Rh and other blood group

alloimmunizations
Dr. Agus Rusdhy Hariawan Hamid, SpOG

Flow cytometry can detect fetal red cell and

red cell precursors in the maternal circulation
in virtually all pregnancies.
In some patients, this exposure to fetal red
cell antigens produces an antibody response
that can be harmful to future offspring.
The process is known as red cell
alloimmunization (formerly isoimmunization).

Prevention of maternal alloimmunization is

almost uniformly successful in the case of
exposure to the RhD or Rhesus antigen.
Prophylactic immunoglobulin (Rhesus
immunoglobulin ; RhIg) is available.
RhIg is not effective once the patient has
developed endogenous antibodies.
Immunoglobulins to prevent sensitization to
other red cell antigens are not available.

All pregnant patients should undergo an

antibody screen to red cell antigens at the
first prenatal visit.
In the case of a negative screen in the RhDnegative patient, further testing is
unnecessary until 28 weeks gestation.
Unless the patients partner is documented to
be RhD negative, a 300-g dose of RhIg
should be administered.

At delivery, a cord blood sample should be

tested for neonatal RhD typing. If the neonate
is determined to be RhD positive, a second
dose of 300 g RhIg should be administered
to the mother within 72 hours of delivery.

In recent years, techniques for fetal

surveillance in cases of RhD alloimmunization
have evolved to a more noninvasive
approach.
In the first affected pregnancy, the maternal
antibody titer continues to be used as the first
level of surveillance.
Once the maternal antibody screen indicates
the presence of an anti-D antibody, a titer
should be ordered.

Ultrasound has revolutionized the surveillance

of the anemic fetus.
In the past, ultrasound was used to detect
fetal hydrops. Unfortunately, this represents
an end-stage phase of HDFN with more than
twothirds reduction in the fetal hemoglobin
below the norm.
The most significant breakthrough in the
surveillance of the potentially anemic fetus
has been the validation of the peak systolic
middle cerebral artery (MCA) Doppler velocity.

First sensitized pregnancy

Follow maternal titers every 4 weeks up to 20 weeks gestation; repeat
every 2 weeks thereafter.
Once a critical value (usually 32) is reached in cases of a heterozygous
paternal phenotype, perform amniocentesis at 1517 weeks to determine
the fetal RhD status.
If an RhD-negative fetus is found, no further testing is warranted.
If a homozygous paternal phenotype or RhD-positive fetus by DNA
analysis, begin serial MCA Dopplers as early as 24 weeks gestation.
Repeat weekly 3 times and assess trend. If not rising rapidly, consider
MCAs every 2 weeks.
If the MCA Doppler is >1.5 MoM, perform cordocentesis with blood
readied for intrauterine transfusion (IUT) for a fetal hematocrit of <30%.
If repeat MCA velocities remain <1.5 MoM, consider induction by 38
weeks gestation.
In the case of an elevated MCA after 35 weeks gestation,consider
repeating the study the following day. If the value remains elevated,
perform amniocentesis for fetal lung maturity and OD450. If immature
and the OD450 value is not in the upper zone 2 of the Liley curve,
consider repeat amniocentesis 1 week later to confirm maturity.
Induce by 38 weeks gestation.

Previous severely affected fetus or infant

Maternal titers are not helpful in predicting the onset of fetal
anemia after the first affected gestation.
In cases of a heterozygous paternal phenotype, perform
amniocentesis at 15 weeks gestation to determine the fetal
RhD status. If an RhD-negative fetus is found, no further
testing is warranted.
Begin MCA Doppler assessments at 18 weeks gestation.
Repeat every week.
When an MCA Doppler >1.5 MoM is noted, perform
cordocentesis with blood readied for IUT for fetal hematocrit
of <30%.
If the MCA Doppler value does not become elevated, follow
the same protocol after 35 weeks as for the first affected
pregnancy