RH INCOMPATIBILITY - NURSING ASSIGNMENT

INTRODUCTION

        The individual who possesses D antigen is Rh positive one without it is Rh negative. Rhesus or Rh(D) incompatibility can occur when a women with an Rh (D) negative blood type is carrying a baby with an Rh (D) positive blood type. The effect on the fetus depends on the severity of the hemolytic.   

DEFINITION

        Is immunization is defined as a production of immune antibodies in an individual in response to an antigen derived from another individual of the same species provided; the first one lacks the antigen.

CAUSES

RH iso-immunization occurs by,

·        Transfusion of mismatched blood

·        As a result of pregnancy

o       Feto-maternal bleed occurs in

·        Abortion: Either elective or spontaneous

·        Procedures like amniocentesis, external cephalic version, caesarean section, manual removal of placenta. 

CLINICAL FETURES

Hydrops Fetalis

        This is most serious form of Rh hemolytic disease excessive destruction of the fetal red cells cads to sever anemia, tissue anoxaemia and metabolic acidosis. These have got adverse effects on the fetal heart and brain and on the placenta.

Lcterus Gravis Neonatorom 

        In this the baby is born alive without evidences of jaundice but soon develops it within 24 hours of birth.

·        Anaemia

·        Cardiac decompensation

·        Cardiomegaly

·        Hepatamegaly

·        Splenomegaly

·        Edema

·        Ascites

·        Hydrothorax   

MECHANISM OF ANTIBODY FORMATION

        If the ABO compatible, Rh- positive red cells enter the maternal circulation, they remain in the circulation fro their remaining life span. Thereafter, they are removed from the circulation by the reticulo-endothelial tissues and are broken down with liberation of the antigen.

        Detectable antibodies usually develops after 6 moths following larges volume of feto-maternal bleed. Antibodies once formed remain throughout life.

TYPES OF ANTIBODIES

        Two types of antibodies one formed

1. Saline agglutinin [lgM]

This type of antibody is the first to appear in the maternal circulation and agglutinates red cells containing it is not harmful to fetus as it cannot pass through the placental barriers.   

2. Albumin agglutinin [lgG]

It is also incomplete or blocking antibody because of its small molecule, it can cross the placental barriers and cause damage to fetus.

DIAGNOSIS

·        Hemantigen screen

·        Coomb’s test

        In this the maternal blood serum is mixed with Rh positive RBC’S the test result is positive if Rh positive RBC’S agglutinate (clump).      The dilution of the specimen of blood at which clomping occurs determines the tiles (level of maternal antibodies). This determines the degree of maternal sensitization [iso-immunization].

Prevention

1.   To prevent active immunization.

·        To prevent active immunization Rh anti-D immunoglobulin (lg) is administered intra muscularly to the mother following child birth or abortion.

·        Anti-D gomma globulin is administered intramuscularly to the mother solug following delivery. 

2.   To prevent or minimize feto-maternal bleed.

·        Prophylachc ergometrine with the delivery of the anterior shoulder should be withheld.

·        Amniocentesis should be done after sonographic localization of the placenta to prevent it injury.

·        Forcible attempt to perform external version under anesthesia should be avoided.

·        Manual removal of placenta should be done gently.

·        Avoid giving Rh, positive blood to one Rh-negative female from her birth to the menopause.

MANAGEMENT

A) Antenatal management

·        Explains the mechanism involved in is immunization.

·        During pregnancy all women have their blood groped for ABO and Rhesus type.

·        Women who one Rh negative are screened fro Rhesus antibodies.

·        In the absence of antibodies the blood is retested at 28^th and 34^th weeks of pregnancy.

·        If antibodies are found, antibody titres are measured regularly.

·        Fetos is monitored closely by ultrasound for any edema and hepatosplenomegaly.

·        Amniountesis may be carried out in the presence of a high maternal antibody titre.

·        The pregnancy may be allowed to continues with ongoing monitoring of bilirubin and antibody levels and fetal status.

·        Delivery of the fetus may be undertaken

·        Emotional support to family.             

B) Postnatal Management

·        At birth cord blood samples one taken from the placental end of the cut cord.

o       ABO blood group and Rhesus type.

o       Direct comb’s test to detect the presence of maternal antibodies on fetal red cells.

o       Hacmoglobin estimation and serum billirobin level.

·        Infants with rhesus iso-immonization one cored for in intensive care unit.

·        A packed cell transfusion may be used to restore hemoglobin  level.

·        Phototherapy and exchange transfusion.

C) Nursing Management

·        Nurse should collect prenatal history about blood type and Rh factor.

·        Nurse should ask the mother if she has eves received Rho GAM.

·        Nurse should provide emotional support to family.

·        Encourage the mother for ongoing assessment of fetal-well being by USG and amniocentesis.

·        Advice the mother to have regular follow-up.

COMPLICATIONS

·        Perinatal asphyxia.

·        Apgar score of 3 or less at 5mts.

·        Hypothermia (se 95^oF or less than 35⁰C).

·        Hypoglycemia.

·        Deterioration of the infants condition.

·        Maternal infection leading to neonatal sepsis.

·        Preterm birth.

·        Low birth weight.

CONCLUSION

        Rh D incompatibility can occur when a women with Rh negative blood type is pregnant with a fetus with a Rh positive but not Rh negative blood type. This can be occur by transfusion of mismatched blood, as a result of pregnancy & abortion Rh incompatibility can prevented by active immunization and minimize feto-maternal bleed.  

BIBILOGRAPHY

·        Myles Textbook for Midwives,

    4^th Edition, Page: 869-875

·        DC Dutta Central Book Agency

    6^th Edition, Page: 332-335

1 lfo5; tab-stops:list .5in'>2.   A Myles Text Book of Obstetrics

14^th Edition

Page No.731, 425