RH INCOMPATIBILITY (Rh Disease)

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dents; Compiled by Hussen N.(Midwife, Lec
• Rh factor (i.e. rhesus factor) is Proteins
(antigens) occurring only on surface of RBC’s
• Rh + ____ if proteins present (85%)
• Rh – ____ if proteins absent (15%)
• The Rh blood group systems consists of
several antigens(eg D,C, c, E,e)
• D is by far the most common and the only
preventable one

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dents; Compiled by Hussen N.(Midwife, Lec
• Rh factor is made up of a pair of genes,
recessive and dominant genes.
• If both genes are recessives(dd),
• the person’s Rh factor is negative
• If one gene is dominant and the other is
recessive(Dd),
• the person’s Rh factor is positive ( heterozygous Rh
positive)-----60%
• If both genes are dominant (DD),
• the person’s Rh factor is positive ( homozygous Rh
positive)------40%

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dents; Compiled by Hussen N.(Midwife, Lec
 Inheritance of Rh factor

• Most important for pregnancy

• Inheritance is Autosomal Dominant
• The fetus inherits the gene for Rh factor from
his/ her parents (father and mother)
– i.e one gene from the father and the other gene
from the mother.

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• What would be the Rh status of child

– If the father is homozygous positive & mother is

negative?
– If the father is heterozygous positive & mother is
negative?
– If both father & mother are negative?
– If both father & mother are heterozygous
positive?

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Rh Incompatibility

• Incompatibility with respect to D-antigen is

the most cause of serious hemolytic disease of
the fetus and new born
• Rh incompatibility occurs when a women with
Rh-negative blood type conceives a fetus
whose Rh factor is positive.
• Rh incompatibility causes Rh iso-immunization

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 Process of Ab formation (Why Does Rh Status Matter?)

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Rh Isoimmunization may occur by 2
mechanisms:

1. Following fetomaternal hemorrhage between a

mother and an incompatible fetus
2. Following incompatible blood transfusion

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Conditions w/c cause fetomaternal hemorrhage
– Abortion(both induced &spontaneous)
– Ectopic pregnancy
– APH
– Amniocentesis
– Abdominal trauma
– External cephalic version
– Manual removal of placenta
– Twin delivery
– Intrapartum bleeding
– C/S
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 Pathophysiology
• Many cells pass between maternal & fetal
circulation
• Rh antigen causes > response than most
– 0.1 ml blood in most deliveries is enough but
generally not sufficient to activate immune
response
• B lymphocyte clones recognizing foreign RBC
antigen are formed

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dents; Compiled by Hussen N.(Midwife, Lec
 Pathophysiology cont…
• Initial IgM followed by IgG in 2 wks- 6 mths
– The first baby might not be affected

• Memory B lymphocytes activate immune

response in subsequent pregnancy
– (Once produced, maternal antibodies remain
permanent)
• IgG Ab cross placenta and attach to fetal RBC’s
• Cells then sequestered by macrophages in fetal
spleen where they get hemolyzed
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Complications of Rh-isoimmunisation
I. Fetal Effects
• Hemolytic fetal anemia
→when the maternal antibodies cross the
placenta and destroy the Rh-positive fetal red
blood cells anemia results

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• Erythroblastosisfetalis
- to compensate anemia, the fetal bone
marrow and later the extramedullary sites
(liver, spleen &placenta) produce RBCs in a fast
rate.
- These results in large number of nucleated
RBcs seen in the fetal circulation called
erythroblastosisfetalis

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• CHF and tissue hypoxia

→in severe case, the extramedullary

hematopoisis cannot cope with the degree of
destruction of RBCs and result in progressive
anemia w/c eventually leads to congestive
heart failure and tissue hypoxia.

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• Fetal hydrops
→the liver parenchyma is replaced by
hematopoietic tissue (extensive liver
erythropoiesis)
→ Disturbance in Normal hepatic architecture
and function
→ portal hypertension, ascites developed from
obstruction of the portal vein.
• The combination of these causes generalized
edema of the fetus called fetal hydrops,
eventually fetal death occurs.
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II. Neonatal Effects

• Hemolytic anemia
– In the immediate neonatal interval, the primary
problem may relate to anemia and the sequelae
mentioned above.

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• Hyperbilirubinemia/Kernicterus

• The immature (and often compromised) liver,

with its low levels of glucuronyltransferase, is
unable to conjugate the large amounts of
bilirubin.
• This results in a high serum bilirubin level,
with resultant kernicterus (bilirubin deposition
in the basal ganglia).

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10/29/2025 Obstetrics II Lecture note for Midwifery Stu 23
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Management of Iso-immunisation
• On the first prenatal visit, all pregnant women
should be screened for the Rh group.
• Possible outcomes will be either Rh- positive or
negative.
– If the mother is Rh-negative, determine the Rh factor
of the father of the baby.
– If her husband’s Rh factor is negative and the mother
has not had history of blood transfusion, no need of
further action
– If the mother is Rh positive and has not had history of
blood transfusion , there is also no need of further
action
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• If the mother is Rh-negative, determine
indirect comb’s test for antibody screening.
• Possible outcomes of indirect comb’s test will
be either
– Rh-negative with -ve antibody screen (un
sensitized)
– Rh-negative with +ve antibody screen(sensitized)

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Management of un sensitized mother
• Determine indirect comb’ test at 28wks and
36wks.
• If the test is negative:
– Consider antepartum prophylaxis with 300µg of
anti-D at 28wks.
– Repeat the drug at 36 weeks if antibody test
reveals negative
• Unless the father of the baby is known to be
Rh-negative, all Rh-negative mothers should
receive prophylaxis

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dents; Compiled by Hussen N.(Midwife, Lec
• Following delivery, determine the blood group
of the neonate and antibody screening.

– If the neonate is Rh-negative, no further

treatment is needed.
– If the antibody screen is negative, provide 300µg
of anti-D as soon as possible within 72hrs.
– Injection of anti-D is given IM→ deltoid muscle

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• Several circumstances that may occur during
pregnancy mandate administration of RhIgG
to the un sensitized patient as a prophylaxis.
• These includes;
– Abortion
– APH
– Amniocentesis
– External version

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Management of sensitized mother
• This woman needs specialized care with

– Measurements anemia level at regular interval

– amniocentesis for bilirubin level
– serial U/S→ for detections of hydrops and
hyperbilirubinemia

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dents; Compiled by Hussen N.(Midwife, Lec
ABO incompatibility
• It occurs when the mother has O blood group
and fetus with A, B &AB blood group.
• Unlike RH isoimmunization, 40-50% of ABO
incompatibility occur in the first born infant
• The destruction of red cells of the fetus is much
less severe than with Rh incompatibility
• ABO incompatibility is also thought to protect
the fetus from Rh isoimmunization as the
mothers anti-A and anti-B antibodies destroy
fetal red blood cells that leak into the maternal
circulation before Rh sensitization can proceed
to a significant extent.
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