AMNIOTIC FLUID OD450 MEASUREMENTS If the maternal antibody titer reaches a critical titer of 1:16 and if there is a possibility

that the fetal red blood cells are positive for the corresponding antigen, serial measurements of amniotic fluid OD450 should be done every 10 to 14 days to evaluate the level of bilirubin in the amniotic fluid. These values are plotted on the modified Liley curve ( Figure 2 ).
Amniotic fluid optical density (OD450) zones for management of pregnancy complicated by Rho(D) alloimmunization Alan H. DeCherney, MD dkk. Current Diagnosis & Treatment Obstetrics & Gynecology.edisi 10.2007. The McGraw-Hill Companies, Inc. United States of America

Rh Isoimmunization & Other Blood Group Incompatibilities Essentials of Diagnosis

Maternal Rh-negativity and presence of antibody on indirect Coombs' test. Rh or other antibody titer posing fetal risk. May have a previous infant with hemolytic disease of the newborn. Postnatal fetal cord blood findings of Rh-positivity and anemia (hemoglobin < 10 g).

General Considerations A fetus receives half of its genetic components from its mother and half from its father; therefore, the fetus may have different blood groups than those of its mother. Some blood groups may act as antigens in individuals not possessing those blood groups. The antigens reside on red blood cells. If enough fetal cells cross into the maternal blood, a maternal antibody response may be provoked. If these maternal antibodies cross the placenta, they then can enter the fetal circulation and destroy the fetal erythrocytes, causing hemolytic anemia. This leads to fetal responses to meet the challenge of enhanced blood cell breakdown. These changes in the fetus and newborn are called erythroblastosis fetalis. Several blood groups are capable of producing fetal risk, but those in the Rh group have caused the overwhelming majority of cases of erythroblastosis fetalis, so the Rh group is used as the example. The Rh blood group is the most complex human blood group. The Rh antigens are grouped in 3 pairs: Dd, Cc, and Ee. The major antigen in this group, Rho (D), or Rh factor, is of particular concern. A woman who is lacking the Rh factor (Rh-negative) may carry an Rhpositive fetus. If fetal red blood cells pass into the mother's circulation in sufficient numbers, maternal antibodies to the Rh-positive antigen may develop and cross the placenta, causing hemolysis of fetal blood cells (Fig 151). Hemolytic disease of the newborn may occur, and severe disease may cause fetal death. Figure 151.

A: Rh-negative woman before pregnancy. B: Pregnancy occurs. The fetus is Rh-positive. C: Separation of the placenta. D: Following delivery, Rh isoimmunization occurs in the mother,

and she develops antibodies (S) to the Rh-positive antigen. E: The next pregnancy with an Rh-positive fetus. Maternal antibodies cross the placenta, enter the fetal bloodstream, and attach to Rh-positive red cells, causing hemolysis. In standard testing when the father is Rh-positive, 2 possibilities exist: he is either homozygous or heterozygous. Forty-five percent of Rh-positive persons are homozygous for D and 55% are heterozygous. If the father is homozygous, all of his children will be Rhpositive; if he is heterozygous, his children will have a 50% chance of being Rh-positive. By way of contrast, the Rh-negative individual is always homozygous. Incidence Basque populations have the highest incidence of Rh-negativity (3035%). Caucasian populations in general have a higher incidence than other ethnic groups (1516%). Blacks in the United States have a rate of 8%, African blacks 4%, Indoeurasians 2%, and North American Indians 1%. In mothers who do not receive prophylaxis with Rh immunoglobulin, the overall risk of isoimmunization for an Rh-positive ABO-compatible infant with an Rh-negative mother is about 16%. Of these, 1.52% of reactions will occur antepartum and 7% within 6 months of delivery; the remainder (7%) manifest early in the second pregnancy, most likely as the result of an amnestic response. ABO incompatibility between an Rh-positive fetus and an Rhnegative mother provides some protection against Rh isoimmunization; in these cases the overall incidence is 1.52%. In mothers who receive prophylaxis with Rh immunoglobulin, the risk of isoimmunization is reduced to 0.2%. Pathogenesis Maternal Rh Isoimmunization Rh antigens are lipoproteins that are confined to the red cell membrane. Isoimmunization may occur by 2 mechanisms: (1) following incompatible blood transfusion or (2) following fetomaternal hemorrhage between a mother and an incompatible fetus. Fetomaternal hemorrhage may occur during pregnancy or at delivery. With no apparent predisposing factors, fetal red cells have been detected in maternal blood in 6.7% of women during the first trimester, 15.9% during the second trimester, and 28.9% during the third trimester. Predispositions to fetomaternal hemorrhage include spontaneous or induced abortion, amniocentesis, chorionic villus sampling, abdominal trauma (eg, due to motor vehicle accidents or external version), placenta previa, abruptio placentae, fetal death, multiple pregnancy, manual removal of the placenta, and cesarean section. Although the exact number of Rh-positive cells necessary to cause isoimmunization of the Rh-negative pregnant woman is unknown, as little as 0.1 mL of Rh-positive cells can cause sensitization. Even with delivery, this amount occurs in less than half of cases. Fortunately, there are other mitigating factors to Rh isoimmunization. A very important factor is that about 30% of Rh-negative persons never become sensitized (nonresponders) when given Rh-positive blood. ABO incompatibility also confers a protective effect (see Incidence).

The initial maternal immune response to Rh sensitization is low levels of immunoglobulin (Ig) M. Within 6 weeks to 6 months, IgG antibodies become detectable. In contrast to IgM, IgG is capable of crossing the placenta and destroying fetal Rh-positive cells. Other Blood Group Isoimmunization Of the other blood groups that may evoke an immunoglobulin capable of crossing the placenta (often called atypical or irregular immunizing antibodies), those that may cause severe fetal hemolysis (listed in descending order of occurrence) are Kell, Duffy, Kidd, MNSs, and Diego. P, Lutheran, and Xg groups may also cause fetal hemolysis, but it usually is less severe. Fetal Effects Hemolytic disease of the newborn occurs when the maternal antibodies cross the placenta and destroy the Rh-positive fetal red blood cells. Fetal anemia results, stimulating extramedullary erythropoietic sites to produce high levels of nucleated red cell elements. Immature erythrocytes are present in the fetal blood because of poor maturation control. Hemolysis produces heme, which is converted to bilirubin; both of these substances are neurotoxic. However, while the fetus is in utero, heme and bilirubin are effectively removed by the placenta and metabolized by the mother. When fetal red blood cell destruction far exceeds production and severe anemia occurs, erythroblastosis fetalis may result. This is characterized by extramedullary hematopoiesis, heart failure, edema, ascites, and pericardial effusion. Tissue hypoxia and acidosis may result. Normal hepatic architecture and function may be disturbed by extensive liver erythropoiesis, which may lead to decreased protein production, portal hypertension, and ascites. Neonatal Effects In the immediate neonatal interval, the primary problem may relate to anemia and the sequelae mentioned above. However, hyperbilirubinemia may also pose an immediate risk and certainly poses a risk as further red cell breakdown occurs. The immature (and often compromised) liver, with its low levels of glucuronyl transferase, is unable to conjugate the large amounts of bilirubin. This results in a high serum bilirubin level, with resultant kernicterus (bilirubin deposition in the basal ganglia). Management of the Unsensitized Rh-Negative Pregnancy Prepregnancy or First Prenatal Visit On the first prenatal visit, all pregnant women should be screened for the ABO blood group and the Rh group, including Du. They should also undergo antibody screening (indirect Coombs' test). Unless the father of the baby is known to be Rh-negative, all Rh-negative mothers should receive prophylaxis according to the following protocol. Visit at 28 Weeks

Antibody screening is performed. If negative, 300 g of Rh immunoglobulin (RhIgG) is given. If positive, the patient should be managed as Rh-sensitized. Visit at 35 Weeks Antibody screening is repeated. If negative, the patient is merely observed. If screening is positive, the patient is managed as Rh-sensitized. Postpartum If the infant is Rh-positive or Du-positive, 300 g of RhIgG is administered to the mother (provided maternal antibody screening is negative). Although RhIgG should generally be given within 72 hours after delivery, it has been shown to be effective in preventing isoimmunization if given up to 28 days after delivery. If the antibody screen is positive, the patient is managed as if she will be Rh-sensitized during the next pregnancy. Special Fetomaternal Risk States Several circumstances that may occur during pregnancy mandate administration of RhIgG to the unsensitized patient outside the management protocol described. Abortion Sensitization will occur in 2% of spontaneous abortions and 45% of induced abortions. In the first trimester, because of the small amount of fetal blood, 50 g of RhIgG apparently is sufficient to prevent sensitization. However, because the cost of RhIgG has dropped, a full 300g dose is usually given. The same dose is recommended for exposure after the first trimester. The risk of Rh isoimmunization after threatened abortion is less well understood, but many experts agree that RhIgG should also be given to these patients. Amniocentesis, Chorionic Villus Sampling, and Cord Blood Sampling If the placenta is traversed by the needle, there is up to an 11% chance of sensitization. Therefore, administration of 300 g of RhIgG is recommended when these procedures are performed in the unsensitized patient. Antepartum Hemorrhage In cases of placenta previa or abruptio placentae, administration of 300 g of RhIgG is recommended. If the pregnancy is carried more than 12 weeks from the time of RhIgG administration, a repeat prophylactic dose is recommended. External Cephalic Version

Fetomaternal hemorrhage occurs in 26% of patients who undergo external cephalic version, whether failed or successful; therefore, these patients should receive 300 Delivery with Fetomaternal Hemorrhage Fetomaternal hemorrhage so extensive that it cannot be managed with 300 g of RhIgG occurs in only about 0.4% of patients. If the sensitive screening test is positive for persistent antibody after RhIgG administration, the amount of hemorrhage is quantitated by the Kleihauer-Bethke test and additional doses of RhIgG given according to the amount of excess hemorrhage. Evaluation of the Pregnancy with Isoimmunization Evaluation of the pregnancy complicated by isoimmunization is guided by 2 factors: whether the patient has a history of an affected fetus in a previous pregnancy (ie, fetus with severe anemia or hydrops) and maternal antibody titers. No History of Previous Fetus Affected by Rh Isoimmunization Once the antibody screen is positive for isoimmunization, these patients should be followed by antibody titers at intake, 20 weeks' EGA, and then every 4 weeks. As long as antibody titers remain below the critical titer (<1:32 in our laboratory, but each laboratory must establish its own norms), there is no indication for further intervention. Once antibody titers reach 1:32, amniocentesis should be performed because a titer of 1:32 places the fetus at significant risk for demise before 37 weeks. An alternative to serial amniocentesis in patients with abnormal antibody titers or a history of a prior affected fetus is assessment of blood flow in the fetal middle cerebral artery (MCA) by Doppler. Ultrasound is performed to identify the circle of Willis, and blood flow in the proximal third of the MCA can be estimated using Doppler. High peak velocity blood flow in this area (> 1.5 multiples of the median) correlates well with severe fetal anemia. This test can be performed at 2-week intervals in these patients, so more invasive diagnostic interventions can be avoided until evidence of severe anemia is observed. History of a Prior Fetus Affected by Rh Isoimmunization Antibody titers need not be followed in these pregnancies because amniocentesis is indicated by the history of prior affected fetus. Amniocentesis should be performed 48 weeks earlier than the gestational age in the previous pregnancy when Rh-associated morbidity was first identified. Amniocentesis, when determined to be necessary, should be performed under ultrasound guidance to minimize the risk of transplacental hemorrhage. The amniotic fluid is analyzed by spectrophotometry. The optical density of the fluid at a wavelength of 450 nm is plotted on a semilogarithmic scale versus gestational age. The amniotic fluid concentration of bilirubin in the unsensitized patient gradually decreases as pregnancy progresses. Thus, the severity of fetal affliction may be approximated and this information used as a guide for further studies and treatment. The alternative of MCA Doppler peak velocity assessment is now more widely used. g of RhIgG.

In addition to MCA Doppler, ultrasound plays an important role in evaluating the isoimmunized patient for hydrops. Ultrasound can be used to evaluate fetal heart size and amniotic fluid index and to detect edema, pericardial effusion, and ascites. Serial ultrasounds can document the progression or reversal of disease. Management of the Pregnancy with Isoimmunization Management of these patients is dictated by amniocentesis or MCA Doppler results (Fig 15 2). Figure 152.

Peak velocity of systolic blood flow in the middle cerebral artery in 111 fetuses at risk for anemia due to maternal red-cell alloimmunization. (From Mari G et al: Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization. Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses. N Engl J Med 2000;342:9.) Mildly Affected Fetus The fetus that falls into zone 1 on the Liley curve or has normal MCA Doppler studies is considered to unaffected or mildly affected. Testing should be repeated every 23 weeks, and delivery should be near term and after the fetus has achieved pulmonary maturity. Moderately Affected Fetus The fetus that falls into zone 2 or has MCA Doppler studies nearing 1.5 multiples of the median (Fig 152) should be tested more frequently, every 12 weeks. Delivery may be required prior to term, and the fetus is delivered as soon as pulmonary maturity is reached. In some cases, enhancement of pulmonary maturity by use of corticosteroids may be necessary. Severely Affected Fetus The severely affected fetus falls into zone 3 on the Liley curve, has MCA Doppler studies > 1.5 multiples of the median, or has frank evidence of hydrops (eg, ascites, pleural or pericardial effusion, subcutaneous edema). Intervention usually is needed to allow the fetus to reach a gestational age at which delivery and neonatal risks are fewer than the risks of in utero therapy. If the fetus is preterm, cordocentesis or percutaneous umbilical cord blood sampling (PUBS) is recommended at this stage to directly assess the fetal hematocrit. Once severe anemia is confirmed, intrauterine transfusion can be performed directly into the umbilical vein. The transfusion is performed using O-negative, cytomegalovirus-negative, washed, leukocytedepleted, irradiated packed red cells. The intraperitoneal technique was used in years past but has largely been replaced by intravascular fetal transfusion secondary to its more predictable absorption.

After transfusion, repeat transfusions or delivery usually will be necessary as production of fetal blood markedly decreases or ceases. Timing of these transfusions may be assisted by ultrasonic determination of MCA Doppler studies. Delivery should take place when the fetus has documented pulmonary maturity.

Hacker, moore, gambone. Essentials obs and gyn.edisi 4.elsevier maunders

16 Rhesus Isoimmunization Khalil Tabsh Nancy Theroux Rhesus (Rh) isoimmunization is an immunologic disorder that occurs in a pregnant, Rhnegative patient carrying an Rh-positive fetus. The immunologic system in the mother is stimulated to produce antibodies to the Rh antigen, which then cross the placenta and destroy fetal red blood cells. NEWER TECHNIQUES FOR EVALUATING FETAL RH STATUS In the last decade, amniocentesis has become the most commonly employed method to test fetal blood type in cases of a heterozygous paternal genotype. Most laboratories offering fetal red cell antigen typing on amniotic cells require an accompanying paternal blood sample, and with the recent discovery of an Rh D pseudogene in 21% of blacks, a maternal blood sample should also be provided. Chorionic villus sampling has been utilized to determine fetal blood type but is discouraged because of the potential for worsening fetal disease if the fetus is Rh D positive. Flow cytometry has been successfully reported in sorting fetal cells from maternal blood. DNA amplification using a single fetal nucleated erythrocyte can be used to determine fetal Rh D blood type. Free fetal DNA in maternal plasma or serum has also been utilized to detect Rh D sequences. CLINICAL MANAGEMENT OF THE Rh-SENSITIZED PATIENT

Table 16-2. Guidelines for the timing of amniocentesis Severity of Disease in Previous Pregnancies Timing of First Amniocentesis (wk) No disease 26-30 Mild-moderate: (delivery at 37-40 wk) 20-28 Severe without death (delivery at 34-37 wk) 20-25

Severely affected neonate with hydrops or stillbirth

20-24

page 213 page 214 Because single OD 450 values are helpful only if they are very high (zone III) or very low (zone I), serial sampling of amniotic fluid is generally indicated. The severity of hemolytic disease in the prior pregnancy provides an index for the timing of the first amniocentesis (Table 16-2). With serial sampling, one of three trends will emerge. Falling OD 450 values are indicative of a fetus that is either unaffected (e.g., Rh-negative) or very mildly affected. No intervention is indicated in these patients. If the OD 450 is either stable or rising, frequent OD 450 determinations are necessary. If the OD 450 enters zone II or III after 34 weeks' gestation, determination of fetal lung maturity and delivery is indicated. If this occurs prior to 34 weeks, however, delivery is best avoided because of the risk of complications from prematurity. In such cases, intrauterine transfusion is the treatment of choice if the OD 450 enters zone III. In addition to serial OD 450 values, the timing of delivery should be based on the patient's obstetric history and fetal well-being assessed by nonstress testing, biophysical profiles, and fetal lung maturity testing. The fetal lung maturity profile, including at least a lecithin-tosphingomyelin (L:S) ratio and a phosphatidylglycerol (PG) level, will help determine the optimum time for delivery. pages 213 - 214 Link to this page: http://www.studentconsult.com/content/default.cfm? ISBN=0721601790&ID=HC016011 Copyright 2007 Elsevier Inc. All rights reserved. Read our Terms and Conditions of Use and our Privacy Policy. For problems or suggestions concerning this service, please contact: studentconsult.help@elsevier.com INTRAUTERINE TRANSFUSION Intrauterine transfusion, initially introduced in 1963 as an intraperitoneal transfusion, has markedly changed the prognosis for severely affected fetuses. The goal is to transfuse fresh group O, Rh-negative packed red blood cells. In addition to routine blood screening, the blood for transfusion is irradiated, washed, processed through a leukocyte-poor filter, and screened for cytomegalovirus. Curare is usually injected directly into the fetal thigh with a 22-gauge spinal needle prior to transfusion, regardless of method, to immobilize the fetus during the procedure. Repeat transfusions are generally scheduled at 1 to 3 week intervals. The final transfusion is typically performed at 34 to 35 weeks' gestation. In general, the fetus is delivered when the lungs are mature. The overall survival rate following intrauterine transfusion is about 85%. In fetuses with no evidence of hydrops, the survival rate is about 90%, and for fetuses with hydrops prior to the transfusion, the survival rate is about 75%. Fetal Intraperitoneal Transfusion Red blood cells are absorbed via the subdiaphragmatic lymphatics and proceed via the right lymphatic duct into the fetal intravascular compartment. After transfusion, the absorption of blood may be monitored with serial transverse ultrasonic scans of the fetal abdomen. In nonhydroptic fetuses, the blood should be absorbed within 7 to 9 days. In the presence of hydrops, absorption is variable and may necessitate removal of ascitic fluid at the time of transfusion. Under real-time ultrasonic guidance, a 20-gauge spinal needle is inserted through the

mother's abdomen into the fetal peritoneal cavity. The correct positioning of the needle is determined by injection of a small amount of normal saline and carbon dioxide, which can be easily visualized with ultrasonography. The red blood cells are slowly injected manually in 10-mL aliquots through an extension catheter attached to the spinal needle. If fetal bradycardia occurs at any time during the procedure, the transfusion is terminated. For intraperitoneal transfusions, the volume to be infused is based on the following formula: For example, a 30-week fetus would require a 100-mL transfusion (30 weeks -2010 = 100 mL). Intravascular Transfusion Because many fetuses are not subjected to transfusion until ascites is present, intravenous fetal transfusion has become increasingly popular. In addition, transfusion into the peritoneal cavity can result in fetal bradycardia or a pseudosinusoidal fetal heart rate pattern following the procedure because of compression at the site of insertion of the umbilical cord. Under ultrasonic guidance, a 22-gauge spinal needle is inserted into the umbilical vein or the hepatic part of the umbilical portal venous system. If the umbilical vein is used, the preferred sites are either at the placental cord insertion or into a loop of umbilical cord. The volume of blood to be transfused is based on the fetal body weight, as determined by ultrasonography. OTHER MODES OF THERAPY Maternal plasmapheresis may be helpful in severe erythroblastosis when intrauterine transfusions are not successful, but perinatal outcome with this technique has not been impressive. Phenobarbital has been used to induce fetal hepatic microsomal glucuronosyltransferase activity, thereby increasing uptake and excretion of bilirubin by the liver. Treatment with phenobarbital is initiated 2 to 3 weeks before delivery. PREVENTION OF RHESUS ISOIMMUNIZATION Because Rh isoimmunization occurs in response to exposure of an Rh-negative mother to the Rh antigen, the mainstay for prevention is the avoidance of maternal exposure to the antigen. RhO-GAM diminishes the availability of the Rh antigen to the maternal immune system, although the exact mechanism by which it prevents Rh isoimmunization is not well understood. RhO-GAM is prepared from fractionated human plasma obtained from hyperreactive sensitized donors. The plasma is screened for hepatitis B surface antigen and anti-HIV-1, the antibody to the acquired immunodeficiency syndrome (AIDS) virus. The globulin is available in several dosages for intramuscular injection. Since the advent of its use in 1967, Rh immune globulin has dramatically reduced the incidence of Rh isoimmunization. Because the greatest risk for fetal-to-maternal hemorrhage occurs during labor and delivery, Rh immune globulin was initially administered only during the immediate postpartum period. This resulted in a 1% to 2% failure rate, thought to be due to exposure of the mother to fetal red blood cells during the antepartum period. The indications for the use of Rh immune globulin have therefore been broadened to include any antepartum event (such as amniocentesis) that may increase the risk of transplacental hemorrhage. The routine prophylactic administration of Rh immune globulin at 28 weeks' gestation is now the standard of care. Despite adherence to this suggested Rh immune globulin protocol, 0.27% of primiparous Rh-negative patients still become sensitized. INDICATIONS FOR ADMINISTRATION OF RHO-GAM

The following provides a practical approach to the administration of Rh immune globulin to an Rh-negative patient with no Rh antibodies. During a normal pregnancy, 300 g of Rh immune globulin is administered at 28 weeks' gestation, following testing for sensitization with an indirect Coombs' test. A 300-g dose is administered following amniocentesis at any gestational age. If a fetomaternal hemorrhage is suspected at any time during the pregnancy, a Kleihauer-Betke test should be performed. If positive, Rh immune globulin is administered in a dose of 10 g/mL of fetal blood that entered the maternal circulation. Following an uncomplicated delivery, 300 g of Rh immune globulin is given within 72 hours. If a larger than normal fetal-tomaternal hemorrhage is suspected, such as may occur in patients with abruptio placentae or those requiring cesarean section or manual removal of the placenta, a Kleihauer-Betke determination should be performed after delivery and the appropriate dose of the Rh immune globulin determined. Establishment of fetal circulation occurs at approximately 4 weeks' gestation, and the presence of the RhO D antigen has been demonstrated as early as 38 days following conception. Consequently, Rh isoimmunization can occur at any time during pregnancy, from the early first trimester on. Because fetal erythrocytes can be readily detected in the maternal blood following induced or spontaneous abortion, 50 g of Rh immune globulin should be given to all Rh-negative women following any type of abortion. Fetal erythrocytes have been demonstrated in the maternal circulation following rupture of a tubal pregnancy. Consequently, Rh immune globulin should be given to an Rh-negative woman with an ectopic pregnancy. Because chorionic villi in gestational trophoblastic disease are avascular and are devoid of fetal erythrocytes, Rh immune globulin is probably not necessary following molar pregnancy. At least one case of sensitization following a molar pregnancy, however, has been reported. Irregular Antibodies Although Rh isoimmunization is the most common cause of hemolytic disease in the newborn, other blood group systems may be involved, such as Kell, Duffy, or Kidd. For example, Kell antigen may elicit a strong IgG response similar to Rh isoimmunization. Suggested Reading American College of Obstetricians and Gynecologists: Prevention of RhD alloimmunization in pregnancy, Practice Bulletin No. 4. Washington, DC, ACOG, 1990. Mari G, Deti L, Oz U, et al: Accurate prediction of fetal hemoglobin by Doppler ultrasonography: Obstet Gynecol 99:589-593, 2002. Medline Similar articles Full article Moise KJ: Management of rhesus alloimmunization in pregnancy. Obstet Gynecol 100(3):600-611, 2002.

Editors: Fortner, Kimberly B.; Szymanski, Linda M.; Fox, Harold E.; Wallach, Edward E. Title: Johns Hopkins Manual of Gynecology and Obstetrics, The, 3rd Edition Copyright 2007 Lippincott Williams & Wilkins > Table of Contents > II - Obstetrics > 18 - Red Blood Cell Alloimmunization 18 Red Blood Cell Alloimmunization Janyne E. Althaus I. Alloimmunization Alloimmunization refers to maternal antibody formation against fetal antigens that lead to destruction of fetal cells. The overall incidence of alloimmunization to all clinically significant red cell antigens is estimated to be 25 per 10,000 births. The most common antigen targeted is the Rhesus or Rh antigen. II. Rhesus (Rh) Alloimmunization Maternal blood type is usually described as ABO+ or ABO-, signifying the absence or presence of the Rh or D antigen. The description is technically incomplete, because the Rh complex not only has the D antigen but also C/c and E/e alleles. No d allele has been identified to date.

Epidemiology. Fifteen percent of all Caucasians are Rh- versus 8% of African Americans and Hispanic Americans. The highest prevalences are in the Basque of Spain (30% to 35%), with the lowest in Native Americans and Inuit Eskimos (1% to 2%). The CDC reported an incidence of alloimmunization in 2000 of 6.8 of 1,000 live births. Pathogenesis. The fetus develops red blood cell antigens by 30 days' gestation. Three conditions must be present for alloimmunization to occur. o The fetus must be Rh+ and the mother must be Rh-. o Maternal Exposure to the Antigen. In normal pregnancies, small amounts of fetal blood (0.1 cc) routinely pass into maternal circulation. Larger amounts of fetal blood can pass if there has been transplacental fetomaternal hemorrhage (FMH), sharing of needles with Rh+ contaminated blood, or mismatched blood transfusions. FMH is the most common etiology and is more likely to occur at later gestational ages and with invasive procedures, such as amniocentesis or chorionic villus sampling. o Immunocompetence in the Mother. The maternal response is to produce immunoglobulin G (IgG) against the Rh antigen. IgG crosses the placenta by receptor-mediated endocytosis, with substantial transfer occurring after 20 weeks. Anemia develops as fetal red cells, laden with maternal antibody, are subsequently sequestered and hemolyzed. The fetal response is to increase erythropoietin production, which leads to fetal bone marrow and

extramedullary hematopoiesis stimulation. Immature red blood cells (RBCs) soon appear in the fetal circulation (erythroblastosis fetalis) as the hemolysis outpaces red cell production. If left untreated, fetal portal hypertension, reduced hepatic protein synthesis, increased cardiac output, increased hydrostatic pressure and increased capillary permeability will all lead to the development of fetal hydrops (hydrops fetalis). Prevention. With the development of Rh(D) Immune globulin (Rhogam) in the 1960s and its prophylactic administration to all Rh- women, the rate of sensitization has dropped dramatically. Untreated, 16% of all Rh- women became sensitized with an Rh+ pregnancy. This rate drops to 1.5% if treated with Rhogam within 72 hours after delivery. If prophylaxis is given at 28 weeks and postpartum, the rate of sensitization is 1:1,000. The most likely time for sensitization secondary to FMH occurs at delivery; however, any disruption of the fetomaternal interface can lead to increased risk. Thus, Rhogam should be given in any of the following situations listed in Table 18.1. o The standard Rhogam dose is 300 mcg given intramuscularly (IM). As each 10 mcg are considered protective for 1 cc of fetal blood, the standard dose is P.232 designed to be protective for 30 cc of fetal hemorrhage into the maternal system. Quantization of FMH by laboratory analysis via a Kleihauer-Betke test can alert the clinician if a greater amount of hemorrhage has occurred and more Rhogam is needed. In the first trimester, a mini-dose of Rhogam (50 mcg) IM is considered sufficient. The half life of Rhogam is 24 days, but maternal titers usually take longer to return to zero. 1. 2. 3. sampling 4. 5. 6. cause 7. 8.
9.

Table 18.1 Indications for Giving Rhogam First trimester spontaneous or elective abortion Ectopic pregnancy Amniocentesis, fetal blood sampling, or chorionic villi Molar pregnancy Second- or third-trimester bleeding Intrauterine fetal demise if FMH is suspected to be the External cephalic version Abdominal trauma

First-trimester vaginal bleeding with viable intrauterine pregnancya a More controversial on whether it is useful. Remember!! Rhogam is given to only Rh

Management of Rh- Unsensitized Patient. See Figure 18.1. o Screen at First Prenatal Visit Screening. If the antibody screen demonstrates Rh antibodies, the person is already sensitized and must be treated as such.

Screen at 28 Weeks. If antibody screen is now positive, STOP! The patient has been sensitized and must be treated as such. However, caution must be taken. If the patient received Rhogam earlier in the pregnancy for one of the reasons stated in Table 18.1, the laboratory must distinguish between sensitization and the presence of Rhogam. If the positive screen is due to previous Rhogam administration, most clinicians will give the standard dose of Rhogam, because it is unlikely that the previous dose will be protective through the remainder of the pregnancy. If antibody screen is negative at 28 weeks, administer standard dose of Rhogam. o Screen Both Patient and Neonate After Delivery. If the neonate is Rh-, no Rhogam is needed, as no exposure to the Rh antigen was present. If the neonate is Rh+ and the mother is still antibody (-), the standard dose of Rhogam is given. In addition, the laboratory should run an assay to determine whether FMH occurred in excess of 30 cc; if so, extra Rhogam must be given to cover the extra hemorrhage. If the neonate is Rh+ and the mother is now antibody (+) with a titer >1:4, the patient must be considered Rh sensitized and treated as such for the next pregnancy. Again, the antibody screen may be positive if the mother received Rhogam within a few weeks of delivery (e.g., after an amniocentesis for fetal lung maturity). So laboratory assays must help distinguish between true sensitization and detection of Rhogam still in the maternal system. o A general rule of thumb: When in doubt, give Rhogam. The risk of Rhogam to an already-sensitized person is small compared to the risk of permanent sensitization if erroneously omitted. Management of the Rh- Sensitized Patient. Any Rh- patient with an anti-D titer >1:4 should be considered sensitized. See Figure 18.2. o Sonogram. Accurate dating for gestational age is crucial to properly interpret fetal tests and to ensure proper timing of fetal interventions. Sonogram should be arranged at first prenatal visit regardless of gestational age at which they first present. o Establish Paternal Blood Type. The pregnancy is at risk only if the fetus has inherited the D antigen. Determining antigen status of the father of the baby (FOB) is vital, because it can potentially avoid multiple fetal interventions. Patient must be asked in private who the FOB is or may be. All possible candidates must have their paternal red cell phenotype ordered; a blood type and antibody screen are not sufficient. If the FOB is Rh-, the fetus will be Rhand not at risk. No further intervention is required. Documentation of paternal blood type is required; verbal report is not sufficient. If the FOB is heterozygous for D, the fetus has a 50% chance of being at risk. Homozygosity in the FOB means that the fetus will be at risk for hydrops. All fetuses must be assumed to be Rh+ until proven otherwise. o Follow Serial Maternal D Antibody Titer. Most Rh-sensitized patients will have a chronic low level titer of D antibody. The fetus is not at risk of being affected unless the critical titer is reached. The critical titer is either an absolute value (1:16 or greater) or an increase of more than one dilution (e.g., 1:2 to 1:8). Once the maternal antibodies surpass the critical titer, further titers will no longer be helpful, and serial fetal testing will be required throughout the remainder of the pregnancy.
o

Amniocentesis. Once the critical titer is reached, the fetal blood type must be determined (Fig. 18.3). If the FOB's antigen status is unknown, paternity is uncertain, or the FOB is heterozygous, amniocentesis should be performed. Fetal blood genotype is determined from amniotic fluid by polymerase chain reaction that carries a false-negative rate of up to 1.5%. Discrepancies between fetal genotype and phenotype can occur, so maternal and paternal P.236 samples should be sent concurrently with the amniotic fluid to help confirm fetal blood type. If the fetus is found to be Rh+, the maternal sample should be checked for the Rh pseudo gene. The Rh pseudo gene is an Rh(D) gene that acts like an Rh- gene on serologic testing. A fetus with an Rh pseudo gene on PCR will be reported as Rh+ but act as an Rh- fetus and is not at risk for hydrops fetalis. If the mother has the pseudo gene, the fetal sample must be tested. Fetal inheritance of the pseudo gene indicates that the fetus is not at risk, and no further studies are indicated. If the maternal pseudo gene is absent, the fetus is considered Rh+ and is at risk. If the fetus is found to be Rh-, the paternal sample should be analyzed. Occasionally, spontaneous gene loci rearrangement results in a fetus mistakenly being labeled Rh- when in fact it did inherit the paternal D antigen. Comparison of paternal and amniotic fluid samples that use the same PCR primers can help verify fetal Rh status. If the fetus is found to be Rh- and a paternal sample is not available, repeat maternal titer in 4 to 6 weeks. If there is no rise, one is reasonably assured that the fetus is in fact Rh-. A fourfold rise in titer should raise suspicion of the test result's accuracy. Serial Fetal Assessment. Two modalities are currently used to both follow the pregnancy and determine timing of intervention.

Amniocentesis. Serial amniocenteses beginning at 24 to 26 weeks are performed to determine the likelihood of fetal anemia. In 1961, Liley demonstrated that amniotic bilirubin secondary to fetal hemolysis was directly proportional to the spectrophotometric peak at 450 nm (OD450). The Liley's curve was thus developed and has three prognostic zones (Fig. 18.4).

P.237

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Zone 1: The fetus is unlikely to be affected at this time, or only mildly affected. Zone 2: The fetus is experiencing mild-to-moderate hemolysis. Zone 3: The fetus is anemic. A high probability of fetal death is present in 7 to 10 days unless intervention occurs. If the OD450 falls in zone 1, recommend repeat amniocentesis in 10 to 14 days. Zone 2 is divided into upper (<80%) and lower (>80%) zones. If the OD450 falls in the lower portion of zone 2, amniocentesis in 10 to 14 days is recommended. If it falls in the upper zone, fetal blood sampling is recommended. All fetuses whose levels are in zone 3 require fetal blood sampling (Table 18.2). Doppler Studies. Doppler studies of the fetal middle cerebral artery (MCA) are emerging as an alternative to serial amniocenteses. MCA Doppler evaluation is based on evidence that when a fetus is anemic, it will preferentially shunt blood to its brain faster to compensate for the low viscosity blood and hence have a higher peak systolic velocity (PSV). Studies using a cutoff of a MCA-PSV greater than 1.5 multiples of the median (MoM) can have demonstrated a sensitivity of 87%, positive predictive value of 53%, and a false-negative rate of 98%. Most centers check Dopplers every 1 to 2 weeks, although the optimal timing has yet to be determined. Doppler studies are to be used with caution. First, the reliability decreases after 35 weeks of gestation, so alternative methods must be used. Second, Dopplers can easily be measured incorrectly and thus should be performed only by experienced clinicians. Although Dopplers may prove to eventually replace the need for invasive fetal assessment, they are currently not considered to be the standard of care and should be used only in conjunction with amniocentesis until further studies determine their full use. Serial NSTs or BPPs Weekly Beginning at 32 Weeks. Delivery. If the fetus has required transfusion or develops abnormal Doppler studies, delivery at or after 35 weeks is recommended. If the maternal critical titers were not reached, induction of labor between 37 and 39 weeks is recommended. Subsequent Pregnancies. If a patient has had a previously affected infant (i.e., hydrops fetalis or need for intrauterine transfusion), following titers will not be helpful for any further pregnancies. After establishing paternal blood status, amniocentesis should be performed between 15 and 18 weeks to determine fetal blood type. If the fetus is Rh+, begin amniocentesis +/- Doppler evaluation beginning at 18 weeks' gestation and repeating every 1 to 2 weeks.