 Anincompatibility in Rh types between a donor

and recipient, or between an fetus–who is Rh

positive, and the mother–who is negative and
produces antibodies against the fetus' RBCs,
which pass to the placenta, and cause HDN
( Hemolytic disease of the newborn.)
 Rh incompatibility is a condition that occurs
during pregnancy if a woman has Rh-negative
blood and her baby has Rh-positive blood.
(Acc. to NHLBI)
Some of the causes of Rh- incompatibility
are :-

 Previous Rh+ baby

 Fetal bleeding
 Miscarriage
 Abortion
 Ectopicpregnancy
 Antepartum hemorrhage
 Amniocentesis
 Chorionic villus sampling
 Bleeding during delivery
 TO PREVENT ACTIVE IMMUNIZATION
 PREVENT OR MINIMIZE FETO-MATERNAL
BLEED
 TO AVOID MISMATCHED TRANSFUSION
Rh anti – D immunoglobulin is
administered in IM to the mother
following childbirth and abortion.
 of action: Antibody mediated
 Mode
immune suppression, the possible
mechanism are:

 Anti –D antibody when injected, it

blocks the Rh-antigen of the fetal cells.
 The intact antibody coated fetal red
cells are removed from the maternal
circulation by the spleen or lymph
node.
 The central inhibition- the fetal red cells
, coated with antibody interferes the
production of IgG from the B- cells.
 Administration: It should be administered
within 72 hours or preferably earlier following
delivery or abortion.

 Dose : It is administered to the mother 300µg

,IM, after the delivery. All Rh –negative
unsensitized women should receive 50 µg of
Rh immunoglobulin within 72 hours of induced
abortion, spontaneous abortion. Women with
pregnancy beyond 12 weeks should have full
dose of 300 µg.
During pregnancy: If the
women is Rh – negative and has
no antibody , she should have 2
doses of 300 µg Rh
immunoglobulin as prophylaxis at
28 weeks and again after birth
(within 24 hours)
 Precaution during caesarean section:
(1) To prevent blood from spilling into the
peritoneal cavity.
(2) Manual removal of placenta should not
be done as routine

 Prophylactic ergometrine with the

delivery of the shoulder should
preferably withheld , as it may facilitate
more fetoplacental bleed.
 Amniocentesis should be done
after sonographic localization of the
placenta to prevent its injury.

 Manual removal of placenta

should be done gently.

 Torefrain from abdominal

palpation as far as possible in
abruptio placentae.
To avoid giving Rh positive blood to
one Rh negative female from birth
to the menopause
 In
cases where there is no detectable
antibody found during pregnancy , an
expectant attitude is followed till term.
Tendency of pregnancy to overrun the
expected date should not be allowed.
 Whenever there is evidence of
haemolytic process in the fetus in
utero, the patient should be shifted to
an equipped center specialized to deal
with Rh problems.
 An intensive neonatal care unit ,
arrangements for exchange transfusion
and an expert neonatologists are the
basic requirements to tackle the
affected babies.
(i)Previous history of still
birth with father being
homozygous.

(ii)
Sudden rise in maternal
antibody titer .
 (iii)
Doppler and ultrasound of fetal
affection:
 In mild affection- pregnancy may be
continued upto 38 weeks and then
termination is done.
 In severe affection – it is reasonable to
terminate the pregnancy around 34 weeks
after maternal steroid is administered. In
every case of premature termination before
34 weeks , it is desirable to confirm the fetal
lung maturation by measuring the L.S ratio
in the amniotic fluid.
 (1)Amniotomy: (low rupture of the
membranes) is quite effective , if termination
is done near term. Vaginal prostaglandin gel
PGE2 could be used to make the cervix ripe.

 (2) Caesarean section : In cases when

termination has to be done prematurely (34 –
37 weeks) cervix will be unfavourable and
considering the severity of affection and
urgency of termination caesarean section is
a safe procedure.
 Vaginal delivery
(1) Careful fetal monitoring is to be done to
detect at the earliest , evidences of
distress

(2) Prophylactic ergometrine during second

stage should be withheld .

(3) Gentle handling of the uterus in the third

stage .

(4) To take care of postpartum hemorrhage.

 Cesarean section
(1)To avoid spillage of blood into the
peritoneal cavity.

(2) Routine manual removal of

placenta should be withheld
 Clamping the umbilical cord: In both
the either methods, cord is to be
clamped as quickly as possible to
minimize even a minute amount of
antibody to cross to the fetus from the
mother.
 The cord should be kept long (15-
20cm) for exchange transfusion if
required.
 Anti-D gamma globulin - given to the mother;
this prevents the development of antibodies in
the mother and is thus used preventively for
any underlying cause that may cause antibody
development during the pregnancy.
 Early induced delivery
 Premature induced delivery - for severe fetal
anemia
 Fetal blood transfusion
 Newborn blood transfusion
 ANTENATAL
 Serial Ultrasound and Doppler
examinations—to detect signs of fetal
anemia such as increased blood flow
velocities and monitor hydrops fetalis.

 Quantitative analysis of maternal

anti-RhD antibodies—an increasing
level is a sign of fetal Rh disease
Intrauterine blood transfusion
 Intraperitoneal transfusion—blood
transfused into fetal abdomen.

 Intravascular transfusion—blood
transfused into fetal umbilical
 Early delivery (usually after about 36
weeks gestation)
 POSTNATAL
 Phototherapy for neonatal jaundice in
mild disease

 Exchange transfusion if the neonate

has moderate or severe disease (the
blood for transfusion must be less than
a week old, Rh negative, ABO
compatible with both the fetus and the
mother, and be cross matched against
the mothers serum)
 IVIGhas been used to successfully treat
many cases of HDN. It has been used
not only on anti-D, but on anti-E as well.
IVIG can be used to reduce the need for
exchange transfusion and to shorten the
length of phototherapy. Intravenous γ-
globulin has been shown to reduce the
need for exchange transfusions in Rh
and ABO hemolytic disease.