In accordance with the definition, Rh immunization (Rh sensitization / Rh conflict) is the appearance of Rh antibodies in a pregnant woman in response to fetal erythrocyte antigens entering the bloodstream, that is, to paraphrase more simply - is the incompatibility of the mother with Rh negative group blood with a child with Rhesus positive group blood (and not with her husband, as many people think).
Rh antigen is a protein found in the membrane of the erythrocytes/red blood cells of most people. The blood of such people is Rh positive, and the blood of those who do not have this protein, respectively, is called Rh negative. About 1/3 of the population are Rh negative.
At rhesus positive parents Rh-negative child may well be born. In this case, a very peaceful, conflict-free relationship develops between the “positive” mother and her “negative” child: this combination does not threaten either the woman or the fetus.
If the mother and father of the child have an Rh negative blood type, the child also has a negative Rh factor.
But if the mother has Rh-negative blood, and the father has positive blood, the Rh-positive fetus occurs in 60% of pregnant women, but only 1.5% of these pregnancies develop incompatibility.
As a rule, with a second pregnancy, the likelihood of incompatibility is higher than with the first.
The mechanism of development of the Rhesus conflict
If Rh-positive erythrocytes meet with Rh-negative, then their adhesion occurs - agglutination. To prevent this from happening, the immune system of an Rh-negative mother produces special proteins - antibodies that combine with the Rh protein in the membrane of the fetal red blood cells (antigens), preventing them from sticking to the mother's own red blood cells. Antibodies are called immunoglobulins and come in two forms: IgM and IgG.
Contact of fetal erythrocytes with antibodies occurs in the space between the wall of the uterus and the placenta. The first encounter of fetal Rh-positive RBCs with the Rh-negative mother's immune system produces IgM, which are too large to cross the placental barrier. That is why, as a rule, during the first pregnancy of an Rh-negative mother with an Rh-positive fetus, conflict occurs relatively rarely. Incompatibility develops when fetal antigens (Rh positive erythrocytes) re-enter the bloodstream of an Rh-negative mother, whose immune system then massively produces IgG, which, having a smaller size, penetrate the placenta and cause hemolysis, i.e. destruction of fetal erythrocytes. This is how hemolytic disease of the fetus / newborn develops.
Complications of Rhesus conflict
As a result of the destruction of erythrocytes, toxic damage occurs to almost all organs and systems of the fetus by the breakdown product of hemoglobin, a substance that is contained in erythrocytes and is responsible for oxygen transport. This is due to the breakdown product - bilirubin. First of all, the fetal central nervous system, liver, kidneys and heart are affected, fluid accumulates in its cavities and tissues, which prevents the normal functioning of organs and systems, up to intrauterine death in severe cases. It is in connection with such a “rejection” of the fetus that Rh-negative mothers often develop the threat of miscarriage, and the risk of intrauterine death of the fetus increases.
Risk factors for Rh conflict
Are divided into:
1. Pregnancy related:
- any type of abortion: miscarriage, instrumental and medical abortion;
- ectopic pregnancy;
- childbirth, namely, in the third period, when the placenta separates from the uterine wall;
- complications of pregnancy or childbirth - premature detachment placenta, which is accompanied by bleeding from the vessels of the placenta;
- any invasive research methods: (amniocentesis, cordocentesis - puncture of the fetal bladder or umbilical cord).
2. Non-pregnancy related:
- immunization by blood transfusion;
- single needle use for intravenous drug use.
Symptoms of Rh conflict
The patient has no clinical manifestations, her condition does not suffer.
Symptoms of hemolytic disease in the fetus during pregnancy can only be detected by ultrasound, they are: swelling, accumulation of fluid in the cavities (abdominal, thoracic, in the cavity of the pericardial sac); due to the accumulation of fluid in the abdominal cavity of the fetus, the size of the tummy increases, the fetus takes a certain position “Buddha posture” (when, unlike the norm, the limbs are retracted from the enlarged tummy), an increase in the size of the liver and spleen, an increase in the size of the heart, a “double” contour appears heads (as a result of swelling of the soft tissues of the head). Also, edema is determined and, accordingly, thickening of the placenta and an increase in the diameter of the umbilical vein. Depending on the predominance of one or another sign, there are three forms of hemolytic disease of the fetus: edematous, icteric and anemic.
Diagnosis of Rh-conflict and tactics of pregnancy management
The purpose of monitoring pregnant women during Rh immunization is: examination to detect sensitization, prophylaxis of Rh immunization, early diagnosis of fetal hemolytic disease and its correction, as well as determining the most optimal timing for delivery. When registering for pregnancy, the determination of the blood group is shown, both for the pregnant woman herself and for the father of the child in a planned manner. In the presence of Rh-negative blood in the mother and Rh-positive blood in the father, pregnant women undergo a blood test for antibodies 1 once a month, monitoring the dynamics of antibody titer. In the presence of any antibody titer, the pregnancy is considered Rh sensitized. If antibodies are detected for the first time, then their class is determined (IgM or IgG). Further, a blood test for antibodies is carried out monthly, observing the patient for up to 20 weeks in a antenatal clinic, and after 20 weeks, they are sent to specialized centers to determine further management tactics, possibly treatment and decide on the method and timing of delivery.
Starting from 18 weeks, the condition of the fetus is assessed using ultrasound.
Methods for assessing the condition of the fetus are divided into:
1. Non-invasive methods.
- Ultrasound, which evaluates: the size of the fetal organs, the presence of free fluid in the cavities, the presence of swelling, the thickness of the placenta and the diameter of the umbilical vein. The first ultrasound is performed at 18-20 weeks, repeated at 24-26 weeks, 30-32 weeks, 34-36 and immediately before delivery. Depending on the severity of the fetal condition, more frequent this study, up to daily (as, for example, after a blood transfusion to the fetus).
- dopplerometry, which evaluates the functional parameters of the heart, blood flow velocity in the large vessels of the fetus and the umbilical cord, etc.
- cardiotocography assesses the reactivity of the fetal cardiovascular system, detects the presence or absence of hypoxia (lack of oxygen).
2. Invasive:
- amniocentesis - puncture of the fetal bladder to collect amniotic fluid to assess the severity of hemolysis by the content of bilirubin (hemoglobin breakdown product), which is one of the most accurate methods for assessing the severity of the fetal condition. Unfortunately, this method is fraught with many complications: infection, prenatal rupture of amniotic fluid, premature birth, bleeding, premature detachment of the placenta.
- cordocentesis - puncture of the umbilical cord for the purpose of blood sampling. The method allows you to accurately assess the severity of hemolysis, simultaneously conduct an intrauterine blood transfusion to the fetus. In addition to those complications that are typical for amniocentesis, with cordocentesis, the development of umbilical cord hematoma and bleeding from the puncture site is also possible. form of HDP in the past or died from it, high level bilirubin in amniotic fluid obtained by amniocentesis.
In connection with the possible risk, before carrying out either procedure, the patient must be informed by the doctor about the possibility of adverse effects of the procedure and give her written consent to it.
Treatment of Rh conflict
In modern obstetrics, the only method of treatment with proven efficacy is intrauterine blood transfusion, which is performed with severe anemia (anemia) in the fetus. This kind of treatment is carried out only in a hospital and allows you to achieve a significant improvement in the condition of the fetus and reduce the risk premature birth and the development of a severe form of the disease after birth.
female patients high group risk (in whom the antibody titer was detected in the early stages, those who have an antibody titer of 1:16 and above, those who had a past pregnancy with a Rh conflict) are observed in a antenatal clinic for up to 20 weeks, and then sent to specialized hospitals for the above treatment.
Various methods of cleansing the mother's blood from antibodies (plasmapheresis, hemosorption), methods that affect the activity of the immune system (desensitizing therapy, immunoglobulin therapy, transplanting the patient's father's skin flap) are currently considered ineffective or even ineffective.
But, unfortunately, despite significant progress in the field of correction of the fetal condition, the most effective way is to stop the flow of maternal antibodies to it, which can only be achieved by delivery.
Delivery in Rh conflict
Unfortunately, with Rh sensitization, it is often necessary to carry out delivery ahead of schedule, because. on later dates Pregnancy is an increase in the number of antibodies that come to the fetus.
Depending on the condition of the fetus and the duration of pregnancy, the method of delivery is individual in each individual case. It is believed that a caesarean section is more gentle for the fetus, and therefore, in severe cases, they resort to it. If the fetus is in a satisfactory condition, the gestation period is over 36 weeks, in a multiparous woman it is possible to conduct labor through the natural birth canal with careful monitoring of the fetal condition, prevention intrauterine hypoxia. If his condition worsens in labor, the management plan may be revised in favor of caesarean section.
Prognosis for Rhesus conflict
The prognosis depends on how early Rh immunization was diagnosed, on the size of the antibody titer and the rate of its increase, as well as on the form of fetal hemolytic disease. The earlier antibodies are detected in the mother's blood, for example, at a period of 8-10 weeks, the more prognostically unfavorable it is. The rapid increase in antibody titer, the titer is above 1:16, its early detection (for periods less than 20 weeks) is the basis for an unfavorable prognosis. In such cases, not only the risk of hemolytic disease of the fetus increases, but also the risk of miscarriage.
The most prognostically unfavorable form of fetal hemolytic disease is edematous. Such children often require treatment in the conditions of the pediatric intensive care unit and intensive care, exchange transfusion. The most prognostically favorable form is the anemic form, (depending on the severity of anemia). In icteric form, the determining criterion is the level of bilirubin. The higher it is, the higher the possibility of damage to the central nervous system of the fetus, which is further manifested by dementia, hearing loss.
Prevention of Rhesus conflict
Currently, in order to prevent Rh sensitization, human anti-rhesus immunoglobulin D. This drug has proven efficacy and exists under several trade names, such as: HyperRow C / D (USA), Resonativ (France), anti-Rhesus immunoglobulin D (Russia).
Prevention should be carried out during pregnancy at 28 weeks in the absence of antibodies in the mother's blood, since it is at this time that the risk of contact between maternal antibodies and fetal erythrocytes increases sharply, and therefore the risk of fetal hemolytic disease also increases. Due to the administration of the drug, an antibody titer may appear in the blood, therefore, after the administration of the drug, the determination of antibodies is no longer carried out. Further, prophylaxis should be repeated within 72 hours after childbirth if the patient is planning a next pregnancy. If bleeding occurs during pregnancy, as well as during cordo- or amniocentesis, as well as in postpartum period it is necessary to repeat the introduction of immunoglobulin, tk. Rhesus sensitization may occur during the next pregnancy in response to the ingress of fetal blood (in case of bleeding from the vessels of the placenta) into the mother's bloodstream.
Also, prophylaxis should be carried out by injection of the drug for any outcome of pregnancy: miscarriage, medical or instrumental abortion, ectopic pregnancy, hydatidiform mole within 72 hours of interruption. Special attention give blood loss, with the appearance of which the dose of the drug should be increased.
Obstetrician-gynecologist Kondrashova D.V.
The content of the article:At the stage of pregnancy planning, a couple must undergo a series of examinations that will help identify possible risks of pregnancy, as well as prevent them in time. One of the most important aspects of planning is the issue of Rhesus conflict. Let's talk about what it is and what it can threaten.
What is the Rh factor of blood
To begin with, the blood Rh factor (Rh) is a specific protein located on the membrane of red blood cells. People who have this protein are said to have Rh-positive (Rh+) blood, while people who do not have this protein are said to be Rh-negative. This does not affect the state of human health in any way, these are genetic mutations of the population. By the way, only about 18% of the world's population have Rh negative blood.
Even at the time of conception, the embryo inherits the Rh factor and blood type from the mother and father. Attention! The blood type and Rh factor do not change throughout life, the Rh factor of the blood will be negative or positive all life, as it was genetically laid down at the time of conception. Let's take a closer look at what inheritance options are possible from the point of view of genetics.
Variants of inheritance of the Rh factor of the blood
We will not go deep into genetics, let's say that there are recessive genes (hidden), denoted by small letters and dominant (explicit), denoted by capital letters. In our case, Rh-negative blood always has recessive genes, that is, rr, in this case, a child can inherit only recessive genes from father and mother, and he will always have Rh-negative blood factor. In turn, Rh-positive blood can carry two types of genetic information RR or Rr. This explains the appearance of Rh-negative children in both Rh-positive parents. If the mother is Rh positive and the father is Rh negative, or if the mother is Rh negative and the father is positive, the baby can be either Rh negative or Rh positive. Moreover, if a child has an Rh-positive blood factor, he will always have a recessive gene, that is, it is likely that his children will have a negative Rh. Let's take a closer look at the schemes of possible options for the inheritance of the Rh factor.
1. Variant of the Rh factor of the blood in a child, if the mother and father are both Rh-negative (Rh-)
2. Variants of the Rh factor of the blood in a child, when both parents are with Rh-positive blood (Rh +)
3. Variants of the Rh factor of blood in a child, when one of the parents has Rh-positive blood (Rh +), and the other has Rh-negative (Rh-)
Percent chance of developing Rh-conflict
What is Rhesus conflict
Rhesus conflict or Rh sensitization is the production of antibodies by the body of a pregnant woman when fetal erythrocyte antigens from the fetus enter her bloodstream, or more simply, this defensive reaction organism for a foreign protein. In percentage terms, the Rh conflict does not develop in all cases, only in 1.5%. With subsequent pregnancies, the possibility of Rh incompatibility increases dramatically.
During pregnancy, blood circulation between mother and child is carried out through the placenta. When the fetus inherits a positive Rh factor, the mother's body (having a negative Rh factor) begins an active fight with a protein foreign to it (fetal erythrocytes). The mother's body produces special antibodies, the purpose of which is to destroy the red blood cells of the unborn child. The fetus, in turn, begins to defend itself against the attack of maternal antibodies with the help of the spleen and liver - it is these two organs that are theoretically capable of neutralizing antigens harmful to the fetus. As a result, the spleen and liver become significantly large sizes than should be normal. That is, the essence of the Rhesus conflict lies in the fact that the mother's body perceives the fetus as a foreign body and tries in every possible way to protect itself from it.
Important! Rh conflict can develop (and even then not in all cases) only in an Rh-negative pregnant woman with an Rh-positive fetus that inherited the dominant gene from the father. If the pregnant woman is Rh positive and the fetus is Rh negative, or if both are either positive or negative, there will be no Rh conflict.
The options are discussed in more detail in the table.
Rh conflict during pregnancy (table)
| Rh factor | Father | Rh-(--) | Rh+(-+) | Rh+(++) | |||
| mother | gene | - | - | - | + | + | + |
| Rh-(--) | - | Rh-(--) | Rh-(--) | Rh-(--) | Rh+(-+) | Rh+(-+) | Rh+(-+) |
| - | Rh-(--) | Rh-(--) | Rh-(--) | Rh+(-+) | Rh+(-+) | Rh+(-+) | |
| Rh+(-+) | - | Rh-(--) | Rh-(--) | Rh-(--) | Rh+(-+) | Rh+(-+) | Rh+(-+) |
| + | Rh+(-+) | Rh+(-+) | Rh+(-+) | Rh+(++) | Rh+(++) | Rh+(++) | |
| Rh+(++) | + | Rh+(-+) | Rh+(-+) | Rh+(-+) | Rh+(++) | Rh+(++) | Rh+(++) |
| + | Rh+(-+) | Rh+(-+) | Rh+(-+) | Rh+(++) | Rh+(++) | Rh+(++) | |
The mechanism of the development of the Rh conflict is that when the Rh-negative erythrocytes of the mother meet with the Rh-positive fetus, agglutination (their adhesion) occurs, in order to prevent this, the mother's immune system begins to produce antibodies (immunoglobulins) to antigens (proteins located on the erythrocyte membrane fetus). That is, the mother's immunoglobulins bind to the Rh protein of the fetal erythrocytes and prevent the adhesion of different Rhesus erythrocytes. The body of a pregnant woman produces two types of immunoglobulins: IgM and IgG.
Fetal erythrocytes meet with immunoglobulins at the junction of the uterine wall and the placenta. The first meeting ends with the production of IgM antibodies, which have big size and cannot cross the placental barrier. Therefore, during the first pregnancy, as a rule, there is no Rh conflict. But during a second pregnancy, the mother's immune system remembers the antigens (erythrocytes of a fetus with a positive Rh factor) that she met during childbirth, and for protection, in addition to IgM antibodies, it starts to produce IgG, which are smaller and can cross the placenta. Penetrating through the placental barrier, IgG antibodies destroy fetal erythrocytes (hemolysis), which leads to the accumulation of bilirubin in the blood, which manifests itself in the development of hemolytic disease of the newborn or fetus.
How is the conflict of Rh factors in the blood of the mother and fetus determined?
It is very important to identify the Rh conflict at the earliest stages of pregnancy. The first thing to do is to take a blood test for the mother and father. If during the laboratory blood test, the mother was found to have a negative Rh factor, and the father is positive, then she will need to take a blood test to determine the level of antibodies in her. In the event that antibodies are not detected, then the next analysis is carried out at the 18th week of pregnancy, from the 19th to the 32nd week, a blood test for antibodies is performed every month, from the 32nd to the 35th week - once every 14 days, after - every 7 days, until childbirth. If any antibody titer is detected in the blood, then the pregnancy is considered Rh sensitized. It is required to determine the type of antibodies: IgM or IgG, and such a pregnancy should be monitored in a specialized center after the 20th week of pregnancy.
In addition to a biochemical blood test to detect antibodies, a pregnant woman should undergo ultrasound diagnostics somewhat more often than other women. If there are no complications associated with the course of pregnancy, then ultrasound is performed every 6-8 weeks. If there are signs of hemolytic disease, then ultrasound is performed in combination with dopplerometry. In severe hemolytic disease, the condition of the fetus should be monitored by ultrasound every 4-5 days.
Rhesus conflict during pregnancy: symptoms
A pregnant woman does not have any clinical symptoms, her immune system turned on a protective mechanism that coped with the penetration of a foreign protein into the body. Things are different with the fetus, its defense systems are still very poorly developed. The fetus develops hemolytic disease.
Symptoms of hemolytic disease in the fetus during pregnancy are recorded using ultrasound. Ultrasound of the fetus can reveal:
Puffiness, accumulation of fluid in the abdominal or chest cavities, in the cavity of the pericardial sac;
Increase in the circumference of the abdomen;
- “Buddha posture” (the child assumes a position with the limbs abducted from the abdomen);
The liver and spleen increase in size;
The size of the heart increases;
- "double" contour of the head due to swelling of the soft tissues of the head;
Swelling and thickening of the placenta;
An increase in the diameter of the umbilical vein.
There are 3 forms of fetal hemolytic disease: edematous, icteric and anemic according to the predominance of one or another symptom of the disease.
Today, any antenatal clinic can supervise such a pregnancy. But only until 20 weeks. After this period, the pregnant woman is issued a referral to medical institution specializing in the pathologies of pregnancy. It is there that questions about the further management of pregnancy and possible options for delivery will be decided.
You can get acquainted with specialized maternity hospitals with blood diseases and Rhesus conflict on our website.
Features of the management of Rh-conflict pregnancy
As described above, at first, when registering, the pregnant woman and her husband take blood tests to determine the Rh factor. With Rh negative mother and Rh positive pope appointed biochemical analysis blood for antibodies. Further monitoring of pregnancy requires increased attention from medical personnel. The main goal of monitoring Rh-conflict pregnancy is to early diagnosis hemolytic disease of the unborn child and, if necessary, its treatment, as well as in deciding on the safest and most optimal delivery option.
In the course of conducting Rh-conflict pregnancy, the condition of the fetus is regularly monitored.
Methods for monitoring and assessing the condition of the fetus in Rh-conflict pregnancy
Methods for monitoring and assessing the condition of the fetus are non-invasive and invasive.
non-invasive methods
Non-invasive methods include the following examinations:
- Ultrasound diagnostics. During the diagnosis, the specialist evaluates the size and location of the organs of the unborn child, the amount of fluid in the uterine cavity, the absence / presence of edema of the soft tissues of the fetus, the thickness / degree of maturity of the placenta, and the diameter of the umbilical cord. The first ultrasound diagnosis is carried out at -12 weeks of pregnancy, the second - at 18-20, then once a month. If the condition of the fetus causes some concern among doctors, then ultrasound can be prescribed more often, sometimes even every day.
- Dopplerography. The purpose of this examination is to evaluate the functional parameters of cardiac activity and the quality of blood flow in the umbilical cord and other large vessels of the fetus.
- Cardiotocography (or CTG). The examination helps to assess the functioning of the heart and vascular system of the child, to identify / refute the presence of fetal hypoxia ( oxygen starvation).
Invasive methods
Invasive methods of examining the condition of the fetus include amniocentesis and cordocentesis.
Amniocentesis called puncture of the fetal bladder, the purpose of which is to collect amniotic fluid to assess the severity of the child's condition. Indication for carrying out this study is an antibody titer equal to 1 to 16 or more, as well as the presence of children in a pregnant woman who have suffered a severe hemolytic disease.
Amniocentesis is considered a rather complicated and risky study, since the risks of infection of the fetus, premature rupture of amniotic fluid, premature birth, placental abruption and bleeding in a pregnant woman after this intervention increase significantly.
Cordocentesis called umbilical cord puncture and blood sampling from it. This method makes it possible to most accurately determine the severity of hemolysis and at the same time perform a blood transfusion to the fetus. A complex intervention carries the same risks as the previous study. Cordocentesis is indicated for those pregnant women whose antibody titer is 1 to 32 or more. And also in those cases when an excessive high rate bilirubin in the waters of the fetal bladder.
Due to the fact that both invasive methods for examining the condition of the fetus carry a serious risk and the possibility of developing some complications, these procedures are carried out only with the written consent of the pregnant woman to conduct them. Before interventions, a woman is necessarily informed by a specialist about all possible risks and complications.
Features of delivery in Rh-conflict of mother and fetus
Most often, Rh-conflict pregnancy requires early delivery, because on recent weeks During pregnancy, the amount of antibodies in the mother's blood increases dramatically and antibodies, respectively, enter the blood of the fetus, which negatively affects its condition.
In each case, the method of delivery is determined by a specialist. The decision depends on the gestational age and the general condition of the fetus. Delivery by caesarean section is considered the most optimal and safe for a child, therefore, in difficult situations, it is used. If the condition of the fetus, according to the results of recent examinations, is found to be satisfactory, then the woman is allowed to give birth naturally. In this case, during childbirth, doctors most carefully monitor the state of the child's cardiac activity, monitor his behavior in order to identify and prevent the possible development of intrauterine oxygen starvation. If in the process natural childbirth the condition of the fetus deteriorates sharply, then most often the delivery plan changes and the child is born already through a caesarean section.
What complications can occur with Rhesus conflict
Rhesus conflict during pregnancy: consequences for the child
When the Rhesus conflict of the blood of mother and child occurs, the destruction of erythrocytes - red blood cells in the blood. As a result, there is a toxic damage to the decay products of hemoglobin in almost all systems and organs of the unborn child. Due to poisoning in the fetus, the heart, kidneys, and liver are affected. And most importantly - the central nervous system. All cavities and tissues accumulate fluid, this fluid, in turn, does not allow the organs and systems of the fetus to function and develop normally. Babies are often born premature and underweight. Mental retardation often occurs. The intellect suffers. Often a child is born with severe forms various diseases liver and kidneys, with median pathologies. In especially severe cases, intrauterine death of the fetus is not excluded.
Rhesus conflict during pregnancy: consequences for a woman
For a woman, the danger of an Rh-conflict pregnancy lies in the threat of interruption and the development of a variety of complications: severe toxicosis in the early stages and late preeclampsia after the 30th week of pregnancy, exacerbation of existing chronic diseases. And if the first Rh-conflict pregnancy proceeds and ends safely, then each subsequent one carries serious risks: miscarriage, spontaneous abortions, intrauterine death of the fetus in the early stages of pregnancy, which often leads to infection of the mother.
Treatment of Rh conflict during pregnancy
Modern obstetrics is the only effective method treatment of this pathological condition recognizes only intrauterine blood transfusion to the fetus. It is carried out with pronounced anemia in a child. This method treatment is carried out in a hospital and can significantly improve general state fetus, as well as significantly reduce the risk of preterm labor.
Previously, Rh-conflict pregnancies were subjected to such methods of treatment as hemosorption and plasmapheresis. The essence of these techniques is to purify the mother's blood from antibodies that adversely affect the fetus. But today these manipulations are considered ineffective and are practically not used.
But, unfortunately, still the only way complete exclusion of contact conflict rhesus maternal and fetal blood is delivery. Specialists do everything possible to prolong the pregnancy as much as possible and at the same time not harm the unborn child.
The prognosis of Rh-conflict pregnancy
The prognosis of the entire course of pregnancy depends on how timely the Rh conflict was detected. The earlier antibodies are detected in maternal blood, the higher the likelihood of an unfavorable outcome of pregnancy, that is, if antibodies were detected already in the first trimester, then with each week of pregnancy their number will increase, which means that the fetus will be subjected to their constant attack.
The most unfavorable prognosis of Rh-conflict pregnancy is the identified edematous form of fetal hemolytic disease. Children born with such a diagnosis most often require stay and treatment in intensive care units and pediatric resuscitation. Often a blood transfusion is required.
The most favorable prognosis is made with an anemic form of the disease. But in such a situation, often the level of bilirubin in the child's blood rises significantly, as a result of which the liver and central nervous system suffer, which in the future is fraught with hearing loss and dementia.
As mentioned above, the likelihood of a Rh conflict during the first pregnancy is very small. But with repeated pregnancies, if during the first pregnancy antibodies arose in the woman's body, the likelihood of developing Rh sensitization between the mother and fetus is very high. To reduce the risk of incompatibility, Rh-negative pregnant women are given prophylaxis.
In modern medicine, anti-Rhesus immunoglobulin D is used to prevent Rhesus conflict between mother and fetus, which is produced under various trade names: anti-Rhesus immunoglobulin D (Russia), HyperRow C / D (USA), Resonativ (France). All of these drugs have been tested and shown to be effective.
How is anti-rhesus immunoglobulin prophylaxis performed?
Rh negative mother with Rh positive father at 28 weeks of gestation, if no antibodies were found in the mother's blood, do intramuscular injection anti-rhesus immunoglobulin. Then, after childbirth, re-vaccination is carried out within 72 hours. And also if during pregnancy there was bleeding or amniocentesis / cordocentesis was performed due to the risk of fetal blood entering the maternal circulation so that a Rh conflict does not develop during the next pregnancy. In addition, other pregnancy outcomes (miscarriage, abortion, ectopic pregnancy, hydatidiform mole) should also be vaccinated.
After the introduction of anti-Rhesus immunoglobulin in the blood, an antibody titer may appear and the blood test ceases to be informative.
A mindful approach to pregnancy helps to reveal all possible deviations in the health of mother and father, as well as significantly reduce the risk of complications of pregnancy and childbirth. As soon as possible after confirmation of pregnancy, you should contact a gynecologist. The doctor will refer to necessary tests, which will help determine the presence or risk of Rh conflicts. Timely passage of the recommended examinations is the key to a favorable course of pregnancy and delivery itself.
The time of bearing a child is one of the most beautiful in a woman's life. Every expectant mother wants to be calm for the health of the baby, enjoy the period of waiting for the addition. But every tenth lady, according to statistics, has Rh-negative blood, and this fact worries both the pregnant woman herself and the doctors who observe her.
What is the possibility of a Rh conflict between mother and baby, and what is the danger, we will tell in this article.
What it is?
When a woman and her future peanut have different blood counts, it may begin immunological incompatibility, it is she who is called the Rhesus conflict. Representatives of mankind who have a Rh factor with a + sign have a specific protein D, which contains red blood cells. A person with Rh negative value of this protein does not have.
Scientists still don't know for sure why some people have a specific Rhesus macaque protein while others don't. But the fact remains - about 15% of the world's population have nothing in common with macaques, their Rh factor is negative.
Between the pregnant woman and the child there is a constant exchange through the uteroplacental blood flow. If the mother has a negative Rh factor, and the baby has a positive one, then the D protein that enters her body is nothing more than a foreign protein for the woman.
The mother's immunity very quickly begins to react to an intruder, and when the protein concentration reaches high values, the Rh conflict begins. This is a merciless war that the pregnant woman's immune defense declares to the child as a source of a foreign antigen protein.
Immune cells begin to destroy the baby's red blood cells with the help of special antibodies that he produces.
The fetus suffers, the woman experiences sensitization, the consequences can be quite sad, up to the death of the baby in the mother's womb, the death of the crumbs after birth or the birth of a disabled child.
Rhesus conflict can occur in a pregnant woman with Rh (-) if the baby has inherited her father's blood characteristics, that is, Rh (+).
Much less often, incompatibility is formed according to such an indicator as a blood type, if the men and women have different groups. That is, a pregnant woman, whose own Rh factor has positive values, has nothing to worry about.
There is no reason to worry about families with the same negative Rh, but this coincidence does not happen often, because among the 15% of people with "negative" blood - the vast majority of the fair sex, men with such blood characteristics are only 3%.
Own hematopoiesis in peanuts in the womb begins around 8 weeks gestation. And from that moment on, maternal blood tests are laboratory-determined a small amount of fetal erythrocytes. It is from this period that the possibility of an Rhesus conflict arises.
Probability tables
From the point of view of genetics, the probability of inheriting the main characteristics of the blood - the group and the Rh factor from the father or mother is estimated equally at 50%.
There are tables that allow you to assess the risks of Rh conflict during pregnancy. And timely weighted risks give doctors time to try to minimize the consequences. Unfortunately, medicine cannot completely eliminate the conflict.
By Rh factor
By blood group
Dad's blood group | Mother's blood group | Child's blood group | Will there be conflict |
0 (first) | 0 (first) | 0 (first) | |
0 (first) | A (second) | 0 (first) or A (second) | |
0 (first) | B (third) | 0 (first) or B (third) | |
0 (first) | AB (fourth) | A (second) or B (third) | |
A (second) | 0 (first) | 0 (first) or A (second) | Chance of conflict - 50% |
A (second) | A (second) | A (second) or 0 (first) | |
A (second) | B (third) | Any (0, A, B, AB) | Chance of conflict - 25% |
A (second) | AB (fourth) | ||
B (third) | 0 (first) | 0 (first) or B (third) | Chance of conflict - 50% |
B (third) | A (second) | Any (0, A, B, AB) | Chance of conflict - 50% |
B (third) | B (third) | 0 (first) or B (third) | |
B (third) | AB (fourth) | 0 (first), A (second) or AB (fourth) | |
AB (fourth) | 0 (first) | A (second) or B (third) | Conflict probability - 100% |
AB (fourth) | A (second) | 0 (first), A (second) or AB (fourth) | Probability of conflict - 66% |
AB (fourth) | B (third) | 0 (first), B (third) or AB (fourth) | Probability of conflict - 66% |
AB (fourth) | AB (fourth) | A (second), B (third) or AB (fourth) |
Causes of the conflict
The likelihood of developing an Rhesus conflict is highly dependent on how and how the woman's first pregnancy ended.
Even a “negative” mother can quite safely give birth to a positive baby, because during the first pregnancy, the woman’s immunity does not yet have time to develop a killer amount of antibodies to the D protein. life saving situations.
If the first pregnancy ended in a miscarriage or abortion, then the likelihood of a Rh conflict during the second pregnancy increases significantly, since the woman's blood already has antibodies ready for attack at the earliest possible date.
In women who had a caesarean section during the first birth, the probability of conflict during the second pregnancy is 50% higher compared to women who gave birth to their first child naturally.
If the first birth was problematic, the placenta had to be separated manually, there were bleeding, then the likelihood of sensitization and conflict in a subsequent pregnancy also increases.
Danger for future mother with a negative Rh factor of blood, diseases during the period of bearing a baby are also present. Influenza, SARS, preeclampsia, diabetes in history can provoke a violation of the structure chorionic villi, and mother's immunity will begin to produce antibodies that are detrimental to the baby.
After childbirth, the antibodies that were developed in the process of bearing the crumbs do not disappear anywhere. They represent long-term memory immunity. After the second pregnancy and childbirth, the amount of antibodies becomes even greater, as after the third and subsequent ones.
Danger
The antibodies that maternal immunity produces are very small, they can easily cross the placenta into the bloodstream of the baby. Once in the blood of the child, the protective cells of the mother begin to inhibit the hematopoietic function of the fetus.
The child suffers, experiences an oxygen deficiency, since decaying red blood cells are the carriers of this vital gas.
In addition to hypoxia, fetal hemolytic disease may develop. and subsequently the newborn. It is accompanied by severe anemia. In the fetus, internal organs increase - the liver, spleen, brain, heart and kidneys. The central nervous system is affected by bilirubin, which is formed during the breakdown of red blood cells and is toxic.
If doctors do not start taking measures in time, then the baby may die in utero, be born dead, be born with severe damage to the liver, central nervous system, and kidneys. Sometimes these lesions are incompatible with life, sometimes they lead to deep lifelong disability.
Diagnosis and symptoms
The woman herself cannot feel the symptoms of the developing conflict of her immunity with the blood of the fetus. There are no symptoms by which the expectant mother could guess about the destructive process that takes place inside her. However, laboratory diagnostics can detect and track the dynamics of the conflict at any time.
For this, a pregnant woman with Rh- negative blood, regardless of what group and Rh factor of the father's blood, they take a blood test from a vein for the content of antibodies in it. The analysis is done several times during pregnancy, the period from 20 to 31 weeks of pregnancy is considered especially dangerous.
About how severe the conflict is, says the antibody titer obtained as a result of a laboratory study. The doctor also takes into account the degree of maturity of the fetus, because the older the baby in the womb, the easier it is for him to resist the immune attack.
Thus, a titer of 1:4 or 1:8 at 12 weeks of gestation is a very alarming indicator, and a similar antibody titer for a period of 32 weeks will not cause panic in the doctor.
When a titer is detected, the analysis is done more often to observe its dynamics. In a severe conflict, the title grows rapidly - 1: 8 can turn into 1: 16 or 1: 32 in a week or two.
A woman with antibody titers in the blood will have to visit the office more often ultrasound diagnostics. By ultrasound, it will be possible to monitor the development of the child, this research method provides quite detailed information about whether the child has hemolytic disease, and even about what form it has.
With the edematous form of fetal hemolytic disease in a child, an ultrasound will reveal an increase in size internal organs and the brain, the placenta thickens, the amount of amniotic fluid also increases and exceeds normal values.
If the estimated weight of the fetus is 2 times higher than the norm, this warning sign - dropsy of the fetus is not excluded, which can be fatal even in the mother's womb.
Hemolytic fetal disease associated with anemia cannot be seen on ultrasound, but can be diagnosed indirectly on CTG, since the number of fetal movements and their nature will indicate the presence of hypoxia.
Damage to the central nervous system will become known only after the birth of a child; this form of hemolytic disease of the fetus can lead to a developmental delay in the baby, to hearing loss.
Doctors in the antenatal clinic will be engaged in diagnostics from the very first day of registering a woman with a negative Rh factor. They will take into account how many pregnancies there were, how they ended, whether children with hemolytic disease were already born. All this will enable the doctor to assume the possible likelihood of a conflict and predict its severity.
A woman will have to donate blood during the first pregnancy once every 2 months, during the second and subsequent - once a month. After 32 weeks of pregnancy, the analysis will be done every 2 weeks, and from 35 weeks - every week.
If an antibody titer appears, which can occur at any time after 8 weeks, may be prescribed additional methods research.
With a high titer that threatens the life of the child, a cordocentesis or amniocentesis procedure may be prescribed. The procedures are carried out under ultrasound guidance.
During amniocentesis, an injection is made with a special needle and a certain amount of amniotic fluid is taken for analysis.
During cordocentesis, blood is taken from the umbilical cord.
These tests allow you to judge which blood type and Rh factor the baby has inherited, how severely his red blood cells are affected, what is the level of bilirubin in the blood, hemoglobin, and determine the sex of the child with 100% probability.
These invasive procedures- it is voluntary, a woman is not forced to do it. Despite the current level of development of medical technologies, interventions such as cordocentesis and amniocentesis can still cause miscarriage or premature birth, as well as death or infection of the child.
The obstetrician-gynecologist who leads her pregnancy will tell the woman about all the risks during the procedures or refusing them.
Possible consequences and forms
Rhesus conflict is dangerous both during the period of bearing a baby, and after it is born. The disease with which such children are born is called hemolytic disease of the newborn (HDN). Moreover, its severity will depend on the amount of antibodies attacked the blood cells of the crumbs during pregnancy.
This disease is considered severe, it is always accompanied by the breakdown of blood cells, which continues after birth, edema, jaundice of the skin, severe bilirubin intoxication.
edematous
The edematous form of HDN is considered the most severe. With her, the little one is born very pale, as if "bloated", edematous, with multiple internal edema. Such crumbs, unfortunately, in most cases are born already dead or die, despite all the efforts of resuscitators and neonatologists, die in as soon as possible from several hours to several days.
icteric
The icteric form of the disease is considered more favorable. Such babies, a couple of days after their birth, "acquire" saturated yellowish color skin, and such jaundice has nothing to do with the common physiological jaundice of newborns.
The baby has a slightly enlarged liver and spleen, blood tests show the presence of anemia. The level of bilirubin in the blood rises rapidly. If doctors fail to stop this process, the disease can turn into kernicterus.
Nuclear
The nuclear type of HDN is characterized by lesions of the central nervous system. The newborn may have seizures, he can involuntarily move his eyes. The tone of all muscles is reduced, the child is very weak.
When bilirubin is deposited in the kidneys, a so-called bilirubin infarction occurs. A greatly enlarged liver cannot normally perform the functions assigned to it by nature.
Forecast
In prognosis for HDN, doctors are always very careful, since it is almost impossible to predict how damage to the nervous system and brain will affect the development of the crumbs in the future.
Children are given detoxification injections in intensive care, very often there is a need for a replacement transfusion of blood or donor plasma. If on the 5-7th day the child does not die from paralysis of the respiratory center, then the forecasts change to more positive ones, however, they are rather conditional.
After hemolytic disease of newborns, children suckle poorly and sluggishly, their appetite is reduced, sleep is disturbed, and there are neurological abnormalities.
Quite often (but not always) such children have a significant lag in mental and intellectual development, they get sick more often, hearing and vision impairments can be observed. Cases of anemic hemolytic disease end most safely, after the level of hemoglobin in the blood of the crumbs can be raised, it develops quite normally.
The conflict, which developed not because of the difference in Rh factors, but because of the difference in blood types, proceeds more easily and usually does not have such devastating consequences. However, even with such incompatibility, there is a 2% chance that the baby will develop quite serious disorders of the central nervous system after birth.
The consequences of the conflict for the mother are minimal. She will not be able to feel the presence of antibodies in any way, difficulties can arise only during the next pregnancy.
Treatment
If a pregnant woman has a positive antibody titer in the blood, this is not a reason for panic, but a reason for starting therapy and taking it seriously on the part of the pregnant woman.
It is impossible to save a woman and her baby from such a phenomenon as incompatibility. But medicine can minimize the risks and consequences of the influence of maternal antibodies on the baby.
Three times during pregnancy, even if antibodies do not appear during gestation, the woman is prescribed courses of treatment. At 10-12 weeks, at 22-23 weeks and at 32 weeks, the expectant mother is recommended to take vitamins, iron supplements, calcium supplements, metabolic enhancers, and oxygen therapy.
If the titers are not detected before 36 weeks of gestational age, or they are low, and the development of the child does not cause concern to the doctor, then the woman is allowed to give birth naturally on her own.
If the titers are high, the child's condition is severe, then delivery can be carried out ahead of time by caesarean section. Doctors try to support the pregnant woman with medications until the 37th week of pregnancy so that the baby has the opportunity to “ripen”.
Unfortunately, this possibility is not always available. Sometimes you have to decide on an earlier caesarean section in order to save the little one's life.
In some cases, when the baby is clearly not yet ready to come into this world, but it is very dangerous for him to remain in the mother’s womb, an intrauterine blood transfusion is performed on the fetus. All these actions are performed under the control of an ultrasound scanner, each movement of the hematologist is verified so as not to harm the baby.
In the early stages, other methods of preventing complications can be used. So, there is a technique for sewing a piece of the skin of her husband to a pregnant woman. The skin flap is usually implanted on the lateral surface of the chest.
While the woman's immunity throws all its strength into rejecting a skin fragment that is foreign to itself (and this is several weeks), the immunological load on the child is somewhat reduced. Scientific disputes do not subside about the effectiveness of this method, but the reviews of women who have gone through such procedures are quite positive.
In the second half of pregnancy, with an established conflict, plasmapheresis sessions can be prescribed for the expectant mother, this will slightly reduce the number and concentration of antibodies in the mother's body, respectively, the negative load on the baby will also temporarily decrease.
Plasmapheresis should not frighten a pregnant woman, there are not so many contraindications to it. Firstly, it is SARS or another infection in the acute stage, and, secondly, the threat of miscarriage or premature birth.
There will be about 20 sessions. Approximately 4 liters of plasma are cleared in one procedure. Together with the infusion of donor plasma, protein preparations are administered, which are necessary for both mother and baby.
Babies who have had hemolytic disease are shown regular examinations by a neurologist, massage courses in the first months after birth to improve muscle tone, as well as courses of vitamin therapy.
Prevention
A pregnant woman at 28 and 32 weeks is given a kind of vaccination - an anti-Rhesus immunoglobulin is injected. The same drug must be administered to a woman in labor after childbirth no later than 48-72 hours after the birth of the crumbs. This reduces the likelihood of conflict in subsequent pregnancies to 10-20%.
If the girl has a negative Rh factor, she should know about the consequences of an abortion during the first pregnancy. It is desirable for such representatives of the fair sex save the first pregnancy at all costs.
Blood transfusion without taking into account the Rh affiliation of the donor and the recipient is not permissible, especially if the recipient has his own Rh with a “-” sign. If such a transfusion takes place, anti-Rhesus immunoglobulin should be administered to the woman as soon as possible.
A complete guarantee that there will be no conflict can only be given by a Rh-negative man, moreover, preferably with the same blood type as his chosen one. But if this is not possible, you should not postpone pregnancy or abandon it just because a man and a woman have different blood. In such families, planning for a future pregnancy plays an important role.
A woman who wants to become a mother needs to take blood tests to detect antibodies to protein D before the onset of an “interesting situation”. If antibodies are found, this does not mean that the pregnancy will have to be terminated or that it is impossible to become pregnant. Modern medicine does not know how to eliminate the conflict, but it knows very well how to minimize its consequences for the child.
The introduction of anti-Rhesus immunoglobulin is relevant for women whose blood does not yet have antibodies that are not sensitized. They need to give such an injection after an abortion, after even a slight bleeding during pregnancy, for example, with a slight detachment of the placenta, after surgery for ectopic pregnancy. If antibodies are already present, then special effect don't expect to get vaccinated.
Common Questions
Is it possible to breastfeed a child?
If a Rh-negative woman has a baby with a positive Rh factor, and there is no hemolytic disease, then breastfeeding is not contraindicated.
Babies who have experienced an immune attack and were born with hemolytic disease of the newborn are not recommended to eat mother's milk for 2 weeks after the introduction of immunoglobulin to their mother. In the future, the decision to breastfeed is made by neonatologists.
Breastfeeding is not recommended in severe hemolytic disease. To suppress lactation, a woman after childbirth is prescribed hormonal drugs that suppress milk production in order to prevent mastopathy.
Is it possible to bear a second child without conflict if there was a conflict during the first pregnancy?
Can. Provided that the child inherits a negative Rh factor. In this case, there will be no conflict, but antibodies in the mother's blood can be detected throughout the entire gestation period, and in a fairly high concentration. They will not affect the baby with Rh (-) in any way, and you should not worry about their presence.
Before getting pregnant again, mom and dad should visit a geneticist who will give them comprehensive answers about the likelihood of their future children inheriting one or another blood characteristic.
Dad's rhesus unknown
When a future mother is registered in a antenatal clinic, immediately after her negative Rh is detected, the father of the future baby is also invited to the consultation for a blood test. Only in this way can the doctor be sure that he knows exactly the initial data of the mother and father.
If the father's Rh is unknown, and for some reason it is impossible to invite him to donate blood, if the pregnancy came from IVF with donor sperm, then a woman will have a blood test for antibodies a little more often than other pregnant women with the same blood. This is done in order not to miss the moment of the beginning of the conflict, if it takes place.
And the doctor's proposal to invite her husband to donate blood for antibodies is a reason to change the doctor to a more competent specialist. There are no antibodies in the blood of men, since they do not become pregnant and do not have any physical contact with the fetus during the wife's pregnancy.
Is there a fertility effect?
Such a connection does not exist. The presence of a negative Rh does not mean that it will be difficult for a woman to get pregnant.
Fertility levels are affected by completely different factors - bad habits, caffeine abuse, excess weight and diseases of the genitourinary system, burdened history, including a large number of abortions in the past.
Are medical or vacuum abortions dangerous for terminating a first pregnancy in an Rh-negative woman?
This is a common misconception. And, unfortunately, often such a statement can be heard even from medical workers. The technique of carrying out an abortion does not matter. Whatever it is, the baby's red blood cells still enter the mother's bloodstream and cause the formation of antibodies.
If the first pregnancy ended in an abortion or miscarriage, how high are the risks of conflict in the second pregnancy?
In fact, the magnitude of such risks is a rather relative concept. No one can say with an accuracy of a percentage whether there will be a conflict or not. However, doctors have certain statistics that estimate (approximately) the likelihood of sensitization of the female body after an unsuccessful first pregnancy:
- miscarriage on short term- +3% to possible future conflict;
- artificial termination of pregnancy (abortion) - + 7% to the likely future conflict;
- ectopic pregnancy and surgery to eliminate it - + 1%;
- delivery at term with a live fetus - + 15-20%;
- delivery by caesarean section - + 35-50% to a possible conflict during the next pregnancy.
Thus, if a woman's first pregnancy ended in an abortion, the second - in a miscarriage, then during the gestation of the third, the risks are estimated at about 10-11%.
If the same woman decides to give birth to another baby, provided that the first birth went well naturally, then the probability of a problem will be more than 30%, and if the first birth ended in a caesarean section, then more than 60%.
Accordingly, any woman with a negative Rh factor who has decided to become a mother once again can weigh the risks.
Does the presence of antibodies always indicate that the child will be born sick?
No, this is not always the case. The child is protected by special filters that are in the placenta, they partially restrain aggressive maternal antibodies.
A small amount of antibodies will not cause much harm to the child. But if the placenta ages prematurely, if the amount of water is small, if a woman falls ill with an infectious disease (even a common ARVI), if she takes medications without supervision by the attending physician, then the likelihood of a decrease in the protective functions of the placental filters increases significantly, and the risk of giving birth to a sick baby will increase. .
It should be borne in mind that during the first pregnancy, antibodies, if they appear, have a fairly large molecular structure, it can be difficult for them to “break through” the protection, but during a second pregnancy, the antibodies are smaller, more mobile, fast and “evil”, so the immunological attack becomes more probable.
Everything related to genetics has not yet been studied well enough, and any “surprise” can be obtained from nature.
There are several cases in history when a mother with Rh (-) and a father with a similar Rh had a child born with positive blood and hemolytic disease. The situation requires careful study.
For more information about the likelihood of a Rh conflict during pregnancy, see the following video.
The Rh factor is a special protein that is found on erythrocytes - red blood cells. If it is not there, they talk about the negative Rh factor of the blood (Rh-), if it is - about the positive (Rh +). Problems during pregnancy can occur when a woman is Rh negative and the future dad is Rh positive. In this case, the woman's immune system may not "accept" the child and begin to get rid of the "stranger". This is the Rhesus conflict during pregnancy.
Coincidence
All expectant mothers need to know that only Rh negative woman. In addition, there are a few other things that must match:
The husband must be Rh-positive;
The child must inherit the father's Rh factor (probability of this is 50%).
Pregnancy in most cases should not be the first.
Rhesus conflict during the first pregnancy usually does not manifest itself. The immune system does not have time to recognize the threat, as it encounters a foreign protein for the first time. Only cellular memory is formed. But having remembered the "stranger", the next time it appears, the woman's immune system will begin to defend itself and produce aggressive antibodies. Getting to the unborn child, they can destroy his red blood cells. Therefore, Rh-negative wives of Rh-positive husbands who have already given birth to a Rh-positive child automatically fall into the risk group. The likelihood of an Rh conflict in the next pregnancy is also high in women whose previous pregnancy was interrupted after 8 weeks, when cellular memory has already formed.
Rhesus conflict during pregnancy: table by blood types
The table below shows the likelihood of a Rh conflict during pregnancy, depending on the Rh factor of future parents.
Rhesus conflict during pregnancy: consequences for the child
Rh-conflict of the mother and fetus for the woman's body has no negative consequences. It only threatens the unborn child. Antibodies destroy his red blood cells, hemoglobin breaks down and bilirubin is released. IN in large numbers bilirubin is very toxic to all organs, but especially to the brain of an unborn child. A small amount of hemoglobin, that is, red blood cells, is fraught with hypoxia and anemia, because red blood cells supply oxygen to the blood.
Rhesus conflict during pregnancy: symptoms
Before the 20th week of pregnancy, the Rh conflict is very rare. As a rule, Rh-conflict during pregnancy, symptoms appear closer to the 28th week of gestation. On ultrasound, the so-called ultrasound markers are determined - polyhydramnios and thickness of the placenta. If the placenta is thicker than expected by the gestational age, this may be a sign of an incipient hemolytic disease, that is, a Rh conflict during pregnancy. The circumference of the abdomen of the future baby, the presence of fluid in his abdominal cavity, an increase in the liver and spleen are also important. If they are enlarged, then these organs may begin to produce young red blood cells instead of destroyed ones. Another symptom is a decrease in blood flow in the baby's cerebral artery. This indicator is measured with dopplerometry.
In order to prevent such serious complications, at the first visit of a woman to a doctor about pregnancy, she is given a referral for a blood test to determine the Rh factor and blood type. If Rh is negative, and the expectant mother does not know her husband's Rh factor, he will also have to pass an analysis to determine the Rh factor and blood type. If the Rh is positive, the woman will be taken under special control.
This means that at the same time as defining negative Rh factor the laboratory will also determine the titer of antibodies in the woman's blood - their number in 1 ml of blood serum. The higher the titer, the more antibodies in the mother's bloodstream. Only the title above 1:16 matters. But even with a very high titer, fetal disease does not always manifest itself.
If an antibody titer is detected, until the 20th week of pregnancy, the analysis is repeated once a month, with its rapid increase - once every 2 weeks. Ultrasound from the 20th week in this case is done every 4 weeks to monitor the symptoms of hemolytic disease in the unborn child.
If at least one symptom of hemolytic disease is found in the future baby, the woman is hospitalized in a specialized hospital. If the antibody titer rises rapidly, the woman will be punctured amniotic fluid to determine the severity of hemolytic disease in a baby. At the same time, it is decided whether cordocentesis is needed - cord blood sampling to determine the level of hemoglobin in the child's blood. With small indicators, intrauterine blood transfusion is done. Then once a week will determine the titer of antibodies. Such measures alleviate the condition of the baby, but do not relieve the disease. You can get rid of it only after birth.
Rhesus conflict: consequences for the child after birth
Treatment for Rh conflict during pregnancy is carried out until 34-36 weeks of gestation. After this period, doctors will try to bring the moment of the birth of the child closer. It is believed that a caesarean section in such cases is the best way for a baby to be born, but it all depends on the condition of the child. By itself, the Rh conflict is not an absolute indication for surgery.
After birth, the child is treated for anemia and other manifestations of hemolytic disease. The level of bilirubin is also monitored daily.
Prevention of Rh conflict during pregnancy
If antibodies are not detected in the blood of a Rh-negative expectant mother, at the 28th-30th week of pregnancy, she will be given an injection of anti-Rhesus immunoglobulin. If an Rh-positive baby is born, then during the first 48-72 hours after birth, the mother is also given an injection of anti-Rh immunoglobulin. This will help prevent conflict in the next pregnancy. The same injection is needed after a miscarriage or abortion after 8 weeks, as well as during an ectopic pregnancy. It is necessary after invasive diagnostics- chorionic villus biopsy, amniocentesis or cordocentesis, with abdominal trauma during pregnancy and bleeding or placental or chorionic abruption.
blood type conflict
Rhesus conflict during pregnancy should not be confused with a blood type conflict. In this case serious problems for the health of the baby usually does not occur. The table below shows the likelihood of such a conflict occurring. Group conflict manifests itself only after childbirth in the form of hemolytic jaundice. Usually on the 5th day everything returns to normal. In contrast to the Rhesus conflict, the group conflict usually manifests itself after the first birth. After the second and subsequent births, it happens much less often.
| Mother | Father | The child will inherit |
Risk of group incompatibility |
|---|---|---|---|
| 0 (I) | 0 (I) |
0 (I) 100% chance |
No |
| 0 (I) | A(II) |
0 (I) or A (II) probability 25/75 |
75% |
| 0 (I) | B(III) |
0 (I) or B (III) probability 25/75 |
75% |
| 0 (I) | AB (IV) |
A (II) or B (III) 50/50 chance |
100% |
| A(II) | 0 (I) |
0 (I) or A (II) probability 25/75 |
No |
| A(II) | A(II) |
0 (I) or A (II) probability 10/90 |
No |
| A(II) | B(III) |
0 (I), A (II), B (III) or AB (IV) probability 10/20/20/50 |
70% |
| A(II) | AB (IV) |
A (II), B (III) or AB (IV) probability 50/15/35 |
50% |
| B(III) | 0 (I) |
0 (I) or B (III) probability 25/75 |
No |
| B(III) | A(II) |
0 (I), A (II), B (III) or AB (IV) probability 10/20/20/50 |
70% |
| B(III) | B(III) |
0 (I) or B (III) probability 10/90 |
No |
| B(III) | AB (IV) | A (II), B (III) or AB (IV) probability 15/50/35 |
50% |
| AB (IV) | 0 (I) |
A (II) or B (III) 50/50 chance |
No |
| AB (IV) | A(II) | A (II), B (III) or AB (IV)
probability 50/15/35 |
No |
| AB (IV) | B(III) |
A (II), B (III) or AB (IV) probability 15 /35 /50 |
No |
| AB (IV) | AB (IV) |
A (II), B (III) or AB (IV) probability 12/25/50 |
No |
A couple of decades ago, a woman's Rh-negative blood was considered almost a curse that prevented her from having many children. The birth of the second, and in some cases even the first, healthy child was an almost insoluble problem. Blame it all - developed during pregnancy Rhesus conflict. What do we know about this pathology, and how are such mothers now being helped?
What is Rhesus conflict
In 85% of the representatives of the Caucasian race, in the outer shell of each red blood cell there is a special protein called the Rh factor. This means that their blood, regardless of the group, is Rh-positive. The remaining 15% of people do not have such a protein in their red blood cells, that is, they are Rh-negative. For their immune system, the Rh protein is a foreign substance, like microbes or an organ transplanted from another person. Therefore, when erythrocytes from a Rh-positive person enter the bloodstream of a Rh-negative person, protective antibodies are inevitably formed in his body. They find strangers and destroy them with the help of immune killer cells (killers). This mechanism is called Rhesus-conflict. Moreover, the immune system of a Rh-negative person forever "remembers" the episode of the meeting with Rh-positive blood. When the Rh protein hits again, a violent reaction of its destruction occurs.
What is dangerous Rhesus conflict for the fetus
Anti-Rh antibodies, penetrating through the damaged placenta to the fetus, destroy its red blood cells. This state is called hemolytic disease. The baby begins to experience oxygen hunger. In response, in an attempt to compensate for hypoxia, new young red blood cells are formed - reticulocytes. Since dead cells accumulate in the spleen, and hematopoiesis in the fetus occurs in the liver, these organs greatly increase in volume. If it is not possible to stop or compensate for the destruction of red blood cells, severe anemia. Under conditions of a pronounced lack of oxygen, the child's organs lag behind in development, and the most sensitive cells, especially in the brain, die.
When erythrocytes break down, it enters the blood toxic substance bilirubin. It causes icteric coloration of the skin and mucous membranes. At high concentrations, it damages the nerve centers in the brain, causing irreversible neurological defects. These can be convulsions, motor disorders up to childhood cerebral palsy, mental disability.
If antibodies enter the baby's body repeatedly, a lot of protein is consumed to replace the decayed cells to build more and more new cells. When its supply in the child's body is depleted, massive edema occurs. The liquid part of the blood is not retained in the bloodstream and accumulates in the cavities:
- in the pleural cavity, preventing immature lungs from opening and causing severe respiratory failure;
- in the abdominal, causing ascites;
- in the pericardial sac, causing heart failure;
- in the brain, causing its edema, which means convulsions and a profound impairment of consciousness.
How does Rhesus conflict manifest in a child?
From the first hours of life, the infant manifests and continues to develop symptoms of hemolytic disease of the newborn. Its severity, which means possible complications and consequences for life and health, directly depends on the aggressiveness of the ongoing intrauterine Rh conflict and on the amount of anti-Rhesus antibodies accumulated in the child's body. In any case, without active supervision by doctors and without adequate treatment, this disease is life-threatening or can lead to disability.
When Rh conflict occurs during pregnancy
The first and main condition- an Rh-negative mother should bear an Rh-positive child who inherited the protein composition of red blood cells from her father. At the same time, according to statistics, half of these dads pass on the Rh factor to all their children, and the second half - in about 50% of cases. That is, only 25% of their babies are born Rh-negative, which means that there is no immunological conflict.
Second condition- a meeting of the mother's body with the Rh protein that occurred before pregnancy with the formation of immunological memory cells. It happens:
- transfusion of Rh-positive blood or red blood cells;
- with previous abortions or miscarriages, if the fetus was Rh-positive;
- after a previous independent birth or caesarean section, if that child inherited the father's Rh factor.
Third condition- violation of the barrier properties of the placenta. In a normal pregnancy, the blood of the mother and fetus never mixes. This can happen when intrauterine infections, with partial detachment of the placenta or its injuries, as well as with amniocentesis and cordocentesis.
Very rarely there are casuistic cases when the Rhesus conflict develops already during the first uncomplicated pregnancy in a woman who has not had a blood transfusion.
The likelihood of developing Rh-conflict in the first and subsequent pregnancies
During the first pregnancy, the Rh conflict develops in no more than 10% of expectant mothers with Rh-negative blood. These are women who have previously received blood transfusions. Each subsequent pregnancy with an Rh-positive fetus, especially with a short time interval, increases the risk of this condition.
How to reduce the risk of developing Rh conflict during pregnancy
Today, an Rh-negative woman can become a mother of many children. The only condition is the timely (that is, no later than 3 days after childbirth, abortion or miscarriage) administration of a special immunoglobulin. One injection of this drug destroys the Rh proteins that have entered the mother's body before her immune system is activated. As a result, a miracle happens: the risk of developing an Rhesus conflict will remain the same as that of a primigravida - no more than 10%.
Anti-Rhesus immunoglobulin is also administered during pregnancy, at about 28 weeks, if during the observation process no signs of intrauterine conflict are detected. This helps to prevent its occurrence until childbirth. The injection is repeated after any manipulation or pregnancy complication, in which there is a risk of violation of the placental barrier: with amnio- or cordocentesis, with partial placental abruption, with hemorrhage, with uterine injuries.
The drug protects for only a few weeks, so during next pregnancies must be entered. The exception is women who have a titer of anti-Rhesus antibodies in their blood. This means that their immune system already has memory cells responsible for the development of the Rhesus conflict. That is, immunoglobulin will not help such mothers. That is why it is important to use it already in the first pregnancy.
Diagnosis of Rh conflict during pregnancy
If future mother has Rh-negative blood, at the time of the first appearance in women's consultation she will be asked to clarify the blood type of the father of the child. If she turns out to be Rh-positive, the woman will be observed by a gynecologist because of the 75% risk of developing an Rh conflict.
A regular blood test that detects Rh antibodies in the mother's blood helps to determine its occurrence and rate of development. It is done from 8 weeks of gestation, when blood group proteins begin to form in the fetus. In the first pregnancy in the absence of blood transfusions in the past, the study is performed every 2 months. If the pregnancy is not the first, or the fact of the introduction of earlier Rh-positive blood is proven, the analysis is carried out monthly, after 32 weeks - twice with an interval of 14 days and then until delivery - weekly.
From the moment of registration for the pregnancy of the expectant mother, at least 5 times, from 16 weeks until delivery, an ultrasound of the fetus is done. During the study, signs of intrauterine Rh conflict can be identified:
- thick edematous placenta;
- enlarged liver and spleen in the fetus;
- polyhydramnios;
- fluid in the abdominal and pleural cavities in a child;
- thickening of the veins of the umbilical cord;
- symptoms of fetal oxygen starvation: low motor activity, heart rhythm disturbance, meconium suspension in the amniotic fluid.
It is possible to suspect that the child is suffering from a lack of oxygen by CTG results(cardiointervalography). A slow, rigid heart rate is recorded with a weak response to various stimuli, rare movements.
Confirm with high precision the fact of the Rhesus conflict is helped by the latest obstetric techniques. During amniocentesis, a small portion of amniotic fluid is taken and the concentration of bilirubin is determined by its optical density, the titer of anti-Rh antibodies and the readiness of the fetal lungs for extrauterine life. With cordocentesis under ultrasound control, fetal blood is taken from the umbilical cord vein for analysis. Clarify his blood group and Rh, examine the level of bilirubin, hemoglobin, mature and young forms of red blood cells, hematocrit, serum protein. The amount of anti-Rhesus antibodies on the child's erythrocytes, the partial tension in the blood of carbon dioxide and oxygen are detected. So even before birth, doctors find out the severity of the Rh conflict and its complications, and have a real opportunity to help the baby maintain health, and sometimes life.
How is Rhesus conflict treated during pregnancy?
The expectant mother throughout her pregnancy takes courses of drugs that reduce the degree of aggressiveness of the immune response and help the fetus to more easily endure oxygen deficiency. These are antihistamines, vitamins, iron preparations. use different kinds oxygen therapy, including hyperbaric oxygen therapy.
Plasmapheresis helps to reduce the amount of anti-Rhesus antibodies.
With the help of cordocentesis, it became possible to perform an exchange transfusion operation in utero, through the veins of the umbilical cord, under ultrasound control. Thanks to this, it is possible to prevent the development of the edematous form of the disease and prolong the pregnancy in order to allow the child to mature for birth.
If the development of the Rh conflict can be restrained, and the condition of the fetus is assessed as satisfactory, childbirth is carried out after 36 weeks. If the baby begins to suffer, a caesarean section is performed.
Breastfeeding with Rh conflict
If the Rhesus conflict has not developed, the baby can be breast-fed after the mother has been injected with anti-Rh immunoglobulin. In the presence of a high titer of antibodies against the infant's erythrocytes, breastfeeding should be postponed for two weeks so as not to cause the progression of hemolytic disease and not worsen the baby's condition.
Methods for the treatment of Rh conflict in newborns
The treatment regimen depends on the severity of the condition. In mild cases, it is sufficient to observe and prevent anemia with iron supplements and folic acid. Donor RBCs may be needed.
by the most frequent method treatment of jaundice in hemolytic disease today is phototherapy. Under the influence of light of a certain spectrum, the formed bilirubin in the surface layers of the skin is converted into a non-toxic compound and excreted in the urine. To speed up the purification of the blood, a plentiful drink is prescribed or fluids are administered intravenously. It is absolutely harmless to the baby.
With the rapid development of hemolytic disease after childbirth, leading to a rapid increase in bilirubin and a threatening fall in hemoglobin, an exchange transfusion operation is performed. The baby's blood is taken out through the vein of the umbilical cord, replacing the donor blood.
With the edematous form of the Rhesus conflict from the moment of birth, the child requires a large amount of resuscitation care.
The mechanisms of development of hemolytic disease of the newborn with Rhesus conflict differ from that with incompatibility by blood group only by a higher rate and more frequent severe course. Therefore, the principles of treatment they have in common.