Readers' Concerns Regarding Rh-immune Globulin and ABO-Incompatibilty
Monday, September 17, 2007
Kenneth F. Trofatter, Jr., MD, PhD
Great information! I just miscarried and I want to know why. I am 0- and received a Rhogam shot at 28 weeks with my 1st child. I did not receive a shot after delivery--I checked my records. Did this (not receiving a shot) contribute to my miscarriage? Wendy
Sun Sep 16, 12:10:00 AM 2007
Kenneth F. Trofatter, Jr., MD, PhD said...
To Wendy Sept 16: I am sorry for your recent loss. The most common cause of sporadic miscarriage in women who have had successful pregnancies is a fetal chromosomal abnormality. With regard to your other question, the routine would have been to give you Rhogam after you delivered UNLESS your baby happened to be Rh-negative as well. It is very unlikely that not getting the Rhogam after delivery caused you to miscarry your recent pregnancy. That doesn't even seem to be a problem with individuals who ARE clearly Rh-isoimmunized. It's dealing with those pregnancies after the first trimester that becomes the challenge! Regards, and thanks for your question.
Dr T
Sun Sep 17, Prefering Anonymity said...
My wife just delivered a baby girl 5 days ago who has elevated bilirubin levels with the cause thought to be ABO incompatibility. My wife is O-negative, I am A-positive and our daughter is A-positive/Combs-positive. My wife was not administered rhoGAM at any point during or after her pregnancy/delivery. Our pediatrician caught the jaundice fairly early and daughter is seems to be recovering, but I am also quite concerned with whether my wife and I can now safely have another child, as she did not receive rhoGAM. Is it possible for us to safely have another child and what would we need to do or screen for to do so? My thanks to you in advance.
Kenneth F. Trofatter, Jr., MD, PhD said...
To preferring anonymity Sept 16: Your wife did not NEED Rhogam if your daughter was Rh-negative. ABO incompatibility is another issue. All people with O blood types make antibodies to A and B blood groups. They are exposed to those antigens in the environment (bacteria) and do not even need to be exposed to another human's blood to generate these antibodies. However, usually these antibodies are of the IgM class of antibodies. IgM antibodies are very large and basically contain a pentamer (5 antibodies) joined together. They are TOO BIG to cross the placenta to the baby. Occasionally, individuals also make anti-A or anti-B antibodies that are IgG class antibodies. These CAN cross the placenta and, indeed, IgG antibodies are a major source of 'immunity (passive immunity)' against common pathogens for the baby during the first 3-6 months of life.
Unfortunately, the placenta doesn't differentiate between 'good' (protective) IgG antibodies and antibodies that might harm the baby. This is the same problem with Rh-isoimmunization when it occurs. The antibodies from the mother cross the placenta, attach to the fetal tissues that are foreign (in your baby's case blood group A red blood cells) and that signals the baby's immune system to destroy whatever the antibodies are attached to - at that point the baby's immune system cannot distinguish what uis 'foreign' and what is 'self'! With the destruction of the baby's own red cells, hemoglobin is released and its breakdown product, bilirubin, can cause jaundice and more serious problems if the bilirubin levels get high enough. When the baby has used up all the antibody it has gotten from Mom, it will not have anymore problems.
To answer your other question, yes it is safe to have another baby under these circumstances. Often ABO incompatibility isn't much of a problem until after the baby is born, unlike with severe Rh-isoimmunization. Your doctors can assess the degree of fetal anemia in utero, indirectly, by doing peak systolic velocity of blood flow in the baby's middle cerebral artery by Doppler flow velocimetry if you are worried about fetal anemia during the pregnancy. Let them explain that to you! Best of luck, congratulations on your new baby, and thanks for reading and the great questions.
Dr T
Labels: ABO incompatibility, rh-immune globulin, Rh-isoimmunization, Rhogam
4 Comments:
At Wed May 28, 10:44:00 AM 2008,
Barbara said…
Dr. T-
I am have O+ blood. My first child, who was slightly jaundiced after birth has A- blood. My second child also had A- blood. Unfortunately my second child, who was born at 36 weeks, died 2 hours after birth. The pathology report states that he died of severe anemia due to a Fetomaternal Hemorrhage. There was no known cause for the hemmorrhage. The report also states that probable ABO incompatibility may have contributed to his death. At this point we am trying to assess the propriety of conceiving another child. My husband and I are not willing to proceed with another pregnancy if the risks are high of suffering another loss. Thank you for your input.
At Wed May 28, 05:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Barbara: Severe ABO incompatibility resulting in fetal or neonatal death is rare but it does occur. You have an O blood type which means you have antibodies against both A and B blood types, but usually those ntibodies are of the IgM class and they do not cross the placenta to harm the baby. Those individuals who develop IgG antibodies that do cross the placenta can have an affected baby. Your doctor should be able to send off studies on your blood to see if you have significant levels of IgG anti-A antibodies. If you do, then the pregnancy should be followed just as if you had Rh-antibodies to look for evidence of fetal anemia in view of the complications you have had. I would suggest you ask to have a 'second opinion' by a specialist in maternal-fetal medicine who can throughly review your case and make some solid recommendations (and explanations) about another pregnancy and how that could be handled. Good luck and thanks for writing! Dr T
At Tue Sep 30, 09:21:00 PM 2008,
Zoe said…
Dear Dr,
Blood tests taken at the time of the birth of my first baby showed an ABO incompatibility - our pediatrician informed us that my body had released antibodies that had attacked our baby's immune system. As a result he had jaundice for almost 12 weeks and many many tests.
I am O+ and my son is A+.
I am currently pregnant with our second child and am concerned after reading articles that state the the severity of the condition is greater with subsequent pregnancies, and can result in serious conditions or even fetal death.
Should we be concerned? Are there tests that can be done during the pregnancy to determine if the baby is at risk?
Many many thanks for your help.
At Wed Oct 08, 10:37:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Zoe: People who have O blood types make antibodoes to both the A and the B blood groups. Usually those antibodies are of the class of IgM antibodies that are too large to cross the placenta, so that even if you have a baby with A or B blood, the antibodies won't be able to get on the baby's side of the placenta and cause destruction of the baby's red blood cells. You are someone who has antibodies against these blood groups of the IgG class. IgG antibodies readily cross the placenta, and indeed are the source of immunity to many of the things in the environment that could hurt the baby during the first 3-6 months of life before its own immune system has matured. Unfortunately, the placenta cannot differentiate which IgG antibodies are there to protect the baby and which might hurt. Your IgG anti-A antibodies can cross the placenta and mediate destryction of the baby's own red blood cells by the baby's own immune system once they have attached themselves to the red blood cells. If you have another baby with an A blood type, this could happen again. However, the degree of fetal anemia caused by the antibodies can be monitored by something called Doppler flow velocimetry by which we can measure the velocity of blood in a vessel called the middle cerebral artery in the baby's brain. If it appeasr the baby is developing severe anemia, the baby could be given a blood transfusion with O type blood through an injection in the umbilical vein. For your next pregnancy, if you choose to have one, you should get a consultation with a specialist in Maternal-Fetal Medicine. In fact, you might even want to do that BEFORE you think seriously about getting pregnant again. Hope this helps. Best wishes! Dr T
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