Rh disease in pregnancy - Causes, Symptoms and Treatment .MF .
According to the definition, rhesus immunization (Rh sensitization / Rh conflict) is the appearance of a pregnant Rh antibodies in response to entering the bloodstream fetal erythrocyte antigens, ie, to paraphrase easier - mother is incompatibility with Rh-negative blood groupa child with Rh positive blood group (and not with her husband, as many think).
Rh antigen - a protein found in the membrane of red blood cells / red blood cells of most people.The blood of these people is positive for the Rh system, and the blood of those individuals who do not have this protein, respectively, is called Rh negative.About 1/3 of the population are Rh-negative.
have Rh-positive parents may well be born Rh-negative child.In this case, between "positive" and her mother "negative" child add up very peaceful, conflict-free relations: such a combination does not threaten either the woman or the fetus.
the presence of the mother and father of the child rhesus negative blood group of the child as a negative Rh factor.
But if the mother Rh-negative blood, the father positive Rh-positive fetus occurs in 60% of pregnant women, but only 1.5% of these pregnancies develop incompatibility.
Usually, after repeated pregnancy probability of incompatibility is higher than in the first.
mechanism of Rh-conflict
If Rh-positive red blood cells are found with Rh-negative, then there is their coalescence - agglutination.To avoid this, the immune system is Rh-negative mother produces a special protein - antibodies that bind to the membrane Rhbelkom fetal red blood cells (antigens) by inhibiting the adhesion of red blood cells with their own mother.The antibodies called immunoglobulins and are of two types: IgM iIgG.
Contact fetal red blood cells with antibodies occurs in the space between the uterine wall and the placenta.At the first meeting of fruit Rh-positive red blood cells from the immune system of an Rh-negative mother's going to develop IgM, which is too large size in order to penetrate through the placental barrier.That is why, as a rule, during the first pregnancy, Rh-negative mothers of Rh-positive fetus conflict occurs relatively rarely.Incompatibility develops with repeated contact with the fetal antigen (Rh positive red blood cells) into the bloodstream Rh-negative mother's immune system which in this case works out massively of IgG, which, having smaller dimensions, cross the placenta and cause hemolysis, ie,destruction of fetal red blood cells.So developing hemolytic fetal / neonatal disease.
The destruction of red blood cells occurs toxic damage of almost all organs and systems of the fetus-product breakdown of hemoglobin, the substance that is found in red blood cells responsible for oxygen transport.This is due to the decay product - bilirubin.Primarily affects the central nervous system of the fetus, the liver, the kidneys and the heart, in the cavities and tissues it accumulates fluid, which prevents the normal functioning of organs and systems up to fetal death in severe cases.It is in connection with the "rejection" of the fetus in Rh-negative mothers often develop a threat of miscarriage, the risk of fetal death.
Risk Factors rhesus
are divided into:
1. Related to pregnancy:
- any kind of termination of pregnancy: miscarriage, tool and medical abortion;
- ectopic pregnancy;
- birth, namely, in the third period, when there is a separation of the placenta from the uterine wall;
- complication of pregnancy or childbirth - premature detachment of the placenta, which is accompanied by bleeding from the placental vessels;
- any invasive research methods (amniocentesis, cordocentesis - amniocentesis or umbilical cord).
2. Unrelated to pregnancy:
- immunization blood transfusion;
- use one needle while injecting drugs.
clinical manifestations of the patient are not available, it does not suffer from the condition.
Symptoms of hemolytic disease of the fetus during pregnancy can only be detected with ultrasound, they are: edema, an accumulation of fluid in the cavities (abdominal, thoracic, in the cavity of the pericardium);due to accumulation of fluid in the abdominal cavity of the fetus belly size increases, the fruit takes a certain position "posture of Buddha" (when in contrast to the norm, limbs withdrawn from the increase in size of the abdomen), enlarged liver and spleen, increase the size of the heart, there is a "double" circuithead (as a result of soft tissue swelling of the head).Also, the swelling is determined and accordingly, thickening the placenta and umbilical cord vein diameter increase.Depending on the predominance of one or another feature, there are three forms of hemolytic disease of the fetus: edematous, icteric and anemic.
Diagnostics Rh-conflict and tactics of pregnancy
purpose of monitoring pregnant women with Rh-immunization is: a survey to identify sensitization, conduct preventive immunization of rhesus, early diagnosis of hemolytic disease of the fetus and its correction, as well as determining the optimal time frame for delivery.When registration for pregnancy shows blood group of both the pregnant woman and the child's father in a planned manner.In the presence of Rh-negative blood in the mother and Rh-positive blood from the father, pregnant women conducted a blood test for antibodies 1 once a month, tracking the dynamics of antibody titer.In the presence of any antibody titer pregnancy is considered Rh sensitized.If antibodies are found first, then determine their class (IgM or IgG).Next, a blood test for antibodies carried out on a monthly basis, observing the patient up to 20 weeks in the antenatal clinic, and after 20 weeks - is sent to specialized centers for the definition of further tactics may conduct treatment and a decision on the method and timing of delivery.
Starting from 18 weeks to assess the status of the fetus by ultrasound.
fetal assessment methods are divided into:
1. Do not invasive.
- ultrasound, in which the estimate: the size of the fruit bodies, the presence of free fluid in the cavities, the presence of edema, placental thickness and diameter of the umbilical vein.The first ultrasound is carried out in a period of 18-20 weeks, repeat at 24-26 weeks, 30-32 weeks, 34-36 and immediately before delivery.Depending on the severity of fetal condition may more frequent the study up to daily (for example, after the transfusion fetus).
- Doppler, which assesses the functional performance of the heart, blood flow in large vessels of the fetus and umbilical cord, etc.
- cardiotocography evaluate reactivity of the cardiovascular system of the fetus, reveals the presence or absence of hypoxia (lack of oxygen).
- amniocentesis - amniocentesis for the purpose of sampling the amniotic fluid to assess the severity of hemolysis on the content of bilirubin (product breakdown of hemoglobin), which is one of the most accurate methods of assessing the severity of fetal well-being.Unfortunately, this method is fraught with many complications: infection, prenatal rupture of membranes, preterm labor, bleeding, premature detachment platsenty.Pokazaniya to amniocentesis: the antibody titer of 1:16 or more, the presence of children patients with severe form of hemolytic disease of the newborn.
- cordocentesis - the puncture of the umbilical cord for the purpose of drawing blood.The method allows to accurately assess the severity of hemolysis, simultaneously hold intrauterine blood transfusion to the fetus.In addition to the complications that are characteristic of the amniocentesis, cordocentesis at the same may develop bruises and bleeding from the umbilical cord punktsii.Pokazaniyami place for cordocentesis is to determine the signs of hemolytic disease of the fetus by ultrasound, the titer of 1:32 or more antibodies, the presence of children patients with severethe shape of the MLP in the past or who died from it, a high level of bilirubin in the amniotic fluid obtained by amniocentesis.
Due to the possible risk, and prior to that and other treatments the patient should be informed by the doctor about the possible adverse effects of the procedure and give its written consent to its holding.
Treatment of Rh-conflict
In modern obstetrics only treatment with proven efficacy is intrauterine blood transfusion, which is held with severe anemia (anemia) in the fetus.Such treatment is carried out only in a hospital, and allows you to achieve a significant improvement of the fetus and reduce the risk of preterm birth and the development of severe disease after birth.
high-risk patients (in which the antibody titer is detected in the early stages, those with antibody titre 1:16 and above, those who have a past pregnancy was with Rh disease) observed in a women's clinic before 20 weeks, and then sentin specialized hospitals to carry out the above treatment.
Various methods of purification of antibodies from the mother's blood (plasma exchange, hemosorbtion) ways that affect the immune system activity (desensitizing therapy, immunoglobulin therapy, transplant patient skin graft child's father) are now considered inefficient or even ineffective.
Unfortunately, despite significant progress in correcting the status of the fetus, the most effective way is to stop the entry into his mother's antibodies, which can be achieved only delivery.
delivery in Rhesus conflict
Unfortunately, Rh sensitization is often necessary to carry out delivery is early, becausein late pregnancy there is an increase in the number of antibodies that act to the fetus.
Depending on the condition of the fetus and gestational age, mode of delivery is different in each case.It is believed that a cesarean section is more gentle to the fetus, due to which in severe cases, resorted to him.When a satisfactory condition of the fetus, pregnancy over 36 weeks, multiparous possible labor management vaginally with careful moni- control fetal status, the prevention of intrauterine hypoxia.With the deterioration of his condition during labor, maintenance plan may be revised in favor of caesarean section.
prognosis of Rh-conflict
Prognosis depends on how early was diagnosed Rh immunization, the magnitude of the antibody titer, and the speed of its growth, as well as the form of hemolytic disease of the fetus.The earlier detected antibodies in the mother's blood, for example, on the age of 8-10 weeks, the more it is adverse prognostic.The rapid increase in antibody titer, titer above 1:16, its early detection (for less than 20 weeks) is the reason for poor prognosis.In such cases, it increases not only the risk of hemolytic disease of the fetus, but also the risk of miscarriage.
most prognostically unfavorable form of hemolytic disease of the fetus is hydropic.These children often require treatment in conditions of pediatric intensive care, exchange transfusion.The most favorable form is prognostically anemic form, (depending on the severity of anemia).When icteric form the determining criterion is the level of bilirubin.The higher it is, the higher the possibility of damage to the central nervous system of the fetus, which manifests itself in the future dementia, hearing loss.
Prevention of Rh-conflict
Currently, in order to prevent Rh sensitization used human Rh immunoglobulin D. This drug has proven efficacy exists under several trade names, such as: "GiperRou C / D» (USA), the resonator (France), Rh immunoglobulin D (Russia).
Prophylaxis should be performed during pregnancy in term of 28 weeks in the absence of antibodies in the mother's blood, as in this period greatly increases the risk of contact with the mother's antibodies by red blood cells of the fetus, and therefore increases the risk of hemolytic disease of the fetus.Because administration of antibody titer in blood may occur and thus determination of antibody administration is not provoditsya.Dalee, repeat prophylaxis for 72 hours after delivery, if the patient plans next pregnancy.If you have any bleeding during pregnancy, as well as during kordo- or amniocentesis, and in the postpartum period should be repeated intravenous immunoglobulin, asRh sensitization may occur during the next pregnancy in response to entering the fetal blood (bleeding from placental blood vessels) in the mother's bloodstream.
Also, it should be prevented by injection of the drug at any outcome of pregnancy: miscarriage, medical or instrumental abortion, ectopic pregnancy, molar pregnancy within 72 hours after an interruption.Particular attention is paid to blood loss, should be increased with the appearance of a dose of the drug.
Obstetrician-gynecologist Kondrashov D.