Why does mother-fetus conflict arise?
Conflict mother-fetus“occurs when there is incompatibility between the blood of the mother and the fetus, when antibodies are formed in the mother’s blood that damage the red blood cells of the fetus, which leads to hemolytic disease of the newborn. This phenomenon is based on the difference in human blood into groups depending on the presence of different antigens in erythrocytes, and group-wide antibodies in plasma. The number of group antigens is large, and they determine the blood type. The child receives the blood group system from the father and mother, according to Mendel's law. In practice, identifying a group is not difficult. Not all antigens are equally common or equally potent, so not all cause serological conflict. Most often, incompatibility occurs in the Rh factor and the AB0 system.
Conflict according to the ABO system
Isoimmunization can develop as a result of incompatibility between the blood of mother and fetus according to the ABO system, when the mother has O(I) blood type, and the fetus has any other. Fetal antigens A and B can enter the mother's bloodstream during pregnancy, leading to the production of immune alpha and beta antibodies, respectively, and the development of a reaction in the fetus
antigen-antibody. Although group incompatibility of mother and fetus occurs more often than incompatibility due to the Rh factor, hemolytic disease of the fetus and newborn is milder and, as a rule, does not require intensive care.
Why does an immunological conflict occur?
The first blood group does not contain antigens A and B in erythrocytes, but there are α and β antibodies. All other groups have such antigens, and therefore the first blood group, having encountered antigens A or B that are foreign to it, begins to “enmity” with them, destroying red blood cells containing these antigens. It is this process that is the immunological conflict in the AB0 system.
A little physiology.
Let's figure out what a blood type is and why such a conflict can arise during pregnancy. Let's remember school biology. Blood consists of blood cells (erythrocytes, leukocytes) and plasma (liquid part). Red blood cells appear as red biconcave discs. 
The red blood cell contains a huge amount of hemoglobin, a complex protein that can carry oxygen. It is estimated that each red blood cell contains more than 3 million hemoglobin molecules.
Also, special proteins, so-called agglutinogens, can be located on the surface of red blood cells. Their presence varies from person to person. If red blood cells that contain certain agglutinogens enter the body of a person who does not have such agglutinogens, he perceives them as foreign and produces special antibodies against them - agglutinins. The purpose of such antibodies is to destroy foreign red blood cells. Approximately this situation occurs when there is a conflict between the blood groups of mother and child during pregnancy. The same thing happens when incompatible blood is transfused.
There are actually a huge number of agglutinogens, but in practical medicine only a few are usually determined. These are agglutinogens A, B, and D. It is by the presence of these agglutinogens that a person’s blood type is judged:
Group I - there are no agglutinogens A and B on red blood cells.
Group II - red blood cells contain agglutinogen A.
Group III - there is agglutinogen B on erythrocytes.
Group IV - red blood cells contain agglutinogens A and B.
And agglutinogen D determines the Rh factor. If it is present on red blood cells, the blood is considered Rh-positive, and if not, it is Rh-negative.
Who should be afraid of a blood type conflict?
Theoretically, this problem can arise if the mother and the unborn baby have different blood types:
- a woman with blood group I or III - a fetus with type II;
- a woman with blood group I or II - a fetus with III;
- a woman with group I, II or III - a fetus with IV.
- have received blood transfusions in the past;
- survivors of several miscarriages or abortions;
- who previously gave birth to a child who developed hemolytic disease or mental retardation.
- woman with group I + man with group II, III or IV;
- woman with group II + man with group III or IV;
- woman with III + man with II or IV.
What contributes to the development of conflict?
A properly functioning and healthy placenta protects against the development of blood group conflict. Its special structure does not allow the blood of the mother and fetus to mix, in particular, due to the placental barrier. However, this can still happen if the integrity of the blood vessels of the placenta is violated, its detachment and other damage or, most often, during childbirth. Fetal cells that enter the maternal bloodstream, if they are foreign, cause the production of antibodies that have the ability to penetrate the fetal body and attack its blood cells, resulting in hemolytic disease. The toxic substance bilirubin, formed as a result of such exposure in large quantities, can damage the child’s organs, mainly the brain, liver and kidneys, which can have serious consequences for the baby’s physical and mental health.
Manifestations of group conflict, its treatment and prevention
A pregnant woman will not experience any signs of developing a blood group conflict. A blood test will help you find out about its occurrence, which will show a high titer of antibodies in the woman’s blood. With the development of hemolytic disease of the fetus and newborn, the following may be observed:
- swelling,
- jaundice,
- anemia,
- enlargement of the spleen and liver.
Sensitization according to the ABO system is not big problem. It is important to know about it, to check the antibody titer twice during pregnancy and not to carry the pregnancy to term, since it is late births that give rise to the most severe forms of HDN, requiring replacement blood transfusions.
Some gynecologists regularly prescribe a test for group antibodies to pregnant women with the first blood group if there are prerequisites for this. In fact, this happens very rarely, due to the fact that a conflict in the AB0 system usually does not entail serious consequences and causes jaundice only in an already born child, with virtually no effect on the fetus in the womb. Therefore, there are no such mass studies as during the pregnancy of an Rh-negative woman.
In a conflict according to the ABO system, the fetus does not get sick, and the newborn does not have anemia. However, the manifestations of jaundice in the first days of life are very severe and many children require treatment.
In most cases, hemolytic disease of newborns about the ABO system does not recur in subsequent children (that is, repeated pregnancies are usually easier, in contrast to Rh sensitization), but it cannot be excluded (HDN). Since there is no threat to the life of the fetus, mass diagnostics ABO conflict is not carried out in pregnant women.
A distinctive feature of immunoconflict according to the ABO system is the later appearance of signs of hemolytic disease in a newborn. As a rule, only on the 3-6th day of life does icteric discoloration of the child’s skin begin to appear, which is often stated as physiological jaundice, and only in severe forms of hemolytic disease, which is observed in one case per 200-256 births, is the correct diagnosis made in a timely manner. Such untimely diagnosed forms of hemolytic disease of newborns according to the ABO system often leave consequences in children.
Hemolytic disease a newborn requires mandatory treatment to avoid the development of severe complications. The more pronounced the symptoms, the more intense the conflict, which is confirmed by a blood test for elevated bilirubin levels. The point of treatment is to remove antibodies, damaged red blood cells and excess bilirubin from the child’s blood, for which phototherapy and other symptomatic treatment are carried out. If this does not help, or the level of bilirubin in the blood increases very quickly, then they resort to the procedure of blood transfusion to the newborn.
Future parents who are at risk of developing such a conflict need to know that, firstly, the likelihood of a real blood group conflict occurring in practice is very small, and secondly, it most often occurs much easier than Rh conflict, and cases of severe are relatively rare, therefore conflict according to the AB0 system is considered less dangerous for the baby’s health.
When registering at the antenatal clinic, the expectant mother receives many referrals for tests. One of the analyzes is to determine the group and Rh factor of not only the pregnant woman, but also her husband.
If earlier the main emphasis was on determining the Rh factor to avoid Rh conflict, now they are trying to minimize the possibility of an immunological conflict between blood groups. Incompatibility occurs because blood group 1 contains antibodies α and β, and the red blood cells of the others contain antigens A and B. As soon as foreign antigens meet each other, they begin to destroy foreign red blood cells. A blood type conflict arises.
Dangerous conditions
You should be wary of blood type incompatibility during pregnancy if the mother and child have the following combinations:
- in the fetus, group IV - in the mother, all the others;
- in the fetus II – in the mother I or III;
- in the fetus III - in the mother I or II.
A dangerous condition almost always occurs if a woman with blood type I develops a fetus with type II or III. At repeat pregnancy such a combination requires mandatory monitoring, as there is a risk of hemophilia in the newborn.
Blood group compatibility during pregnancy is most difficult to achieve for women with group I, regardless of Rh factors. If a man belongs to another group, then there is already a high risk of an immunological conflict.
Women with other groups are compatible with men of their “category” and those with group I.
Future mothers who have already had miscarriages or undeveloped pregnancies in the past, or have children with pathologies: mental retardation or diseases of the circulatory system should be under special supervision. The risk of a dangerous condition increases in women who have had blood transfusions in the past.
Negative and positive blood group during pregnancy
It is believed that if the mother's blood type is negative, pregnancy is always problematic. This is far from true.
- If both partners do not have a discrepancy in the Rh factor or the Rh factor is the same in the blood of the child and the mother, no conflict is observed, and the baby can be delivered without complications - on this side.
- There are no problems when the mother has a positive status and the fetus has a negative status.
- If the situation is the opposite, then the mother’s blood may begin to produce antibodies to destroy foreign proteins and there will be a threat of termination of pregnancy.
Treatment is necessary. Injections of anti-D immunoglobulin will help stop the Rh conflict. Despite the fact that during pregnancy they try not to prescribe any medications, such therapeutic measures are necessary to stabilize the condition. The therapy does not have a negative effect on fetal development.
If it was possible to carry the pregnancy to term, but the necessary therapeutic measures were not taken, the process triggered by the production of antibodies continues after the birth of the baby.
Hemolytic disease appears, in which the functioning of the hematopoietic system is disrupted.
Blood type conflicts
- Hemolytic disease in a newborn also occurs with the development of an immunological conflict between blood groups. But - unlike Rhesus conflict - this condition appears much less frequently. The placental barrier protects the bloodstream of the fetus from the penetration of antibodies. The risk of foreign proteins being introduced increases during childbirth.
- Suspicion of an immunological conflict arises if the newborn has severe anemia, swelling is visually visible, an ultrasound examination notes that the liver and spleen are enlarged, and jaundice does not go away for a long time.
- To prevent hemolytic disease immediately after childbirth, women with a negative Rhesus or a positive blood type, if no treatment was carried out during pregnancy, take blood from a large vessel of the umbilical cord for analysis. They find out the status of the child and compare it with the status of the mother, and at the same time determine the level of bilirubin.
- If necessary, treatment is prescribed. Sometimes blood samples from the baby are taken within a few hours during the first day to determine changes in dynamics during the adaptation period.
Special group
Gynecologists very carefully monitor women with IV negative blood group during pregnancy.
- Since carriers of this group are quite rare - especially in combination with a negative Rh factor - an immunological conflict often arises. If incompatibility is detected from the very beginning, then observation is established immediately and at the first symptoms of blood incompatibility with the embryo, the necessary therapy begins.
- However, it can only achieve success during the first pregnancy - doctors do not advise carriers of this blood group with a negative Rh factor to tempt fate and try to get pregnant again. Incompatibility threatens not only the health of the baby, but also his mother, and repeated births can result in serious problems for her.
- However, no one can prevent a woman from giving birth, and if she is registered from the very beginning and the condition is monitored over time, there is a possibility of birth healthy baby. True, if the baby is female, the possibility of transmitting “dangerous blood” to him increases.
Women need to know!
Each week of pregnancy plays a huge role in the development of immuno- or Rh-conflict.
The later a dangerous condition is detected, the more antibodies accumulate in the blood, which means that even after a full-term birth, the child may develop hemolytic disease.
At the current level of development of medicine, it is possible to carry out treatment at the intrauterine stage - the fetus can receive a blood transfusion even before birth.
In the presence of Rh conflict, the therapeutic regimen is developed to the point of automaticity - which allows the woman to give birth to a healthy baby.
The immunological conflict due to the group factor has not yet been fully studied, but if a dangerous condition is identified in a timely manner, it is possible to take the necessary measures. In addition, the likelihood of developing a dangerous condition in different blood groups is minimal, and severe cases are extremely rare.
The materials posted on this page are informational in nature and intended for educational purposes. Site visitors should not use them as medical advice. Determining the diagnosis and choosing a treatment method remains the exclusive prerogative of your attending physician.
Related articles
Many women, while pregnant, are faced with a diagnosis such as Rh conflict. Most people know that this is something dangerous, both for the mother and for the future...
One of the significant reasons why difficulties may arise in conceiving a child is blood type incompatibility among those wishing to become parents. Is it so...
As you know, during pregnancy a woman becomes a frequent visitor to the antenatal clinic, where she regularly receives referrals for various tests and…
Rh conflict is a concept familiar to every pregnant and planning woman. This is especially relevant possible problem for those who have negative...
Human blood has two important characteristics– blood group (AB0 system) and Rh factor (Rh system). Most often, during pregnancy, problems arise with pregnancy due to incompatibility according to the Rh system, so we will analyze it first.
What is the Rh factor?
Rh factor (Rh) is an erythrocyte antigen of the Rh system. Simply put, it is a protein located on the surface of red blood cells (erythrocytes).
People who have this protein are Rh+ (or Rh positive). Accordingly, negative Rh Rh- (or negative Rh) indicates the absence of this protein in human blood.
What is Rh conflict and how is it dangerous for the fetus?
Rhesus conflict– the immune response of the mother’s body to the appearance of a “foreign” agent within itself. This is the so-called struggle of the mother’s Rh-negative blood bodies with the child’s Rh-positive blood bodies, which is fraught with the appearance of hemolytic anemia or jaundice, hypoxia and even fetal hydrops.
During the first pregnancy, the bloodstream of the mother and child function separately from each other and their blood does not mix, but during previous births (possibly also during abortions and miscarriages), the child’s blood may enter the mother’s blood, and as a result, the woman’s body becomes Rh negative -factor will produce antibodies to the antigen even before the next pregnancy occurs. Therefore, a repeat pregnancy may end at an early stage. intrauterine death embryo, and as a result, miscarriage.
The first pregnancy usually proceeds without complications, since the mother’s blood does not yet have antibodies to the “foreign” blood of the child.
Simply put, fetal blood cells penetrate through the placenta into the blood of the pregnant woman and if the blood is incompatible, the body expectant mother perceives the baby as a “stranger”, after which the protective reaction of the woman’s body produces special antibodies that destroy the baby’s blood cells.
The destruction of fetal red blood cells by antibodies is called hemolysis, which leads to anemia in the baby. The pregnant woman’s condition does not worsen, and the woman is not even aware of the previous threat to the baby’s health.
When does Rh conflict occur during pregnancy?
If the mother's Rh is positive, Rh conflict will never arise, no matter what the blood of the child's father is.
If both future parents have a negative Rh factor, there is also no reason to worry, the child will also have a negative Rh factor, it cannot be any other way.
If the blood Rh factor is negative in the pregnant woman and the father of the child is positive, the baby can inherit both the Rh factor of the mother and the Rh factor of the father.
If the father of the child is Rh-positive, homozygous, and has the DD genotype, and the pregnant woman is Rh-negative, then in this case all children will be Rh-positive.
If the father is Rh-positive, heterozygous, and has the Dd genotype, and the pregnant woman is Rh-negative, then in this case a child can be born with both Rh-positive and Rh-negative factors (the probability in this case is 50 to 50).
Therefore, it is also important for a man to donate blood for the Rh factor to determine the genotype in case of a negative blood group in a woman planning a pregnancy or carrying a fetus.
If there is a risk of developing an Rh conflict, a pregnant woman is prescribed a blood test to check for the presence of Rh antibodies.
Table 1 - Probability of developing Rh conflict during pregnancy
Judging by the table above, we can say that Rh conflict occurs only when the pregnant woman has a negative Rh and the child’s father has a positive Rh, and only in 50 cases out of a hundred possible.
That is, it is not necessary to experience a Rh conflict during pregnancy. The fetus can also inherit negative Rh from the mother, then there will be no conflict.
It should also be noted that during the first pregnancy, antibodies are produced for the first time, and therefore they are larger in size than during a second pregnancy. It is more difficult for large antibodies of the IgM type to penetrate the placental barrier into the child’s blood; they seem to be unable to “get through” the walls of the placenta, and during the next pregnancy, other, more “modified” antibodies of the IgG type are produced. They are smaller, and their ability to penetrate the walls of the placenta is much higher, which is more dangerous for the fetus. Then the antibody titer increases.
Therefore, first-time mothers should not worry about Rh conflict, just be vigilant (it is enough to determine the antibody titer once a month), and enjoy the pregnancy period, because the worries of caring for the baby and raising him lie ahead.
Prevention and treatment of Rh conflict
During the first pregnancy (i.e. there have been no abortions or miscarriages in the past), the first test for antibodies is carried out from 18-20 weeks 1 time per month (until 30 weeks), then from 30 to 36 weeks - 2 times a month, and after 36 weeks of pregnancy - 1 time per week.
In case of repeated pregnancy, they begin to donate blood for antibodies from the 7-8th week of pregnancy. If the titer is no more than 1:4, then this test is performed once a month, and if the titer increases, more often, once every 1-2 weeks.
An antibody titer of up to 1:4 inclusive is considered acceptable (normal) during a “conflict” pregnancy.
Titles of 1:64, 1:128 and more are considered critical.
If there is a risk of developing a “conflict” pregnancy, but antibodies were never detected before week 28 (or were detected, but not more than 1:4), then later they may appear in significant quantities.
Therefore, for preventive purposes, pregnant women are given human anti-Rhesus immunoglobulin D at 28 weeks, which blocks the work of the woman’s immune system to destroy foreign bodies, i.e. after the injection, the woman’s body will not produce antibodies that destroy the blood cells of the embryo.
It is advisable to carry out an immunoglobulin injection in the absence of antibodies in the blood of a pregnant woman, since in other cases it is simply useless.
The vaccine does not have any effect negative influence on the health of the mother and fetus, it is completely safe.
After an injection (provided there are no antibodies in the blood shortly before the injection, or at least when their titer is no more than 1:4), it is not reasonable to donate blood for antibodies, since a false-positive result may be observed.
It is also advisable to monitor the baby’s cardiac activity by regularly conducting cardiotocography (CTG), starting from 26 weeks.
Doppler or Doppler is an ultrasound examination of blood flow in the fetal vessels, uterine arteries and umbilical cord.
When the fetus is suffering, the blood flow velocity (V max) in the middle cerebral artery will be higher than normal. When this indicator approaches the 80-100 mark, an emergency CS is performed to prevent the baby from dying.
If there is an increase in antibodies and the child’s health deteriorates, this indicates the development of hemolytic disease of the fetus (abbreviated as HDP), then it is necessary to carry out treatment, which consists of intrauterine fetal blood transfusion.
In case of “conflict” course of pregnancy during ultrasound examination The following signs of fetal hemolytic disease may be observed:
- enlargement of the fetal abdomen due to accumulation in its abdominal cavity liquid, as a result of which the baby takes the “Buddha pose”, spreading his bent legs to the sides;
- swelling of the subcutaneous fatty tissue of the head (ultrasound shows a “double contour” of the fetal head);
- an increase in the size of the heart (cardiomegaly), liver and spleen;
- thickening of the placenta up to 5-8 cm (normal 3-4 cm) and expansion of the umbilical cord vein (more than 10 mm).
Due to increased swelling, the weight of the fetus will increase by 2 times compared to the norm.
If it is not possible to carry out a blood transfusion, then it is necessary to discuss the issue of early delivery. You cannot delay, and if the baby’s lungs have already formed (the 28th embryonic week or more), then it is necessary to perform labor stimulation, otherwise the pregnant woman risks losing the child.
If the baby has reached 24 weeks, a series of injections can be given to mature the fetal lungs so that he can breathe on his own after an emergency delivery.
After the baby is born, he is given a replacement blood transfusion, plasmapheresis (filtration of blood from dangerous cells) or phototherapy, otherwise the destruction of the baby’s red blood cells will continue to occur.
Modern labor intensive care services are capable of delivering a premature baby even if it is born at 22 weeks of pregnancy, so in a critical case, entrust saving the baby’s life to qualified doctors.
Group incompatibility of mother and fetus
Less commonly, but still, blood type incompatibility does occur.
Blood group is a combination of surface antigens (agglutinogens) of red blood cells of the AB0 system, genetically inherited from biological parents.
Each person belongs to a certain blood group according to the AB0 system: A (II), B (III), AB (IV) or 0 (I).
This system is based on a laboratory test to determine two agglutinogens (A and B) in human blood.
- Blood group I - otherwise it is group 0 (“zero”), when agglutinogens neither A nor B were found on red blood cells during a blood group test.
- Blood group II is group A, when the red blood cells contain only A agglutinogens.
- Blood group III is group B, that is, only B agglutinogens are found.
- Blood group IV is group AB; both A and B antigens are present on red blood cells.
Group incompatibility is often observed if the expectant mother has blood type I, and the future father of the child has IV, then the fetus will inherit blood group II or III. But there are other options for blood group incompatibility (see Table 2).
Table 2 - Probability of developing a blood group conflict during pregnancy
Typically, group incompatibility is much easier than Rhesus incompatibility, so blood type conflict is considered less dangerous, and babies who have suffered a blood type conflict are born with normal jaundice, which soon goes away.
The time of bearing a child is one of the most beautiful times in a woman’s life. Every expectant mother wants to be calm about the baby’s health and enjoy the period of waiting for a new addition. But every tenth woman, according to statistics, has Rh-negative blood, and this fact worries both the pregnant woman herself and the doctors who observe her.
What is the possibility of Rh conflict between mother and baby, and what the danger lies, we will tell you in this article.
What is it?
When a woman and her future toddler have different blood counts, immunological incompatibility may begin; this is what is called Rh conflict. Representatives of humanity who have a Rh factor with a + sign have a specific protein D, which is contained in red blood cells. A person with Rhesus does not have a negative value for this protein.
Scientists still don't know for sure why some people have the specific Rhesus monkey protein and others don't. But the fact remains that about 15% of the world’s population have nothing in common with macaques; their Rh factor is negative.
There is a constant exchange between the pregnant woman and the child through the uteroplacental blood flow. If the mother has a negative Rh factor, and the baby is positive, then protein D entering her body is nothing more than a foreign protein for the woman.
The mother's immune system begins to react very quickly to uninvited guest, And when protein concentration reaches high values, Rh conflict begins. This is a merciless war that the pregnant woman’s immune defense declares on the child as the source of a foreign antigen protein.
Immune cells begin to destroy the baby's red blood cells with the help of special antibodies that he produces.
The fetus suffers, the woman experiences sensitization, the consequences can be quite sad, including the death of the baby in the mother’s womb, the death of the baby after birth, or the birth of a disabled child.
A Rh conflict can occur in a pregnant woman with Rh (-), if the baby has inherited her father’s blood characteristics, that is, Rh (+).
Much less often, incompatibility occurs based on such an indicator as blood group, if a man and a woman have different groups. That is, a pregnant woman whose own Rh factor has positive values has nothing to worry about.
There is no reason to worry for families with the same negative Rhesus, but this coincidence does not happen often, because among the 15% of people with “negative” blood, the vast majority are representatives of the fair sex, men with such blood characteristics are only 3%.
Toddlers' own hematopoiesis begins in the womb at approximately 8 weeks of gestation. And from this moment on, in maternal blood tests, a small number of fetal red blood cells is determined in the laboratory. It is from this period that the possibility of Rh conflict arises.
Probability tables
From a genetic point of view, the probability of inheriting the main characteristics of blood - type and Rh factor from father or mother is estimated at 50%.
There are tables that allow you to assess the risks of Rh conflict during pregnancy. And timely weighed risks give doctors time to try to minimize the consequences. Unfortunately, medicine cannot eliminate the conflict completely.
By Rh factor
By blood type
Dad's blood type | Mom's blood type | Child's blood type | Will there be a conflict? |
0 (first) | 0 (first) | 0 (first) | |
0 (first) | A (second) | 0 (first) or A (second) | |
0 (first) | B (third) | 0 (first) or B (third) | |
0 (first) | AB (fourth) | A (second) or B (third) | |
A (second) | 0 (first) | 0 (first) or A (second) | Probability of conflict - 50% |
A (second) | A (second) | A (second) or 0 (first) | |
A (second) | B (third) | Any (0, A, B, AB) | Probability of conflict - 25% |
A (second) | AB (fourth) | ||
B (third) | 0 (first) | 0 (first) or B (third) | Probability of conflict - 50% |
B (third) | A (second) | Any (0, A, B, AB) | Probability of conflict - 50% |
B (third) | B (third) | 0 (first) or B (third) | |
B (third) | AB (fourth) | 0 (first), A (second) or AB (fourth) | |
AB (fourth) | 0 (first) | A (second) or B (third) | Probability of conflict - 100% |
AB (fourth) | A (second) | 0 (first), A (second) or AB (fourth) | Probability of conflict - 66% |
AB (fourth) | B (third) | 0 (first), B (third) or AB (fourth) | Probability of conflict - 66% |
AB (fourth) | AB (fourth) | A (second), B (third) or AB (fourth) |
Causes of the conflict
The likelihood of developing a Rh conflict greatly depends on how and how the woman’s first pregnancy ended.
Even a “negative” mother can quite safely give birth to a positive baby, since during the first pregnancy the woman’s immune system does not yet have time to develop a killer amount of antibodies to protein D. The main thing is that before pregnancy she is not given a blood transfusion, without taking into account the Rh factor, as sometimes happens in an emergency situations to save lives.
If the first pregnancy ended in miscarriage or abortion, then the likelihood of a Rh conflict during the second pregnancy increases significantly, since the woman’s blood already contains antibodies ready to attack at a very early stage.
In women who had a caesarean section during the first birth, the likelihood of conflict during the second pregnancy is 50% higher compared to women who gave birth to their first child naturally.
If the first birth was problematic, the placenta had to be separated manually, and there was bleeding, then the likelihood of sensitization and conflict in a subsequent pregnancy also increases.
Diseases during pregnancy also pose a danger to an expectant mother with a negative Rh factor. Influenza, ARVI, gestosis, diabetes in the anamnesis can provoke a structural disorder chorionic villi, and the mother’s immunity will begin to produce antibodies that are harmful to the baby.
After childbirth, the antibodies that were developed during pregnancy do not disappear. They represent long-term immune memory. After the second pregnancy and childbirth, the number of antibodies becomes even greater, as well as after the third and subsequent ones.
Danger
The antibodies that maternal immunity produces are very small in size; they can easily penetrate the placenta into the baby’s bloodstream. Once in the baby’s blood, the mother’s protective cells begin to inhibit the fetal hematopoietic function.
The child suffers and experiences oxygen deficiency, since decaying red blood cells are the carriers of this vital gas.
In addition to hypoxia, hemolytic disease of the fetus may develop, and subsequently the newborn. It is accompanied by severe anemia. The fetus' internal organs enlarge - liver, spleen, brain, heart and kidneys. The central nervous system is affected by bilirubin, which is formed during the breakdown of red blood cells and is toxic.
If doctors do not take measures in time, the baby may die in utero, be born still, or be born with severe damage to the liver, central nervous system, kidney. Sometimes these lesions turn out to be incompatible with life, sometimes they lead to profound lifelong disability.
Diagnosis and symptoms
The woman herself cannot feel the symptoms of a developing conflict between her immunity and the blood of the fetus. There are no symptoms by which the expectant mother could guess the destructive process that is taking place inside her. However, laboratory diagnostics can detect and track the dynamics of the conflict at any time.
To do this, a pregnant woman with Rh-negative blood, regardless of the blood group and Rh factor of the father, takes a blood test from a vein to determine the content of antibodies in it. The analysis is done several times during pregnancy, the period from 20 to 31 weeks of pregnancy is considered especially dangerous.
The antibody titer obtained as a result of laboratory testing indicates how severe the conflict is. The doctor also takes into account the degree of maturity of the fetus, because the older the baby is in the womb, the easier it is for him to resist an immune attack.
Thus, titer 1:4 or 1:8 at 12 weeks of pregnancy is a very alarming indicator, and a similar antibody titer at 32 weeks will not cause panic in the doctor.
When a titer is detected, the analysis is done more often to monitor its dynamics. In a severe conflict, the titer increases rapidly - 1:8 can turn into 1:16 or 1:32 in just a week or two.
A woman with antibody titers in her blood will have to visit the ultrasound diagnostic room more often. Using an ultrasound, it will be possible to monitor the development of the child; this research method provides fairly detailed information about whether the child has hemolytic disease, and even about what form it has.
In the case of an edematous form of hemolytic disease of the fetus, an ultrasound will reveal an increase in the size of the internal organs and brain, the placenta thickens, the number amniotic fluid also increases and exceeds normal values.
If the estimated weight of the fetus is 2 times higher than normal, this is warning sign - hydrops of the fetus is not excluded, which can lead to death in the womb.
Hemolytic disease of the fetus associated with anemia cannot be seen on ultrasound, but can be diagnosed indirectly on CTG, since the number of fetal movements and their nature will indicate the presence of hypoxia.
Damages to the central nervous system will become known only after the birth of the child; this form of hemolytic disease of the fetus can lead to developmental delays in the baby and hearing loss.
Doctors at the antenatal clinic will be involved in diagnostics from the very first day a woman with a negative Rh factor is registered. They will take into account how many pregnancies there were, how they ended, and whether children with hemolytic disease have already been born. All this will enable the doctor to assume the possible likelihood of a conflict occurring and predict its severity.
During the first pregnancy, a woman will have to donate blood once every 2 months, during the second and subsequent ones - once a month. After the 32nd week of pregnancy, the analysis will be done once every 2 weeks, and from the 35th week - every week.
If an antibody titer appears, which can occur at any time after 8 weeks, they may be prescribed additional methods research.
In case of a high titer that threatens the life of the child, a cordocentesis or amniocentesis procedure may be prescribed. The procedures are carried out under ultrasound control.
During amniocentesis, an injection is made with a special needle and a certain amount of amniotic fluid is taken for analysis.
During cordocentesis, blood is taken from the umbilical cord.
These tests make it possible to judge what blood type and Rh factor is inherited by the baby, how severely his red blood cells are affected, what is the level of bilirubin in the blood, hemoglobin, and with 100% probability determine the sex of the child.
These invasive procedures are voluntary and the woman is not forced to undergo them. Despite the current level of development of medical technologies, interventions such as cordocentesis and amniocentesis can still cause miscarriage or premature birth, as well as death or infection of the child.
The obstetrician-gynecologist who is managing her pregnancy will tell the woman about all the risks when performing procedures or refusing them.
Possible consequences and forms
Rhesus conflict is dangerous both during the period of bearing a baby and after its birth. The disease with which such children are born is called hemolytic disease of the newborn (HDN). Moreover, its severity will depend on the amount of antibodies that attacked the baby’s blood cells during pregnancy.
This disease is considered severe; it is always accompanied by the breakdown of blood cells, which continues after birth, edema, jaundice of the skin, and severe bilirubin intoxication.
Edema
The most severe form of HDN is the edematous form. With it, the little one is born very pale, as if “bloated”, swollen, with multiple internal edema. Such babies, unfortunately, in most cases are born dead or die, despite all the efforts of resuscitators and neonatologists, they die in the shortest possible time from several hours to several days.
Jaundice
The icteric form of the disease is considered more favorable. Such babies, a couple of days after their birth, “acquire” a rich yellowish skin color, and such jaundice has nothing in common with the common physiological jaundice of newborns.
The baby's liver and spleen are slightly enlarged, and blood tests show anemia. The level of bilirubin in the blood increases rapidly. If doctors fail to stop this process, the disease can develop into kernicterus.
Nuclear
The nuclear variety of HDN is characterized by lesions of the central nervous system. The newborn may experience convulsions and may involuntarily move his eyes. The tone of all muscles is reduced, the child is very weak.
When bilirubin is deposited in the kidneys, a so-called bilirubin infarction occurs. A greatly enlarged liver cannot normally perform the functions assigned to it by nature.
Forecast
Doctors are always very careful when making predictions for TTH, since it is almost impossible to predict how damage to the nervous system and brain will affect the development of the baby in the future.
Children undergo detoxification infusions in intensive care conditions; very often there is a need for a replacement transfusion of blood or donor plasma. If on the 5th-7th day the child does not die from paralysis of the respiratory center, then the forecasts change to more positive ones, however, they are also quite conditional.
After suffering from hemolytic disease of newborns, children suck poorly and sluggishly, they have decreased appetite, disturbed sleep, and have neurological abnormalities.
Quite often (but not always) such children experience significant mental and mental retardation. intellectual development, they get sick more often, and hearing and vision impairment may occur. Cases of anemic hemolytic disease end most successfully; after the level of hemoglobin in the baby’s blood can be raised, it develops quite normally.
A conflict that has developed not because of a difference in Rh factors, but because of a difference in blood groups, proceeds more easily and usually does not have such destructive consequences. However, even with such incompatibility, there is a 2% chance that the baby will develop quite serious disorders of the central nervous system after birth.
The consequences of the conflict for the mother are minimal. She will not be able to feel the presence of antibodies; difficulties can arise only during the next pregnancy.
Treatment
If a pregnant woman has a positive antibody titer in her blood, this is not a reason for panic, but a reason for starting therapy and taking it seriously on the part of the pregnant woman.
It is impossible to save a woman and her baby from such a phenomenon as incompatibility. But medicine can minimize the risks and consequences of the influence of maternal antibodies on the baby.
Three times during pregnancy, even if antibodies do not appear during pregnancy, the woman is prescribed courses of treatment. At 10-12 weeks, at -23 weeks and at 32 weeks, the expectant mother is recommended to take vitamins, iron supplements, calcium supplements, drugs that improve metabolism, and oxygen therapy.
If titres are not detected before 36 weeks of gestation, or they are low, and the development of the child does not cause concern to the doctor, then the woman is allowed to give birth naturally on her own.
If the titres are high and the child’s condition is serious, then delivery can be carried out ahead of schedule by caesarean section. Doctors try to support a pregnant woman with medications until the 37th week of pregnancy, so that the baby has the opportunity to “mature.”
Unfortunately, this possibility is not always available. Sometimes you have to decide on an earlier caesarean section in order to save the baby’s life.
In some cases, when the baby is clearly not yet ready to come into this world, but remaining in the mother’s womb is very dangerous for him, an intrauterine blood transfusion is performed to the fetus. All these actions are performed under control ultrasound scanner, every movement of the hematologist is verified so as not to harm the baby.
In the early stages, other methods of preventing complications can be used. So, there is a technique for suturing a pregnant woman with a piece of her husband’s skin. The skin flap is usually implanted on the lateral surface of the chest.
While the woman’s immune system is putting all its effort into rejecting the foreign skin fragment (which takes several weeks), the immunological load on the child is somewhat reduced. Scientific debate continues about the effectiveness of this method, but reviews from women who have undergone such procedures are quite positive.
In the second half of pregnancy, if a conflict has been established, the expectant mother may be prescribed plasmapheresis sessions, this will slightly reduce the number and concentration of antibodies in the mother’s body, and accordingly, the negative load on the baby will also temporarily decrease.
Plasmapheresis should not frighten a pregnant woman; there are not many contraindications to it. Firstly, it is an acute respiratory viral infection or another infection in the acute stage, and, secondly, there is a threat of miscarriage or premature birth.
There will be about 20 sessions. Approximately 4 liters of plasma are purified in one procedure. Along with the infusion of donor plasma, protein preparations are administered, which are necessary for both mother and baby.
Babies who have suffered hemolytic disease are advised to undergo regular examinations by a neurologist, massage courses in the first months after birth to improve muscle tone, as well as courses of vitamin therapy.
Prevention
A pregnant woman is given a kind of vaccination at 28 and 32 weeks - anti-Rhesus immunoglobulin is administered. The same drug must be administered to a woman in labor after childbirth no later than 48-72 hours after the birth of the baby. This reduces the likelihood of conflict developing in subsequent pregnancies to 10-20%.
If a girl has a negative Rh factor, she should know about the consequences of an abortion during the first pregnancy. It is desirable for such representatives of the fair sex save the first pregnancy at any cost.
Blood transfusion without taking into account the Rh affiliation of the donor and recipient is not permissible, especially if the recipient has his own Rh with a “-” sign. If such a transfusion occurs, the woman should be given anti-Rhesus immunoglobulin as soon as possible.
A complete guarantee that there will be no conflict can only be given by a Rh-negative man, preferably with the same blood type as his chosen one. But if this is not possible, you should not postpone pregnancy or refuse it just because a man and a woman have different blood. In such families, planning a future pregnancy plays an important role.
A woman who wants to become a mother needs to undergo blood tests to detect antibodies to protein D before the onset of an “interesting situation”. If antibodies are detected, this does not mean that the pregnancy will have to be terminated or that pregnancy cannot be achieved. Modern medicine does not know how to eliminate conflict, but it knows very well how to minimize its consequences for the child.
The introduction of anti-Rhesus immunoglobulin is important for women who do not yet have antibodies in their blood that are not sensitized. They need to get such an injection after an abortion, after even minor bleeding during pregnancy, for example, with a slight placental abruption, after surgery for ectopic pregnancy. If you already have antibodies, then you shouldn’t expect any special effect from vaccination.
Common Questions
Is it possible to breastfeed a child?
If a woman with a negative Rh factor gives birth to a child with a positive Rh factor, and there is no hemolytic disease, then breast-feeding not contraindicated.
Babies who have experienced an immune attack and were born with hemolytic disease of the newborn are not recommended to feed on breast milk for 2 weeks after the administration of immunoglobulin to the mother. In the future, decisions about breastfeeding are made by neonatologists.
In severe hemotylic disease, breastfeeding is not recommended. To suppress lactation, a woman after childbirth is prescribed hormonal drugs that suppress milk production in order to prevent mastopathy.
Is it possible to carry a second child without conflict if there was conflict during the first pregnancy?
Can. Provided that the child inherits a negative Rh factor. In this case, there will be no conflict, but antibodies in the mother’s blood can be detected throughout the entire period of gestation, and in a fairly high concentration. They will not affect a baby with Rh (-) in any way, and there is no need to worry about their presence.
Before getting pregnant again, mom and dad should visit a geneticist who will give them comprehensive answers about the likelihood of their future children inheriting a particular blood characteristic.
Dad's Rh factor is unknown
When the expectant mother is registered at the antenatal clinic, immediately after her negative Rh is detected, the father of the future baby is also invited to the consultation to take a blood test. This is the only way the doctor can be sure that he knows exactly the initial data of the mother and father.
If the father’s Rh is unknown, and for some reason it is impossible to invite him to donate blood, if the pregnancy resulted from IVF with donor sperm, then a woman will have her blood tested for antibodies a little more often than other pregnant women with the same blood. This is done in order not to miss the moment of the beginning of a conflict if it occurs.
And the doctor’s offer to invite my husband to donate blood for antibodies is a reason to change the doctor to a more competent specialist. There are no antibodies in the blood of men, since they do not become pregnant and do not have any physical contact with the fetus during their wife’s pregnancy.
Is there an impact on fertility?
There is no such connection. The presence of negative Rh does not mean that it will be difficult for a woman to get pregnant.
Fertility levels are influenced by completely different factors - bad habits, caffeine abuse, overweight and diseases genitourinary system, aggravated medical history, including a large number of abortions in the past.
Are medication or vacuum abortion safe for terminating a first pregnancy in an Rh-negative woman?
This is a common misconception. Moreover, unfortunately, such a statement can often be heard even from medical workers. The method of performing an abortion does not matter. Whatever it is, the baby’s red blood cells still enter the mother’s bloodstream and cause the formation of antibodies.
If the first pregnancy ended in abortion or miscarriage, how great are the risks of conflict in the second pregnancy?
In fact, the magnitude of such risks is a rather relative concept. No one can say with one percent accuracy whether there will be a conflict or not. However, doctors have certain statistics that estimate (approximately) the likelihood of sensitization of the female body after an unsuccessful first pregnancy:
- miscarriage at a short term - +3% to a possible future conflict;
- artificial termination of pregnancy (abortion) – +7% to the probable future conflict;
- ectopic pregnancy and surgery to eliminate it – +1%;
- delivery at term with a live fetus – + 15-20%;
- delivery by cesarean section – + 35-50% to a possible conflict during the next pregnancy.
Thus, if a woman’s first pregnancy ended in abortion, the second in a miscarriage, then while carrying the third, the risk is estimated at approximately 10-11%.
If the same woman decides to give birth to another baby, provided that the first birth went well naturally, then the probability of a problem will be more than 30%, and if the first birth is completed caesarean section, then more than 60%.
Accordingly, any woman with a negative Rh factor who is planning to become a mother again can weigh the risks.
Does the presence of antibodies always mean that a child will be born sick?
No, this doesn't always happen. The child is protected by special filters that are in the placenta; they partially restrain aggressive maternal antibodies.
A small amount of antibodies will not cause much harm to the child. But if the placenta ages prematurely, if the amount of water is small, if a woman is sick with an infectious disease (even a common ARVI), if she takes medications without supervision from the attending physician, then the likelihood of a decrease in the protective functions of the placenta filters increases significantly, and the risk of giving birth to a sick baby will increase. .
It should be borne in mind that during the first pregnancy, antibodies, if they appear, have a fairly large molecular structure, it can be difficult for them to “break through” the defense, but with a second pregnancy, the antibodies are smaller, more mobile, fast and “evil”, so the immunological attack becomes more probable.
Does conflict occur during pregnancy, contrary to all forecasts and tables, in two negative parents?
This cannot be ruled out, despite the fact that all existing genetic tables and teachings indicate that the probability tends to zero.
One of the three mother-father-child may turn out to be a chimera. Chimerism in people sometimes manifests itself in the fact that once transfused blood of a different group or rhesus “takes root”, and the person is a carrier of genetic information about two types of blood at once. This is a very rare and little-studied phenomenon, although experienced doctors will never discount it.
Everything related to issues of genetics has not yet been studied well enough, and any “surprise” can be obtained from nature.
History knows several cases when a mother with Rh (-) and a father with a similar Rh gave birth to a child with positive blood and hemolytic disease. The situation requires careful study.
For more information about the likelihood of Rh conflict during pregnancy, see the following video.
