Rh disease

Rh disease (also known as rhesus isoimmunization, Rh (D) disease, or rhesus incompatibility, and blue baby disease) is a type of hemolytic disease of the fetus and newborn (HDFN). The term "Rh disease" is commonly used to refer to HDFN as prior to the discovery of anti-Rho(D) immune globulin, it was the most common type of HDFN. The disease ranges from mild to severe, and occurs in the second or subsequent pregnancies of Rh-D negative women when the biological father is Rh-D positive due to the presence of anti-D antibodies (the D antigen being only one of more than 50 in the Rh complex). Due to several advances in modern medicine HDFN can be prevented by treating the mother during pregnancy and soon after delivery with an injection of anti-Rho(D) immune globulin (Rhoclone, Rhogam, AntiD). With successful mitigation of this disease by prevention through the use of anti-Rho(D) immune globulin, other antibodies are more commonly the cause of HDFN today.

Mechanism

During pregnancy, there is normally a barrier between maternal and fetal blood called the placenta, a temporary organ that connects a mother's uterus to the umbilical cord to provide nutrients and oxygen to the fetus. However, in certain circumstances, small amounts of fetal blood cells may enter the mother's circulation. Certain types of events where this occurs are during childbirth, miscarriage or abortion, trauma, and invasive procedures such as amniocentesis. Once the fetal Rh-positive red blood cells enter the bloodstream of a Rh-negative mother, they are recognized as foreign. The mother's immune system reacts to the Rh-positive red blood cells the same way that it would respond to something like a virus or bacteria, activating B cells—a type of white blood cell that is key to the triggering of an immune response. These activated B cells then differentiate into plasma cells, which produce anti-D antibodies. After the primary exposure, some of these B cells become memory cells that remember the original exposure, and produce IgG antibodies, which are smaller and can cross the placental barrier. Once they cross this barrier into the fetal bloodstream, they bind to fetal Rh-positive cells, triggering opsonization, which marks the red blood cells for destruction. The fetal spleen and liver then begin to break down those red blood cells, thinking that they are a foreign invader when in reality they are just mismatched.

Signs and symptoms Symptoms of Rh disease include yellowish amniotic fluid and enlarged spleen, liver or heart or buildup of fluid in the abdomen of the fetus.

Pathophysiology

During the first pregnancy, the Rh− mother's initial exposure to fetal Rh+ red blood cells (RBCs) is usually not sufficient to activate her Rh-recognizing B cells. However, during delivery, the placenta separates from the uterine wall, causing umbilical cord blood to enter the maternal circulation, which results in the mother's proliferation of IgM-secreting plasma B cells to eliminate the fetal Rh+ cells from her blood stream. IgM antibodies do not cross the placental barrier, which is why no effects to the fetus are seen in first pregnancies for Rh-D mediated disease. However, in subsequent pregnancies with Rh+ fetuses, the IgG memory B cells mount an immune response when re-exposed, and these IgG anti-Rh(D) antibodies do cross the placenta and enter fetal circulation. These antibodies are directed against the Rhesus (Rh) factor, a protein found on the surface of the fetal RBCs. The antibody-coated RBCs are destroyed by IgG antibodies binding and activating complement pathways. The resulting anemia has multiple sequelae:

The immature haematopoietic system of the fetus is taxed as the liver and spleen attempt to put immature RBCs into circulation (erythroblasts, thus the previous name for this disease erythroblastosis fetalis). As the liver and spleen enlarge under this unexpected demand for RBCs, a condition called portal hypertension develops, and this taxes the immature heart and circulatory system. Liver enlargement and the prolonged need for RBC production results in decreased ability to make other proteins, such as albumin, and this decreases the plasma colloid osmotic pressure (the fluid-retaining ability of blood plasma) leading to leakage of fluid into tissues and body cavities, termed hydrops fetalis. The severe anemia taxes the heart to compensate by increasing output in an effort to deliver oxygen to the tissues and results in a condition called high output cardiac failure. If left untreated, the result may be fetal death. The destruction of RBCs leads to elevated bilirubin levels (hyperbilirubinemia) as a byproduct. This is not generally a problem during pregnancy, as the maternal circulation can compensate. However, once the infant is delivered, the immature system is not able to handle this amount of bilirubin alone and jaundice or kernicterus (bilirubin deposition in the brain) can develop which may lead to brain damage or death. Sensitizing events during pregnancy include c-section, miscarriage, therapeutic abortion, amniocentesis, ectopic pregnancy, abdominal trauma and external cephalic version. However, in many cases there was no apparent sensitizing event. Approximately 50% of Rh-D positive infants with circulating anti-D are either unaffected or only mildly affected requiring no treatment at all and only monitoring. An additional 20% are severely affected and require transfusions while still in the uterus. This pattern is similar to other types of HDFN due to other commonly encountered antibodies (anti-c, anti-K, and Fy(a)).

Diagnosis

Maternal blood In the United States, it is a standard of care to test all expecting mothers for the presence or absence of the RhD protein on their RBCs. However, when medical care is unavailable or prenatal care not given for any other reason, the window to prevent the disease may be missed. In addition, there is more widespread use of molecular techniques to avoid missing women who appear to be Rh-D positive but are actually missing portions of the protein or have hybrid genes creating altered expression of the protein and still at risk of HDFN due to Anti-D.

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