Rh disease
Rh disease | |
---|---|
Other names | Rhesus isoimmunization, Rh (D) disease, rhesus incompatibility |
haematology, transfusion medicine | |
Causes | Incompatibility between mother antibodies and fetal Rhesus factor |
Diagnostic method | Blood compatibility testing, sonography, physical assessment |
Prevention | Administration of antibody therapy to the mother |
Treatment | Prophylactic antibody therapy, intrauterine transfusion |
Medication | Rho(D) immune globulin |
Frequency | Of maternal-fetal blood incompatibilities: 16% without antibody therapy, 0.1% with therapy |
This article may be too technical for most readers to understand.(April 2024) |
Rh disease (also known as rhesus
Due to several advances in modern medicine, HDFN due to anti-D is preventable by treating the mother during pregnancy and soon after delivery with an
Signs and symptoms
Symptoms of Rh disease include yellowish amniotic fluid and enlarged spleen, liver or heart or buildup of fluid in the abdomen of the fetus.[1]
Pathophysiology
During the first pregnancy, the Rh- mother's initial exposure to fetal Rh+ red blood cells (RBCs) is usually not sufficient to activate her Rh-recognizing B cells. However, during delivery, the placenta separates from the uterine wall, causing umbilical cord blood to enter the maternal circulation, which results in the mother's proliferation of IgM-secreting plasma B cells to eliminate the fetal Rh+ cells from her blood stream. IgM antibodies do not cross the placental barrier, which is why no effects to the fetus are seen in first pregnancies for Rh-D mediated disease. However, in subsequent pregnancies with Rh+ fetuses, the IgG memory B cells mount an immune response when re-exposed, and these IgG anti-Rh(D) antibodies do cross the placenta and enter fetal circulation. These antibodies are directed against the Rhesus (Rh) factor, a protein found on the surface of the fetal RBCs. The antibody-coated RBCs are destroyed by IgG antibodies binding and activating complement pathways.[3]
The resulting anemia has multiple sequelae:[4][5][6]
- The immature haematopoietic system of the fetus is taxed as the liver and spleen attempt to put immature RBCs into circulation (erythroblasts, thus the previous name for this disease erythroblastosis fetalis).
- As the liver and spleen enlarge under this unexpected demand for RBCs, a condition called portal hypertension develops, and this taxes the immature heart and circulatory system.
- Liver enlargement and the prolonged need for RBC production results in decreased ability to make other proteins, such as plasma colloid osmotic pressure (the fluid-retaining ability of blood plasma) leading to leakage of fluid into tissues and body cavities, termed hydrops fetalis.
- The severe anemia taxes the heart to compensate by increasing output in an effort to deliver oxygen to the tissues and results in a condition called high output cardiac failure.
- If left untreated, the result may be fetal death.
The destruction of RBCs leads to elevated bilirubin levels (
Diagnosis
Maternal blood
In the United States, it is a standard of care to test all expecting mothers for the presence or absence of the RhD protein on their RBCs. However, when medical care is unavailable or prenatal care not given for any other reason, the window to prevent the disease may be missed. In addition, there is more widespread use of molecular techniques to avoid missing women who appear to be Rh-D positive but are actually missing portions of the protein or have hybrid genes creating altered expression of the protein and still at risk of HDFN due to Anti-D.[7][8]
- At the first prenatal visit, the mother is typed for ABO blood type and the presence or absence of RhD using a method sensitive enough to detect weaker versions of this antigen (known as weak-D) and a screen for antibodies is performed.
- If she is negative for RhD protein expression and has not formed anti-D already, she is a candidate for RhoGam prophylaxis to prevent alloimmunization.
- If she is positive for anti-D antibodies, the pregnancy will be followed with monthly titers (levels) of the antibody to determine if any further intervention is needed.
- A screening test to detect for the presence or absence of fetal cells can help determine if a quantitative test (Kleihauer-Betke or flow cytometry) is needed. This is done when exposure is suspected due to a potential sensitizing event (such as a car accident or miscarriage).
- If the screening test is positive or the appropriate dose of RhoGam needs to be determined, a quantitative test is performed to determine a more precise amount of fetal blood to which the mother has been exposed.
- The Kleihauer–Betke test or Flow Cytometry on a maternal blood sample are the most common ways to determine this, and the appropriate dose of RhoGam is calculated based on this information.
- There are also emerging tests using Cell-free DNA. Blood is taken from the mother, and using PCR, can detect fetal DNA.[8] This blood test is non-invasive to the fetus and can help determine the risk of HDFN. Testing has proven very accurate and is routinely done in the UK at the International Blood Group Reference Laboratory in Bristol.[9]
Paternal blood
Blood is generally drawn from the biological father to help determine fetal antigen status.[10] If he is homozygous for the antigen, there is a 100% chance of all offspring in the pairing to be positive for the antigen and at risk for HDFN. If he is heterozygous, there is a 50% chance of offspring to be positive for the antigen.[11]
Prevention
In an RhD negative mother, Rho(D) immune globulin can prevent temporary sensitization of the maternal immune system to RhD antigens, which can cause rhesus disease in the current or in subsequent pregnancies. With the widespread use of RhIG, Rh disease of the fetus and newborn has almost disappeared in the developed world. The risk that an RhD negative mother can be alloimmunized by a RhD positive fetus can be reduced from approximately 16% to less than 0.1% by the appropriate administration of RhIG.[citation needed]
Management
As medical management advances in this field, it is important that these patients be followed by high risk obstetricians/maternal-fetal medicine, and skilled neonatologists postpartum to ensure the most up to date and appropriate standard of care[citation needed]
Antenatal
- Routine prenatal labs drawn at the beginning of every pregnancy include a blood type and an antibody screen. Mothers who are Rh negative (A−, B−, AB−, or O− blood types) and have anti-D antibodies (found on the antibody screen) need to determine the fetus's Rh antigen. If the fetus is also Rh negative (A−, B−, AB−, or O− blood types) then the pregnancy can be managed like any other pregnancy. The anti-D antibodies are only dangerous to Rh positive fetuses (A+, B+, AB+, or O+ blood types).
- The fetal Rh can be screened using non-invasive prenatal testing (NIPT). This test can screen for the fetus's Rh antigen (positive or negative) at the 10th week of gestation using a blood sample drawn from the mother. The Unity test uses NGS technology to look for Rh alleles (genes) in the cell free fetal DNA in the maternal bloodstream. In healthy pregnancies, at least 5% (fetal fraction) of the cell free DNA in the maternal bloodstream comes from the fetus (placenta cells shed DNA into the maternal bloodstream). This small fraction of cell free DNA from the fetus is enough to determine the fetus's Rh antigen.
- Once a woman has been found to have made anti-D (or any clinically significant antibody against fetal red cells), she is followed as a high risk pregnancy with serial blood draws to determine the next steps
- Once the titer of anti-D reaches a certain threshold (normally 8 to 16), serial Ultrasound and Doppler examinations are performed to detect signs of fetal anemia
- Detection of increased blood flow velocities in the fetus are a surrogate marker for fetal anemia that may require more invasive intervention
- If the flow velocity is found to be elevated a determination of the severity of anemia needs to ensue to determine if an intrauterine transfusion is necessary
- This is normally done with a procedure called percutaneous umbilical cord blood sampling (PUBS or cordocentesis) [12]
- Intrauterine blood transfusion[citation needed]
- Intraperitoneal transfusion—blood transfused into fetal abdomen
- Intravascular transfusion—blood transfused into fetal umbilical vein—This is the method of choice since the late 1980s, and more effective than intraperitoneal transfusion. A sample of fetal blood can be taken from the umbilical vein prior to the transfusion.
- Often, this is all done at the same PUBS procedure to avoid the needs for multiple invasive procedures with each transfusion
Postnatal
- Phototherapy for neonatal jaundice in mild disease
- Exchange transfusion if the neonate has moderate or severe disease
- Intravenous Immunoglobulin (IVIG) can be used to reduce the need for exchange transfusion and to shorten the length of phototherapy.[13][14]
History
In 1939 Drs.
The first treatment for Rh disease was an
Animal studies had previously been conducted by Dr. Pollack using a rabbit model of Rh.[25] This model, named the rabbit HgA-F system, was an animal model of human Rh, and enabled Pollack's team to gain experience in preventing hemolytic disease in rabbits by giving specific HgA antibody, as was later done with Rh-negative mothers. One of the needs was a dosing experiment that could be used to determine the level of circulating Rh-positive cells in an Rh-negative pregnant female derived from her Rh-positive fetus. This was first done in the rabbit system, but subsequent human tests at the University of Manitoba conducted under Dr. Pollack's direction confirmed that anti-Rho(D) immune globulin could prevent alloimmunization during pregnancy.[citation needed]
Ms. Marianne Cummins was the first at risk woman to receive a prophylactic injection of anti-Rho(D) immune globulin (RHIG) after its regulatory approval.
See also
- James Harrison (blood donor) – Australian who donated blood over 1150 times to save babies with Rh disease
References
- ^ "Rh Disease". The Children's Hospital of Philadelphia. 2014-08-23. Retrieved 2021-11-21.
- ^ PMID 26889318.
- ^ Punt J, Stranford S, Jones P, Owen JA (2018). "Chapter 15: Allergy, Hypersensitivities, and Chronic Inflammation.". Kuby immunology (8th ed.). WH Freeman. pp. 1086–1087.
- )
- ^ Wong EC, ed. (2015). "Alloimmune cytopenias.". Pediatric Transfusion: A physician's handbook (4th ed.). AABB. pp. 45–61.
- ^ Fung MK, Grossman BJ, Hillyer CD, Westhoff CM, eds (2014). Technical Manual (18th ed.). Bethesda, MD: AABB.
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- ^ "Percutaneous Umbilical Cord Blood Sampling". pennmedicine.adam.com. Retrieved 2019-09-11.
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- ^ Zimmerman DR (1973). Rh: The Intimate History of a Disease and Its Conquest. Macmillan Publishing Co.
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- PMID 21026828.
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- ^ "William Pollack dies at 87; helped conquer deadly Rh disease". Los Angeles Times. 2013-11-17. Retrieved 2019-09-11.
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Further reading
- Friesen AD, Bowman JM, Price HW (1981). "Column Ion Exchange Preparation and Characterization of an Rh Immune Globulin (WinRho) for Intravenous Use". J. Appl. Biochem. 3: 164–175.