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8/3/2019 Blood Type Incompatibility
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Blood TypeBlood TypeIncompatibilityIncompatibilityBlood TypeBlood TypeIncompatibilityIncompatibility
RH & ABORH & ABO
Rebecca Jo HelmreichRebecca Jo Helmreich
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Rh incompatibility RH+ fetal cells (Rh antigen)
enter the blood circulation of an
RH- mother
² through breaks in the maternal-fetal circulation 1st IgM antibodies are formed, followed by IgG antibodies
capable of crossing the placenta
IgG Antibodies cross to fetus
coat fetal RBC·s and hemolysis occurs Mild = >erythropoiesis HbF = compensates Severe = >anemia ² hydrops fetalis from CHF--Death
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Hemolytic Disease of the
Newborn Red cells of a fetus or neonate are destroyed by IgG antibodies produced
by the mother
Maternal IgG antibody directed against fetal RBCantigen
Antibody production stimulated throughpregnancy or transfusion
Most often, fetal cells enter maternal circulation at birth as placenta separates from uterus (fetal maternal
hemorrhage)
Occasionally during pregnancy itself IgG molecules cross the placenta and sensitize
fetal red cells
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Pathogenesis Antibody-coated RBCs removed from fetal
circulation by spleen and liver ² anemia may result.
In response to anemia, Fetal bone marrow increases erythocytosis ² (HbF)
immature red cells are released into fetal circulation
Rate of hemolysis after birth decreases,
because there is no additional antibody enteringinfant·s circulation
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Continued Pathogenesis Hemolysis results in production of bilirubin
In utero, excreted by mother
(transported across placenta, conjugated in maternalliver)
After birth, infant liver is unable toconjugate bilirubin so unable to excrete
(deficiency in glucuronyl transferase) Bilirubin can cause kernicterus.
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Rh HDN Anti-D causes most cases of severe HDN
² Importance of anti-D has decreasedsubstantially, due to introduction of Rh immune
globulin (RHOGham) Women usually sensitized after first Rh-
postive pregnancy but may occur anytimemixing of blood
Rh neg women with ABO-incompatible, Rh postivefetus have decreased risk of Rhsensitization
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Diagnosis History & Physical
History of previous abortion, blood transfusion, orinfant with jaundice
Kleihauer-Betke test: to determine amount of fetal blood inmaternal circulation & determine the dose of Rh immune globulinwhen large maternal-fetal bleed is suspected
Blood:² Blood group, Rh factor, (RH- not a problem if father also RH-)
² serial antibody screening Indirect Coomb·s test: ? Rh- mother has developed antibodies to the Rh
antigen Direct Coomb·s test: on infant·s blood after birth to identify maternalantibodies attached to fetal RBC·s
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Nursing Diagnosis &
Evaluation Nsg. Dx
Risk for injury
Deficient Knowledge
Anxiety
Evaluation The client delivers a healthy infant with negative
direct Coombs· test
The client receives RhoGam to prevent maternalantibody formation that might complicate futurepregnancies
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Interventions Provide support and education
Have carry an Rh-negative identification card & informthat may need RhoGam with future reproductive events
Ultrasound Evaluate fetus for amniotic fluid volume, fetal size, development
of edema or >heart
Fetal well being FHT monitoring (sinusoidal FHT = >anemia); Biophysical profile Middle cerebral artery (MCA) Doppler = detect anemia close to
term Early delivery with phototherapy and possible exchange
transfusion PRN
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Prevention ² Rh HDN
Concentrate of IgG anti-D preparedfrom pooled human plasma
Protects women from sensitizationduring pregnancy and after deliveryof a Rh positive infant
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Guidelines for RhIG All doses within 72 hours of delivery or procedure Women should not already be sensitized to D
antigen 50 mg (IM) dose up to 12th week gestation for: Abortion Miscarriage
Termination of ectopic pregnancy
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Guidelines for RhIG 300 mg dose
² 28 weeks of gestation² After amniocentesis (repeat if procedures are >21 days apart)² After any procedure that can cause fetal-maternal
hemorrhage (communication of blood between mom & fetus) After delivery of Rh-positive infant 120 mg dose
² Termination of pregnancy after 12th week gestation² Amniocentesis² Other manipulations after 34th week of gestation
² Delivery of Rh-positive infant
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Postnatal Testing for
?HDN Mother·s blood
² ABO
² Rh including Du if negative² Indirect antiglobulin test (antibody
screen) and ID if positive
² If ID is positive for IgG, do hemoglobinand bili on baby
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Postnatal Testing for
?HDN Cord Blood
² ABO-
² Rh including Du if negative
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Treatment for HDN In Utero
Intrauterine transfusion
Postpartum ² lower bilirubin levels² Phototherapy
² Exchange transfusion
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Blood selection for Intrauterineand
Exchange Transfusions Group O (or ABO-compatible) Rh negative RBCs that are Dry packed and reconstituted with
AB fresh frozen plasma
Less than 7 days after collection CMV negative (or leukoreduced) Gamma irradiated Hemoglobin S negative
Negative for offending antibody Crossmatched with maternal serum
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ABO HDN
Most common cause Anti-A and anti-B in group B and A persons are mostly IgM; in group O persons, partially IgG
Mild HDN in 1 in 150 births Reasons not severe
² A and B antigens not fully developed at birth² Smaller number of A and B antigenic sites on fetal RBCs
² A and B antigens also on tissues ² combine with maternalantibody