Rh conflict during pregnancy: what should a woman with a negative Rh factor do to avoid consequences

Rh conflict during pregnancy occurs as a result of blood incompatibility according to the Rh system (Rh). According to statistics, this type of incompatibility occurs in 13% of married couples, but immunization during pregnancy occurs in 1 out of 10-25 women.

Pregnancy of a woman with a negative Rh factor, in which the fetus has a positive Rh factor, leads to the production of antibodies by the mother's immune system to the child's red blood cells.

As a result, the fetal red blood cells “stick together” and are destroyed. This is a humoral immune response to the presence of the Rh factor protein, which is foreign to the mother’s body.

• Rh factor - what is it?
• Probability of developing Rh conflict during pregnancy: table
• Reasons
  • Feto-maternal transfusion
• Rh conflict during pregnancy: mechanism of occurrence
• Consequences for the child
• Risks
• Diagnosis, symptoms and signs of Rh conflict during pregnancy
• Treatment
  • Plasmapheresis for Rh-conflict pregnancy
  • Cordocentesis
• Immunoglobulin for negative Rhesus
• Can the Rh factor change during pregnancy?

What is Rh factor

To understand what Rh conflict is during pregnancy, you need to take a closer look at the concept of Rh factor.

Rh (+) is a special protein - an agglutinogen - a substance that can stick red blood cells together and damage them when they encounter an unfamiliar immune agent.

The Rh factor was first discovered in 1940. There are about 50 types of Rh antigens. The most mutagenic dominant antigen is D, which is found in the blood of 85% of people.

Antigen C is found in 70% of people, and antigen E is found in 30% of people on the planet. The presence of any of these proteins on the red blood cell membrane makes it Rh positive Rh (+), the absence makes it Rh negative Rh (-).

The presence of agglutinogen D has an ethnicity:

• among people of Slavic nationality, 13% are Rh-negative people;
• among Asians 8%;
• Among people of the Negroid race, there are practically no people with Rh-negative blood factor.

Recently, women with negative Rh factor blood have become increasingly common; according to the literature, this is associated with mixed marriages. Consequently, the frequency of Rh conflict during pregnancy in the population is increasing.

Inheritance of system D antigen

The types of inheritance of any traits are divided into homozygous and heterozygous. For example:

1. DD – homozygous;
2. Dd – heterozygous;
3. dd – homozygous.

Where D is a dominant gene, and d is a recessive gene.

Rh conflict during pregnancy - table

If the mother is Rh positive, the father is Rh negative, then one of their three children will be born Rh negative with a heterozygous type of inheritance.

If both parents are Rh negative, then their children will 100% have a negative Rh factor.

Table 1. Rh conflict during pregnancy

Reasons

The cause of Rh conflict during pregnancy is:

• transfusion of incompatible blood using the AB0 system is extremely rare;
• feto-maternal transfusion.

What is feto-maternal transfusion?

Normally, during any pregnancy (physiological or pathological), a small number of fetal blood cells enter the mother’s bloodstream.

A negative Rh factor during pregnancy in a woman definitely poses a danger for a baby with a positive Rh factor. Rh conflict develops, just like any immunological reaction. At the same time, the first pregnancy can proceed without complications, but subsequent ones (second and third) lead to Rh conflict and severe symptoms of hemolytic disease of the fetus and newborn.

Mechanism of immunization (development of Rhesus conflict)

The Rh-negative mother and the Rh-positive fetus exchange blood cells, the mother’s immune system perceives the baby’s red blood cells as foreign proteins and begins to produce antibodies against it. For the development of a primary immune response, 35-50 ml of fetal red blood cells enter the mother’s bloodstream.

The volume of blood that flows from the baby's bloodstream to the mother increases during invasive obstetric procedures, cesarean section, childbirth, and other obstetric procedures.

The first immune response begins with the appearance of immunoglobulins M - these are large pentagram molecules (polymers) that hardly penetrate the placental barrier and do not destroy the red blood cells of the fetus, thus cannot cause harm to it. Therefore, the first pregnancy most often proceeds without consequences.

Secondary fetoplacental transfusion entails consequences for the child. It occurs during a repeat (second, third, fourth) pregnancy.

Cellular memory works in the body of a pregnant woman and, due to repeated contact with the Rh factor protein, protective antibodies are produced - immunoglobulins G - Rh conflict develops. Immunoglobulin G molecules are small monomers that can penetrate the placental barrier and cause hemolysis - the destruction of red blood cells of the fetus and newborn.

What contributes to the development of Rh sensitization?

The first pregnancy in an Rh-negative mother with an Rh-positive fetus in most cases ends successfully and ends with the birth of the fetus. Any subsequent pregnancy, regardless of the outcome (early miscarriage, abortion, spontaneous abortion) in an Rh-negative woman becomes an impulse for the development of a secondary immune response and the appearance of immunoglobulins that destroy the baby’s red blood cells in utero.

The cause of Rh conflict during pregnancy in an Rh negative mother can be:

• In the first trimester:
  • medical abortion (surgical or medical), provided that these complications arose at 7-8 weeks.

Immunological incompatibility of the Rh factor in the blood of a Rh-negative mother and a Rh-positive fetus, characterized by sensitization of the maternal body. The cause of Rh conflict is the transplacental penetration of fetal red blood cells carrying a positive Rh factor into the bloodstream of a Rh-negative mother. Rh conflict can cause intrauterine fetal death, miscarriage, stillbirth and hemolytic disease of the newborn.

General information

Rh conflict can occur in women with negative Rh during pregnancy or during childbirth if the child has inherited a positive Rh father. The Rh factor (Rh) of human blood is a special lipoprotein (D-agglutinogen) in the Rh system, located on the surface of red blood cells. It is present in the blood of 85% of the human population who are Rh positive Rh (+), and 15% who do not have an Rh factor belong to the Rh negative group Rh (–).

Causes of Rh conflict

Isoimmunization and Rh conflict are caused by the entry of Rh-incompatible blood of the child into the mother’s bloodstream and largely depend on the outcome of the first pregnancy in an Rh (–) woman. Rh conflict during the first pregnancy is possible if the woman has previously received a blood transfusion without taking into account Rh compatibility. The occurrence of Rh conflict is facilitated by previous terminations of pregnancy: artificial (abortions) and spontaneous (miscarriages).

The entry of the baby's umbilical cord blood into the mother's bloodstream often occurs during childbirth, making the mother's body susceptible to the Rh antigen and creating the risk of Rh conflict in the next pregnancy. The likelihood of isoimmunization increases with delivery by cesarean section. Bleeding during pregnancy or childbirth due to abruption or damage to the placenta, manual separation of the placenta can provoke the development of Rh conflict.

After invasive prenatal diagnostic procedures (chorionic villus biopsy, cordocentesis or amniocentesis), Rh sensitization of the maternal body is also possible. A pregnant woman with Rh (-), suffering from preeclampsia, diabetes, who has had influenza and acute respiratory infections, may experience a violation of the integrity of the chorionic villi and, as a result, activation of the synthesis of anti-Rhesus antibodies. The cause of Rh conflict may be long-standing intrauterine sensitization of a Rh(-) woman, which occurred at birth from an Rh(+) mother (2% of cases).

The mechanism of development of Rh conflict

The Rh factor is inherited as a dominant trait, therefore, in an Rh (-) mother with homozygosity (DD) Rh (+) father, the child is always Rh (+), which is why the risk of Rh conflict is high. In the case of heterozygosity (Dd) of the father, the chances of having a child with positive or negative Rh are the same.

The formation of fetal hematopoiesis begins from the 8th week of intrauterine development; at this period, fetal red blood cells can be found in small quantities in the mother’s bloodstream. In this case, the Rh antigen of the fetus is foreign to the Rh (–) immune system of the mother and causes sensitization (isoimmunization) of the maternal body with the production of anti-Rh antibodies and the risk of Rh conflict.

Sensitization of Rh (–) women during the first pregnancy occurs in isolated cases and the chances of pregnancy during Rh conflict are quite high, since the antibodies formed during this process (Ig M) have a low concentration, penetrate the placenta poorly and do not pose a serious danger to the fetus.

The likelihood of isoimmunization during delivery is greater, which can lead to Rh conflict in subsequent pregnancies. This is due to the formation of a population of long-lived immune memory cells, and in the next pregnancy, upon repeated contact with even a small volume of Rh antigen (no more than 0.1 ml), a large number of specific antibodies (Ig G) are released.

Due to their small size, IgG is able to penetrate into the fetal bloodstream through the hematoplacental barrier, causing intravascular hemolysis of the child's Rh (+) erythrocytes and inhibition of the hematopoietic process. As a result of Rh conflict, a severe, life-threatening condition for the unborn child develops - hemolytic disease of the fetus, characterized by anemia, hypoxia and acidosis. It is accompanied by damage and excessive enlargement of organs: liver, spleen, brain, heart and kidneys; toxic damage to the child’s central nervous system - “bilirubin encephalopathy.” Without timely preventive measures, Rh conflict can lead to intrauterine fetal death, spontaneous miscarriage, stillbirth, or the birth of a child with various forms of hemolytic disease.

Symptoms of Rh conflict

Rh conflict does not cause specific clinical manifestations in a pregnant woman, but is detected by the presence of antibodies to the Rh factor in her blood. Sometimes Rh conflict can be accompanied by functional disorders similar to gestosis.

Rh conflict is manifested by the development of hemolytic disease of the fetus, which, with early onset, can lead to intrauterine death from the 20th to 30th week of pregnancy, miscarriage, stillbirth, premature birth, as well as the birth of a full-term child with an anemic, icteric or edematous form of this disease. Common manifestations of Rh conflict in the fetus are: anemia, the appearance of immature red blood cells in the blood (reticulocytosis, erythroblastosis), hypoxic damage to important organs, hepato- and splenomegaly.

The severity of the manifestations of Rh conflict can be determined by the amount of anti-Rh antibodies in the mother’s blood and the degree of maturity of the child. An edematous form of hemolytic disease of the fetus can be extremely difficult in case of Rh conflict - with an increase in the size of the organs; severe anemia, hypoalbuminemia; the appearance of edema, ascites; thickening of the placenta and increased volume of amniotic fluid. With Rh conflict, hydrops fetalis, edematous syndrome of the newborn, and an increase in the child's weight by almost 2 times can develop, which can lead to death.

A small degree of pathology is observed in the anemic form of hemolytic disease; the icteric form is expressed by icteric discoloration of the skin, enlargement of the liver, spleen, heart and lymph nodes, and hyperbilirubinemia. Bilirubin intoxication during Rh conflict causes damage to the central nervous system and is manifested by the child's lethargy, poor appetite, frequent regurgitation, vomiting, decreased reflexes, convulsions, which can subsequently lead to a delay in his mental and mental development, and hearing loss.

Diagnosis of Rhesus conflict

Diagnosis of Rh conflict begins with determining the Rh affiliation of a woman and her husband (preferably before the onset of the first pregnancy or at its earliest stage). If the expectant mother and father are Rh negative, there is no need for further examination.

To predict Rh conflict in Rh (-) women, important are data on past blood transfusions without taking into account Rh-relatedness, previous pregnancies and their outcomes (presence of spontaneous miscarriage, medical abortion, intrauterine fetal death, birth of a child with hemolytic disease), which may indicate possible isoimmunization.

Diagnosis of Rh conflict includes determination of the titer and class of anti-Rh antibodies in the blood, which is carried out during the first pregnancy for women who are not sensitized for Rh - every 2 months; sensitized - up to 32 weeks of gestation every month, from 32 to 35 weeks - every 2 weeks, from 35 weeks - weekly. Since there is no direct dependence of the degree of fetal damage on the titer of anti-Rhesus antibodies, this analysis does not give an accurate idea of ​​the condition of the fetus in case of Rh-conflict.

To monitor the condition of the fetus, an ultrasound examination is carried out (4 times in the period from 20 to 36 weeks of pregnancy and immediately before birth), which makes it possible to observe the dynamics of its growth and development. In order to predict Rh conflict, ultrasound evaluates the size of the placenta, the size of the fetal abdomen (including the liver and spleen), and identifies the presence of polyhydramnios, ascites, and dilation of the umbilical cord veins.

Carrying out electrocardiography (ECG), fetal phonocardiography (FCG) and cardiotocography (CTG) allows the gynecologist caring for pregnancy to determine the degree of fetal hypoxia in case of Rh conflict. Important data are provided by prenatal diagnosis of Rh conflict using amniocentesis (study of amniotic fluid) or cordocentesis (study of umbilical cord blood) over time under ultrasound control. Amniocentesis is carried out from the 34th to the 36th week of pregnancy: the titer of anti-Rhesus antibodies, the sex of the unborn child, the optical density of bilirubin, and the degree of maturity of the fetal lungs are determined in the amniotic fluid.

Cordocentesis, which helps determine the fetal blood type and Rh factor from the umbilical cord blood of the fetus, can accurately determine the severity of anemia in case of Rh conflict; levels of hemoglobin, bilirubin, serum protein; hematocrit, reticulocyte count; antibodies fixed on fetal red blood cells; blood gases.

Treatment of Rhesus conflict

To alleviate the Rh conflict, all Rh (–) pregnant women at 10-12, 22-24 and 32-34 weeks of gestation are given courses of nonspecific desensitizing therapy, including vitamins, metabolic agents, calcium and iron supplements, antihistamines, and oxygen therapy. At a gestation period of more than 36 weeks, in the presence of Rh-sensitization of the mother and satisfactory condition of the fetus, independent delivery is possible.

If a severe condition of the fetus is noted during Rh-conflict, a planned cesarean section is performed at 37-38 weeks. If this is not possible, the fetus undergoes an intrauterine blood transfusion through the umbilical vein under ultrasound control, which allows partially compensating for the phenomena of anemia and hypoxia and prolonging pregnancy.

In case of Rh conflict, it is possible to prescribe plasmapheresis to a pregnant woman in the second half of gestation in order to reduce the titer of antibodies to Rh (+) fetal red blood cells in the mother’s blood. In case of severe hemolytic damage to the fetus, immediately after birth, the child undergoes a replacement transfusion of single-group Rh-negative blood or plasma or red blood cells of group I; begin treatment for hemolytic disease of the newborn.

Within 2 weeks after birth, breastfeeding a child with signs of hemolytic disease is not allowed, so as not to worsen the baby’s condition. If the newborn has no symptoms of this disease during a Rhesus conflict, then after injection of anti-Rhesus immunoglobulin into the mother, breastfeeding is carried out without restrictions.

Prevention of Rhesus conflict

To avoid very serious consequences for the child during an Rh-incompatible pregnancy, the primary task in gynecology is to prevent the development of Rh immunization and Rh conflict. Of great importance for the prevention of Rh conflict in an Rh (-) woman is taking into account Rh compatibility with the donor during blood transfusion, mandatory preservation of the first pregnancy, and the absence of a history of abortions.

An important role in preventing Rh conflict is played by pregnancy planning, with examination of the woman for blood type, Rh factor, and the presence of anti-Rh antibodies in the blood. The risk of developing a Rh conflict and the presence of antibodies to Rh in a woman’s blood are not a contraindication to pregnancy or a reason to terminate it.

A specific prevention of Rh conflict is an intramuscular injection of anti-Rhesus immunoglobulin (RhoGAM) from donor blood, which is prescribed to women with Rh (-) who are not sensitized to the Rh antigen. The drug destroys Rh (+) red blood cells that may have entered the woman’s bloodstream, thereby preventing her isoimmunization and reducing the likelihood of Rh conflict. For high effectiveness of the preventive action of RhoGAM, it is necessary to strictly adhere to the timing of drug administration.

Administration of anti-Rhesus immunoglobulin Rh (-) to women to prevent Rh conflict is carried out no later than 72 hours after transfusion of Rh (+) blood or platelet mass; artificial termination of pregnancy; spontaneous miscarriage, surgery associated with ectopic pregnancy. Anti-Rhesus immunoglobulin is prescribed to pregnant women at risk of Rh conflict at 28 weeks of gestation (sometimes again at 34 weeks) to prevent hemolytic disease of the fetus. If a pregnant woman with Rh (-) experienced bleeding (due to placental abruption, abdominal trauma), invasive manipulations were performed with the risk of developing a Rh conflict, anti-Rh immunoglobulin was administered at the 7th month of gestation.

In the first 48–72 hours after birth, in the case of the birth of an Rh (+) child and the absence of antibodies to Rh in the mother’s blood, the RhoGAM injection is repeated. This allows you to avoid Rh sensitization and Rh conflict in the next pregnancy. The effect of immunoglobulin lasts for several weeks and with each subsequent pregnancy, if there is a possibility of the birth of an Rh (+) child and the development of Rh conflict, the drug must be administered again. For Rh (-) women already sensitized to the Rh antigen, RhoGAM is not effective.

Update: October 2018

Most women who are preparing to become mothers have heard about the “terrible and terrible” Rh conflict during pregnancy. But this problem concerns only those representatives of the fairer sex whose blood is Rh negative.

Rh conflict during pregnancy threatens only those pregnant women and those planning a pregnancy who have negative Rh blood, and even then, not in 100% of cases.

Let's understand the Rh factor

It is known that human blood consists of red blood cells or erythrocytes, which are responsible for the transport of oxygen, white blood cells - leukocytes, which guard the health of the body, platelets, which are responsible for blood clotting and many other cells and systems.

Rh factor is a D protein, which is an antigen and is localized on the surface of red blood cells. A significant proportion of people have the Rh factor, then their blood is called Rh positive. For example:

• Among Europeans, there are 85% of Rh-positive people
• while for Africans this figure rises to 93%
• among Asians up to 99%

If D protein is not detected, then such people are called Rh negative. The Rh factor is determined genetically, just like hair or eye color, it remains for life and does not change. The presence or absence of the Rh factor does not bring any benefit or harm; it is simply a characteristic feature of each person.

What is this – Rhesus conflict?

Click to enlarge

It becomes clear that pregnancy with Rh conflict occurs in situations where the mother’s blood is Rh negative, and the father’s, on the contrary, is Rh positive, and the unborn child inherits the Rh factor from him.

However, this situation occurs in no more than 60% of cases, and the occurrence of Rh conflict accounts for only 1.5%. The mechanism of Rh conflict while waiting for the birth of a baby is that the red blood cells of the fetus, which carry the D-antigen, meet the red blood cells of a Rh-negative pregnant woman and stick together, that is, agglutination occurs.

To prevent clumping, the mother’s immunity is activated, the immune system begins to intensively synthesize antibodies that bind to the antigen - the Rh factor and prevent clumping. These antibodies or immunoglobulins can be of two types, both IgM and IgG.

• Rh conflict during the first pregnancy

It almost never occurs, which is due to the production of type 1 immunoglobulins. IgM is very large and cannot cross the placenta to enter the fetal bloodstream. And in order for the red blood cells of the unborn child and antibodies to meet, they need to “collide” in the gap between the uterine wall and the placenta. The first pregnancy almost completely eliminates this situation, which prevents the development of a Rh conflict situation.

• If a woman becomes pregnant again with an Rh-positive fetus

In this case, his red blood cells, penetrating the mother’s vascular system, “trigger” an immune response, during which IgG begins to be produced. These antibodies are small in size, they easily cross the placental barrier, penetrate the baby’s bloodstream, where they begin to destroy his red blood cells, that is, cause hemolysis.

In the process of destruction of the red blood cells of the fetus, bilirubin is formed from them, which in significant quantities is a toxic substance for the child. Excessive formation of bilirubin and its action contributes to the development of such a formidable pathology as hemolytic disease of the fetus and newborn.

What leads to Rh conflict?

For the development of Rh conflict, two conditions are needed:

• Firstly, the fetus must have Rh-positive blood, which means it will inherit its Rh-positive father
• Secondly, the mother’s blood must be sensitized, that is, have antibodies to the D-protein.

The production of antibodies is mainly due to previous pregnancies, no matter how they ended. The main thing is that there was a meeting between maternal blood and fetal blood, after which IgM antibodies were developed. It could be:

• previous births (during the expulsion of the fetus, a woman cannot avoid contact with its blood)
• C-section
• ectopic pregnancy
• artificial termination of pregnancy (regardless of the method, both surgical and)
• spontaneous miscarriage
• separation of the placenta by hand.

It is also possible to develop antibodies after performing invasive procedures during gestation, for example, after cordocentesis or amniocentesis. And such a reason cannot be ruled out, although this is rather nonsense, like transfusion of Rh-positive blood to a woman in the past who has an Rh-negative factor.

Diseases of the woman who is carrying the baby are also important. , diabetes mellitus, ARVI and influenza damage the villi, and, consequently, the chorion vessels and the blood of the mother and the unborn baby mix.

But you should know that hematopoiesis in the fetus begins to form from the 8th week of embryogenesis, which means that abortions performed before 7 weeks are safe in terms of the development of an Rh conflict situation in the future.

Manifestations of Rh conflict

There are no external, that is, visible manifestations of Rh conflict. Incompatibility of maternal and fetal blood does not in any way affect the condition of the pregnant woman. As described above, the Rh conflict “ripens” during the second pregnancy, and with each subsequent pregnancy the risk of this condition increases.

Incompatibility of the blood of the child and the expectant mother according to the Rh factor has a very adverse effect on his condition and health in the future. To find out what devastating damage the Rhesus conflict has caused to the baby, an ultrasound scan of the fetus is performed. During an ultrasound examination, the following signs are clearly visualized:

• the contour of the head becomes double, which indicates edema
• the placenta and umbilical vein swell and increase in diameter
• Fluid accumulates in the abdominal cavity, heart sac, and chest
• the size of the fetal abdomen exceeds the norm
• splenohepatomegaly develops (increase in the size of the liver and spleen), the fetal heart is larger than normal
• the baby in the uterus takes a certain position in which the legs are spread apart due to the large belly - this is called the “Buddha pose”

All of these ultrasound signs indicate the development of hemolytic disease of the fetus, and after birth it will be called hemolytic disease of the newborn. This pathology has three forms:

• icteric
• edematous
• and anemic

The most unfavorable and severe is the edematous form. The icteric form ranks second in severity. A child who has high levels of bilirubin in the bloodstream after birth is very lethargic, apathetic, has poor appetite, constantly regurgitates (see), has reduced reflexes, and often has convulsions and vomiting.

Bilirubin intoxication negatively affects the child in utero, and is fraught with the development of mental and mental disability. In the anemic form, the fetus has a lack of red blood cells, which causes oxygen starvation (hypoxia) and immature red blood cells (erythroblasts, reticulocytes) are present in large quantities in the blood.

Diagnostics and dynamic control

In the diagnosis of the described pathology, the woman’s early attendance at the antenatal clinic is of great importance, especially if this is the second, third, etc. pregnancy and the pregnant woman has been diagnosed with either antibody sensitization in the past, or, which is much more unfavorable, a history of hemolytic disease of the fetus/newborn.

• When registering at a dispensary, all pregnant women, without exception, are determined by their blood type and Rh status.
• If the mother is diagnosed with Rh-negative blood, in this case, determination of the group and Rh factor in the father is indicated.
• If he has a positive Rh factor, a woman up to 20 weeks of pregnancy is prescribed tests for antibody titer every 28 days.
• It is important to determine the type of immunoglobulins (IgM or IgG).
• After the pregnancy has reached the second half (after 20 weeks), the woman is sent for observation to a specialized center.
• After 32 weeks, a blood test for antibody titer is carried out every 14 days, and after 35 every 7 days.
• The prognosis depends on the gestational age (see) in which the antibodies were detected. The earlier the Rh factor immunoglobulins were diagnosed, the more unfavorable it is.

If antibodies are detected, especially if there is a second pregnancy and the chances of an Rh conflict increase, the condition of the fetus is assessed, which is carried out using both non-invasive and invasive methods.

Non-invasive ways to determine the condition of the unborn baby:

Ultrasound should be performed at 18, 24–26, 30–32, 34–36 weeks of gestation and on the eve of birth. The position of the child, swelling of the tissues, dilated umbilical veins, and how the baby grows and develops are determined.

• Doppler

The speed of blood flow in the placental vessels and in the unborn child is assessed.

• Cardiotocography (CTG)

Allows you to determine the state of the heart and vascular system in the fetus and diagnose the presence of a lack of oxygen (hypoxia).

Invasive methods:

• Amniocentesis

During amniocentesis, amniotic fluid is collected by puncturing the amniotic fluid and the bilirubin content in it is determined. Amniocentesis is prescribed when the antibody titer is 1:16 or higher and is performed at 34–36 weeks. The negative aspects of this procedure should also be taken into account. Carrying out amniocentesis is fraught with infection, leakage of amniotic fluid, premature rupture of water, bleeding and placental abruption.

• Cordocentesis

The essence of the procedure is to puncture the umbilical vein and take blood from it. A highly informative method for diagnosing hemolytic disease, in addition, it allows intrauterine blood transfusion to the fetus. Cordocentesis has the same negative aspects as amniocentesis, and the formation of a hematoma at the puncture site or bleeding from it is also possible. This manipulation is carried out when the antibody titer is 1: 32 and in the case of hemolytic disease of the fetus/newborn in the previous child or his death.

Methods for countering Rhesus conflict

Today, there is only one way to alleviate the condition of the fetus and improve its situation - this is intrauterine blood transfusion through cordocentesis. This method reduces the likelihood of premature birth and the development of severe hemolytic disease after birth. All other methods do not have a significant effect or are completely useless (desensitizing treatment, transplantation of a skin flap from the mother’s husband, etc.).

A woman usually gives birth ahead of schedule. Preference is given to abdominal delivery, since in this case the risk of complications is reduced. But in some situations (absence of hypoxia, gestational age more than 36 weeks, not the first birth) independent childbirth is also possible.

To prevent Rh conflict during the next pregnancy, a first-time mother is given anti-Rh immunoglobulin within 72 hours after the birth of the child, which will destroy the baby's red blood cells that enter the mother's blood, which will prevent the formation of antibodies to them.

It is for the same purpose that specific immunoglobulin is administered after artificial and spontaneous termination of pregnancy. In addition, the administration of immunoglobulin after an ectopic pregnancy and for bleeding during the current period of gestation is indicated. For prevention purposes, administration of this immunoglobulin is indicated at 28 and 34 weeks.

Rhesus conflict and breastfeeding

There is no consensus on the issue of breastfeeding during Rh conflict. Doctors evaluate the baby’s condition and possible risks, and in some cases, immediately after birth, they do not recommend breastfeeding for several days, sufficient to remove antibodies from the mother’s body.

However, there is also the opposite opinion of doctors that such a restriction is not necessary. There are no proper studies in this area confirming this or that position yet.

What does rhesus conflict portend?

The consequences of pregnancy with Rh-conflict are very unfavorable. The presence of a huge amount of bilirubin in a child’s blood affects the condition of his internal organs and brain (the damaging effect of bilirubin).

Hemolytic disease of the newborn often develops, the baby has mental retardation, and his death is possible, both in the womb and after birth. In addition, Rh conflict is the cause of termination of pregnancy and recurrent miscarriage.

Knowledge about the Rh factor can easily be called one of the most valuable knowledge acquired by man in the entire history of medicine. It allows you to avoid a huge number of serious relationships during blood transfusion, as well as during pregnancy and childbirth, in particular in cases where the child and mother have a so-called Rh conflict. So, what is the Rh factor, and what does it mean for expectant mothers?

Rh conflict: essence and mechanism

The Rh factor is a specific protein that is found on the surface of red blood cells in approximately 85% of the world's population. That is, those who have such a protein are called people Rh positive, and those who lack it - Rh negative. The Rh factor does not affect the health of the mother and the course of pregnancy, however, if a “negative” woman is pregnant from a “positive” man, in this case there is a possibility of a so-called Rh conflict.

Its essence lies in the fact that the red blood cells of the mother and child, having different signs, meet each other, as a result of which a specific reaction begins in the woman’s body, reminiscent of an allergy. Antibodies produced by the immune system begin to destroy the child’s red blood cells, which leads to the most disastrous consequences.

It should be noted that such complications are especially likely due to the so-called sensabilization: a condition when the baby’s blood enters the pregnant woman’s blood, causing her body to begin producing antibodies. This happens in cases where the mother has a history of abortions, miscarriages, ectopic pregnancies, uterine bleeding and other complications during pregnancy. In addition, sensabilization can occur if there is any damage to the placenta due to infections, gestosis, abruption, as well as certain medical procedures (amniocentesis).

If there have been no similar situations in the past, and the woman is pregnant for the first time, then serious problems usually do not arise: the doctor carefully monitors the patient’s condition, and childbirth most often goes well. However, during the second and subsequent pregnancies, the mother will require special treatment, which can eliminate the occurrence of serious complications. In addition, in order to protect the baby, every woman needs to know about the possible risk of Rh conflict in each specific case.

Possibility of Rh conflict depending on the Rhesus of the parents

To determine the possibility of Rh conflict, you should remember the laws of genetics, according to which certain blood groups, as well as Rhesus, are inherited from parents. In particular, in At risk are families where the expectant mother is Rh negative and the father is Rh positive. To determine this risk, you can use the following table.

Rh factor inheritance

Inheritance of blood groups

It must be remembered that it is impossible to determine the probability of a conflict with complete confidence using such tables; This will require blood tests from the father and mother, as well as a consultation with a doctor.

Diagnosis and symptoms

The danger of a Rhesus conflict is that it usually does not give any clinical manifestations that may alert a pregnant woman. In some cases, she may feel symptoms similar to those of gestosis, but it can be very difficult to clearly identify a hemolytic disorder.

That's why all women at risk must be strictly monitored gynecologists throughout pregnancy, and regularly undergo an ultrasound procedure. Symptoms of Rh factor conflict in the fetus include the following:

• severe swelling;
• accumulation of fluid in the body cavities (abdominal, thoracic), as well as in the area of ​​the pericardial sac;
• increase in abdominal size;
• the so-called “Buddha pose”: a large belly and limbs removed from it;
• enlargement of the spleen, liver and heart;
• “double contour” (soft tissue swelling) of the head;
• thickening of the veins of the umbilical cord and placenta.

To diagnose Rh conflict and prevent symptoms, it is very important to determine the group and Rh of both the expectant mother and the expectant father, regularly test for antibodies, and, if necessary, prescribe adequate treatment.

Possible consequences

In the event of a Rh conflict, the woman’s antibodies begin to attack the “foreign” red blood cells of the fetus, gradually destroying them, as a result of which bilirubin is released into the blood, which turns the skin yellow. In addition, the number of red blood cells in the baby's blood drops rapidly, leading to a deterioration in the ability to carry oxygen. Tissues and organs, including the brain, begin to experience severe oxygen starvation, which disrupts their development and leads to a variety of diseases.

In the most difficult cases, due to severe tissue damage, the fetus develops hydrops; Unfortunately, in such cases, saving the child’s life is often impossible.

As for the mother, it does not pose a direct danger to her condition, however, if the first pregnancy was interrupted or occurred with complications (for example, with uterine bleeding), then the second and subsequent ones require special attention. This is due to the so-called immune memory: the mother’s body produces specific antibodies to the child’s red blood cells, which means the risk of problems and complications increases significantly. That is why so-called “negative” women are especially not recommended to have abortions.

How to prevent complications from developing

To completely eliminate the risk of complications due to Rh conflict, it is necessary even before conception, that is, at the stage of pregnancy planning, or at least in the earliest stages undergo a rhesus test. If Rh is negative, it will be necessary to conduct another study on the type of antibodies and their concentration (titer) in the woman’s blood, which can answer the question of how dangerous their amount is for the child. This test must be taken before 18-20 weeks, and if the pregnant woman has had cases in the past Rh conflicts, then the determination of antibody concentration is carried out earlier.

• Considered normal titer less than 1:4. In this case, the woman only needs regular monitoring of the condition of the fetus, and a repeat analysis is performed at week 28 (if no abnormalities are found in the fetus).
• If the amount of antibodies remains at this time at 1:4 level and mless, the pregnant woman is given a dose of a special vaccine (anti-Rhesus immunoglobulin), which can prevent possible complications.
• At titer more than 1:4, antibody testing should be carried out approximately once every one to two weeks, carefully monitoring their dynamics.

In any case, if even a minimal amount of antibodies is detected, the woman requires regular examinations (ultrasound, Doppler ultrasound, etc.). If the fetal condition worsens, it is necessary to carry out a blood transfusion procedure in utero, which will compensate for the lack of red blood cells in the fetal blood. In situations where such a solution is impossible, the question of urgent delivery is raised, since any delay may threaten the death of the fetus.

Anti-Rhesus immunoglobulin: prevention of Rh conflict

A vaccine against Rhesus conflict is a drug that can prevent sensabilization, that is, the production of specific antibodies in a woman’s body. The mechanism of action of anti-Rhesus immunoglobulin is as follows: it destroys “positive” red blood cells, preventing the mother’s immune system from launching a protective reaction.

It is believed that about 20 mcg of the drug neutralizes 1 ml of red blood cells, therefore, to “neutralize” “foreign” red blood cells of the child that accidentally enter the mother’s blood, approximately 300 mcg of the vaccine is needed.

The first dose of the drug is usually given to a woman between 28 and 34 weeks (preferably at 28 weeks) if there are no antibodies in her blood and the fetal blood type is unknown. The second dose must be administered within 3 days after delivery (if the child is Rh positive).

Also, the administration of anti-Rhesus immunoglobulin is strongly recommended for all “negative” women after abortions, ectopic pregnancies or miscarriages: this can protect them from serious problems in the future.

It should be noted that in most cases, anti-Rhesus immunoglobulin is well tolerated by women, however, like any other medical drug, it can cause various allergic reactions, including anaphylactic shock. Therefore, after administering the vaccine, a pregnant woman should wait at least 30 minutes. be under the supervision of doctors.

Typically, anti-Rhesus immunoglobulin is available in domestic perinatal institutions, but it can only be purchased by prescription. The average cost is 5 thousand rubles. The vaccine is a colorless or light yellow solution (a small sediment is allowed) for intramuscular administration. Before administration, the ampoule must be kept for approximately two hours at room temperature, and after opening, the drug must be used immediately for its intended purpose. The shelf life of anti-Rhesus immunoglobulin is three years.

Rh conflict during pregnancy is a pathological process that manifests itself in a situation where the mother has a negative Rh factor and the father is positive, and the child acquires the positive Rh factor of the father. If both parents are Rh positive or Rh negative, Rh conflict is not detected.

Rh factor is a special substance that is found in human blood. Doctors have proven that the absence of the Rh factor in a woman’s blood negatively affects the course of pregnancy.

Rh factor (D-antigen) is a protein located on the surface of red blood cells - erythrocytes. It follows from this that a positive Rh factor is inherited by people who have the D antigen on the surface of their red blood cells, and if this substance is absent, the person acquires a negative Rh factor.

A child at an early stage of pregnancy acquires a protein of this kind, and if it turns out to be in a person with a negative blood type, the immune system tries in every possible way to protect the body from the protein entering the blood, since it perceives it as a foreign substance - this is the answer to the question that This is a Rhesus conflict. Unfortunately, this is exactly the situation faced by an Rh-positive mother, in whose body a fetus with a negative Rh factor develops. Rh conflict is observed much more often during the second pregnancy than during the first.

Etiology

Rh conflict occurs only in situations where a woman’s body already has antibodies that interfere with the proper formation and development of the child.

The following factors can provoke signs of Rh conflict:

• miscarriage that occurred at 6 weeks;
• pathological course of pregnancy;
• spontaneous termination of pregnancy;
• Rh positive blood transfusion;
• bleeding during childbirth, despite the fact that the mother’s blood had contact with the baby’s blood;
• injury during pregnancy;
• abortive termination of pregnancy;
• gestosis.

In some situations, Rh conflict during pregnancy can develop before pregnancy, for example, in the case where blood with a positive Rh factor was mistakenly transfused. Unfortunately, the risk that Rh conflict will develop is quite high, and depends on the following reasons:

• profuse bleeding;
• mother's immune reaction;
• the presence of a conflict in the AVO system.

The likelihood of a Rh conflict occurring during pregnancy does not exceed 5% of cases with timely diagnosis and treatment by a clinician.

The table below indicates the likelihood of encountering this type of problem.

Symptoms

Rhesus conflict during pregnancy, unfortunately, does not have any symptoms, however, some clinicians describe the development of “mirror syndrome”, as a result of which, simultaneously with the activation of signs of “intrauterine catastrophe,” symptoms characteristic of gestosis are observed, namely:

• swelling of the placenta;
• headache;
• nausea, vomiting;
• lethargy, drowsiness.

There is a list of factors that cause danger according to ultrasound diagnostics:

• disruption of uteroplacental blood flow;
• liver enlargement;
• enlarged spleen;
• fetal development abnormalities;
• enlargement of the heart muscle;
• swelling of the subcutaneous tissue and intestinal wall.

Doctors spend quite a lot of time on pregnant women with Rhesus conflict. The thing is that Rh conflict during pregnancy causes unfavorable consequences, the most dangerous of which is hemolytic disease of the fetus. In addition, there is a high probability of spontaneous miscarriage.

Clinicians distinguish the following forms of hemolytic disease of the newborn:

• edematous form - severe;
• anemic form - lethargy, loss of appetite, increase in the size of the liver and spleen;
• icteric form - the appearance of rapidly progressing jaundice 1-2 days after birth, the tissues undergo slight swelling.

Only the doctor decides whether the pregnant woman will be able to carry the child to term or whether she will have to induce premature labor. Therefore, there is no single clinical picture in this case.

Diagnostics

The specialist must carry out the following activities:

• study the patient’s medical history to determine the exact clinical picture;
• prescribe a blood test for anti-Rhesus antibodies;
• order additional tests;
• prescribe injections of anti-Rhesus immunoglobulin.

All pregnant women are required to undergo a blood test to determine their Rh factor. If a pregnant woman has a Rh-negative blood group, the level of antibodies to the Rh factor is determined. The father's Rh factor is also determined using laboratory tests, and if they are negative, the research is completed.

From the 18th week of gestation, the fetal condition is assessed. Methods are divided into groups: invasive and non-invasive.

Non-invasive methods include:

• Ultrasound – performed in each trimester and immediately before delivery, the size of the fetal organs, umbilical cord, thickness of the placenta and the presence of swelling are assessed;
• Dopplerometry - assessment of fetal blood flow speed and heart parameters;
• cardiotocography – assessment of the reaction of the fetal cardiovascular system.

The indication for the use of the following methods is the result of an ultrasound examination, which confirms the presence of severe anemia in the fetus, since intrauterine treatment is appropriate only with such a diagnosis.

There are invasive methods such as:

• amniocentesis - assessment of the severity of hemolysis in relation to the bilirubin content;
• cordocentesis - assessment of the severity of hemolysis, intrauterine blood transfusion to the fetus.

The specialist is obliged to familiarize the patient with the consequences of each of the procedures, and the pregnant woman is obliged to provide written consent to their implementation.

Treatment

Unfortunately, the only effective treatment for Rh conflict during pregnancy is intrauterine blood transfusion to the fetus. This operation has a high risk of negative developments, but with a positive result, the condition of the child in the mother’s body improves significantly, which contributes to the full gestation of the fetus.

Previously, before scientists fully understood the concept of Rh conflict, a different treatment method was used: plasmapheresis, skin transplantation of the spouse to a pregnant woman, and some other methods that turned out to be completely ineffective.

A timely visit to an obstetrician-gynecologist and undergoing the necessary tests will help reduce the risks of complications to a minimum.

Prevention

Prevention of Rh conflict during pregnancy involves the administration of anti-Rhesus hemoglobin D to prevent hemolytic disease.

Immunoglobulin is administered in the following situations:

• after a blood transfusion with positive Rh;
• after placental abruption;
• when injured during pregnancy;
• after a chorionic villus biopsy.

The drug is administered to a pregnant woman at 28 weeks of gestation: it is at this period that there is an increase in the risk of developing Rh conflict in the mother and fetus.

At the moment, experts are developing a special program for the prevention of Rh sensitization during pregnancy. For this purpose, it will be proposed to administer immunoglobulin to mothers with a negative Rh factor in the middle of pregnancy.

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