For many years, Rh-conflict during pregnancy was a mystery for obstetricians and the cause of many, then it seemed, unexplained problems with pregnancy and hemolytic disease of the newborn (a condition when red blood cells in the fetus are destroyed - red blood cells that carry oxygen). And only about 60 years ago, with the help of the rhesus monkey, scientists discovered a system of proteins in human erythrocytes (red blood cells), which were the main reason for the incompatibility of mother and fetus. These proteins-antigens are called the system - rhesus. Later it was proved that it is the incompatibility of the blood of the mother and the fetus for these antigens that leads to hemolytic disease of the newborn.

To begin with, it is worth understanding what the Rh factor is, who has it and under what conditions it becomes a problem for a developing baby.

What is Rh factor?

This is a special protein that is located on the surface of red blood cells. It is found in almost all people - they are considered Rh positive, and only 15% of the white population does not have it, this small group is Rh negative. The Rh factor is indicated by two Latin letters - Rh - and plus and minus signs.

The presence of the Rh factor is not a disease, just like its absence, it is just one of the characteristics of blood. Just like we are all different.

Why does Rh-conflict arise?

Rh-conflict occurs when an Rh-negative woman is pregnant with an Rh-positive fetus. In this case, in the late stages of pregnancy, fragments of the Rh-positive erythrocytes of the fetus enter the mother's bloodstream, are perceived as foreign and cause a protective reaction in her body, the essence of which is the formation of anti-Rh antibodies. Here they are, penetrating back to the baby through the placenta, and can cause the destruction of red blood cells in his blood. This process is called hemolysis. With the destruction of red blood cells in the blood of the fetus, bilirubin begins to form in large quantities. It has a toxic effect. The amount of bilirubin in the baby's blood helps to determine the severity of the Rh-conflict.

The destructive effect of Rh-positive erythrocytes of the fetus does not occur immediately. First, anti-Rh immunoglobulins M are formed in the blood of a Rh-negative woman, which means that she is pregnant with a Rh-positive child and the so-called acquaintance of two organisms has occurred, as a result of which the sensitivity of the cells and tissues of the mother's body increases (this process is called sensitization). So far, this is not yet a Rh-conflict, since immunoglobulins M are not able to cross the placenta due to their large sizes and, accordingly, cannot harm the growing fetus. Then, after about 8-9 weeks, and in some women even after 6 months, immunoglobulins G appear. This means that sensitization has occurred and Rh-conflict is now possible, since these immunoglobulins are not so large and can already penetrate back from mother to baby through the placenta. After 28 weeks of pregnancy, the blood flow between the woman and the fetus increases, which leads to an increase in the amount of anti-rhesus antibodies in the baby's body and an increase in their damaging effect. They cause the fetal red blood cells to stick together, which, without proper treatment, can lead to such a serious complication as hemolytic disease of the newborn.

Later, with a repeated pregnancy with a Rh-positive fetus, the mother's body immediately begins to produce immunoglobulin G, and this is the reason for the earlier onset of the Rh-conflict and its stronger manifestation.

Risk factors for the development of Rh-conflict

If the expectant mother has a negative Rh factor, and the child's dad is positive, then the risk factors for the development of the Rh conflict will be:

• second and subsequent pregnancies from this partner - both uterine and ectopic;
• miscarriages and abortions from this partner;
• arterial hypertension in the expectant mother;
• cesarean section, carried out in a previous pregnancy, and pregnancy-related invasive gynecological manipulations: termination of pregnancy, ectopic pregnancies, miscarriages carried out without the introduction of anti-rhesus immunoglobulin.

Diagnostics

Diagnostics for Rh-conflict is aimed not only at identifying this condition, but also at assessing the condition of the baby. What kind of research will need to be done expectant mother?

Determination of the Rh factor and. All pregnant women, upon registration, regardless of what kind of pregnancy it is, are screened for blood group and Rh factor.

Determination of anti-rhesus antibodies. This analysis is carried out when registering for all expectant mothers, Rh-negative women are given a second referral for this analysis for a period of 18–20 weeks, regardless of the partner's Rh factor. If the partner has Rh-positive blood, the determination of anti-Rh antibodies is repeated monthly until 32 weeks of pregnancy (starting from 18-20 weeks), from 32 to 35 weeks of pregnancy, the analysis is performed twice a month, from the 35th week of pregnancy - weekly to determine delivery tactics. The presence of these antibodies in large quantities (or, as doctors say, titer) and / or their rapid and massive increase indicate the presence of Rh-conflict. In such cases, the pregnant woman is monitored together with the doctors of the perinatal center, where she is given a referral to the antenatal clinic.

Ultrasound examination of the fetus at 18–20 weeks of gestation. Rh-conflict can be suspected by the following ultrasound signs:

• swelling and accumulation of fluid in the cavities of the fetus;
• unnatural fetal posture - the so-called Buddha posture, when, due to the large amount of liquid in the tummy, the baby is forced to spread the legs to the sides;
• double head contour;
• thickening of the placenta.

Subsequent ultrasound examinations fetuses are usually carried out in dynamics to assess the condition of the baby at 24-26, 30-32 and 34-36 weeks.

Doppler imaging and cardiotocography also allow you to understand how the baby is feeling and whether he needs active therapeutic measures.

According to the indications, invasive diagnostic methods are carried out:

Amniocentesis- this is a study when a small amount is taken through a puncture in the membranes amniotic fluid for analysis to determine the level of bilirubin.

Cordocentesis- This is a study when a small amount of fetal blood is taken through a puncture of the umbilical cord to determine the amount of bilirubin.

Complications of Rh-conflict

Why do doctors pay so much attention to the Rh factor of the expectant mother? The fact is that the Rh-conflict can adversely affect the course of pregnancy and the condition of the fetus. He is dangerous with the following complications:

• miscarriage;
• the development of hemolytic disease of the newborn (HDN) is the most frequent complication of the Rh-conflict. The disease can occur in three different forms: edematous, icteric and anemic. The most dangerous form HDN is edematous, as the edema interferes with the normal functioning of the baby's organs. Such babies often require resuscitation measures immediately after birth and long-term treatment. In second place in danger is the icteric form, since a large amount of bilirubin damages the baby's organs - the brain, kidneys. And in third place is the anemic form, which is not so dangerous, but requires control and restoration of the hemoglobin level;
• intrauterine.

However, expectant mothers do not need to be upset and panic, because at present, thanks to the actions of doctors, in 90–97% of cases, complications of the Rh-conflict can be avoided.

In the first pregnancy, the risk of developing Rh-conflict is approximately 10%; in repeated pregnancies, this risk remains the same if antibodies were not detected, or increases with each subsequent pregnancy if antibodies were produced. The increase in risk depends on how the pregnancy proceeded, what the titer (amount) of antibodies was and whether vaccination was carried out. After termination of pregnancy or miscarriages in an Rh-negative woman who is pregnant with an Rh-positive fetus, the risk of developing Rh-conflict is approximately 3-5%.

Pregnancy management with Rh-conflict

The main goal of a gynecologist is to prevent the development of complications, since it is impossible to cure the Rh-conflict itself.

Since the main cause of the baby's suffering in Rh-conflict is hypoxia, then it is precisely at its elimination that most of the manipulations and drugs are directed. The main task of a woman is to fulfill all the recommendations of her doctor as accurately as possible. After all, this is the only way to avoid serious consequences for this and, importantly, for subsequent pregnancies.

If anti-rhesus antibodies are found in the blood of the expectant mother, then it is necessary to carry out treatment that will prevent an increase in their number. For this, non-specific and specific methods are used.

Non-specific means are aimed at strengthening the blood vessels of the placenta, which helps to reduce the amount of antibodies that penetrate through it to the fetus. These are vitamin therapy, oxygen therapy, UV radiation sessions, plasmapheresis.

Specific treatment is the introduction of anti-rhesus immunoglobulin. This drug prevents sensitization (sensitization) of a Rh-negative woman with Rh-positive fetal red blood cells. It is administered twice - at the 28th week of pregnancy and after childbirth, provided that the child was born with a positive Rh factor. To achieve a protective effect, this must be done within 48, maximum 72 hours after delivery. It is worth remembering that a low level of anti-rhesus antibodies in the mother's blood is not a reason to refuse vaccination. After all, the introduction of anti-Rh immunoglobulin helps to significantly reduce the complications of the Rh-conflict in subsequent pregnancies, but does not exclude the Rh-conflict in principle. And in some cases, booster vaccinations may be required. Also, a Rh-negative woman needs a vaccine for abortion, blood transfusion, obstetric invasive procedures.

How to help a baby with Rh-conflict?

On this moment there is only one method with proven therapeutic efficacy - intrauterine blood transfusion. It has been used since 1963 for severe forms of Rh-conflict - dropsy of the fetus, severe hypoxia and ineffectiveness of the above methods. At the moment, the technique of the procedure has been fully worked out, and the risk of complications has greatly decreased. Intrauterine blood transfusion is performed under ultrasound control through a small puncture in the mother's abdomen. An erythrocyte mass is injected into the umbilical cord, which makes it possible to relieve intrauterine oxygen starvation of the fetus. Studies have shown that most babies who have undergone intrauterine blood transfusion grow and develop normally.

Subsequent pregnancies after Rh-conflict

Many women planning to become a mother for the second time are concerned about the question: if the first pregnancy proceeded with Rh-conflict, does this mean that next time we should expect the same development of events? No, it’s not like that. But in order for everything to be good, the following conditions are necessary:

• Of course, it would be ideal if a woman with a negative Rh factor gets pregnant with a Rh negative baby. Unfortunately, we cannot influence this factor.
• Timely administration of anti-rhesus immunoglobulin during the first and current pregnancy - either at the 28th week of pregnancy, or within 48–72 hours after.
• Refusal of abortions and blood transfusions without the use of anti-rhesus immunoglobulin.
• Compliance with all the prescriptions of your doctor.

Childbirth with Rh-conflict

Childbirth is the main "treatment" for Rh-conflict. After the chain breaks between the mother and the fetus, the woman's body stops transmitting anti-rhesus antibodies to the baby, which makes it possible for the baby's body to recover. However, this does not happen immediately, since antibodies are present in the blood of the newborn for several more days. Most births with Rh-conflict go away naturally... But in some cases, a cesarean section is performed, since this type of delivery is considered more gentle for the fetus when the baby suffers from a lack of oxygen and is weakened.

The indication for premature delivery in Rh-conflict is the deterioration of the fetus and the degree of maturity of its lungs.

Breastfeeding with Rh-conflict

Of course, the question of whether it is possible to breastfeed a baby during Rh-conflict worries so many mothers. However, experts still have no consensus on this matter. According to the latest recommendations, breastfeeding is possible a few days after birth (usually 3-5 days), until most of the antibodies are removed from the mother's body, and it is recommended to express milk before breastfeeding to establish lactation.

Some experts believe that no restrictions are needed at all for breastfeeding. In fact, everything is individual and depends on the state of both the mother and the baby after childbirth.

In conclusion, I would like to note that at the moment, thanks to the development of medicine and the control of doctors over the course of pregnancy accompanied by Rh-conflict, it is quite possible to endure and give birth to a healthy baby.

Is it possible to determine the Rh factor of the fetus?

Of course, it would be convenient to know what Rh factor the future baby has - after all, it will immediately become clear whether the expectant mother needs to regularly donate blood for antibodies and whether there is a need to inject anti-rhesus immunoglobulin... If a Rh-negative mother also has a baby with an Rh-negative blood factor, then all these precautions will not be needed. However, until recently, it was impossible to determine this in a safe way for a developing child and in a publicly available way. But at the moment, expectant mothers have such an opportunity - it is possible to determine the Rh factor of the child by the mother's blood using the PCR method. The method is based on the fact that during pregnancy, the baby's DNA enters the mother's bloodstream, which makes it possible to determine the Rhesus DNA of the future baby. This examination can be carried out from the 12th week of pregnancy.

A couple of decades ago, a woman's Rh-negative blood was considered almost a curse that prevented her from having many children. The birth of the second, and in some cases even the first, healthy child was an almost insoluble problem. Blame it all - developing during pregnancy rhesus conflict... What do we know about this pathology, and how are they helping such mothers now?

What is Rh-conflict

85% of Caucasians have a special protein called the Rh factor in the outer membrane of each red blood cell. This means that their blood, regardless of the group, is Rh positive. The remaining 15% of people do not have such protein in red blood cells, that is, they are Rh negative. For their immune system, Rh protein is a foreign substance, like microbes or an organ transplanted from another person. Therefore, when erythrocytes from a Rh-positive person enter the bloodstream of a Rh-positive person, protective antibodies are inevitably formed in his body. They find strangers and destroy them with the help of immune killer cells. This mechanism is called Rh-conflict. Moreover, the immune system of a Rh-negative person forever "remembers" the episode of meeting with Rh-positive blood. When the Rh protein gets in again, a violent reaction of its destruction occurs.

What is the danger of Rh-conflict for the fetus

Anti-Rhesus antibodies, penetrating the damaged placenta to the fetus, destroy its erythrocytes. This state is called hemolytic disease... The baby begins to experience oxygen hunger. In response, in an attempt to compensate for hypoxia, new young red blood cells - reticulocytes - are formed. Since dead cells accumulate in the spleen, and hematopoiesis in the fetus occurs in the liver, these organs greatly increase in volume. If it is not possible to stop or compensate for the destruction of red blood cells, severe anemia... In conditions of a pronounced lack of oxygen, the child's organs lag behind in development, and the most sensitive cells, especially in the brain, die.

When erythrocytes break down, the toxic substance bilirubin enters the bloodstream. It causes an icteric staining of the skin and mucous membranes. In high concentrations, it damages nerve centers in the brain, causing irreversible neurological defects. It can be convulsions, movement disorders up to infantile cerebral palsy, mental disability.

If antibodies enter the baby's body repeatedly, a lot of protein is consumed to build more and more cells instead of the decayed ones. When its supply in the child's body is depleted, massive edema occurs. The liquid part of the blood is not retained in the bloodstream and accumulates in the cavities:

• in the pleural space, preventing immature lungs from opening and causing severe respiratory distress;
• in the abdominal, causing ascites;
• in the pericardial sac, causing heart failure;
• in the brain, causing it to edema, which means convulsions and deep impairment of consciousness.

How does the Rh-conflict manifest in a child

From the first hours of life, the baby shows and continues to develop symptoms of hemolytic disease of the newborn. Its severity, which means possible complications and the consequences for life and health, directly depends on the aggressiveness of the ongoing intrauterine Rh-conflict and on the amount of anti-Rh antibodies accumulated in the child's body. In any case, without active supervision by doctors and without adequate treatment, this disease is life-threatening or can lead to disability.

When Rh-conflict occurs during pregnancy

First and foremost condition- Rh-negative mother must carry a Rh-positive child who inherited the protein composition of red blood cells from his father. Moreover, according to statistics, half of these dads transmit the Rh factor to all their children, and the second half - in about 50% of cases. That is, all of their 25% of babies are born Rh-negative, which means - without an immunological conflict.

Second condition- the meeting of the mother's body with the Rh protein that happened before pregnancy with the formation of immunological memory cells. It happens:

• with transfusion of Rh-positive blood or erythrocytes;
• with previous abortions or miscarriages, if the fetus was Rh-positive;
• after a previous spontaneous birth or a caesarean section, if that child inherited the father's Rh factor.

Third condition- violation of the barrier properties of the placenta. In a normal pregnancy, the blood of the mother and the fetus never mixes. This can happen with intrauterine infections, with partial placental abruption or trauma, as well as with amniocentesis and cordocentesis.

Very rarely there are casuistic cases when the Rh-conflict develops already during the first uncomplicated pregnancy in a woman whose blood was not transfused.

The likelihood of developing Rh-conflict during the first and subsequent pregnancies

During the first pregnancy, Rh-conflict develops in no more than 10% of expectant mothers with Rh-negative blood. These are the women who have previously received blood products. Each subsequent pregnancy with a Rh-positive fetus, especially with a short time interval, increases the risk of this condition.

How to reduce the risk of developing Rh-conflict during pregnancy

Today, a Rh negative woman can become a mother of many children. The only condition is the timely (that is, no later than 3 days after childbirth, abortion or miscarriage) the introduction of a special immunoglobulin. One injection of this drug destroys the Rh proteins that have entered the mother's body before her immune system is activated. As a result, a miracle occurs: the risk of developing a Rh-conflict will remain the same as in a first-pregnant woman - no more than 10%.

Anti-Rhesus immunoglobulin is also administered during pregnancy, at about 28 weeks, if the observation process does not reveal signs of the development of intrauterine conflict. This helps to prevent its occurrence right up to delivery. The injection is repeated after any manipulation or complications of pregnancy in which there is a risk of violation of the placental barrier: with amniocentesis or cordocentesis, with partial placental abruption, with blood anesthesia, with injuries of the uterus.

The drug protects for only a few weeks, so it must be administered during the next pregnancies. The exception is women who have a titer of anti-rhesus antibodies in their blood. This means that their immune system already has memory cells responsible for the development of Rh-conflict. That is, immunoglobulin will not help such mothers. This is why it is important to use it already in the first pregnancy.

Diagnostics of the Rh-conflict during pregnancy

If the expectant mother has Rh negative blood, during the first visit to the antenatal clinic, she will be asked to clarify the blood group of the child's father. If she is Rh-positive, the woman will be seen by a gynecologist because of the 75% risk of developing Rh-conflict.

To determine its occurrence and the rate of development, a regularly performed blood test helps to detect Rh antibodies in the mother's blood. It is done from 8 weeks of gestation, when proteins of the blood group begin to form in the fetus. During the first pregnancy, in the absence of blood transfusions in the past, the study is performed every 2 months. If the pregnancy is not the first, or the fact of the introduction of earlier Rh-positive blood has been proven, the analysis is carried out monthly, after 32 weeks - twice with an interval of 14 days and then before delivery - weekly.

From the moment of registration for pregnancy of the expectant mother at least 5 times, from 16 weeks to delivery, an ultrasound of the fetus is done. During the study, signs of intrauterine Rh-conflict can be identified:

• a thick, edematous placenta;
• an enlarged liver and spleen in the fetus;
• polyhydramnios;
• fluid in the abdominal and pleural cavities in a child;
• thickening of the veins of the umbilical cord;
• symptoms of oxygen starvation of the fetus: low physical activity, disturbance of the rhythm of heart contractions, meconium suspension in the amniotic fluid.

It is possible to suspect that the child is suffering from a lack of oxygen based on the results of CTG (cardiointervalography). A slow rigid heart rate with a weak response to various stimuli and rare movements is recorded.

The latest obstetric techniques help to confirm with high accuracy the fact of the Rh-conflict. During amniocentesis, a small portion of amniotic fluid is taken and the concentration of bilirubin is determined by its optical density, the titer of anti-Rh antibodies and the readiness of the fetal lungs for extrauterine life. With cordocentesis under ultrasound control, fetal blood from the umbilical cord vein is taken for analysis. Clarify his blood group and rhesus, examine the level of bilirubin, hemoglobin, mature and young forms of erythrocytes, hematocrit, whey protein. Reveal the amount of anti-Rhesus antibodies on the erythrocytes of the child, the partial tension in the blood of carbon dioxide and oxygen. So even before birth, doctors find out the severity of the Rh-conflict and its complications, and have a real opportunity to help the baby maintain health, and sometimes life.

How is Rh-conflict treated during pregnancy

Throughout pregnancy, the expectant mother takes courses of drugs that reduce the degree of aggressiveness of the immune response and help the fetus to more easily endure oxygen deficiency. These are antihistamines, vitamins, iron preparations. Use different kinds oxygen therapy, including hyperbaric oxygenation.

Plasmapheresis procedure helps to reduce the amount of anti-rhesus antibodies.

With the help of cordocentesis, it became possible to carry out a replacement blood transfusion in utero, through the veins of the umbilical cord, under the control of ultrasound. Thanks to this, it is possible to prevent the development of the edematous form of the disease and prolong the pregnancy in order to enable the child to mature for birth.

If the development of the Rh-conflict can be contained, and the condition of the fetus is assessed as satisfactory, childbirth is carried out after 36 weeks. If the baby begins to suffer, a cesarean section is performed.

Breastfeeding with Rh-conflict

If the Rh-conflict has not developed, the baby can be breastfed after the mother is given anti-Rh immunoglobulin. In the presence of a high titer of antibodies against the baby's erythrocytes, breastfeeding should be postponed for two weeks, so as not to cause the progression of hemolytic disease and worsen the baby's condition.

Methods for treating Rh-conflict in newborns

The treatment regimen depends on the severity of the condition. In mild cases, it is sufficient to observe and prevent anemia with iron and folic acid preparations. It may be necessary to administer a donor red blood cell mass.

The most common treatment for jaundice in hemolytic disease today is phototherapy. Under the influence of light of a certain spectrum, the formed bilirubin in the surface layers of the skin is converted into a non-toxic compound and excreted in the urine. To speed up blood cleansing, drink plenty of fluids or inject fluids intravenously. It is completely harmless to the baby.

With the rapid development of hemolytic disease after childbirth, leading to a rapid increase in bilirubin and a threatening drop in hemoglobin, a replacement blood transfusion is performed. The baby's blood is removed through the umbilical cord vein, reimbursing in return for donor blood.

With the edematous form of Rh-conflict, from the moment of birth, the child requires a large amount of resuscitation care.

The mechanisms of development of hemolytic disease of a newborn with Rh-conflict differ from that with incompatibility in blood group only by a higher rate and a more frequent severe course. Therefore, they have common principles of treatment.

Isoserological incompatibility of the blood of the mother and the fetus is a condition in which there is a conflict in the Rh or ABO system. A special case of this pathology is the Rh-conflict. In the absence of adequate therapy and timely assistance, such a condition threatens spontaneous interruption pregnancy, fetal death at a later date, or the development of hemolytic disease. Serious consequences await the child after birth. What should a woman know about this dangerous pathology?

Rhesus: general concepts

In the body of each person there are specific antibodies that determine the Rh-belonging of his blood. Rhesus is a set of 50 special antibodies - proteins located on erythrocytes. In practical medicine greatest value have antibodies of group D. It is these proteins that determine the Rh of each person.

The Rh factor is established at the time of conception and does not change throughout life. 85% of people have protein D and are considered Rh positive (Rh +). The remaining 15% of the world's population lacks a specific protein and is considered Rh negative (Rh-).

In ordinary life, the Rh factor does not matter. Both Rh-positive and Rh-negative people are equally likely to suffer from various diseases. Rhesus does not affect the conception of a child. Problems arise only in Rh-negative women during pregnancy. It has been proven that the absence of an important protein can fatally affect the development of the fetus under certain circumstances.

Excursion into genetics

The Rh of the embryo is laid at the time of conception and is determined by the Rh of its parents:

Based on these data, several conclusions can be drawn:

1. In a Rh-positive woman, the conflict never develops, and the Rh of the fetus does not matter.
2. An Rh negative woman may have an Rh + or Rh- baby.
3. If the Rh-mother carries the Rh-child, there will be no conflict.

Rh-conflict occurs in a single case: when a Rh-negative woman is pregnant with an Rh-positive fetus.

Causes of Rh-conflict

The essence of the problem lies in the fact that specific antibodies are absent in the blood of Rh-women, while they are present on the Rh + erythrocytes of the embryo. During gestation, the blood of the mother and baby inevitably mixes. Fetal antibodies enter the mother's bloodstream. Here they are perceived as a kind of alien object. The woman's immune system tries to protect the body from the introduction of a stranger, and does everything to get rid of the problem. This explains all clinical manifestations Rh-conflict during pregnancy.

Rh antibodies that have entered a woman's bloodstream are very aggressive. They are absolutely not dangerous to the mother, but they pose a real threat to the health and life of the fetus. Moreover, the first pregnancy for a Rh-woman usually ends well. The likelihood of developing Rh-conflict occurs mainly in the second and subsequent pregnancy.

Why is the risk of Rh-conflict minimal during the first pregnancy? The thing is that during gestation, the fetus is reliably protected from direct contact with the mother's blood. During the first pregnancy, antibodies of class M (YgM) are produced, which are not able to pass through the hemato placental barrier and get to the fetus. Subsequently, with repeated contact (second pregnancy), antibodies of class G (YgG) are formed, which easily pass through the placenta, enter the fetal bloodstream and exert their negative effect.

The entry of Rh-positive antibodies into a woman's bloodstream occurs in the following situations:

• during childbirth;
• with abortions, miscarriages;
• with an ectopic pregnancy (at the time of its termination).

The risk of developing antibodies increases in such situations:

• in case and bleeding during pregnancy;
• with invasive manipulations during pregnancy (amniocentesis, cordocentesis, chorionic biopsy);
• with traumatic childbirth;
• with manual separation of the placenta;
• during a cesarean section.

In all these situations, a large number of fetal erythrocytes carrying Rh + antibodies enter the maternal bloodstream. It is also possible the formation of antibodies during transfusion of Rh-positive (incompatible) blood to a woman. This phenomenon is called Rh sensitization.

In most cases, a woman is immunized in the first birth. At the same time, the child is born healthy, but Rh antibodies penetrate into the mother's body. Once they appear, they remain in the bloodstream forever. It is impossible to get rid of Rh antibodies. In repeated pregnancies, these antibodies will quickly recognize the Rh + fetus and send a signal to the immune system. That's why repeated pregnancy Rh + fetus leads to the development of serious complications up to its interruption. With each subsequent pregnancy, the severity possible consequences increases.

Symptoms in women

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

Some experts talk about the existence of "mirror syndrome". It is believed that with an increase in antibodies in the blood, a woman has characteristic symptoms of gestosis as a sign of a violation of the body's adaptation to pregnancy. The appearance of edema, an increase in blood pressure, a deterioration in the general condition are noted. Currently, the connection of these signs with the Rh-conflict has not been proven, so you should not be guided by them.

Consequences for the fetus

Rh-conflict poses a certain threat to the child. The growth of aggressive antibodies leads to disruption of the vital functions of the fetus and threatens the development of the following complications:

• spontaneous miscarriage;
• premature birth (after 22 weeks);
• HDF - fetal hemolytic disease;
• HDN - hemolytic disease of the newborn.

The first two complications should be considered as manifestations of HDN, but it is not always possible to find out the exact reason for the termination of pregnancy.

Hemolytic disease of the fetus and newborn

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

• 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 liver and spleen of the fetus to work in an enhanced mode, 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.
• Damage to the fetal brain cells is observed.

Hemolytic disease makes itself felt in the second half of pregnancy. Pathology is detected during 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 others internal organs do not cope with the load, fetal death occurs at any stage of pregnancy.

Quite often, the Rh-conflict manifests itself after the birth of a child. This condition is called hemolytic disease of the newborn (HDN). Symptoms are similar to HDF, since the initial symptoms of pathology are noted even during intrauterine development.

Forms of hemolytic disease (HD):

Anemic form

The easiest variant of the GB flow. With this form, it is noted:

• a 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 a baby's life, pallor is noted. skin... The general condition of the baby is not disturbed. Anemia responds well enough to correction. In the future, this form of HD has practically no effect on the development of the child.

Icteric form

The main symptoms are:

• anemia;
• early jaundice of a newborn (up to the 2nd day of life);
• enlargement of the liver and spleen.

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

Edematous form

The most difficult variant of the course of GB. The first symptoms are noted during the period of intrauterine development. Massive hemolysis of erythrocytes leads not only to anemia, but is also accompanied by edema of all tissues. A child is born in an extremely serious condition with dysfunction of vital organs. The prognosis is unfavorable, however, under certain conditions, it is possible to save the child's life. Often, the edematous form leads to early termination of pregnancy.

Diagnostic methods

To identify pathology, the following methods are used:

Laboratory research

All women registering for pregnancy donate blood three times to determine the blood group and Rh-affiliation:

• at the first appearance;
• for a period of 30 weeks;
• before childbirth.

If Rh is detected, analysis is carried out every month. Be sure to determine the antibody titer over time. Absolute titer value of particular importance does not have. The doctor pays attention to the rate of antibody growth. Too rapid growth or abrupt change in antibody titer may indicate the development of complications. Regular monitoring of the level of antibodies helps to notice the onset of the Rh-conflict in time and prevent the development of undesirable consequences.

Ultrasound

The condition of the fetus is assessed during an ultrasound scan. The first signs of HD can be detected at 18-21 weeks, during the second ultrasound screening. Further tactics will depend on various factors:

1. In the absence of Rh sensitization (according to a blood test, i.e., in the absence of antibodies in the mother's blood), a second ultrasound scan is performed at 32-34 weeks (III screening).
2. In the case of Rh sensitization and a satisfactory condition of the fetus, ultrasound control is indicated every 2 weeks.
3. If GBP is detected, ultrasound is performed every 3-7 days (according to indications - daily).

Ultrasound signs of HDF:

• an increase in the thickness of the placenta by 0.5 cm or more (in relation to the norm for this period pregnancy);
• an increase in the size of the liver and spleen;
• polyhydramnios;
• expansion of the umbilical cord vein more than 10 mm (additional feature).

An accurate diagnosis can be made only with the edematous form of HDF. In this case, there is a pronounced increase in the liver and spleen, ascites, a significant thickness of the placenta (up to 6-8 cm). There is an increase in the size of the heart. An effusion in the pleural cavity, swelling of the intestinal walls, subcutaneous tissue of the head, and fetal limbs are diagnosed.

Of great importance is the determination of the blood flow velocity in the middle cerebral artery by Doppler. An increase in this indicator by more than 1.5 MoM for a specific gestational age indicates severe anemia. In this case, additional invasive diagnostics is indicated.

Invasive procedures

To assess the condition of the fetus, it is shown:

• amniocentesis - amniotic fluid intake (from 16 weeks);
• cordocentesis - cord blood sampling (from 18 weeks).

Cordocentesis - exact method diagnostics of GBP. It is also used to assess the severity of pathology. The only indication for this procedure is severe anemia detected by ultrasound. In this case, cordocentesis serves not only for diagnosis, but also for treatment (intrauterine blood transfusion). In other situations, cordocentesis is not indicated, since such an intervention in itself increases the risk of sensitization and antibody growth.

During cordocentesis, the received portion of blood is examined, the level of hemoglobin, hematocrit, and bilirubin is determined. The data obtained is checked against the norm for each gestational age.

Non-invasive diagnostics

Determination of the Rh factor of the fetus by the mother's blood is a modern procedure used in many progressive clinics. The woman donates the shelter for analysis, and fetal erythrocytes are detected in the material received. In the laboratory, the blood group and Rh factor of the fetus are determined. Establishment of Rh-fetal blood in the early stages of pregnancy allows avoiding the appointment of dangerous invasive procedures and thereby significantly reducing the risk of possible complications.

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. Medicines that can change the level of antibodies in the mother's blood or reduce the likelihood of developing HDF does not exist.

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

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

Childbirth with Rh-conflict

Since the operation increases the risk of further sensitization and massive ingestion of fetal red blood cells into the mother's bloodstream, labor is tried to be carried out through the vaginal birth canal. Indications for a cesarean section may include the following conditions:

• severe condition of the fetus with HDF;
• immature cervix;
• the presence of extragenital pathology or other factors.

Prophylaxis

Specific prevention of Rh-conflict involves the timely administration of anti-Rh immunoglobulin in certain situations:

1. When pregnant with Rh + fetus at 28 weeks.
2. In natural or operative childbirth (the maximum period is 72 hours after delivery).
3. After spontaneous miscarriage, induced abortion, interrupted ectopic pregnancy within 72 hours.
4. When carrying out any invasive manipulations during gestation.

Anti-Rhesus immunoglobulin is injected intramuscularly once (dosage 300 mg). It is recommended to carry out prophylaxis during the first hours after childbirth, abortion, etc. The maximum possible time for drug administration is 72 hours.

Non-specific prophylaxis:

1. Preservation of the first pregnancy in a Rh-woman.
2. Competent contraception.
3. Refusal of abortion.
4. Blood transfusion taking into account the Rh factor.

Why is it so important to keep your first pregnancy? In most cases, immunization does not occur during the first pregnancy, and a woman can give birth to a healthy baby without any problems. In the second and subsequent pregnancies, the risk of developing HDF increases significantly (without specific prophylaxis). In the event that a woman has an abortion in her first pregnancy and does not inject an anti-rhesus immunoglobulin, she has every chance of being left without children in the future.

Currently, an IVF program has been developed that allows you to give birth to a healthy baby, even in severe cases. IVF is indicated for Rh sensitization and previous death of the fetus or newborn. In this case, embryos with Rh-blood are pre-selected, and it is they who are implanted into the uterus. In this situation, the Rh-conflict is not observed, and the woman can safely endure pregnancy.

A special antigen is present on the erythrocyte membrane in 85% of the population, which endows people with a positive Rh factor. Those with a negative Rh factor do not have this antigen.

The Rh factor has no effect on human health, however, a negative Rh can complicate the course of pregnancy in a woman, provoking the Rh conflict between mother and child.

Forums about motherhood contain questions - what does Rh incompatibility mean, when there is a blood conflict, how is childbirth going on, and is it possible to breastfeed in a conflict? This article will help you understand - what is the essence of the Rh-conflict, what are its consequences during pregnancy and what a woman should do if it is detected.

Rh-conflict during pregnancy is the immune response of the Rh-negative female body to the antigens of her Rh-positive fetus, the woman's body perceives the proteins (antigens) of the child as foreign and tries to destroy them. Rh-conflict leads to hemolysis of red blood cells and causes developmental abnormalities in the baby.

Rh-conflict occurs when the erythrocytes of the mother and the fetus meet in the gap between the placenta and the uterus and agglutination (adhesion) occurs, while the woman's immune system begins to produce immunoglobulins - antibodies that prevent adhesion of "conflict" erythrocytes. At the first collision of negative erythrocytes of the mother with positive blood of the fetus, large antibodies of the IgM type are produced, which, if they penetrate into the blood, then in small quantities. Based on this, the first pregnancy is relatively rarely burdened by the consequences of a blood conflict.

Due to the fact that positive blood is stronger, then in the situation of carrying a baby with negative blood, no conflict will occur against the background of clumping of erythrocytes. There are no problems in the case of negative rhesus of both parents, since the baby will genetically acquire negative blood. The risk of developing Rh-conflict is clearly shown in the table:

From the indicators in the table, we can conclude that a blood conflict with differences in Rh factors in parents does not always develop. With a negative rhesus in the mother, the baby can inherit negative blood, which will exclude the possibility of conflict.

The likelihood of Rh-conflict can be traced by the blood groups of the parents based on the table compiled by studying the interaction of erythrocytes: