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Rhesus disease (Diagnosis (Natural history (the most frequent)…
Rhesus disease
Diagnosis
- Assessment of antibodies titer during pregnancy – at the beginning pf pregnancy, if negative, repeated bewteen 2nd and 3rd trimester, if positive, repeated every 4 weeks (>1:16 – every 2 weeks)
- Ultrasound scan, Fetal blood lab work
- Amniocentesis, Cordocentesis
ultrasound
Doppler
- Flow speed in cerebral vessels is increased in fetuses with anemia in correlation to severity of anemia.
- For every pregnancy week median value of Middle Cerebral Artery Peak Systolic Volume is established. MCA PSV >1.5 multiple of median qualifies fetuses to invasive diagnosis.
Severe Rhesus disease
hepatomegaly, hyperplacentosis
umbilical vein dilatation, mild ascites
hydrothorax, hydropericardium, ascites
skin edema, cardiomegaly
-
Invasive diagnosis
Severe hemolytic disease
- Severe anemia (MCA PSV >1.5 MoM)
- Hydrops
- Positive obstetric history:
Severe anemia in the neonate
Exchange transfusions
Intrauterine fetal therapy
Fetal/neonatal hydrops
Intrauterine death
- Antibodies titer >1:32 (1:16). Antibodies titer correlates with disease severity only during first pregnancy
- Lower antibodies titer but ultrasound symptoms of fetal hemolytic disease
Cordocentesis, fetal umbilical vein blood tests:
fetal blood group,
antibodies titer,
Ht, Hb, E,
bilirubin,
albumins,
pHmetry
Prophylaxis
2015 recommendations
- Anti-RhD immunoglobulin should be given to every Rh-negative woman up to 72 hours after:
-giving birth to Rh-positive child
150μg afte normal delivery
300μg after pathological delivery
-spontaneous miscarriage, pregnancy termination
-invasive prenatal diagnosis (amniocentesis, cordocentesis, chorion villus sampling)
-ectopic pregnancy removal
-threatening miscarriage or preterm delivery with bleeding,
-after external version: 50μg up to 20 weeks, 150μg after 20 weeks
- in cases of complete spontaneous miscarriage below 12 weeks (without curettage), without heavy pain, immunoglobulin is not administered, gestational age should be confirmed by ultrasound
- in recurrent bleeding immunoglobulin administration every 6 weeks should be considered
2018 recommendations
- Prenatal prophylaxis:
300μg of anti-RhD immunoglobulin should be administered at 28-30 weeks to every Rh-negative pregnant woman who has no anti-RhD antibodies
-
Risk of immunisation
Spontaneous miscarriage, Induced miscarriage
Ectopic pregnancy, Molar disease
Fetoreduction, Amniocentesis
Bleeding in 3rd trimester, Term delivery
Blood transfusion (55-80%)
-
treatment
- maternal plasmapheresis: (1000-1500 ml/week),
- gammaglobulin i.v.: (ut to 2 g/kg/set),
- transfusions:
intraperitoeal,
intravenous (therapeutic crodcentesis)
- Rh according to Fischer and Race:
6 antigens: C, D, E, c, d, e
inheritage with separate genes
antigen „d” is not detectable in serologic tests – no antibodies exist
- First blood cells - blood production in yolk sac in 2 weeks old embryo
- at 35th day of fetal life – liver erythropoesis
- Bone marrow at 5 weeks.
- Marrow erythropoesis from
17 weeks.
- IgG placental transportation
by pinocytosis from 18 weeks
- Immunologic response:
Primary – Ig M, weak, develops slowly, 8-9 weeks to 6 months after introducing antigen
Secondary – Ig G, quick, strong expression