CAFONGTAN, Krisha L.

BSN 2
10. ABO/RH Incompatibility
Introduction
Definition of terms:
a) Hemolytic disease of the newborn (HDN) - also called erythroblastosis fetalis - is a blood disorder that occurs
when the blood types of a mother and baby are incompatible.
b) ABO Incompatibility - ABO incompatibility results when the fetal blood type is different from the mother's blood
type.
c) RH Incompatibility - Rh incompatibility is a condition that develops when a pregnant woman has Rh-negative
blood and the baby in her womb has Rh-positive blood
d) Hemolysis - medical term used to describe the destruction of red blood cells. Your body is constantly destroying
old or damaged red blood cells and replacing them with new ones. Red blood cell destruction is a normal, healthy
process.
e) Hydrops Fetalis - a condition in which large amounts of fluid build-up in a baby's tissues and organs, causing
extensive swelling (edema).
f) Kernicterus - a type of brain damage that can result from high levels of bilirubin in a baby's blood

Body
ABO Incompatibility
 Maternal blood type: O, Fetal blood type: A (most common), AB, or B (most serious)
o Mother – Type O; Fetus – Type A →most common
o Mother – Type O; Fetus – Type B →most severe
 Hemolysis can become a problem with a first pregnancy - hemolysis/ destruction of RBC leading to ↓ O2
carrying capacity leading to IUGR with pathologic jaundice w/in 24 hours. Hemolysis of the blood begins with
birth, when blood and antibodies are exchanged during the mixing of maternal and fetal blood as the placenta is
loosened; destruction of red cells may continue for up to 2 weeks of age.
 These antibodies are of the large (IgM) class and do not cross the placenta. Only IgG are involved because they
can cross the placenta. IgM antibodies represent response to a current or recent infection while IgG antibodies
represent response from a past infection
 An infant of an ABO incompatibility, is not born anemic, as is the Rh-sensitized child.
 Hydrops Fetalis
o Common in abo incompatibility
o Newborn is edematous, on lethal state, accompanied by pathologic jaundice w/in 24 hours
 Difference from Rh Incompatibility o First pregnancy is affected or NB is yellow and edematous
RH Incompatibility

 Is a condition that develops when a pregnant client has Rh- blood and the baby in her womb is RH+, the
introduction of fetal blood causes sensitization to occur, and the woman begins to form antibodies against the D
antigen.
 Typically occurs in the second or subsequent pregnancies
 Causes:
 Tests like amniocentesis and chorionic villus sampling (CVS).
 Any type of vaginal bleeding during pregnancy.
 Injury or trauma to the mothers’ abdomen.
 Early pregnancy complications like miscarriage or ectopic pregnancy.
CAFONGTAN, Krisha L.
BSN 2
 Uteroplacental barrier – prevents blood of baby and mother to mix. Through pinocytosis, antibodies cross
membrane
Pathophysiology

 Mother (-) and Baby (+) Usually first baby not affected →birth of placenta (Most antibodies form in the
woman’s bloodstream in the first 72 hours after birth because there is an active exchange of fetal–maternal blood
as placental villi loosen and the placenta is delivered.) → baby’s blood goes into mommy’s blood →
production of antibody (anti-Rh (+)) (After this sensitization, in a second pregnancy there will be a high level
of antibody D circulating in the woman’s bloodstream, which will then act to destroy the fetal red blood cells
early in the pregnancy if the new fetus is Rh positive) → second pregnancy →uteroplacental barrier allows
antibodies to cross membrane → hemolysis → destruction of baby’s blood → Manifestations:
 Jaundice/ Alive but with pathologic jaundice - Under normal circumstances, the liver enzyme glucuronyl
transferase converts indirect bilirubin to direct bilirubin. Direct bilirubin is water soluble and combines
with bile for excretion from the body with feces. In preterm infants or those with extreme hemolysis, the
liver cannot convert indirect to direct bilirubin, so jaundice becomes extreme.
 Total body swelling - If the number of red cells has significantly decreased, the blood in the vascular
circulation may be hypotonic to interstitial fluid; fluid will shift from the lower to higher isotonic
pressure by the law of osmosis, causing extreme edema.
 Respiratory distress
 Circulatory collapse
 Kernicterus (occurs several days after delivery)
Assessment of ABO/RH Incompatibility
- Common is Hydrops fetalis, edematous on lethal state with pathologic jaundice within 24 hours
- Diagnostic Tests:
o Indirect Coombs test
 can be predicted by finding a rising anti-Rh titer or a rising level of antibodies (indirect Coombs’
test) in a woman during pregnancy.
 It can be confirmed by detecting antibodies on the fetal erythrocytes in cord blood (positive direct
Coombs’ test)
o If mommy and baby are not compatible:
CAFONGTAN, Krisha L.
BSN 2
 After 1st baby, COOMB’s TEST (baby) - determines presence of maternal antibody on the
baby’s blood
 If mother is not compatible with baby and Coomb’s is negative, then RhIg (RHOGAM)
is given to mother within 72 hours after delivery or abortion of an incompatible fetus
 If Coomb’s test is (+) →EXCHANGE TRANSFUSION
 Can be given during pregnancy
o Blood test for Rh factor

Management of ABO/RH Incompatibility

o Initiation of breastfeeding
 Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel
elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or
formula), therefore, stimulates bowel peristalsis and accomplishes this.
o Use phototherapy –

o
 The stools of an infant under bilirubin lights are often bright green because of the excessive
bilirubin that is excreted as the result of the therapy. They are also frequently loose and may be
irritating to skin.
 Urine may be dark-colored from urobilinogen formation.
 Exchange transfusion – remove blood
a) Removal of baby’s blood and replacement with fresh whole blood (Rh Negative)
b) Rh (+) is not allowed because of the presence of antibodies
c) Mother cannot donate because antibodies came from her
d) Albumin may be administered 1 to 2 hours before the procedure to increase the number of
bilirubin binding sites and to increase the efficiency of the transfusion.
e) Monitor bilirubin levels for 2 or 3 days after the transfusion to ensure the level of bilirubin is
not rising again and that no further transfusion is necessary.
f) Erythropoietin may be administered to increase new blood cell growth and prevent extended
anemia.
 Immunoglobulin Injection
 Give an injection of Rho immune globulin 28th week of the pregnancy
 This desensitizes the mother's blood to Rh (+) blood. Injection of immune globulin within 72
hours after delivery
 Erythropoietin may be administered to increase new blood cell growth and prevent extended anemia.
CAFONGTAN, Krisha L.
BSN 2

Conclusion
ABO Incompatibility RH Incompatibility
 More common, less severe  Less common, more severe
 Maternal blood type: O, Fetal blood type: A, AB, or B  Maternal RH type: -, Fetal RH type: +

A single drop of blood can cause a severe problem. Prevention is always the best intervention. As early as possible, run
tests and attend prenatal checkups during pregnancy
Reference:
Pilliteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. 6th Edition.
Pages 731-735