Case history
Case history #1
A 32-year-old woman presents at 25 weeks' gestation in her third pregnancy with a positive antibody screen. She is known to be Rh-negative with an Rh-positive partner. Two previous children were born overseas: the first child was carried to term and is healthy. The second child, also born at term, underwent phototherapy in the immediate neonatal period due to jaundice. The patient did not have Rho(D) immune globulin prophylaxis given prenatally or postpartum in the previous pregnancies. Physical exam is normal.
Case history #2
A 38-year-old primigravida woman presents for routine prenatal care. Her blood type is known to be Rh-negative with a negative indirect Coombs test, and her partner is Rh-positive. She has been counseled regarding the need for Rh immunoprophylaxis at 28 weeks of pregnancy and postpartum if her newborn is found to be Rh-positive.
Other presentations
Manifestations of severe erythroblastosis fetalis include ultrasound evidence of significant effusions in serous cavities, organomegaly, polyhydramnios, and extensive skin edema (anasarca). Anti-RhD antibody titers in severe disease are usually high (>1:32 dilutions). Anti-Kell antibodies may be associated with profound fetal anemia and hydrops in the presence of low antibody titers due to suppression of erythropoiesis. Evidence suggesting severe fetal anemia includes high peak systolic velocities on Doppler ultrasound of the middle cerebral artery, low biophysical profile scores, and a sinusoidal fetal heart rate pattern. Although these manifestations of severe fetal disease are usually not detected in a first affected pregnancy, significant fetomaternal hemorrhage from any cause may lead to a secondary immune response and hydrops fetalis, even in a primiparous patient.
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