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Management of the Rhesus Negative Mother

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Title: Management of the Rhesus Negative Mother


1
www.totalpregnancycare.com
2
Management of the Rhesus Negative Mother
  • Dr Shantala Vadeyar
  • MD, FRCOG, DM
  • Advanced Obstetric Ultrasound (RCOG / RCR)
  • Subspecialist Fetal Maternal Medicine (RCOG)
  • Consultant Obstetrician, Fetal Maternal
    Medicine
  • Kokilaben Dhirubhai Ambani Hospital, Mumbai

3
Background
  • Incidence of Rh neg individuals varies with race
  • Caucasians (whites) 15
  • Afro-Carribeans (blacks) 7-8
  • Asians 5
  • Chinese and Japanese 1

4
What is the Rhesus factor?
  • It is a Red blood cell antigen
  • Other Red cell antigens include -
  • A, B blood groups
  • Duffy, Kell, Kidd

5
Genetics of Rh factor
  • C, D and E antigens
  • D antigen is the most important and determines Rh
    positivity
  • cDe is Rh positive
  • Two alleles heterozygotes or homozygotes
  • Rh negative person has dd genotype

Rh positive
Rh neg
6
Pathophysiology in pregnancy
  • Rh negative mother
  • Carrying a Rh positive fetus
  • Some Rh positive RBCs cross over into the
    maternal circulation
  • Since the mother has not been exposed to these
    antigens,
  • She makes antibodies to this D antigen

7
Pathophysiology of isoimmunisation
  • These circulating anti-D antibodies enter fetus
  • They will attack fetal RBCs that are rhesus
    positive
  • This causes RBC destruction (hemolysis)
  • This leads to fetal anemia
  • Fetus does not get hyperbilirubimemia
  • Manifests as hydrops and fetal loss

8
Management of Rh negative gravida
  • Careful history
  • Previous pregnancy losses
  • h/o blood transfusions
  • Check husbands blood group and Rh factor
  • Check anti-D antibodies
  • If no antibodies at booking, then repeat titres
    at 28, 36 weeks

Coombs test
9
Prophylactic Anti-D
  • Prophylactic antenatal anti D at 28, 34 weeks 300
    IU injection
  • Following any episode of antepartum haemorrhage
  • Miscarriage, Ectopic pregnancy
  • Amniocentesis / CVS / FBS
  • Delivery normal and LSCS

10
Anti DMechanism of Action
  • The Rh positive fetal RBCs that enter the
    maternal circulation are destroyed by the anti D
  • Thus, the D antigen is not allowed to be
    presented to the maternal immune system
  • Prevents sensitisation

11
Rh Sensitised Pregnancy
12
Middle Cerebral Artery
13
MCA Doppler- Rhesus isoimmunisation
14
MCA Doppler- IUGR
15
Rh Sensitised Pregnancy - 2
16
Fetal assessment of hemolysis invasive
procedures
  • Amniocentesis and checking ODD 450 to check
    level of bilirubin in AF
  • Fetal Blood Sampling and checking fetal
    Haemoglobin level

17
Amniotic fluid ODD 450
18
Intrauterine blood transfusion
19
Overshoot - prepathological
20
Antenatal Steroids
  • If preterm delivery lt36 wks may be predicted,
    then antenatal steroids must be given to enhance
    fetal lung maturity
  • 2 doses of betamethasone 12 mg
  • 24 hours apart
  • Careful blood sugar monitoring in GDM
  • May also cause hyperacidity

21
Delivery
  • Most commonly with Rh sensitised pregnancies
    LSCS
  • May try induction of labour
  • Continuous FHR monitoring
  • Early recourse to LSCS is any doubts
  • Neonatologists present at delivery

22
Neonatal Management
  • Commonly need Phototherapy
  • May need Exchange Transfusion
  • Bone marrow suppressed if IUT
  • Anemia blood transfusion
  • Haematinics long term
  • Good long term outcome

23
Rhesus isoimmunisation-1
  • Mrs KC, age 38, P1, 15 yr girl
  • Rh negative, booking antibody screen
  • Anti D at 15 weeks- 11iu/ml
  • Scan at 20 weeks- MCA Doppler normal
  • Repeat Anti D titres and scans for MCA PSV every
    2-3 weeks.
  • 26 weeks- raised titres 20iu/ml and MCA PSV
    raised to 1.5MoMs

24
Rh isoimmunisation-2
  • Amniocentesis ODD450- below action line
  • 29, 30 weeks- MCA Doppler normal
  • 30 weeks- repeat amniocentesis- slight increase
    in ODD 450 levels, but below action line
  • 31 weeks- Steroids, MCA Dopplers every week-
    within 1.5 MoMs- normal

25
Delivery
  • 32 weeks- amniocentesis- action line
  • Options- Intrauterine transfusion v/s delivery
  • 335 w- delivery- 2.2kg female
  • Exchange transfusions and phototherapy
    postnatally- discharged 2 weeks

26
Profile
  • Total Pregnancy Care is an online guide for
    pregnancy, childbirth and motherhood related
    information. Women wanting to conceive, pregnant
    women, expecting parents, and new mothers can use
    this pregnancy portal for a healthy pregnancy,
    fulfilling childbirth and joyful motherhood. With
    pregnancy at its core, this portal covers various
    important aspects and especially addresses those
    matters that the Indian Woman always wanted to
    know but did not know whom to ask.
  • This website is compiled by Dr. Shantala, an
    Indian Obstetrician and Gynaecologist. She has
    over 20 years of extensive medical and
    diagnostics experience in areas commonly related
    to the Maternity and Pregnancy fields. She has
    studied and practiced in India as well as in the
    United Kingdom and thus brings about the fusion
    of best practices of the Oriental East and the
    Progressive West.
  • A mother of three children, she has complete
    understanding of the emotional, mental and
    physical needs of the New Age Pregnant Woman. Her
    patients appreciate her empathic approach and
    wholeheartedly express their gratitude for her
    generosity and care. Dr.Shantala is presently a
    full time Obstetrics and Gynaecology Consultant
    at the Kokilaben Dhirubhai Ambani Hospital and
    Medical Research Institute, a premier health care
    initiative of the Reliance ADA Group. Dr.Shantala
    has a clear vision to promote a holistic
    pregnancy approach and her mission is to provide
    comprehensive maternity care. This website,
    www.TotalPregnancyCare.com, is her first step
    towards this future.

27
Services Offered
  • Pre-pregnancy counseling
  • Genetic counseling
  • Antenatal care, Labour Delivery
  • Specialist Ultrasound scans
  • Viability scan
  • The First trimester scan / Nuchal translucency
    scans
  • Detailed anatomy / anomaly scans
  • Fetal Echocardiograph
  • 3D / 4D scans
  • Assessment of the High risk Fetus and Mother
  • Amniocentesis
  • Chorionic Villous sampling
  • Cordocentesis
  • Intra-uterine transfusions
  • Embryo Reduction / Selective fetocide
  • Second opinion scans

28
Topics covered
  • Pre-Conception
  • Working on getting pregnant or just starting to
    think about a family, this is the place for you
  • Pregnancy
  • From trying to conceive to the first trimester to
    labor, learn what to expect during your pregnancy
    and more
  • Labor Delivery
  • From that first contraction to the final push,
    here's what to expect during labor and delivery
  • Post-Pregnancy
  • Learn more about your diet and workouts,
    shopping, feeding and your child's health

29
Interactive Corner
  • Month by Month happenings
  • Articles
  • FAQs
  • Gestation Calendar

30
Society Memberships
  • British Maternal Fetal Medicine Society
  • Fetal Medicine Centre
  • Kokilaben Dhirubhai Ambani Hospital Medical
    Research Institute
  • Royal College of Obstetricians and
    Gynaecologists
  • International Society of Ultrasound in
    Obstetrics and Gynecology

31
Contact Us
  • Email shantala_at_totalpregnancycare.com
  • Mobile 91 9324304212
  • KDAH Board line 91 22 30999999

32
T H A N K
Y O U
www.totalpregnancycare.com
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