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CP Conference Hemolytic Disease of The Fetus and Newborn (HDFN)

This document summarizes hemolytic disease of the fetus and newborn (HDFN), specifically regarding Rh disease. It discusses that maternal alloantibodies can cross the placenta and cause fetal hemolysis if the mother is sensitized, most commonly from a previous pregnancy. It notes that ABO incompatibility is now the leading cause of HDFN since anti-D prophylaxis has reduced Rh disease. The document outlines testing and treatment for preventing Rh HDFN, including dosing of Rh immunoglobulin G.

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155 views17 pages

CP Conference Hemolytic Disease of The Fetus and Newborn (HDFN)

This document summarizes hemolytic disease of the fetus and newborn (HDFN), specifically regarding Rh disease. It discusses that maternal alloantibodies can cross the placenta and cause fetal hemolysis if the mother is sensitized, most commonly from a previous pregnancy. It notes that ABO incompatibility is now the leading cause of HDFN since anti-D prophylaxis has reduced Rh disease. The document outlines testing and treatment for preventing Rh HDFN, including dosing of Rh immunoglobulin G.

Uploaded by

fathog
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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CP conference Hemolytic disease of the fetus and newborn (HDFN)

1/19/12

Pathophysiology
Maternal alloantibodies cross the placenta, enter the fetal circulation and cause hemolysis Alloimmnunization via
Previous transfusion Previous pregnancy Current pregnancy (CVS, amniocentesis, trauma, spontaneous/elective abortion, etc.)

Pathophysiology
Depending on severity, hemolysis can lead to bilirubin in amniotic fluid, fetal anemia and hydrops fetalis
Severity of disease determined by IgG subclass Amount of antibody Number of antigenic sites on red cells

All of the following antibody classes are capable of causing HDFN except?
A. IgG1 B. IgG2 C. IgG3 D. IgG4 E. All of the above can cause HDN

B. IgG2
In addition to dimeric IgA and pentameric IgM, IgG2 is unable to cause HDN because it is unable to cross the placental membrane

Subclasses of IgG
Differ in their AA sequence on the heavy chain in the constant domain Ability to bind complement affects clinical significance
IgG3 > IgG1 > IgG2 > IgG4

What is the most common antigen involved in HDFN?


A. Rh B. ABO C. Kell D. c E. Duffy

B. ABO
Anti-D prophylaxis for Rh-negative women has dramatically reduced Rh HDFN so that ABO incompatibility is #1

ABO HDFN
Leading cause of HDFN Usually group O mom and group A or B child
Unlike other groups, O patients have IgG (antiA,B antibody) that crosses the placenta into fetal circulation Since these ABO antibodies are naturally occurring, interaction can occur during the first pregnancy

Hemolysis is very mild since fetal/neonatal RBCs only have weak ABO antigen expression

Other causes of non-Rh HDFN


HDFN due to Kell is the most common cause of severe HDFN followed by anti-c
Kell is present on fetal RBCs, unlike other antigens

Rh HDFN
Classic HDFN, caused by anti-D antibodies Usually not seen in first pregnancy
Not naturally occurring, so mom must have picked up D+ erythrocytes from prior transfusion or pregnancy

Before introduction of anti-D immunoglobulin G (RhIg) in 1966, incidence of sensitization in an Rh- mom bearing an Rh+ child was 8%, now 0.1% with 28 wk and term ppx

Preventing Rh HDFN
D- women should be checked for anti-D ab:
If she does not have anti-D antibodies, give prophylactic doses of RhIg at 28 weeks gestation and anytime there is fetomaternal hemorrhage If she does have anti-D antibodies, maternal antibody titer is determined; if titer is high, monitor fetal hemolysis intrauterine transfusion or early delivery may be necessary

What is the titer threshold for the presence of clinically significant anti-D antibody in pregnancy?

A. 1: 1,000 B. 1: 100 C. 1: 50 D. 1: 16 E. 1: 4

1:16
Titers less than 1:16 have very low risk of hemolysis Titers greater than 1:16 warrant monitoring for fetal hemolysis

Indications for RhIg


D- woman with a D+ or D-unknown fetus
Ppx= 300 g (full vial) at 28 wks and at term Fetomaternal hemorrhage of unknown qty (ectopic, amnio, CVS)= 50 g (small vial) in first 12 wks of gestation and 300 g (full vial) after 12 wks

NOT indicated for D+ moms or D- moms who already have anti-D antibodies

Dosing RhIg
Vials of RhIg= Maternal blood volume (mL) x % fetal cells in moms blood 30
Maternal blood volume can be calculated as moms weight (in kg) x 70 mL/kg; may also estimate 5,000 mL % fetal red cells calculated by Kleihauer-Betke test Each full dose vial protects against 30 mL of whole blood or 15 mL of red cells

Questions?

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