Inadequate response to prophylaxis
Incompatible blood transfusion

5. Rh Incompatibility (Sensitization)
2. Rh Sensitization/Rh
Isoimmunization - cont’d
B. Fetal blood & maternal blood are
separated by placental barrier.
Sometimes, breaks in the placental
barrier can occur during pregnancy &
cause few RBCs from the fetus to leak
the placenta & enter the mother’s
circulation.
Greatest transfer is during placental
separation
0.5 ml of fetal Rh+ blood can stimulate
massive production of antibodies
during 1
st 72 hours from delivery
C. Antibodies do not disappear in
maternal blood stream & will attack
subsequent Rh+ pregnancies
ANTIBODIES (via placenta)
DESTROY FETAL RBC resulting to
fetal ANEMIA fetal bone marrow
release immature RBC (as
compensatory mechanism) into fetal
circulation causing
ERYTHROBLASTOSIS FETALIS

6. Rh Incompatibility (Sensitization)
3. Fetal Complications
of Erythroblastosis
Fetalis
A.Anemia
B.Splenomegaly &
hepatomegaly
C.Hyperbilirubinemia
D.Hydrops fetalis
E.Stillbirth
PREVENTION:
1.Prenatal screening
A.Hx: When woman
is Rh- elicit
Past pregnancies
Blood Type
Abortion
Invasive diagnostic
procedure during
pregnancy
B. Screening Tests: Blood
typing & Rh factor
determination
IF FATHER IS Rh+:
Antibody Titer Test
Indirect Coomb’s Test
(detects antibodies in
maternal serum)
Direct Coomb’s Test
(detects antibodies in
fetal cord blood)

7. Rh Incompatibility (Sensitization)
PREVENTION: - cont’d
If Antibody Titer is (-)
Maternal Rh antibody
titer should be
measured again at
16-20 week, then at
26-27 wk of
pregnancy.
Give Rh immune
globulin IM (Rhogam)
at 28 weeks & w/in 72
hrs after delivery.
Rhogam should be
given to all Rh- women
who:
Have delivered Rh+
fetus
Have had untypeable
pregnancies
Have received ABO
compatible Rh
positive blood
Have had invasive
diagnostic procedure
SIGNS & SYMPTOMS:
Mother will not
experience any s/s
unless the baby dies
in the utero
If baby dies:
cessation of
pregnancy & fetal
movement

8. Rh Incompatibility (Sensitization)
1.Fetal Surveillance (when
mother’s antibody titer is +).
When antibody titer rises to 1:16
or greater:
A.Amniocentesis q 2 wks
beginning at 26 wks for exam of
bilirubin level
Spectrophotometry
If bilirubin levels (BL) in AF remain
normal, pregnancy may be
allowed to continue
If BL ↑, BT may be performed to
remove bilirubin & replaced
hemolysed fetal RBC
B. Percutaneous
umbilical sampling
(PUBS) – if result of
spectrophotometry
indicate severe
hemolysis:
PUBS can be started
at 18-20 wks
gestation
Mother may be pre-
medicated to ↓
anxiety & promote
cooperation
Management

9. Rh Incompatibility (Sensitization)
C. UTZ – limited use in early diagnosis
of hemolytic disease
May be done to assess for
complications related to Rh
isoimmunization
D. Administering phenobarbital to
women during last weeks of pregnancy
to reduce symptoms in newborns as it
speeds liver maturity so that the infant
liver better converts indirect to direct
bilirubin.
This, unfortunately, also carries the
risk of fetal sedation.
E. Blood transfusion
To fetus by either
intraperitoneal (IPT) or
Intravascular (IVT) method
Factors considered in
determining method of
transfusion are:
Position of the fetus
Placement of the placenta
Degree of fetal illness
Management

10. Rh Incompatibility (Sensitization)
F. IPT may be used to treat the
less severely ill fetuses and
those who do not suffer from
hydrops.
This is because the
absorption of the transfused
blood in IPT is very
unpredictable &
In very ill fetuses, there may
be little or no absorption at all
Management
G. Intravenous fetal transfusion
(IVT is more effective treatment
modality than IPT).
IVT may be undertaken as
early as 17 to 20 weeks
gestation.
It replaces fetal RBCs with
donor blood that does not
undergo hemolysis by
maternal antibodies.

11. Rh Incompatibility (Sensitization)
1.Under ultrasonic guidance, a
large bore needle is used to
introduce an epidural catheter
into the peritoneal cavity of the
fetus.
2.Packed RBCs, which are cross
matched against maternal serum,
is then, transfused thru catheter
into peritoneal cavity of fetus.
3.The blood is absorbed into fetal
circulation thru subdiaphragmatic
lymphatics & thoracic duct.
4. It takes about eight to nine days
for two-thirds of the transfused
blood to be absorbed.
5. A second IPT is done in 9 – 12
days, & subsequent transfusions
are scheduled about every four
weeks until 32 weeks gestation.
6. Delivery is planned about 36
weeks gestation. Up to 86% of
nonhydropic IPT transfused
fetuses survive.
IPT Procedure

12. Rh Incompatibility (Sensitization)
1.Mother is prepared as in IPT.
2.Fetus is injected IM/IV with a
neuromuscular blocking agent
designed to decrease fetal
movement for about 40 to 50
minutes.
3.A transfusion site is selected.
UV or UA in the placental cord
root - best site because of its
stability.
Intrahepatic vein may also be
used.
Intracardiac route is an option in
extreme circumstances only.
4. Once the needle is inserted into umbilical vein,
a small amount of blood is aspirated for stat hgb/
hct)level analysis.
According to the level of:
•hgb & hct, a transfusion volume formula is
then used to calculate the amount of blood
to be transfused.
•Blood is administered via a 30 ml syringe,
over a 20-minute period, at a rate of 1 to 3 ml
per minute.
Subsequent transfusions may be given at two-
day to four-week intervals, depending on the
severity of fetal disease.
Overall IVT survival rate is about 93 percent.
IVT Procedure

13. Rh Incompatibility (Sensitization)
During post-procedure, mother &
fetus are observed for 6-24 hours.
Then mother is discharged & given
specific instructions regarding:
•Signs and symptoms of preterm
labor
•Counting & recording of fetal
movement
•Advised to immediately contact
her healthcare provider if she
notices: fetal movement, vaginal
bleeding, PROM, or PTL.
IVT Procedure - cont’d

14. Rh Incompatibility (Sensitization)
Goal - to minimize opportunity for
maternal-fetal bleeds.
A.Do not remove placenta
manually
B.Clamp cord immediately after
birth
C. Ensure that blood sample is
drawn from mother for
Kleihauer-Betke blood test
shortly after birth
Goals - to prevent sensitization in
unsensitized woman & to quickly
diagnose & treat hemolytic disease in
newborn (HDN). 
A.Immunize mother with RhoGam
within 72 hours after delivery if
Coombs test is negative
Rationale:
To destroy any fetal blood that
entered her circulation during
delivery & prevent formation of
antibodies.
Labor & Delivery Post Partum Care

15. Rh Incompatibility (Sensitization)
B. If Kleihauer-Betke shows that a
larger quantity of fetal blood entered
the maternal circulation, repeated
doses of Rh immune globulin are
necessary.
An additional 300 micrograms is
given for every 30 ml of Rh positive
blood or
For every 15 ml of fetal red cells in
maternal circulation.
These additional doses may be given
at one time, using multiple injection
sites, or at 12-hour intervals.
C. If mother’s indirect Coombs test
is positive or her Rh positive
newborn has a positive direct
Coombs test, this means that
mother has already produced
antibodies against Rh positive
blood.
Rh immune globulin should no
longer be given to mother.
But newborn should be monitored
for signs of hemolytic disease &
be treated appropriately.
Post Partum Care - cont’d

16. Rh Incompatibility (Sensitization)
A.Suspension of breastfeeding
during the first 24 hours to
prevent pregnanediol from
interfering with the
conjugation of indirect bilirubin
to direct bilirubin.
B. Phototherapy:
1.Destruction of RBC results in formation of
indirect bilirubin.
Indirect bilirubin must be converted first to
direct bilirubin by the liver cells before it
can be excreted by the body.
2.Phototherapy speed up the maturation of
the liver to enable it to conjugate indirect
bilirubin to direct bilirubin more efficiently.
3.Uses single quarts halogen lamp or a bank
of 4 to 8 cool white, day bright, or special
blue fluorescent lights positioned 12 -30”
above the infant.
Management of Hemolytic disease in Newborn (HDN)
FIGURE 26.12 A newborn receiving phototherapy is
undressed except for a diaper so he receives maximum
exposure to the lights. His eyes are covered snugly to
protect them from the bright light.

17. Rh Incompatibility (Sensitization)
4. Nursing intervention during
phototherapy:
Close eyes & cover w/ dressing
Expect stool to be loose & bright
green from excessive bilirubin
excretion.
Provide good skin care because
stool is highly irritating to skin.
Remove all traces of stool from
skin.
Expect urine to be dark colored.
Assess for dehydration:
Monitor I & O and skin turgor.
Offer glucose water q 2hrs to px
dehydration
Maintain body temp b/n 36⁰C -37 ⁰C
Remove infant from the isolette
during feeding & eye patches
removed to allow interaction & visual
stimulation.
5. Home Phototherapy - exposure to
early morning sunlight.
Management of Hemolytic disease in Newborn (HDN)

18. Rh Incompatibility (Sensitization)
C. Exchange Transfusion
1.Beneficial effects:
Immediately removes 85% of
sensitized RBC
Removes bilirubin from fetal
circulation
Prevent congestive heart failure
2.The procedure takes about 1 to 2
hours to complete.
3.The type of blood used is O Rh
negative blood even if the infant is
Rh positive.
4. Indicated when bilirubin level is:
5 mg per 100 ml at birth
10 mg per 100 ml at 8 hours
12 mg per 100 ml at 16 hours
15 mg per 100 ml at 24 hours
Or if bilirubin is rising more than
0.5 mg’hr in Rh
incompatibility
1 mg/hr in ABO
incompatibility

19. Rh Incompatibility (Sensitization)
C. Exchange Transfusion
5. It involves withdrawing minute amounts of
infant’s blood (20ml) and then replacing it
with the donor’s blood.
An umbilical catheter is used to perform
the exchange.
Amount of donor blood is twice that of
the newborn volume.
7. An infusion of albumin several hours
before the procedure.
8. Calcium gluconate is administered after
each 100 ml of blood to prevent ACD.
8. If blood is heparinized, protamine
sulfate is administered after transfusion to
restore clotting ability.
9. Monitor:
During transfusion: HR, RR, venous
pressure
After procedure: Umbilical bleeding; v/s
q 15min during 1
st hr & then q 30min X
3h/↑
Bilirubin level is monitored up to the 3
rd
day after the procedure
10. Complication - Necrotizing Endocolitis