RH Incompatibility Lhr Dec06

8/2/2019 RH Incompatibility Lhr Dec06

http://slidepdf.com/reader/full/rh-incompatibility-lhr-dec06 1/28

Modern Management of

Rhesus disease

Pakistan Experience

Prof. Dr. Yasmin RaashidMBBS MCPS FRCOG

King Edward Medical University, Lahore



RH Incompatibility

1941 Levine identified RH Incompatibility

1961 Liley successfully transfused a sickfetus intra-peritonealy with adultRBC’s

.

1964 Freda and colleague demonstratedthat passive immunization of RH (-ve)individuals is possible.

1981 Rodeck et al achieved a high survivalrate for hydropic fetus using intravascular transfusion.



Begins in yolk sac at 21 days moves toliver and then bone marrow at 16 weeks

ABO antigens weakly expressed in fetalred blood cells

Rhesus antigens well developed by day 30

IgG crosses placenta and binds to the fetalred cells

Destroyed by the reticulo-endothelialsystem

Fetal Haematopoiesis



Maternal fetal ABO incompatibility has aprotective effect on the risk ofalloimmunisation to D

If father hetrozygous 50% of childrenaffected



Pathophysiology

Exposure and response to a foreign redblood cell antigen

Causes

Fetal to maternal transplacental

haemorrhageHeterologous blood transfusion



Prevention of sensitisation

Anti-D immunoglobulin given

After any bleed

Amnio /CVS/ Cordocentesis EVC

Delivery

Prophylaxis

at 28 and 34 (500 IU)

At 28 (1500IU)



Fetal sequelae are a result ofanaemia

Fetus tolerates mild anaemia well

As anaemia worsens, other metabolicalterations occur

Red cells principle buffer

Metabolic acidosis

hydrops



Hydrops

Precise mechanism unknown

Hb 7g below expected

Hepatomegaly may hinder blood flow orproduce portal hypertension

Cardiac dysfunction

• Cause or effect





Intraperitoneal transfusion

Blood absorbed by lymphatics

requires fetal respiration

In presence of hydrops absorption poor

Volume = (weeks gestation - 20) x 10 mls

repeat at 2 weeks thereafter every 3-4weeks



Intraperitoneal transfusion

Hazards

Slow to correcthaemoglobin deficit

Higher risk of trauma

Can obstruct cardiacreturn

Death per transfusion6 x that of IVT



Intravascular transfusion -indication

Rh and other blood group antibodiescausing anaemia

Anti platelet antibodies

Parvovirus induced anaemia



First Intravascular Transfusion for RhIncompatibility in Pakistan was donesuccessfully in 1998

To Date 42 Patients have receivedintravascular transfusion



Selection of patients

Patients with Rh Negative Blood Group

Husband’s Blood Group Rh Positive

Previous history of IUD or Neonatal Death Positive Antibody Titre



Middle cerebral artery Lateral branch of circle of Willis



Peak systolic velocity ofmiddle cerebral artery (MCA-

PSV)

Increases with increasing gestational

age Plot on reference values



Inutero Transfusion Team

Perinatal Obstetrician

Ultra-Sonologist

Hematologist

Paediatrician



Preparation

Preparation of donor blood as fresh aspossible (O-ve packed cells)

Compatible with both mother and fetus

Final hematocrit 70-80%

Acetone wipe to remove ultrasound contactgel form the skin

Providine or alcohol surgical preparation ofthe skin

Drape as desired and prepare surgical tray



Intravascular transfusion

Position mother

Identify site for needle insertion

Maternal sedation

Local FBS

Transfuse at 2-3 mls/minute

Monitor FHR

Post transfusion sample

CTG

Home

Repeat 1-3 weeks









Calculating the volume of blood to transfuse(using Hb)



Results of Our Center

Total no. of patients who have received in-utero transfusion are 42.

Live births 30

IUD 8

Neonatal deaths 3

Ongoing pregnancies 1

success rate 71%





Post natal management

Mild – phototherapy

More severe exchange transfusion

After 2 IUT most babies will not requireexchange

Greater the number of IUT the less severethe hyperbilirubinaemia but the longer thesuppression of erythropoiesis





HOPE FOR THE

FUTURE

Documents

RH Incompatibility Lhr Dec06