HEMOLYTIC DISEASE OF THE NEWBORN AND FETUS

continues until birth. The most efficient subclasses to

HEMOLYTIC DISEASE OF THE NEWBORN AND FETUS cause red cell lysis are IgG1 and IgG3.
 HDN is the destruction of fetal RBCs and neonate by antibodies 4. Antibody specificity
produced by the mother. o of all the Rh antigens, D is the most immunogenic, the
reason why an Rh negative blood is always given to an Rh
negative female of childbearing potential.
5. Influence of ABO group
o Investigators noted that the incidence of D immunization
is less in mothers with major ABO incompatibility with the
fetus.
o It is because the ABO incompatibility protects the mother
from Rh immunization by the hemolysis in the mother’s
circulation of ABO-incompatible D-positive fetal RBCs
before the D antigen can be recognized by the mother’s
immune system.

PATHOGENESIS:
1. Lysis of the RBCs leading to anemia
Two common causes of HDN: o stimulate the bone marrow to produce RBCs at an
1. Rh incompatibility accelerated rate even to the point that immature
o Less common but severe. RBCs(erythroblasts) are released into the circulation,
2. ABO incompatibility hence it was known as “erythroblastosis fetalis.”
o more common yet less severe. 2. Enlargement of the spleen & liver
o due to extramedullary hematopoiesis.
Rh HDN 3. Hypoproteinemia caused by decreased production of plasma
 The Rh positive firstborn infant of an Rh negative mother is proteins by the liver leading to generalized edema, effusions
unaffected because the mother has not yet been immunized. and ascites, a condition known as hydrops fetalis.
During gestation, and particularly at delivery when the Placenta 4. In newborn infants, unconjugated bilirubin increases and reach
separates from the uterus, variable numbers of fetal RBCs enter levels toxic to infant’s brain and if left untreated may lead to
the maternal circulation. The fetal cells w/c are D positive kernicterus or permanent damage to the brain.
(inherited from the father) immunize the mother and stimulate
the production of anti-D. Once the mother is immunized to the DIAGNOSIS & MANAGEMENT:
D antigen, all subsequent offspring inheriting the D antigen will 1. Serologic testing
be affected. The maternal anti-D crosses the placenta and binds o type-and-antibody screen at the first prenatal visit during
to fetal RBCs leading to hemolysis and eventually anemia. the first trimester.
a. ABO and Rh typing
Factors affecting immunization and severity: b. Antibody screen
1. Antigenic exposure  to detect clinically significant antibodies, IgG
o Fetomaternal hemorrhage during pregnancy can cause antibodies reactive at 37oC and in the antiglobulin
significant increases in maternal antibody titers leading to phase. Enhancement medium used are
increasing severity of HDN. polyethylene glycol(PEG) or low ionic strength
o In addition, interventions such as amniocentesis and saline(LISS).
chorionic villus sampling as well as trauma to the abdomen c. Antibody identification
may increase the risk of fetomaternal hemorrhage. As d. Paternal phenotype
little as 1 mL can elicit an immune response. e. Fetal DNA testing
2. Host factors f. Antibody titer
o the ability of the individual to produce anti-D is dependent 2. Color doppler MCA-PSV – non-invasive
on complex genetic factors. The risk of immunization in 3. Amniocentesis and Cordocentesis
Rh-negative mother after an Rh positive pregnancy if Rh o usually done at 18-20 weeks gestation.
immune globulin is not administered, is only about 9%.  Amniocentesis – transabdominal puncture of the
3. Immunoglobulin class amniotic sac using a needle and syringe in order to
o the only immunoglobulin that can cross the placenta is IgG collect amniotic fluid.
and active transport begins in the 2nd trimester and

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HEMOLYTIC DISEASE OF THE NEWBORN AND FETUS
 Cordocentesis - a method of fetal blood sample 6. Phototherapy
collection in w/c a needle is inserted into the o ultraviolet light is used to change unconjugated bilirubin to
umbilical vessel with the aid of a high resolution biliverdin
ultrasound with color Doppler enhancement. 7. Intravenous IG – used to treat hyperbilirubinemia of the
o the concentration of bilirubin pigment in the amniotic fluid newborn.
is determined while hemoglobin, hematocrit, blood type, SEROLOGIC TESTING OF THE NEWBORN INFANT
antigen phenotype and DAT are tested from fetal blood 1. ABO grouping
sample obtained from cordocentesis. 2. Rh typing
o The amniotic fluid is subjected to a spectrophotometric 3. DAT
scan at steadily increasing wavelengths so that the change 4. Elution – performed on eluate of infants with a positive DAT.
in optical density can be calculated. This is then plotted on
a Liley graph according to gestational age. The optical NEWBORN TRANSFUSIONS:
density of the amniotic fluid is high in the 2nd trimester and  a newborn infant may receive small aliquot transfusions or
steadily decreases until delivery. exchange transfusions or both.
Exchange transfusion- use of whole blood or equivalent to replace
the neonate’s circulating blood.

Objectives of exchange transfusion:

1. To remove high levels of unconjugated bilirubin thus preventing
kernicterus.
2. Removal of part of circulating maternal antibody.
3. Removal of sensitized RBCs.
4. Replacement of incompatible RBCs with compatible RBCs.
5. Suppression of erythropoiesis.

SELECTION OF BLOOD:
1. Group O, Rh negative RBCs for both intrauterine transfusion
and neonatal transfusion.
2. Cytomegalovirus negative
3. The hematocrit level of the RBCs should be greater than 70% for
o Values in Zone I – mild or no disease; do not require intrauterine transfusion.
intervention 4. For exchange transfusion, RBCs from O whole blood and
o Values in Zone II – moderate disease that may require plasma from a type AB.
intervention. 5. Blood is irradiated to prevent graft-versus-host disease.
o Values in Zone III – severe & often life-threatening 6. Does not contain hemoglobin S.
hemolysis and require urgent intervention. 7. Less than 7 days from collection.
4. Intrauterine transfusion 8. Kell negative
o usually done when one or more of the ff.
conditions exists: Rh Ig (Rh immune globulin)
a. Amniotic fluid OD 450 nm results are high in Zone II
 a concentrated purified anti-Rho prepared from human serum
or Zone III.
that is given to Rh negative mothers after they have given birth
b. Cordocentesis blood sample has hemoglobin level less
to an Rh positive baby.
than 10 g/dL.
 this is to prevent the mother from immunization to D antigen.
c. Fetal hydrops is noted on ultrasound examination.
Mechanism of action:
o Intrauterine transfusion can be performed intraperitoneally
 The RhIg attaches to fetal RBCs in the maternal circulation. The
by injecting RBCs into the fetal peritoneal cavity where it is
antibody-coated cells are then removed by macrophages in the
absorbed into the circulation or by cordocentesis, where
maternal spleen, therefore preventing alloimmunization.
donor’s blood is injected directly into the umbilical vein.
Indications:
o Once started, the procedure is repeated every 2 to 4 weeks
 Antenatal – It should be given early in the 3rd trimester or about
until 34 to 36th weeks gestation or until the lungs are mature.
28 weeks of gestation.
5. Early delivery
 Postpartum – RhIg should be administered within 72 hours after
o to interrupt the transport of maternal antibodies to the fetus
delivery. Even if more than 72 hours have elapsed, it should still
be given.

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HEMOLYTIC DISEASE OF THE NEWBORN AND FETUS
Dose and Administration
 1 regular-dose vial = 300 ug = can protect against 15 mL packed
RBCs or 30 mL whole blood
o administered either intramuscularly or intravenously.
Procedure:
1. Rosette technique – a screening test for massive fetomaternal
hemorrhage using maternal sample obtained within one hour of
delivery.
2. If positive for rosette technique, perform the Kleihauer-Betke
test.
o Kleihauer-Betke test – quantitation of the hemorrhage
using flow cytometry. A maternal blood smear is treated
with acid and then stained with counterstain. Fetal cells
contain fetal hemoglobin(Hb F)that is resistant to acid and
will remain pink, while the maternal cells will appear ghosts.
2000 cells are counted, the percentage of fetal cells is
determined. The volume of fetal hemorrhage is calculated
as follows:

Volume of fetomaternal = No. of fetal cells X Maternal blood vol.

hemorrhage Number of maternal cells

o the calculated volume is then divided by 30 to determine the

number of required vials of [Link] percentage of fetal
cells is multiplied by 50 to get the volume of fetal
hemorrhage(mL). Since Kleihauer-Betke is an estimate, 1
vial is added to the calculated answer.

ABO HDN
 maternal ABO IgG antibodies cross the placenta and attach to
ABO incompatible antigens of the fetal RBCs. However,
destruction of fetal RBCs leading to severe anemia is extremely
rare. The disease is manifested by the onset of
hyperbilirubinemia and jaundice within 12 to 48 hours of birth.
Increased bilirubin can be treated with phototherapy and severe
cases requiring exchange transfusion are extremely rare.
Factors affecting incidence and severity
1. Tetanus toxoid administration
2. Helminth parasite infection during pregnancy.
 ABO HDN is less severe than Rh HDN due to poor development
of ABO antigens on fetal red cells.

Laboratory findings:
1. Microspherocytes & increased RBC fragility in the infant.
2. Increased bilirubin
o detection of ABO HDN is best done after birth.

Postnatal diagnosis:
 No single serologic test is diagnostic for ABO HDN.
 DAT – most important diagnostic test especially done on cord
or neonatal RBCs.
 If neonatal infant develops jaundice, ABO, Rh and DAT results
can be assessed.

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