THE MANAGEMENT OF RH NEGATIVE PREGNANCY.pptx

Rh negative

1. 1 THE MANAGEMENT OF RH NEGATIVE PREGNANCY Dr Simi J

2. 2 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

3. 3 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

4. 4 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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7. 7 Development of Rhesus antibodies depends on: Inborn inability to respond to Rh-antigenic stimulus Protection if ABO incompatible 1\10 Strength of Rh antigen stimulus (CDe=R1) Volume of leaking feta blood(0.1 ml) Immunological nonresponders found in 30% of Rh- negative women

8. 8 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

9. 9 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 9. Cesarean section 10. Manual removal of placenta 11. silent feto-maternal haemorrhage

10. 10 Amount needed for sensitization 0.1ml

11. 11 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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13. 13 MANAGEMENT Rh negative women categorized in two groups Rh-negative non immunized women Rh-negative immunized women Immunized against -D antigen -nonD Rh antigen -other blood group system

14. 14 Objectives Non immunized women – prevention of alloimmunization Immunized women – a. early detection b. adequate treatment of fetal anemia and timely delivery

15. 15 Rh- negative non immunized

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17. 17 RH-NEGATIVE IMMUNIZED WOMEN

18. 18 Management based on a) First affected pregnancy b)Previous affected pregnancy

19. 19 First affected pregnancy Should have antibody triter every 4 weeks If triter>critical level→ -amniocentasis -MCA-PSV If triter< critical level up-to 36wks of gestation, should delivered between38-40 weeks

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21. 21 PREVIOUS AFFECTED PREGNANCY Maternal anti-D titre not predict the fetal anemia MCA-PSV to determine the anemia Serial amniocentasis

22. 22 Previous affected pregnancy Maternal anti-D triter not predict the fetal anemia MCA-PSV to determine the anemia Serial amniocentasis

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30. 30 Transfusion therapy can be given intraperitoneal or intravascular Other therapies Plasmapheresis: tried to remove several liters of maternal plasma with anti-D antibodies High dose I.v immunoglobulin: 1000mg/kg weekly

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32. 32 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)

33. 33 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)

34. 34 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

35. 35 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

36. 36 INTRAPARTUM MANAGEMENT

37. 37 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)

38. 38 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 3 rd 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 core

39. 39 At birth Maternal blood Antibodies by indirect Comb’s test(ICT) Fetal red blood cells in maternal circulation Cord blood sample (neonatal blood sample) for Antibodies by Comb’s test (DCT) Infant blood group and rh-typing Infant bilirubin level Infant Hb and Hct level

40. 40 Anti-D Immunoglobulin

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43. 43 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 should be given at least a single dose between 28-30 weeks. All cases of fetomaternal heemorrhage before 12 weeks should be given 150mcg anti D

44. 44 Inj Anti D is advised in case of Ectopic pregnancy and molar pregnancy in Rh negative mother In case of any APH in the 2 nd and 3 rd 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

45. 45 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,

46. 46 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 3 rd stage. Postpartum inj Anti D 300mcg is given to all Rh negative mother whose baby is Rh positive ideally within 72 hrs of delivery.

47. 47 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.

48. 48 Reference 1. Williams obstetrics-25th edition 2. High risk pregnancy 5 th 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