Why conflict occurs
There are antigen proteins on the surface of red blood cells. If the mother has Rh-negative blood, and the child inherited Rh-positive blood from the father, then when his red blood cells enter the woman’s bloodstream, her body produces antibodies. This usually occurs during childbirth, so the first pregnancy is often calm, but the risk increases with subsequent ones. Blood type conflict develops differently: it is possible already during the first pregnancy, if the mother has the first group, and the child has the second or third, and it usually proceeds more easily. Incompatibility with other antigens is less common.
- Rh conflict with Rh negative mother and Rh positive child
- The risk increases with each subsequent pregnancy
- Conflict according to the AB0 system is possible already during the first pregnancy
- Abortions, miscarriages, and ectopic pregnancies increase the risk
- Bleeding, amniocentesis, abdominal trauma during pregnancy
- Blood transfusion without taking into account Rh in the past
Forms and symptoms
The severity depends on the amount and activity of antibodies. The most common form is jaundice: the child is born outwardly healthy, but in the first hours the skin begins to turn yellow, and the level of bilirubin increases faster than with normal physiological jaundice. The anemic form is milder: pronounced pallor, lethargy, weak sucking with moderate jaundice. The most severe is edematous, in which the fetus suffers while still in utero. The key feature that distinguishes the disease from physiological jaundice is its early onset on the first day and rapid progression.
- Jaundice in the first 24 hours of life
- Rapid increase in bilirubin levels
- Pale skin and mucous membranes
- Enlarged liver and spleen
- Lethargy, decreased sucking reflex
- Swelling and enlargement of the abdomen in severe form
- Neurological signs of very high bilirubin
Why is high bilirubin dangerous?
Indirect bilirubin is soluble in fats and is able to penetrate into the brain tissue, damaging the nuclei of the brainstem. This condition is called bilirubin encephalopathy, and it can leave lasting consequences: hearing impairment, movement disorders, and developmental delays. That is why in the maternity hospital they monitor the level of bilirubin and do not wait until jaundice becomes noticeable to the eye. The threshold at which treatment is started depends on the child’s age in hours, gestational age and the presence of risk factors, and is determined by the doctor using special nomograms.
- Bilirubin encephalopathy at critical values
- Hearing impairment up to hearing loss
- Movement disorders and developmental delays
- Severe anemia in the first weeks of life
- Late anemia several weeks after discharge
- Thickening of bile with cholestasis
Diagnosis and monitoring of pregnancy
Blood type and Rh factor are determined during registration. If a woman is Rh negative, the titer of anti-Rh antibodies is regularly examined. The condition of the fetus is assessed by ultrasound and Doppler sonography: the speed of blood flow in the middle cerebral artery allows one to suspect anemia in a child without intervention. After birth, blood is taken from the baby's umbilical cord: the group, Rh, hemoglobin, bilirubin are determined and a Coombs test is performed, which detects antibodies on red blood cells. Next, bilirubin is monitored over time.
- Blood type and Rh factor of mother and father
- Titer of anti-Rhesus antibodies over time during pregnancy
- Fetal ultrasound and Doppler ultrasound of the middle cerebral artery
- Umbilical cord blood: group, rhesus, hemoglobin, bilirubin
- Direct Coombs test in a newborn
- Reticulocytes and complete blood count
- Repeated measurements of bilirubin according to the life clock
Treatment and prevention
The main method for treating the icteric form is phototherapy: under a lamp, bilirubin turns into a water-soluble form and is excreted. The baby continues to be fed, but breastfeeding does not need to be stopped. For high bilirubin values, intravenous immunoglobulin is used, and for critical values, an exchange blood transfusion is used. Anemia is corrected with iron supplements or red blood cell transfusions as indicated. The most important thing is prevention: Rh-negative women without antibodies are given anti-Rhesus immunoglobulin at the time determined by the doctor, and after giving birth to a Rh-positive child.
- Phototherapy under the control of bilirubin levels
- Continued breastfeeding and adequate nutrition
- Intravenous immunoglobulin according to indications
- Replacement blood transfusion at critical values
- Intrauterine fetal transfusion for severe anemia
- Anti-Rhesus immunoglobulin during pregnancy and after childbirth
- Administration of immunoglobulin after abortion, miscarriage, bleeding
- Hemoglobin monitoring after discharge due to risk of late anemia