Why does Rh conflict occur during the first or second pregnancy?

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Author of the article: Ekaterina Sergeevna Churaeva

Practicing obstetrician-gynecologist, ultrasound diagnostics doctor

Women have heard that during pregnancy there is a Rh conflict if the child’s father has different blood.

Most people know that this is a dangerous condition, but few understand why it occurs. The lack of necessary information about what Rh conflict is often leads to unnecessary worries for the pregnant woman.

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.

The 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.

Rh incompatibility

Rhesus conflict appears only under the following conditions:

• the woman has Rh-negative blood (Rh-);
• the fetus inherited the father's Rh+ blood.

Important! Rh sensitization occurs more often if partners have compatible or same blood type.

Since the majority of the population (85%) has Rh+, the likelihood of developing a Rh conflict is too small - only 0.8%. However, much attention is paid to Rh sensitization, since the immunological conflict is fraught with serious consequences for the fetus.

The protein present on the surface of the red blood cells of Rh-positive blood is recognized by the woman’s immune cells as foreign and triggers the immune system to fight it. When a woman’s immune system first encounters Rh-positive red blood cells, it synthesizes specific IgM antibodies. During the first pregnancy, fairly large protein formations enter the fetal blood only in small quantities, so the probability of immunological incompatibility is only 10%. However, with subsequent pregnancies, the chances of developing Rh incompatibility between mother and child increase significantly.

Upon repeated contact, smaller IgG antibodies are produced, which easily penetrate the placenta into the fetal blood, activating the process of hemolysis (destruction of red blood cells) and accumulation of bilirubin (a substance resulting from the breakdown of hemoglobin).

What is this – Rhesus conflict?

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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.

Does it show any symptoms?

Having learned how dangerous a Rh conflict is for a baby, the expectant mother wants to promptly notice developing deviations. But visible symptoms of Rh conflict do not appear during pregnancy. Despite the fact that immune complexes are actively produced in the body, the woman does not feel unwell.

Signs of fetal Rh conflict on ultrasound:

• splenomegaly;
• liver enlargement;
• expansion of the umbilical vein;
• bloating;
• thickening of the placenta.

The woman is diagnosed with polyhydramnios, and a blood test shows the presence of characteristic immune complexes.

During the second and subsequent pregnancies, when antibody titers are high, the woman develops symptoms of gestosis:

• swelling;
• blood pressure surges;
• dizziness with a sudden change in body position.

A woman should not rely on her well-being during pregnancy to determine the Rh conflict. Most expectant mothers feel well, but note that the intrauterine activity of the fetus is reduced. If there is a risk of developing group or rhesus incompatibility, you need to undergo a timely examination. This will allow you to bear a healthy baby.

Signs of gestosis

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 process of expulsion of the fetus, contact with its blood cannot be avoided by a woman)
• C-section
• ectopic pregnancy
• artificial termination of pregnancy (regardless of the method, both surgical and medical abortion are equally dangerous)
• spontaneous miscarriage
• premature placental abruption
• 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. Preeclampsia during pregnancy, diabetes mellitus, ARVI and influenza damage the villi, and, consequently, the chorionic 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.

Antibodies during pregnancy: reasons for their appearance

Contents
The occurrence of an immunological conflict between mother and child is due to incompatibility in Rhesus or blood group and the production of specific antibodies in the female body.

AB0 incompatibility

Group incompatibility occurs in cases where:

• the mother has group I, and the partner has group IV (incompatibility always occurs);
• the mother has group II, and the father has group IV (probability of incompatibility - 66%);
• the mother has group III, and the father has group IV (probability - 66%);
• the mother has group I, and the father has group II or III (probability of incompatibility - 50%);
• the mother has group II, and the father has group III (probability - 50%);
• the mother has group III, and the father has group II (probability - 25%).

In a woman’s blood there are isohemagglutinins to erythrocyte antigens of another group. The presence of these substances suggests the occurrence of incompatibility. With other combinations of the AB0 system, incompatibility does not arise in future parents.

Sometimes antibodies appear even before pregnancy. Their production is activated by transfusion of blood or donor serum that is incompatible with the ABO (group) system, or vaccination. AB0 incompatibility of partners can occur if the history contains the following data:

• recurrent miscarriage;
• prematurity, artificial abortion in later stages;
• intrauterine fetal death;
• caesarean section and complicated childbirth (manual separation of the placenta, premature detachment).

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 reasons for regurgitation in a newborn), 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.

What are the consequences for the child?

The conflict of Rh factors is accompanied by hemolysis of red blood cells. Red blood cells are responsible for transporting nutrients. When destroyed, the fetus appears:

• oxygen starvation;
• developmental delay due to lack of nutrients;
• violation of organ formation.

In severe cases, the child dies, and the pregnancy stalls or a miscarriage occurs. Why you can’t get pregnant – read here.

The consequences of Rhesus conflict for the child persist after birth. Maternal immune complexes circulate in the baby’s bloodstream for some time, which is why hemolytic disease of the newborn develops. Hemolysis can provoke various complications.

• bilirubin level increases;
• hypoxia develops (due to the destruction of red blood cells);
• swelling appears.

The heart, liver, kidneys and nervous tissue suffer most from increased accumulation of bilirubin.

The consequences of Rh conflict during pregnancy are severe for the baby. With severe hemolysis, the newborn may die from hypoxia or internal edema. There are 3 forms of hemolytic lesions in a newborn:

1. Edema. Occurs when immune complexes begin to be synthesized early. Happens with frequent pregnancies. With pathology, the permeability of the vascular wall is increased and fluid and protein compounds leak from the bloodstream into the surrounding tissues. The accumulation of liquid secretions leads to swelling of the internal organs.
2. Anemic. A decrease in red blood cells leads to a deterioration in the supply of oxygen to tissues. The baby has pale skin and develops tachycardia. The child is lethargic and sucks poorly.
3. Jaundice. Due to increased bilirubin, the skin turns yellow and hepatosplenomegaly appears. In severe cases, bilirubin encephalopathy develops. Damage to the central nervous system is accompanied by increased muscle tone and suppressed reflexes, and convulsions are possible.

Swelling of internal organs is considered the most dangerous form. Due to edema, the liver, spleen and intestines become enlarged. Babies die during childbirth or a few hours after birth. With a moderate increase in bilirubin, the prognosis is favorable: jaundice disappears, and the liver and spleen gradually return to normal.

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 to have 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 calculator for calculating the gestational age) 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.

Prevention

In the antenatal clinic, the group of not only the mother, but also the father is determined. When a possible incompatibility is identified, the woman is told how the child’s Rh conflict manifests itself and whether there is a need to take preventive measures.

Prevention of Rh conflict during pregnancy is as follows:

1. Antibody testing. The first test is taken when a woman registers for pregnancy. The study is repeated at 18-20 weeks, and then the analysis is done monthly until 32 weeks. The analysis is carried out every 2 weeks before the baby is born.
2. Administration of anti-Rhesus immunoglobulin. The serum destroys the red blood cells that have entered the bloodstream from the child and the synthesis of antibodies stops. The injection is given at 28 weeks and again (if indicated) at 32 weeks.
3. Hospital treatment. If a Rhesus conflict is detected, the woman is sent for preservation at any stage of pregnancy. In an inpatient setting, the pregnant woman is examined and therapy is selected to reduce the risk of fetal development disorders.

Immediately after delivery, the newborn’s group and Rh. If they differ from the maternal ones, then to prevent Rh incompatibility during re-pregnancy, the woman is given an anti-Rh vaccine within 3 days after birth, which destroys the fetal red blood cells remaining in the bloodstream. This will prevent the production of immune complexes and reduce the likelihood of Rh conflict during a subsequent pregnancy. Similar prophylaxis is done after an abortion or miscarriage.

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

• Ultrasound

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).

Diagnostics

Testing for RK begins with determining the Rh factor and blood type. If the Rh affiliation of the expectant mother is revealed to be “-“, then a similar procedure is indicated for the baby’s father. If the father’s result shows Rh(+), then control over the progress of the pregnancy is significantly enhanced.

It is preferable if such a procedure is carried out in advance, at the stage of planning the first child, or in the early stages of gestation.

It is possible to determine Rh mismatch exclusively in a laboratory, by analyzing the presence and level of anti-Rh antibodies. If the problem situation is confirmed, it is important to record the class of immunoglobulins IgM and IgG secreted by the female body.

The frequency of such research is determined by gestational age:

• up to the 20th week, it is indicated every 28 days, then it is advisable to be observed under the supervision of doctors at the perinatal center - a specialized wide-profile medical institution dealing with pregnancy management;
• at 32-35 weeks of gestation, the intensity of blood testing for antibodies increases to twice a month, then after 35 weeks the analysis is performed every week.

Such a study records the fact of the presence of Rh conflict, but a detailed picture of the current condition of the fetus is not visible, and there is no direct relationship between the level of anti-Rh antibodies and the degree of damage to the fetus.
Dynamic monitoring of fetal growth is carried out using ultrasound; in the gestation interval from 18 to 36 weeks, such a study is carried out four times, the final fifth immediately before birth.

The results of an ultrasound examination make it possible to make predictions about the development of RK, to understand how seriously the pathological process has affected the fetus, and it becomes possible to evaluate:

• size of the placenta;
• location (position) of the baby;
• degree of swelling;
• the size of the future baby’s tummy, certain organs (spleen, liver).

With the help of ultrasound, disorders associated with RK are detected:

• varicose veins of the umbilical vein;
• increased volume of amniotic fluid (amniotic fluid);
• abdominal ascites.

An obstetrician-gynecologist, dynamic monitoring of the progress of pregnancy, in addition to ultrasound of the fetus, is helped by other non-invasive techniques:

• CTG - cardiotocography helps to assess the current state of the cardiovascular system of the unborn baby, the severity of hypoxic-ischemic damage to the central nervous system;
• FCG - phonocardiography analyzes the cardiac activity of the fetus using ultrasonic waves;
• ECG - testing the bioelectric potential of the cardiac system;
• Dopplerometry - evaluates the intensity of blood movement in the vessels.

Prenatal diagnosis of RK:

• Biochemical examination of amniotic fluid - mainly prescribed at gestational ages of 34-36 weeks, reveals the level (optical density) of bilirubin in the amniotic fluid. It is necessary to take into account the risk of negative nuances of such a procedure, among possible pathological conditions are leakage, premature rupture of amniotic fluid, bleeding, infection;
• cord blood analysis - diagnoses the severity of anemia in RC, allows you to determine a number of necessary hematological characteristics;

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. 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.

Conflict: who is to blame?

Rh sensitization (Rh conflict) is the production in the body of a Rh-negative mother of antibodies to the antigens of the Rh system of the fetus, that is, to a protein located on the child’s red blood cells.

A problem can only arise when the expectant mother is Rh negative, that is, there is no Rh factor in her blood, and the future father is Rh positive (the Rh factor is detected in his blood), then the baby can inherit Rh from him - accessory. Thus, the baby, like his dad, will be Rh-positive (the Rh factor will form in his blood). The formation of the baby's Rh status is completed by the 8th week of pregnancy.

It turns out that the expectant mother is carrying her baby, who differs from her in the presence of the Rh factor in her blood, while she herself does not have this Rh factor. The mother's immune system recognizes the foreign protein - the baby's Rh factor - and begins to fight it. The fight against the “enemy” is carried out as follows: the mother’s body secretes Rh antibodies, which begin to attack the red blood cells of the fetus.

The results of this struggle may be very disastrous. Red blood cells (erythrocytes) in the fetal blood are destroyed and die. As a result, the baby’s total number of red blood cells decreases and he develops anemia (anemia). As the fetal red blood cells break down, they release bilirubin, a substance that is a toxin for the baby. Circulating in the baby’s blood, bilirubin poisons it and paralyzes the functioning of the vital organs of the child’s body. This condition is called hemolytic disease of the fetus. Without specific and timely treatment, the fetus may die, so suspicion of the development of Rh conflict is an indication for hospitalization in a specialized clinic.

It is important to understand that such serious complications of pregnancy as Rh conflict and hemolytic disease of the baby occur only in one case - if the unborn baby has an Rh negative mother and an Rh positive father. But even with an Rh-positive dad, it is very possible (up to 50% probability) that the baby will be Rh-negative, like his mother, and he will not face any complications!

In all other cases:

• father and mother are Rh positive,
• father and mother are Rh negative,
• the father is Rh negative, the mother is Rh positive - the development of Rh conflict and hemolytic disease of the fetus is impossible.

It must be said that even if a Rh-positive child develops, a Rh-negative mother will not necessarily develop a Rh conflict, that is, in this case, antibodies to the fetal red blood cells will not always form in the mother’s body. For an Rh negative woman who becomes pregnant for the first time in her life, the risk of developing an Rh conflict is only 10%. In the absence of complications (antibody formation) in the first pregnancy, the same degree of risk (10%) remains in the next pregnancy.

Even if Rh antibodies are found in the blood of a pregnant woman, this does not mean a 100% risk of disease in the fetus, because the baby has so many protectors. There are special biological filters in the blood of the expectant mother, in the waters surrounding the baby, and, of course, in the main organ of pregnancy - the placenta. These filters block Rh antibodies, trapping them and preventing them from passing further to the baby. However, the effectiveness of such protection largely depends on the general health of the expectant mother and the course of pregnancy. Unfortunately, chronic diseases of a pregnant woman (primarily infections) and complications of pregnancy (threat of miscarriage, toxicosis, partial placental abruption) reduce the effectiveness of protection and increase the risk of developing Rh conflict. Normally, during pregnancy, a small amount of fetal blood enters the mother’s bloodstream, insufficient for sensitization, however, in the presence of bleeding, arterial hypertension, during obstetric manipulations and intrauterine interventions, the volume of fetal blood entering the woman’s bloodstream increases. Thus, carrying out invasive studies during pregnancy (techniques including micropuncture of the amniotic sac and sampling of fetal cells, umbilical cord, placenta of fetal fluid) increases the risk of developing Rh conflict and hemolytic disease of the fetus. Also, a large volume of blood enters the woman’s bloodstream during artificial or spontaneous abortion and caesarean section.

Rh antibodies in a woman whose blood does not have the Rh factor can be formed during pregnancy termination: spontaneous abortion (miscarriage), medical abortion and the development of an ectopic pregnancy. The incidence of antibodies in various types of abortion is about 3%. These antibodies circulate in a woman’s blood throughout her life and can cause Rh conflict during the next pregnancy, even after many years. As a result, the next pregnancy may end in hemolytic disease of the fetus or miscarriage.

All expectant mothers should remember the importance of maintaining their first pregnancy with a negative Rh factor. When considering whether to terminate your first pregnancy, think about the possible complications, the severity of hemolytic disease, the complexity of its treatment, miscarriage in subsequent pregnancies, and the high risk of childlessness! Perhaps this will be a strong argument in favor of continuing the pregnancy, will help maintain the health of the unborn baby and will give you happiness.

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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-Rhesus 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.

Antibody titer determination

Pregnant women with Rh- are determined for the presence of specific proteins during their initial visit to the gynecologist. Antibody titer is the serum dilution ratio at which the blood is able to cope with Rh-positive red blood cells. The amount of antibodies may change (increase/decrease) during pregnancy. The amount of specific proteins is monitored once a month until 28 weeks, then twice a month and every 7 days after 36 weeks.

It is not possible to predict the development of HDN in case of group blood incompatibility based on the titer of specific proteins.

Non-detection of antibodies in the analysis.

If antibodies are not detected during the first test, Rh sensitization can be avoided by administering anti-Rh immunoglobulin. This drug stops the synthesis of antibodies in the mother's body.

Antibodies detected.

In this case, their identification is important. Only the presence of IgG can cause hemolytic pathology of the fetus. The risk of developing TTH depends on the indicator:

• a titer of 1:4 indicates the beginning of the development of an immunological reaction; usually a similar ratio is observed during the first pregnancy;
• titer 1:16 is an indication for amniocentesis (puncture of amniotic fluid and its examination to identify intrauterine pathology), in 10% of cases indicates a high risk of intrauterine death;
• a titer of 1:64 or a 4-fold increase during a subsequent study requires early delivery.

The IgG titer, in combination with medical history, makes it possible to predict the development of tension-type headache in 60% of cases, and fetal ultrasound and amniocentesis increase the diagnostic accuracy to 90%.

The presence of antibodies in the mother does not at all mean the need to abandon pregnancy. Early registration of a pregnant woman, a blood test for antibodies, regular ultrasound of the fetus and vaccination with immunoglobulin will help maintain the pregnancy and give birth to a healthy child on time.

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.

Author:

Sozinova Anna Vladimirovna obstetrician-gynecologist

How dangerous it is for mother and child

Rh conflict is not dangerous for the mother herself, since it is caused by her antibodies that fight a foreign object - the fetus. Accordingly, the mother has no symptoms of conflict, and there are no changes in her well-being that would cause the pregnant woman to suspect that something is wrong with the baby. Everything is not so rosy for the future baby, so it is important to know how Rh conflict manifests itself in a child.

When a conflict arises, the mother's antibodies penetrate the placenta and destroy the red blood cells (special red cells in the blood that carry oxygen) of the fetus. As a result, the baby may develop a state of anemia (anemia), which can lead to hemolytic disease and consequences of varying severity.

Consequences of Rh conflict for a child:

• State of anemia (anemia).

The initial stage of hemolytic disease. Characterized by a lack of oxygen in the fetus.

• Jaundice of the newborn and fetus.

The protective antibodies of the expectant mother destroy the fetal red blood cells, as a result of the breakdown of which bilirubin is formed. The baby's kidneys and liver are still immature and cannot adequately cope with the removal of this substance.

The most dangerous form of this disease for the baby, kernicterus, is expressed in the accumulation of bilirubin in the cells of the nervous system and the child’s brain, which can lead to severe neurological pathologies and even death. The good news is that this is an extremely rare variant of the disease, and practically never occurs in the practice of modern gynecology.

• Hydrops of the fetus and newborn.

As a result of poor oxygen supply to the internal organs of the fetus, the liver and spleen increase in volume, and because of this, the baby’s tummy increases and swells. On an ultrasound in such cases, you can see that the baby is not lying in the fetal position with the legs pressed to the chest, but in the Buddha position, when the legs are spread apart due to a swollen tummy.

There is also swelling in other parts of the body.

Principles of therapy

Specific therapy for Rh conflict has not been developed. Until recently, methods such as plasmapheresis and hemosorption were practiced, but they were found to be ineffective. There are no medications that can change the level of antibodies in the mother's blood or reduce the likelihood of developing HDP.

The only method to compensate for severe anemia in the fetus is intrauterine blood transfusion. The manipulation is carried out during cordocentesis. After receiving the material, the necessary laboratory tests are carried out, and the volume of red blood cells for transfusion is determined. Red blood cells of 0 (I) blood group Rh- are introduced. After completion of the blood transfusion, a control blood sample is taken and the necessary parameters are re-determined.

If necessary, the procedure is repeated until the 34th week of pregnancy. Next, the issue of possible delivery is decided.

Content

• Rh factor - what is it?

• Inheritance of system D antigen

• Probability of developing Rh conflict during pregnancy: table
• Causes
• 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?

How to avoid the appearance of Rh antibodies

Family planning plays an important role in the prevention of Rh sensitization. A guarantee of the birth of a healthy child in an Rh-negative woman (in the absence of previous sensitization during blood transfusion) is the continuation of the first pregnancy. For specific prevention, a drug is used - anti-Rhesus immunoglobulin. This drug is administered intramuscularly once after childbirth if a Rh-positive child is born; after artificial or spontaneous termination of pregnancy, after surgery performed in connection with an ectopic pregnancy. It should be remembered that the drug must be administered no later than 48 hours after birth (preferably within the first two hours), and in the case of artificial termination of pregnancy or ectopic pregnancy - immediately after the end of the operation. If the timing of administration is not observed, the effect of the drug will be ineffective.

If you have a negative Rh, and the unborn baby is positive, or if the father’s Rh is unknown, there is no way to establish it, then if there are no antibodies until the end of pregnancy, you should take care that, if necessary, if the child is determined to have a positive Rh, there are there was anti-Rhesus immunoglobulin. To do this, it is advisable to find out in advance whether the maternity hospital you have chosen is provided with this drug. If immunoglobulin is not available, you must purchase it in advance.

A program for the prevention of Rh sensitization during pregnancy is currently being developed. To achieve this, it is proposed to administer anti-Rh immunoglobulin to Rh-negative mothers who do not have antibodies detected in the middle of pregnancy.

Rh conflict during pregnancy occurs as a result of blood incompatibility according to the Rh (Rh) system. 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.

The pregnancy of an Rh negative woman whose fetus is Rh positive results in the mother's immune system producing antibodies to the baby's red blood cells.

Subsequent pregnancies after conflict

Each new pregnancy will differ in the severity of complications. In this case, the conflict will become more difficult. If a woman is pregnant for the first time, in very rare cases a Rhesus conflict occurs. Typically, the meeting of maternal antibodies with fetal red blood cells occurs in the eighth week. But in this case, antibodies are produced slowly in small quantities and do not have time to penetrate to the child.

If a woman’s body was already familiar with foreign antigens, then during the second pregnancy the antibodies will behave more aggressively. In the fetal blood, red blood cells die, the main function of which is to transport oxygen and hemoglobin. The more red blood cells died, the more severe the consequences for the brain and other organs. They begin to fight hypoxia, as a result of which they increase in size.

At the time of the third pregnancy, a large number of antibodies accumulate in the woman’s body. It becomes more difficult to fight them during Rhesus conflict, even if all treatment methods are strengthened. The outcome in this case is rarely successful.

Preparation and analysis itself

Analysis for hemolysins and antibody titers may show false indicators if you do not properly prepare for the procedure. All women with a negative Rh factor undergo such an analysis on a mandatory basis.

The procedure is performed once in the first trimester in the eighth week. In the second trimester, two tests are already performed. To get the results as close as possible to real ones, it is recommended to start preparing two to three days before the test.

We are talking about normalizing the diet, avoiding fatty, spicy and fried foods. It is forbidden to drink caffeinated drinks and soda with sugar. On the eve of the test, you should not perform procedures related to physiotherapy. Some drugs can change the parameters suggested in the results, so it is important to inform your doctor about taking them in advance.

Blood donation is performed in the morning after a preliminary eight-hour fast. A vein in the elbow is used for sampling. It is important to take an analysis for the Rh factor on a monthly basis until the 32nd week arrives in the case of a combination of negative maternal Rh and positive paternal Rh.

If the antibody titer shows an increase, then there is a risk of the fetus developing various pathologies. Everything can be so serious that termination of pregnancy is indicated. If tests demonstrate lgM antibodies, then we are talking about the development of a disease caused by an infection. The presence of IgG indicates that the woman encountered an infection even before the moment of conception, which means that the child is not in danger.

Symptoms in women

There are no specific manifestations of Rh conflict. The expectant mother does not notice any changes in her condition. The woman’s well-being is not affected. Without laboratory diagnostics and ultrasound, it is impossible to determine pathology based on clinical symptoms alone.

Some experts talk about the existence of “mirror syndrome”. There is an opinion that with an increase in antibodies in the blood, a woman experiences characteristic symptoms of gestosis as a sign of a violation of the body’s adaptation to pregnancy. There is the appearance of edema, increased blood pressure, and deterioration in general condition. Currently, the connection of these signs with Rh conflict has not been proven, so you should not focus on them.

Preparing for the procedure

Rh-negative pregnant women should definitely be tested. The procedure is carried out three times: the first time is done in the 1st trimester, and the second and third time in the 2nd trimester.

If parents have different Rhesus, it is necessary to donate blood for Rh conflict every month until 32 weeks.

In order for the tests to be reliable, it is recommended that 3 days before the procedure you follow a diet in which you need to exclude:

• fat;
• roast;
• sweet;
• spicy;
• carbonated drinks;
• coffee.

If any physiotherapeutic procedures were performed, they were excluded the day before the study. Taking medications can also affect the result, so the doctor must know what medications the patient is currently being treated with.

The test is taken in the morning on an empty stomach. Blood is taken from a vein located in the elbow joint.

Symptoms of Rh factor conflict during pregnancy

Rhesus conflict is a very complex phenomenon, so it is extremely difficult to track the symptoms. The conflict is determined only through ultrasound.

Signs of this violation:

• a pregnant woman experiences swelling in all parts of the body, which is explained by the accumulation of fluid;
• the study showed a significant increase in fetal size;
• the abnormal size of the fetal abdomen is visible, which is why the legs are moved to the side;
• the liver and spleen suffer, which leads to their enlargement;
• swelling of the placenta is observed.

Reasons leading to conflict

Most pregnant women (about 75%) have a specific protein in their blood - Rh antigen. It is located in red blood cells and determines the blood as positive. Negative Rh during pregnancy is determined in the remaining 15% of women.

If both parents have a Rh negative blood group, then pregnancy will occur without complications.

In this case, the child will not have Rh factor in his blood. The pathological process develops when the fetus inherits Rh positive from the father, and the mother does not have the Rh factor in her blood. In this situation, the pregnant woman’s immune system perceives the red blood cells of the developing organism as foreign material and begins to fight it. In this case, the woman produces specific antibodies.

For the first time, the meeting of opposite Rh factors occurs at the uterus-placenta level. During the first pregnancy, the antibodies of the female body are large and cannot penetrate to the child. Accordingly, they do no harm. When subsequent pregnancies occur, the power and strength of the antibodies produced increases, and their size decreases.

Therefore, they easily penetrate the placenta and begin their destructive activities. In this case, the child’s red blood cells disintegrate, and hemolytic disease develops. The disease manifests itself in the child after birth.

Hemolytic disease of the fetus and newborn

Passing through the hematoplacental barrier and penetrating the fetal bloodstream, Rh+ antibodies enter into a specific reaction with fetal antigens located on red blood cells. As a result of all these actions, hemolysis develops - the destruction of red blood cells, and a chain of pathological reactions is launched:

• Massive hemolysis leads to a decrease in the number of red blood cells and the development of anemia.
• Anemia provokes fetal hypoxia.
• The constant death of red blood cells forces the fetal liver and spleen to work harder, as a result of which these organs increase in size.
• The load on the kidneys increases, which leads to their failure up to the complete cessation of their function.
• There is damage to fetal brain cells.

Hemolytic disease makes itself felt in the second half of pregnancy. Pathology is detected by ultrasound. The progression of the disease leads to the formation of severe pathologies in the fetus and the birth of a sick child. If the liver, kidneys and other internal organs cannot cope with the load, fetal death occurs at any stage of pregnancy.

Quite often, Rh conflict appears after the birth of a child. This condition is called hemolytic disease of the newborn (HDN). The symptoms are similar to HDP, since the initial symptoms of the pathology are noted during the period of intrauterine development.

Forms of hemolytic disease (HD):

Anemic form

The mildest variant of headache. With this form it is noted:

• decrease in the level of red blood cells with the development of anemia and concomitant fetal hypoxia;
• slight enlargement of the liver and spleen.

During the first week of the baby's life, the skin becomes pale. The general condition of the baby is not affected. Anemia can be corrected quite well. In the future, this form of hypertension has virtually no effect on the child’s development.

Jaundice form

Main symptoms:

• anemia;
• early jaundice of a newborn (before the 2nd day of life);
• enlarged liver and spleen.

In utero this form of pathology is practically not expressed in any way. All major changes occur after the birth of the child. Jaundice indicates the rapid breakdown of hemoglobin and an increase in the product of its destruction - bilirubin - in the blood. The baby's condition is deteriorating, and neurological symptoms are noted. Treatment is carried out in a specialized department or in intensive care.

Edema form

The most severe variant of headache. The first symptoms are observed during the period of intrauterine development. Massive hemolysis of red blood cells leads not only to anemia, but is also accompanied by swelling of all tissues. The child is born in an extremely serious condition with dysfunction of vital organs. The prognosis is unfavorable, but under certain conditions it is possible to save the child’s life. Often the edematous form leads to early termination of pregnancy.

The presence of group antibodies during pregnancy and the risk of Rh conflict

A blood test for antibodies during pregnancy, the interpretation of which is carried out by the doctor caring for the woman, is considered mandatory in the following cases:

• habitual miscarriage;
• presence of diseases of the cardiovascular system;
• constant headache;
• thrombocytopenia;
• the presence of renal or hepatic pathology.

Blood is donated to determine the levels of antibodies to cardiolipin and phosphatidylserine. A significant amount of antibodies does not directly confirm the development of APS. The doctor takes into account the severity of clinical signs and medical history.

With values:

• 1:16 amniotic fluid is punctured to collect amniotic fluid. Based on the level of immunoglobulins in the water, the doctor determines the condition of the fetus: if the antibody level is above 0.16, the development of HDN is diagnosed; above 0.7, possible fetal death. The procedure is called amniocentesis and is prescribed no earlier than 33 weeks of pregnancy.
• 1:32 shows the cordocentesis procedure. Using the method of puncture of the umbilical cord vessels, fetal blood is collected and sent for analysis.

How does pathology occur?

In the case when the mother does not have Rhesus, her body reacts to it as a foreign protein, producing appropriate antibodies. This reaction is designed to protect the woman’s internal environment from the penetration of genetically foreign material. A variety of antibodies are produced in response to any foreign antigen.

Normally, the blood of the mother and fetus practically does not mix during pregnancy, so Rh incompatibility usually does not occur during the first pregnancy. However, such a possibility still exists if bearing a child is accompanied by pathology of the placenta and increased permeability of its blood vessels.

How do Rh-positive red blood cells enter the blood of an Rh-negative patient:

• during pregnancy, especially if it is accompanied by gestosis, threat of miscarriage or serious illness of the woman; in this case, the integrity of the placental vessels is disrupted, and the fetal blood mixes with the mother’s blood;
• with amniocentesis, cordocentesis or chorionic villus biopsy - diagnostic procedures performed during pregnancy;
• with premature placental abruption, its manual separation, as well as during cesarean section;
• as a result of miscarriage, induced abortion, surgery for ectopic pregnancy;
• in case of Rh-positive blood transfusion.

In response to the first entry of a foreign protein into a woman’s body, IgM class antibodies are synthesized. Their molecule is large in size and does not penetrate into the bloodstream of the fetus, so most often there are no negative consequences for the child during the first pregnancy. There was a slight increase in the incidence of preterm birth.

A second pregnancy with negative Rh in the mother is accompanied by repeated contact of her body with the positive Rh factor of the fetus. In this case, a large number of much smaller IgG antibodies are quickly produced. They easily penetrate the blood vessels of the placenta and cause hemolytic disease in the child.

Antibodies in Rh negative pregnancy bind to the Rh antigen on the surface of the fetal red blood cells. In this case, blood cells are destroyed, their breakdown products are converted into a toxic substance - indirect bilirubin. A decrease in the number of red blood cells leads to anemia, and bilirubin stains the skin, urine and thus causes jaundice.

Anemia (lack of red blood cells, accompanied by oxygen starvation - hypoxia) causes an adaptive reaction - increased formation in the child's body of the hormone erythropoietin, which stimulates hematopoiesis, that is, the formation of red blood cells. This substance acts not only on the bone marrow, which normally synthesizes red blood cells.

Under its influence, extramedullary (outside the bone marrow) foci of red blood cell synthesis arise in the spleen, kidneys, liver, adrenal glands, fetal intestines and placenta. This is accompanied by a decrease in the lumen of the umbilical and hepatic veins, increased pressure in the portal vein system, metabolic disorders and impaired protein synthesis in the liver.

A decrease in protein content in the blood leads to a decrease in its colloid osmotic pressure. Plasma rushes from the blood into tissues where the osmotic pressure is greater. Fluid is retained in the body and causes extensive swelling, especially pronounced in the subcutaneous fatty tissue and placenta.

As a result of edema, compression occurs on the smallest vessels - capillaries, in which oxygen, carbon dioxide and metabolic products are exchanged between blood and tissues. Oxygen starvation occurs. Due to the lack of oxygen, under-oxidized (“unburnt”) metabolic products accumulate, and acidification of the body’s internal environment develops (acidosis). As a result, pronounced changes occur in all organs of the fetus, accompanied by a sharp disruption of their functions.

Indirect bilirubin penetrates well into brain tissue and causes damage to nerve centers - encephalopathy and kernicterus. As a result, the child’s central nervous system is disrupted: movements, sucking reflex, muscle tone.

So, what is Rh conflict during pregnancy? This is a state of incompatibility between the child and the mother according to the Rh system, as a result of which the fetus’s red blood cells are destroyed by antibodies from the mother’s blood. Negative consequences for the child are associated with manifestations of hemolytic disease.

Treatment of hemolytic disease in case of Rh conflict during pregnancy

In all developed countries, prevention of the development of hemolytic disease of the fetus (hemolytic disease of the fetus) is mandatory.

Treatment of Rh-conflict during pregnancy begins with prevention after the first birth of an Rh-positive fetus. Since during childbirth there is a massive exchange of red blood cells between mother and fetus. This is done using an injection of anti-Rhesus immunoglobulin.

Plasmapheresis for Rh-conflict pregnancy

During pregnancy, plasmapheresis may be recommended. There are about 5 sessions. The essence of the method is as follows: when the anti-Rhesus antibody titer reaches 1:16 – 1:32, antibodies are mechanically removed from the mother’s blood. To do this, blood is collected, which is centrifuged, the cell mass is “returned to the woman’s body, and the plasma with antibodies is disposed of.

The loss of plasma volume is replaced with saline solutions, albumin and fresh frozen donor plasma. This procedure can be performed at any stage of pregnancy. In one session of plasmapheresis, 25-50% of the volume of circulating plasma is removed; the break between procedures should be at least 1 week.

Contraindications to plasmapheresis during pregnancy:

• acute respiratory diseases;
• cardiovascular diseases;
• anemia and hypoproteinemia (decreased protein levels in the blood plasma);
• hypocoagulation – decreased blood clotting ability;
• threat of miscarriage or premature birth;
• individual allergic reaction.

The criterion for the effectiveness of the procedure is a reduction in the titer of anti-Rhesus antibodies to a level below 1:16.

Cordocentesis

Cordocentesis for Rh-conflict during pregnancy is carried out for diagnostic and therapeutic purposes. This requires special equipment and qualified specialists. Using an umbilical cord needle, 2-3 ml of fetal cord blood is obtained. The sample is examined for the amount of hemoglobin, hematocrit and bilirubin are determined, the blood type and Rh factor of the fetus are determined, and if necessary, the baby’s phenotype is examined.

• complications from the umbilical cord puncture site (40%);
• umbilical cord hematoma (17%);
• increase in anti-Rhesus antibody titer (16.6%);
• premature birth (5-8%);
• infection (1%);
• fetal death (1%).

Cordocentesis not only allows you to diagnose the baby’s condition; if the results of the blood test are unsatisfactory, you can immediately give him a blood transfusion from a donor. Indications for intrauterine blood transfusion are low hemoglobin levels (less than 80 g/l) and a decrease in hematocrit to less than 25%.

Antiphospholipid antibodies

Phospholipids, being in the cell membrane, nervous tissue and blood vessels, play a significant role in hemostasis - maintaining blood in a liquid state and its coagulation at the time of disruption of the integrity of blood vessels.

With autoimmune aggression in pregnant women, the number of antibodies to phospholipids increases, which leads to antiphospholipid syndrome.

This syndrome is divided into two types:

1. Primary – often asymptomatic and does not require treatment.
2. Secondary – poses a significant danger to the mother and baby and cannot be avoided without treatment.

The development of APS disrupts blood circulation in the placenta, which leads to oxygen starvation of the fetus and can cause miscarriage or intrauterine diseases.

Therefore, women should be more thoroughly examined to detect antibodies to phospholipids:

• previously had a miscarriage;
• with previous obstetric pathologies;
• who have diseases of the cardiovascular system;
• those suffering from headaches;
• with low platelet levels;
• having problems with the kidneys and liver.

It is better to be examined in advance and undergo a course of treatment or take preventive measures before conception. This will prevent possible complications. If there are indications for the study, it is performed more often in the first trimester.

When taking tests, they check for the presence of antibodies to phosphatidylserine, as well as cardiolipin. When drawing up an overall picture of the situation, not only the high titer, even if it is elevated, is taken into account, but also the clinical indications.

To exclude the influence of various external factors, a repeat study is prescribed. If the diagnosis of APS is established, drugs that prevent blood clotting are prescribed.

Conflict of Rh blood during pregnancy - What to do? How not to miss it? How and where to treat?

Last modified 08/22/2017

I am an Rh-negative mother and during pregnancy I read a lot of information about managing pregnancy in Rh-negative women. I describe everything in detail and share the necessary links below. A must read for pregnant women who are Rh negative.

Rh conflict can only happen if the mother is negative (Rh blood factor (-)), the father is positive (Rh blood factor (+))

And then, if you are a negative mother, this does not mean that there will definitely be a conflict and that you have to worry through the entire pregnancy and not sleep at night. Your pregnancy just requires more attention. And knowing medical negligence, it is you who should study the issue yourself and always be on the alert, checking with your local gynecologist.

There CANNOT BE A CONFLICT in all other cases:

• Mom is positive (Rh blood factor (+));
• Dad - negative (Rh factor (-));
• Mom and Dad are negative (both have Rh blood factor (-));

Here is a link to the methodological documents of the Ministry of Health on how to manage pregnancy in Rh-negative women

What is Rh conflict between mother and child?

In simple words, Rh conflict is when a mother’s body sees her child as a foreign body and begins to get rid of it, destroying its red blood cells.

Causes of Rh conflict between mother and child

The most important thing that any woman (girl) who has Rh blood factor (-) should know is that if blood with Rh factor (+) can get into your blood, you must inject Immunoglobulin within 48 hours! NECESSARILY!

Options when blood can enter and antibodies may be produced:

• during the birth of a positive baby;
• in case of miscarriage (the child was +);
• during an abortion or frozen pregnancy (the child was +);
• with blood transfusion (+);
• for any manipulations related to abdominal puncture during pregnancy with a positive baby

Prevention of Rhesus conflict

The only prevention of Rh conflict is anti-Rhesus immunoglobulin at 28 weeks of pregnancy (to protect the current pregnancy) and within 72 hours after the birth of a positive baby (to protect the next pregnancy).

There is no need to be afraid of it, in Europe for a long time all pregnant women have been diagnosed with Rh negative blood, without even asking, so in Europe the conflict occurs in isolated cases and then mainly among emigrants. In our clinics, try to get the anti-Rhesus immunoglobulin out of the manager!!!! And it is legally free!!! And sometimes there are cases when local gynecologists dissuade pregnant women from giving an injection, telling them: “What should you be afraid of, this is your first pregnancy, etc.” Girls, dear ones, don’t listen to anyone! Conflict is a terrible thing, because then it is not the local doctor who will have to turn gray from fear for your child, but you. It’s understandable why they say that, because the injection costs a decent amount of money. When I installed it, it cost around 5 thousand rubles.

You should ask yourself about the injection at least 4 weeks before hour X, i.e. at 24 weeks of pregnancy. You should ask your gynecologist if you will be given an IG. If she refuses or doesn’t have the information, we go to the head of the antenatal clinic. If the manager tries to brush you off as an “annoying fly,” motivating his answer “there are not enough funds for purchases,” “we won’t have time to purchase,” “out of stock,” etc. Below I present an algorithm with an LCD according to the law!

Step 1

The first thing to say is that if you are denied an IG injection, you will call the health committee. This step helps 99%.

Ippolitova Marina Fedorovna, tel.: 595 89 88

Head of Department Vladimir Petrovich, tel.: 252-63-46 Step 2

Federal Law of the Russian Federation of November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”

Chapter 10. Program of state guarantees of free medical care to citizens

Article 80. Program of state guarantees of free medical care to citizens

GOVERNMENT OF THE RUSSIAN FEDERATION ORDER No. 2199-r dated December 7, 2011 (as amended by “Order” of the Government of the Russian Federation dated July 30, 2012 N 1378-r) This List is applied in 2013 (“Order” of the Government of the Russian Federation dated July 30, 2012 N 1378-r).

In order to ensure state regulation of prices for certain drugs for medical use, approve the attached “list” of vital and essential drugs for 2012. In the list approved for 2013 there is number 1378-r dated July 30, 2012. Drug code: J06BB01 - specific immunoglobulins - human immunoglobulin anti-rhesus RHO (D)

By the way, from my own experience. When I gave birth to my daughter at the Perinatal Center of St. Petersburg at the Pediatric Academy, her blood was immediately taken for Rh in the delivery room. The child turned out to be Rh positive, like his father. In response to my requests to immediately administer immunoglobulin, I was told that this is a rapid test and requires confirmation from the laboratory. I gave birth on Friday. When the gynecologists on duty came, I asked each one when they would finally give me an injection. Nobody really answered. On Monday, at the end of 72 hours, I went and yelled at the nurse on duty: “If they don’t give me an injection now, I will complain to the right place.” She immediately ran with a syringe straight into the room.

What if I didn’t know I needed an injection? Does this concern anyone at all? There is also an example of a friend who gave birth in a maternity hospital in Kronstadt, they did not have immunoglobulin there and she had to buy it herself. But since the girl is a lawyer by training, she immediately wrote a complaint to the court. And the maternity hospital paid her the required amount of money, just to avoid dealing with the court and moral damage.

Blood test for Rh antibodies during pregnancy

Every pregnant woman with a negative Rh factor needs to donate blood for antibodies:

1. up to 20 weeks - once a month;
2. from 20 weeks to 28 weeks - 2 times a month;
3. at 28 weeks we MUST donate blood in a specialized place; if there are no antibodies, then we give an injection of anti-Rhesus immunoglobulin

After an IG injection, you no longer need to donate blood; a minimal amount of antibodies will be present in the blood as a result of the administration of the drug. This is absolutely not scary and these antibodies will disappear by childbirth.

Where can I donate blood for antibodies?

You can take it up to 28 weeks at your antenatal clinic. If it is negative, then there is no need to recheck, but if the consultation comes back with positive results, before you panic, you should retest the blood.

The best laboratory in St. Petersburg “City Blood Transfusion Station”

at the address: Moskovsky pr. 114

You can also donate blood to the following addresses:

• Polyclinic at the Ott Research Institute at the address: V.O., Mendeleevskaya line, 3, tel.
• 17 maternity hospital at the address: 192174, St. Petersburg st. Lesnozavodskaya, 4 building 1 tel.
• Paid laboratories Helix, Invitro and other addresses are many

If you have doubts about the tests in the LCD, you can sometimes take them to another laboratory. Better to play it safe.

Anti-Rhesus immunoglobulin injection

Immunoglobulin is administered only if there are no antibodies!

Before the injection at 28 weeks, you must have a fresh test (at least 4 days) for antibodies. It is better to give the injection day after day. We took the test, got the result and immediately gave the injection.

Human anti-Rhesus immunoglobulin comes in different manufacturers and names. There is Hyper Row, Cam Row, Russian Ivanovo, etc. The principle of operation is the same for all. Unfortunately, we have supply interruptions. Previously, IG was most often found in the Fialka pharmacy chain. You can check availability in all pharmacies in the city by calling 003.

If you purchase IG yourself at a pharmacy, check in advance with the LCD who will be able to supply it to you and when, since immunoglobulin requires special storage conditions. It is better to buy at the pharmacy immediately before the injection.

In order to install IG without the help of LCD, you can contact:

1. “European Vaccination Center” at the address: Fontanka River Embankment, 132 lit. 3 tel.;
2. Polyclinic at the Ott Research Institute at the address: V.O., Mendeleevskaya line, 3, tel.
3. 17 maternity hospital at the address: 192174, St. Petersburg st. Lesnozavodskaya, 4 building 1 tel

Be sure to ask by phone for the availability of immunoglobulin, the required documents for the injection, whether you will need to wait until the ampoule warms up

An IG injection after childbirth is given only if the child has a “positive” Rh factor. This is a MUST! Otherwise, during your next pregnancy with a “positive” baby (even after 10 years), your body will immediately begin to produce antibodies in large quantities, because it encountered positive blood during the first pregnancy.

Rh antibody titer? — Which titer is dangerous?

Dynamics are important. To correctly diagnose the titer, the test must be taken in the same laboratory (as is the dynamics of hCG). No one can accurately answer the question: “Which titer is dangerous?” There may be problems with a titer of 1:2, or maybe, on the contrary, a titer of 1:4000 and there are no special problems. Doctors are most alarmed when the titer increases rapidly or constantly jumps.

Antibodies for Rhesus conflict were detected - What to do?

The main thing is calm! Having antibodies is not a death sentence! Firstly, all antibodies are divided into types. Some antibodies are more harmful, others less so. Some easily penetrate the placenta, while others do the opposite. Trust doctors who understand this.

In St. Petersburg:

1. 17 maternity hospital at the address: 192174, St. Petersburg st. Lesnozavodskaya, 4 building 1 tel

Doctors:

Mikhailov Anton Valerievich – chief physician of Maternity Hospital No. 17, Doctor of Medical Sciences, Professor of the Department of Obstetrics, Gynecology and Reproductology of St. Petersburg State Medical University named after I.I. Mechnikov

Kashtanova Tatyana Aleksandrovna - Head. Outpatient department of Maternity Hospital No. 17, obstetrician-gynecologist

We take a referral from our residential complex, then the consultation is free (it’s better to clarify the information)

2. Polyclinic at the Ott Research Institute at the address: V.O., Mendeleevskaya line, 3, tel.

Doctors:

Shelaeva Elizaveta Valerievna

In Moscow:

TsPSiR at the address: Moscow, Sevastopolsky Prospekt, 24 “A” telephone; +7 (499) 794-43-73 (from 8.00 to 19.00)

Rhesus conflict treatment

First of all, you will be asked to take tests for antibodies, since everyone only trusts their own laboratory. Next, the treatment tactics are to minimize the risks for the child:

You will be constantly monitored for ultrasound + Doppler. Doppler is the only way to monitor the development of Rh conflict. That's it, now antibodies are not so important. Doppler helps evaluate:

• blood flow speed in the cerebral artery;
• thickness of the uterine walls;
• amount of amniotic fluid;
• enlargement of the child’s liver and spleen;
• signs of swelling in a child, etc.

If antibodies begin to destroy the baby's red blood cells and his hemoglobin drops sharply, then you will have to go to the hospital for an intrauterine blood transfusion or red blood cell transfusion to the child. It is done under ultrasound control. The abdomen is pierced and red blood cells are injected, thereby replenishing the child’s lack of hemoglobin. In utero blood is transfused only up to 34 weeks, after which you give birth. One transfusion maintains hemoglobin for 2-3 weeks. Then a transfusion may be required again. The maximum gestational age that doctors allow for Rhesus conflict is 37-38 weeks.

When the baby is born, bilirubin is checked. If the value of toxic bilirubin increases rapidly, then a replacement blood transfusion or purification of the baby’s blood from our harmful antibodies + addition of missing red blood cells may be required. The baby is taken away immediately after birth and placed under lamps to sunbathe.

It happens that the body of an unborn baby is tired of fighting antibodies and producing an increased number of red blood cells and hemoglobin drops. Such anemia is treated in a hospital with injections of Epocrine + vitamins. When the hemoglobin level is below 70, another red blood cell infusion may be required, or more than one. But then everything falls into place and the body of the new little person begins to produce as many red blood cells as needed!

Conclusions:

1. Women and girls with a negative Rh factor MUST know and convey to their friends and daughters that after any abortions and miscarriages (ectopic, frozen, etc.) they should be given an injection of human anti-Rhesus immunoglobulin. (Unless, of course, a man with a positive Rh factor). If the child was negative, then IG will not have any effect, but if the child was +, it will save your subsequent pregnancy;
2. Be sure to remind your gynecologist about directions for a blood test for antibodies;
3. Sometimes donate blood to a paid laboratory to check your digestive tract;
4. If you get a positive result for antibodies, don’t panic! We retake the test in a paid laboratory and immediately make an appointment with a doctor;
5. At 28 weeks we donate blood in a paid laboratory and immediately give an immunoglobulin injection;
6. After giving birth, ask for a blood test from the baby and, if he is Rh positive, within 72 hours after birth you MUST be given a free immunoglobulin injection

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What are antibodies and why get tested for them during pregnancy?

The human body is unique. To protect against adverse environmental influences and combat various microorganisms, nature provides many mechanisms, the main one of which is the production of antibodies or immunoglobulins. Antibodies are formed as a result of antigens (dangerous substances) entering the body; the key task of immunoglobulins is protection against foreign bodies.

If, in fact, the production of immunoglobulins is a protective reaction of the body, then why donate blood for antibodies during pregnancy, and why is it so important to determine their presence in the blood or their complete absence? During the period of gestation, antibodies can perform a protective function, but at the same time they can provoke pregnancy complications, including miscarriage. It all depends on what the action of those same antibodies is directed against.

Thanks to an antibody test during pregnancy, it is possible to determine whether the body is able to cope with difficulties on its own or whether it needs help, which means protecting the child.

There are situations when the female body identifies the fetus as a foreign object and begins to reject it through the production of antibodies. This happens if parents have blood incompatibility (type or Rh), which is fraught with a pathological condition - an immunological conflict between mother and baby. It reduces the possibility of a favorable delivery.

Detection of antibodies during pregnancy helps prevent all sorts of risks associated with the health of the unborn baby. An immunoglobulin test is one of the most important clinical studies during the waiting period, and you definitely shouldn’t neglect it.

Treatment of conflict

Rh factor incompatibility requires immediate treatment. It is aimed at reducing maternal antibodies, the resulting antigen-antibody complexes, maintaining the vital activity of the growing organism and prolonging the pregnancy period. Treatment includes the following:

• If during the examination serious disturbances in the development of the fetus were revealed, then an intrauterine blood transfusion is performed through the umbilical cord. This operation is performed under ultrasound guidance.
• To weaken the effect of Rh conflict on the fetus, a pregnant woman may be prescribed a course of oxygen therapy.
• Antihistamine therapy is carried out.
• An additional vitamin complex enriched with iron and calcium is prescribed.
• Therapy is carried out to strengthen the immune system.
• In the fifth month of pregnancy, a woman goes to the maternity hospital. There she is under the supervision of obstetricians and gynecologists, and the child’s condition is monitored.

Antibodies are constantly supplied to the fetus, so it is possible to stop their access only if the pregnancy is terminated. Usually in a hospital they do not wait for the natural end of the pregnancy period, but set the date of delivery earlier. A common method for rhesus conflict is caesarean section. If the child feels satisfactory, then the woman can give birth herself, but no later than 36 weeks. To achieve this, labor is stimulated.

Antibodies to TORCH infections

The presence of TORCH infection in the body of the expectant mother can be dangerous for the fetus.

Diseases include:

• Toxoplasmosis.
• Rubella.
• Cytomegaloviruses.
• Herpes.

The word TORCH is derived from the initial letters of the names of pathologies written in Latin.

These diseases threaten the unborn child with developmental disorders and sepsis. Miscarriages and stillbirths are possible.

As a rule, it is impossible to unequivocally evaluate the results of a study. The data may indicate the presence of infection in the body, as well as its duration.

When examining antibodies to TORCH infections, the ratio of immunoglobulins of classes M and G is taken into account. Possible results:

• Lack of immunoglobulins in the blood (classes M and G). This means that the woman’s body has never encountered these diseases and there is no immunity. Since the risk of getting sick is high, pregnant women undergo this study every subsequent month.
• The presence of antibody titers of both classes indicates an illness (in acute form), which is either ongoing or occurred after conception. Additional testing may be done to determine if there are any risks to the unborn baby.
• The presence of G-antibodies and the absence of M-antibodies. This is the most favorable result. It informs about immunity to dangerous infections. Even if the disease occurs, it will not be dangerous for the baby.

During pregnancy, the titer of antibodies to TORCH infections is given special attention during the first 12 weeks, when these diseases pose the greatest risk.

It is best to test your blood for antibodies during pregnancy planning. This will help, if a pathology is detected, to carry out appropriate therapy.

Causes of the conflict

A woman with negative Rh and a man with positive Rh are able to conceive. If the mother’s Rh factor is positive and the father’s is negative, then the risk of developing a conflict is 50%. The parent's blood type during pregnancy affects the degree and speed of formation of possible pathologies. During the first pregnancy, if a blood transfusion was not performed, the chances of avoiding a conflict increase sharply. This means that if the mother’s Rh is negative, the child may be born with Rp (+).

It happens that the female body is not able to produce a sufficient amount of antibodies. The main reasons for the development of incompatibility are fertilization of the egg after abortion or miscarriage. In this case, the risk of developing a conflict increases several times. In a woman, the factor does not change during pregnancy and for the rest of her life, only the amount of antibodies produced by the body in the blood may increase.

A conflict can develop in a woman whose first pregnancy ended in a caesarean section. If during childbirth doctors separated the placenta manually, and the patient has a history of uterine bleeding, then the risk of Rp incompatibility is 50-60%. Women with a negative Rp factor should be especially attentive to their own health - mothers who have suffered the following pathologies while pregnant are at risk:

• acute respiratory viral infections;
• gestosis;
• cold.

Antibodies produced by the body do not disappear anywhere. Their number increases with each subsequent pregnancy. If the structural structure of the chorionic villi is disrupted, the mother’s immunity begins to produce antibodies at an accelerated rate.

Group and allogeneic antibodies

If a negative Rh factor (Rh) is detected in the mother, a positive factor in the baby and the appearance of alloimmune anti-erythrocyte bodies, they speak of a Rh conflict. But during the first pregnancy, anti-D antibodies are not always produced in sufficient quantities to provoke an Rh conflict. This often happens due to a violation of the integrity of the amniotic membrane. And with subsequent conceptions, the likelihood of developing anti-Rhesus antibodies is high and can lead to the death of the baby.

An ABO conflict develops even during the first pregnancy if the baby’s blood, incompatible with the mother’s, enters the woman’s bloodstream in large quantities. In this case, anti-group antibodies are produced. The pathology does not have serious consequences, but regular monitoring is necessary to exclude complications.

Factors that can provoke the development of group or Rh conflict:

• late pregnancy termination;
• miscarriage;
• transfusion of incompatible blood group;
• difficult previous births;
• placental abruption;
• ectopic pregnancy if the embryo has an incompatible Rh.

Today, there is effective prevention to prevent the serious consequences of Rh conflict. For Rh-negative women, after the end of the first pregnancy, the titer level is reduced with Anti-D gamma globulin.

During the period of bearing a child, immunoglobulin is constantly monitored, and if its level increases, the drug is administered several times according to a specially designed regimen. There is no prevention for group conflict.

Decoding the results

To make it easier to decipher the data, all indicators are recorded in a form in the form of a table. Each AT group has its own indicators that are considered normal. For example, if the lgA concentration is 0.35–3.55 g/l, this is normal. For IgG, the normal level is 7.8–18.5 g/l, and for lgM – 0.8–2.9 g/l.

When checking antibodies to phospholipids, their quantity should not exceed 10 U/ml. AT values ​​for thyroglobulin should be less than 4.1 IU/ml.

If, during the study of Rh conflict, the titer is higher than expected, this has a bad effect on the health of the fetus. In such situations, abortion is sometimes performed. A titer of less than 1:4 is considered normal; if it is higher, constant monitoring is necessary. With a titer of 1:16, the likelihood of the baby's death increases. To avoid this, amniocentesis is performed - amniotic fluid is taken to identify congenital diseases. But this is allowed after 26 weeks of pregnancy.

Sometimes, if the titer at 16–18 weeks of pregnancy is higher than 1:128, it is impossible to notice on an ultrasound how much the fetus is suffering. Then doctors recommend that patients undergo regular examinations, and especially carefully monitor the child’s condition after 20 weeks.

And if the titer results are 1:256 or higher, early delivery is performed at 34–35 weeks so that the fetus is not harmed.

It is especially dangerous if the titer is within 1:1024 or more, but if the antibodies do not penetrate the child’s bloodstream, pathology will not develop.