Hemolytic disease according to the av system. Hemolytic disease of the newborn is not a sentence! Pathogenesis in edematous form of hemolytic disease of the newborn

Hemolytic disease of the newborn (HDN): causes, manifestations, how to treat

Hemolytic disease of the newborn (HDN) is a very common disease. Approximately 0.6% of born children register this pathology. Despite the development various methods treatment, mortality from this disease reaches 2.5%. Unfortunately, this pathology is common a large number of scientifically unfounded "myths". For a deep understanding of the processes occurring in hemolytic disease, knowledge of normal and pathological physiology is necessary, as well as, of course, obstetrics.

What is hemolytic disease of the newborn?

TTH is the result of a conflict between the immune systems of mother and child. The disease develops due to the incompatibility of the blood of a pregnant woman to the antigens on the surface of the erythrocytes of the fetus (first of all, this is). Simply put, they contain proteins that are recognized by the mother's body as foreign. That is why in the body of a pregnant woman, the processes of activation of her immune system begin. What is going on? So, in response to the ingress of an unfamiliar protein, biosynthesis of specific molecules occurs that can bind to the antigen and “neutralize” it. These molecules are called antibodies, and the combination of antibody and antigen is called immune complexes.

However, in order to get a little closer to a true understanding of the definition of TTH, it is necessary to understand the human blood system. It has long been known that blood contains different types cells. The largest number of cellular composition is represented by erythrocytes. At the present level of development of medicine, at least 100 various systems antigenic proteins present on the erythrocyte membrane. The following are the most well studied:, Rhesus, Kell, Duffy. But, unfortunately, the erroneous judgment is very common that hemolytic disease of the fetus develops only according to group or Rh antigens.

The lack of accumulated knowledge about erythrocyte membrane proteins does not mean at all that incompatibility is ruled out for this antigen in a pregnant woman. This is the exposure of the first and, perhaps, the most basic myth about the causes of this disease.

Factors causing immune conflict:


Video: about the concepts of blood type, Rh factor and Rh conflict

The likelihood of conflict if the mother is Rh-negative, and the father is Rh-positive

Very often, a woman who has a negative Rh worries about her future offspring, even before she is pregnant. She is afraid of the possibility of developing a Rhesus conflict. Some are even afraid to marry a Rh-positive man.

But is it justified? And what is the probability of developing an immunological conflict in such a pair?

Fortunately, the sign of Rh belonging is encoded by the so-called allelic genes. What does it mean? The fact is that the information located in the same sections of paired chromosomes can be different:

  • The allele of one gene contains a dominant trait, which is the leading one and manifests itself in the body (in our case, the Rh factor is positive, we will denote it with a capital letter R);
  • A recessive trait that does not manifest itself and is suppressed by a dominant trait (in this case, the absence of the Rh antigen, we will denote it with a small letter r).

What does this information give us?

The bottom line is that a person who is Rh-positive can contain in their chromosomes either two dominant traits (RR), or both dominant and recessive (Rr).

In this case, the mother, who is Rh-negative, contains only two recessive traits (rr). As you know, during inheritance, each parent can give his child only one trait.

Table 1. Probability of inheriting a Rh-positive trait in a fetus if the father is a carrier of a dominant and recessive trait (Rr)

Table 2. Probability of inheriting a Rh-positive trait in a fetus if the father is a carrier of only dominant traits (RR)

Mother(r)(r)Father (R) (R)
Child(R)+(r)
Rh positive		(R)+(r)
Rh positive
Probability100% 100%

Thus, in 50% of cases, there may not be an immune conflict at all if the father is a carrier recessive trait Rh factor.

So, we can draw a simple and obvious conclusion: the judgment that immunological incompatibility must certainly be in a Rh-negative mother and a Rh-positive father is fundamentally wrong. This is the "exposure" of the second myth about the causes of the development of hemolytic disease of the fetus.

In addition, even if the child still has a positive Rh affiliation, this does not mean at all that the development of HDN is inevitable. Do not forget about the protective properties. With a physiologically proceeding pregnancy, the placenta practically does not pass antibodies from mother to child. The proof is the fact that hemolytic disease occurs only in the fetus of every 20th Rh-negative woman.

Prognosis for women with a combination of negative Rh and the first blood group

Upon learning about the belonging of their blood, women with a similar combination of group and Rhesus panic. But how justified are these fears?

At first glance, it may seem that the combination of "two evils" will create high risk development of HDN. However, the usual logic does not work here. It's the other way around: the combination of these factors, oddly enough, improves the prognosis. And there is an explanation for this. In the blood of a woman with the first blood group, there are already antibodies that recognize a foreign protein on red blood cells of a different group. So laid down by nature, these antibodies are called alpha and beta agglutinins, they are present in all representatives of the first group. And when hit a small amount fetal erythrocytes into the mother's bloodstream, they are destroyed by the already existing agglutinins. Thus, antibodies to the Rh factor system simply do not have time to form, because agglutinins are ahead of them.

In women with the first group and Rh negative a small titer of antibodies against the Rh system, therefore, hemolytic disease develops much less frequently.

Which women are at risk?

We will not repeat that a negative Rh or the first blood group is already a certain risk. However, it is important to know about the existence of other predisposing factors:

1. Lifetime blood transfusion in an Rh-negative woman

This is especially true for those who, after transfusion, had various allergic reactions. Often in the literature one can find a judgment that it is precisely those women who are transfused with a blood group without taking into account the Rh factor that are at risk. But is it possible in our time? Such a probability is practically excluded, since the Rh affiliation is checked at several stages:

  • When taking blood from a donor;
  • at the transfusion station;
  • The laboratory of the hospital where blood transfusion is carried out;
  • A transfusiologist who conducts a three-fold test of the compatibility of the blood of the donor and the recipient (the person who is to be transfused).

The question arises: how then can a woman be sensitized (presence of hypersensitivity and antibodies) to Rh-positive erythrocytes?

The answer was given quite recently, when scientists found out that there is a group of so-called "dangerous donors" in whose blood there are red blood cells with a weakly expressed Rh-positive antigen. It is for this reason that their group is defined by laboratories as Rh-negative. However, when such blood is transfused in the recipient's body, specific antibodies may begin to be produced in a small volume, but even their quantity is sufficient to the immune system“remembered” this antigen. Therefore, women with similar situation even in the case of the first pregnancy, an immune conflict may arise between her body and the child.

2. Re-pregnancy

It is believed that in During the first pregnancy, the risk of developing an immune conflict is minimal. And the second and subsequent pregnancies already proceed with the formation of antibodies and immunological incompatibility. And indeed it is. But many forget that the first pregnancy should be considered the fact of development gestational sac in the mother's body at any time.

Therefore, at risk are women who have had:

  1. Spontaneous abortions;
  2. Frozen pregnancy;
  3. medical, surgical interruption pregnancy, vacuum aspiration of the fetal egg;
  4. Ectopic pregnancy (tubal, ovarian, abdominal).

Moreover, in the group increased risk there are also primigravida with the following pathologies:

  • Detachment of the chorion, placenta during this pregnancy;
  • Formation of a post-placental hematoma;
  • Bleeding with low placenta previa;
  • Women who have used invasive methods diagnostics (piercing of the fetal bladder with amniotic fluid sampling, blood sampling from the umbilical cord of the fetus, biopsy of the chorion site, examination of the placenta after 16 weeks of pregnancy).

Obviously, the first pregnancy does not always mean the absence of complications and the development of an immune conflict. This fact dispels the myth that only the second and subsequent pregnancies are potentially dangerous.

What is the difference between fetal and neonatal hemolytic disease?

There are no fundamental differences between these concepts. Just hemolytic disease in the fetus occurs in the prenatal period. HDN means leak pathological process already after the birth of the child. In this way, the difference lies only in the conditions of the baby's stay: in utero or after childbirth.

But there is another difference in the mechanism of the course of this pathology: during pregnancy, the mother's antibodies continue to enter the fetus, which lead to a deterioration in the condition of the fetus, while after childbirth this process stops. That's why women who have given birth to a baby with hemolytic disease are strictly forbidden to breastfeed their baby. This is necessary in order to exclude the entry of antibodies into the baby's body and not aggravate the course of the disease.

How is the disease progressing?

There is a classification that well reflects the main forms of hemolytic disease:

1. Anemic- the main symptom is a decrease in the fetus, which is associated with the destruction of red blood cells () in the baby's body. Such a child has all the signs:


2. Edema form. The predominant symptom is the presence of edema. Distinctive feature is a deposit excess fluids in all tissues:

  • In the subcutaneous tissue;
  • in chest and abdominal cavity;
  • In the pericardial sac;
  • In the placenta (during the prenatal period)
  • Hemorrhagic rashes on the skin are also possible;
  • Sometimes there is a violation of the function of blood clotting;
  • The child is pale, lethargic, weak.

3. Icteric form characterized, which is formed as a result of the destruction of red blood cells. With this disease, there is toxic injury all organs and tissues:

  • The most severe option is the deposition of bilirubin in the liver and brain of the fetus. This condition is called "nuclear jaundice";
  • Yellowish staining of the skin and sclera of the eyes is characteristic, which is a consequence of hemolytic jaundice;
  • It is the most common form (in 90% of cases);
  • Possible development diabetes with damage to the pancreas.

4. Combined (the most severe) - is a combination of all previous symptoms. It is for this reason that this type of hemolytic disease has the highest percentage of mortality.

How to determine the severity of the disease?

In order to correctly assess the condition of the child, and most importantly, to prescribe effective treatment, it is necessary to use reliable criteria in assessing the severity.

Diagnostic methods

Already during pregnancy, you can determine not only the presence of this disease, but even the severity.

The most common methods are:

1. Determination of the titer of Rh or group antibodies. It is believed that a titer of 1:2 or 1:4 is not dangerous. But this approach is not justified in all situations. Here lies another myth that "the higher the titer, the worse the prognosis."

The antibody titer does not always reflect the real severity of the disease. In other words, this indicator is very relative. Therefore, it is necessary to assess the condition of the fetus, guided by several research methods.

2. Ultrasound diagnostics is a very informative method. The most characteristic signs:

  • Enlargement of the placenta;
  • The presence of fluid in tissues: fiber, chest, abdominal cavity, swelling of the soft tissues of the fetal head;
  • An increase in blood flow velocity in uterine arteries, in the vessels of the brain;
  • The presence of suspension in the amniotic fluid;
  • Premature aging of the placenta.

3. Increasing the density of amniotic fluid.

4. At registration - signs and violation of the heart rhythm.

5. In rare cases perform research cord blood (determine the level of hemoglobin and bilirubin). This method is dangerous premature termination of pregnancy and fetal death.

6. After the birth of a child, there are more simple methods diagnostics:

  • Taking blood to determine: hemoglobin, bilirubin, blood type, Rh factor.
  • Examination of the child (in severe cases, jaundice and swelling are pronounced).
  • Determination of antibodies in the blood of a child.

Treatment of HDN

You can start treatment for this disease during pregnancy, to prevent deterioration of the fetus:

  1. The introduction of enterosorbents into the mother's body, for example "Polysorb". This drug helps to reduce the titer of antibodies.
  2. Drip administration of glucose and vitamin E solutions. These substances strengthen cell membranes erythrocytes.
  3. Injections of hemostatic drugs: Dicinon (Etamzilat). They are needed to increase blood clotting ability.
  4. AT severe cases may be required intrauterine fetus. However, this procedure is very dangerous and fraught with adverse effects: fetal death, premature birth and etc.

Methods for treating a child after childbirth:


For severe disease, use following methods treatment:

  1. Blood transfusion. It is important to remember that only “fresh” blood is used for blood transfusion, the date of preparation of which does not exceed three days. This procedure is dangerous, but it can save the baby's life.
  2. Purification of blood with the help of hemodialysis and plasmapheresis devices. These methods help to remove from the blood toxic substances(bilirubin, antibodies, erythrocyte destruction products).

Prevention of the development of immune conflict during pregnancy

Women at risk for the development of immunological incompatibility must adhere the following rules, there are only two of them:

  • Try not to have abortions, for this you need to consult a gynecologist for the appointment of reliable methods of contraception.
  • Even if the first pregnancy went well, without complications, then after childbirth, within 72 hours, it is necessary to introduce anti-Rhesus immunoglobulin (KamROU, HyperROU, etc.). The completion of all subsequent pregnancies should be accompanied by the administration of this serum.

Hemolytic disease of the newborn is a serious and very dangerous disease. However, one should not unconditionally believe all the "myths" about this pathology, even though some of them are already firmly rooted among most people. A competent approach and strict scientific validity are the key to a successful pregnancy. In addition, due attention must be paid to prevention issues in order to avoid potential problems as much as possible.

Today, this disease is very rare, it can be prevented with the help of a regular blood test of a pregnant woman. If necessary, the baby will receive a blood transfusion before or after birth.

Hemolytic disease of the newborn (HDN) is a disease based on the destruction of red blood cells due to an immunological conflict between the blood of the mother and the fetus. The disease develops when the blood of the mother and fetus is incompatible according to the Rh factor or blood groups. If a woman is Rh-negative, that is, her red blood cells do not contain the Rh antigen, and the fetus is Rh-positive, that is, her red blood cells have the antigen, then a conflict may develop. Or if the mother has an 0 (1) blood type (and her red blood cells do not have antigens), and the fetus has A (P) or B (III) blood type, that is, the erythrocytes of the fetus have antigen A or B - in this case, a conflict may develop group incompatibility.

For the birth of a child with HDN, prior sensitization of the woman during previous pregnancies, abortions, transfusions of Rh-positive blood is necessary. For development conflict situation not all Rh-negative women, or those with 0 (1) blood type, have a conflict, since importance for its development has the state of the placenta. If the placenta is healthy and performs a barrier function, then it is not permeable to antibodies, that is, they do not penetrate from the mother's body to the fetus. Violation of the permeability of the placenta can be with gestosis of pregnancy and diseases of the mother, when already during the first pregnancy the development of a conflict, that is, HDN, is possible.

The problem of blood incompatibility. Hemolytic disease occurs most often with the incompatibility of the Rh factor. When the mother's blood is Rh negative and the baby's blood is Rh positive, the mother produces antibodies that destroy the baby's red blood cells. However, antibodies from other blood types can also be involved in this disease.

Without treatment, a baby is born with an excess of free bilirubin (a toxic breakdown product of red blood cells), which manifests as jaundice and can cause permanent brain damage.

Causes of hemolytic disease of the newborn

The cause of the disease can also be a mismatch in group compatibility: for example, the mother has the first blood group, and the fetus has a different group.

Unfortunately, rhesus hemolytic disease occurs in 99% of women with negative rhesus blood.

When Rh antigens enter the mother's blood through the placenta from the fetus, Rh antibodies begin to be produced in the mother's blood, which can destroy or damage only the emerging hematopoietic organs: the liver, spleen, Bone marrow.

This happens around the third month of pregnancy, when his personal Rh factor is established in the blood of the fetus.

Increase the likelihood and severity of the course of the disease: a past transfusion of the mother with incompatible blood, previous births or a pregnancy that ended in an abortion.

Pathogenesis. Rh - AG, antigens A or B of fetal erythrocytes enter the mother's blood through the placenta, causing the formation of antibodies (AT) to them. Antibodies penetrate the placental barrier and are fixed on the erythrocytes of the fetus, an antigen-antibody is formed on the membranes of erythrocytes, which causes the destruction of erythrocytes, hemoglobin is released, which decomposes into heme and globin. Globin is converted to indirect bilirubin or free bilirubin, which is converted to direct (bound bilirubin) in the liver and excreted into the intestine with bile. With a high level of erythrocyte decay, hemoglobin does not have time to pass into direct bilirubin in the liver, accumulates in the blood and leads to the development of jaundice. Indirect bilirubin is fat-soluble, therefore it accumulates in fat cells of the subcutaneous fat cells. nervous tissue, exhibits neurotoxic properties, causes bilirubin encephalopathy. In addition, it damages other organs: the liver, heart, lungs.

Clinical forms and symptoms of hemolytic disease of the newborn

There are 3 forms of the disease: edematous (2%), icteric (88%), anemic (10%). Clinical form depends on the degree and state of sensitization of the mother, that is, the amount of antibodies produced.

anemic form- the most mild form. Pallor is noted skin, slight enlargement of the liver and spleen. Children are lethargic, suckle poorly, the amount of hemoglobin and erythrocytes in the blood is reduced with an increase in immature forms of erythrocytes - reticulocytes, erythro- and normoblasts. Level indirect bilirubin slightly increased.

icteric form occurs most frequently. The main symptom is jaundice, which is already present at birth or appears during the first or second day, in contrast to physiological jaundice appearing on the third day. There is an increase in the liver, spleen, anemia in the blood, a decrease in hemoglobin, erythrocytes, an increase in reticulocytes, blast forms of erythrocytes, that is, immature forms. An increase in the amount of indirect bilirubin leads to the development of symptoms of bilirubin intoxication: lethargy, drowsiness, inhibition of physiological reflexes, decreased muscle tone. The newborn appears on time normal color skin and body weight, but on the 2nd day jaundice appears. The child sucks badly at the breast, sluggish, reflexes appear inhibited.

If the level of bilirubin reaches the critical figures of 340 μmol / l in full-term and 200 μmol / l in premature infants, then symptoms of bilirubin encephalopathy may appear: neck stiffness, tension of the large fontanel, a piercing cry, a symptom of the "setting sun", there may be heat central character, respiratory and cardiac disorders. The urine is dark yellow, the color of the stool does not change.

edematous form the heaviest. The fetus dies in utero or is born prematurely. Children are not viable. Marked swelling of all tissues, pallor of the skin and mucous membranes, accumulation of fluid in all cavities - abdominal, chest. The liver and spleen are greatly enlarged. In the blood test, the amount of hemoglobin and erythrocytes is significantly reduced. The placenta is enlarged, edematous. The newborn appears with general edema.

If a mother has Rh-negative blood or 0(1) blood type, even if the baby was born without visible manifestations diseases (THD), everyone takes blood from the umbilical cord immediately after it is cut to the level of indirect bilirubin and hemoglobin. The child is then monitored for the hourly increase in bilirubin, that is, blood is taken every hour to determine the level of bilirubin. With a rapid increase in the level of indirect bilirubin, the issue of an exchange transfusion is decided, without waiting for the onset of symptoms of HDN.

The final diagnosis is made according to the history of pregnancy, blood test (group and Rh), determination of the level of birubilin and some other laboratory tests.

Observation of pregnancy in hemolytic disease of the newborn

Usually, a woman who has already had a child with an Rhesus conflict needs to take preventive measures in order to stop the production of antibodies against a positive Rh (gamma globulin injections, for example). But if, despite all the precautions, antibodies still appear in the blood of a pregnant woman, a blood test is performed to determine and assess the risk possible complications depending on the gestational age.

The development of the fetus is monitored using ultrasound in order to detect as quickly as possible any anomaly in which anemia can result: hemorrhage around the heart, general edema ... In some cases, amniocentesis is done to clarify the risk and measure the level of bilirubin in the amniotic fluid taken on analysis.

Transfusion in the womb or after birth

In the case of intrauterine transfusion, Rh-negative blood is used (to avoid the destruction of new red blood cells by antibodies contained in the mother's blood). The introduction is made through the umbilical cord under ultrasound control and can be repeated many times before delivery.

Treatment of hemolytic disease of the newborn

Treatment is primarily aimed at as much as possible prompt removal toxic decay products from the body of the newborn. If birubilin builds up too quickly, decide on a blood transfusion.

Therapeutic measures are aimed at reducing the level of bilirubin, removing antibodies from the child's body and eliminating anemia.

Conservative treatment: infusion of 10% glucose solutions, gemodez, albumin; drugs that promote the transfer of NB to PB - phenobarbital; drugs that prevent suction bilirubin from the intestine - carbolene, cholestyramine; phototherapy - irradiation of a child with blue light, since under the action of light, NB decays in the skin and subcutaneous tissue, thereby reducing its level in the child's body. This procedure is usually carried out in couveuses, over which a special illuminator is installed. of blue color The child is put on protective goggles. You can also use normal sunlight, for which the opened child is placed in bright sunlight (near the window).

Surgical treatment - an exchange transfusion of blood (ZPK) with a rapid rate of increase in bilirubin or with its high concentration without waiting for complications. For ZPK, Rh-conflict is used with "Rh-negative one-group blood, with ABO-incompatibility, one-group at the rate of 150 ml / kg. During the operation, 70% of the patient's blood is replaced. The operation is performed through an umbilical catheter: alternately, 20 ml of blood is taken and the same amount of freshly prepared donated blood. Before the operation, the nurse prepares the equipment, rinses the stomach, makes cleansing enema and swaddles the baby in sterile underwear, leaving open belly. The child is placed on heating pads or in an incubator and the temperature and activity of vital organs are monitored. After PKK surgery, intensive monitoring is necessary. In addition to ZPK, hemosorption or plasmapheresis (removal of bilirubin from blood or plasma by passing them through a sorbent) can be used.

The first 5 days the child is fed with donor milk. The child is applied to the chest after a decrease in the content of bilirubin in the blood and a decrease in jaundice.

Prevention of hemolytic disease of the newborn

Strict accounting - Rh-affiliation of the blood of the donor and recipient during blood transfusion, warnings unwanted pregnancy, since during abortions there is a high sensitization of women, therefore Rh-negative women are not recommended to interrupt their first pregnancies.

A specific method of prevention is the introduction of anti-D immunoglobulin, which inhibits the formation of antibodies, to a woman with Rh-negative blood. Immunoglobulin is administered after the birth of a healthy Rh-positive child, as well as after an abortion.

With an increase in antibody titer in pregnant women, detoxification, hormonal, antihistamine therapy is carried out. Replanting in progress skin flap from her husband in order to fix antibodies on the transplant.

The prognosis for HDN depends on the severity of the disease, the highest level of bilirubin, whether there was bilirubin encephalopathy, how severe. After moderate and severe bilirubin encephalopathy, paralysis, blindness, deafness, and mental retardation may remain. After mild encephalopathy, inadequate responses to preventive vaccinations, lag in psychomotor development, psychovegetative disorders.

Hemolytic disease is a disease that is caused by the incompatibility of the blood of the mother and the unborn baby for various antigens. There is incompatibility and Rh factor. This often happens when the mother and fetus have a different Rh factor (for example, the mother is positive, the fetus is negative, or vice versa). With group incompatibility, the mother and fetus may have different groups blood (for example, the mother has group 0 (1), and the fetus has any other). Hemolytic disease of the newborn can also develop with incompatibility of other blood antigens, but this happens extremely rarely.

What are the reasons?

Hemolytic disease in women with is quite common. This is very serious and dangerous disease. The process of occurrence of the Rhesus conflict is simple: antigens come from the fetus to the mother through the placenta. In response, the woman's body produces its own Rh-negative antibodies to destroy the opposite Rh-positive erythrocytes of the unborn baby, thereby detrimental to his liver, spleen, bone marrow and hematopoietic organs. Thus, the destroyed red blood cells lead to the accumulation of bilirubin in the tissues of the fetus, which has a toxic effect on the infant's brain. The Rh factor is determined in the blood of the child already in the third month prenatal development. It was from this time that his “conflicts” with his mother began.

Hemolytic disease of the newborn. Symptoms

To date, three forms have been studied insidious disease: edematous, icteric and anemic. The edematous form is considered the most severe, in which children are born prematurely or die immediately after birth. Wherein appearance the newborn has a characteristic appearance: a moon-shaped face, waxy pallor, sometimes cyanosis or icterus, edematous subcutaneous tissue. There is free fluid in the pleural, abdominal, pericardial cavities, sometimes bruises, petechiae. The baby's liver and spleen are enlarged. In the blood, there is a decrease in erythrocytes and hemoglobin, as well as leukocytosis, erythroblastosis, reticulocytosis.

Hemolytic is mild, moderate and severe degree. It is characterized by the appearance of jaundice immediately after the birth of the fetus or a few hours later. At the same time, even amniotic fluid can be colored in yellow. Hemolytic jaundice in an infant grows very quickly, the liver and spleen increase, and there is a tendency to bleed. Such babies are born lethargic, suckle their breasts poorly, all physiological reflexes they may be reduced. The level of bilirubin in the blood increases and reaches its maximum on the third or fifth day. If at this moment the child is not treated, develops Appears tonic convulsions, limb tremor. The tone of the extensor muscles of the hands is considered characteristic of this type of disease, while general hypotension is increasing.

The anemic form is the mildest manifestation of this disease. With it, an increase in the liver and spleen is observed, the number of red blood cells and hemoglobin in the blood decreases.

Hemolytic disease of the newborn. Treatment

The most important thing in therapeutic measures- this is the fastest detoxification of the body of the newborn, the removal of decay products of erythrocytes, antibodies and bilirubin. All this is done in order to stop the hemolysis of the baby after birth. During this period, the child is shown plentiful drink, vitamins, enterosorbents, detoxification solutions. Severe anemia is an indication for exchange transfusion.

To prevent hemolytic disease modern medicine conducts transfusion of blood and its components strictly according to emergency indications in order to prevent the woman from being immunized with foreign antigens. In the case when a Rh conflict is detected in a pregnant woman, she is hospitalized and everything possible is done to preserve the health and life of the baby.

One of the most severe childhood pathologies is hemolytic disease of the newborn, which occurs when the immune systems of the mother and the child conflict, which is accompanied by massive destruction of red blood cells. Therefore, hemolytic disease of the fetus and newborn is also known as erystoblastosis.. This is a sad result of categorical differences in the blood of mother and baby according to the Rh system or the ABO system.

The main cause of erythroblastosis of the infant (hemolytic disease of the newborn) is the opposite difference between the blood of mother and baby, most often by the Rh factor, more rarely the culprits are blood group antigens (in the ABO system), and are least likely to encounter antigens of a different nature.

What is the predisposition to the Rhesus conflict of mother and baby? When a mother with a minus rhesus is pregnant with a baby with a plus rhesus. Most often, this is why hemolytic disease of the newborn manifests itself, starting development already in the womb.

The cause of the clash of immunities in the ABO system is a mismatch in blood types: O (1) -blood group in the mother and A (2) or B (3) in the fetus.

It is worth noting that not always a child is born sick. And only when the mother had previously experienced the so-called sensitization, that is, increased sensitivity to foreign blood components that she encountered for one reason or another.

Maternal sensitization can have different sources. For example, an Rh-negative mother becomes sensitized after receiving a blood transfusion with Rh positive(this could have happened a very long time ago, even when she was a child). In addition, sensitization occurs during a miscarriage, and if there was an artificial abortion. Also, the main culprits of maternal sensitization are childbirth. Therefore, with each subsequent child, the risk increases.

If a we are talking about immune incompatibility according to the ABO system, it does not matter what kind of pregnancy a woman has, since we are faced with sensitization to antigens every day - when eating, with vaccinations, during certain infections.

In addition to the aforementioned mismatches in the Rh factor and the ABO system special place the placenta occupies, since it provides direct contact between the organisms of the mother and the baby when he is in the womb. If the barrier itself is violated, it is easier to exchange antibodies and antigens in the bloodstreams of mother and baby.

In the prenatal period, along with red blood cells, hostile blood cells penetrate inside. These bodies (Rh factor, antigens A and B) contribute to the formation of antibodies in the blood, and they then penetrate through the protective barrier into the bloodstream of the baby to be born. The result of this exchange is the combination of antigens and antibodies that cause pathological destruction of red blood cells.

The consequences of such destruction, with the participation of hostile bodies, have a detrimental effect on the development of the fetal organism. As one of the consequences of this decay is an increase in the concentration of toxic bilirubin and the development of anemia (anemia).

Bilirubin that has not passed through the liver is toxic to humans, and even more so to an infant. He has the ability to overcome the obstacle that separates circulatory system and the central nervous system, and also causes damage to the subcortical nuclei and the cerebral cortex, which is the cause of "nuclear jaundice".

If it has developed, then as a result of the destruction of red blood cells, new ones are formed blood cells- erythroblasts. Therefore, hemolytic disease of the newborn is also called erythroblastosis.


Forms

Depending on the type of immunological conflict, the following forms are distinguished

  • Hemolytic disease of the newborn due to a conflict on the Rh factor;
  • Hemolytic disease of the newborn due to a blood type conflict (ABO incompatibility);
  • More rare forms(conflict over other antigenic systems).

Clinical forms:

  • edematous;
  • icteric;
  • Anemic.

According to the severity, the following forms of the disease are distinguished:

  • Mild: Symptoms are mild or only laboratory findings are present.
  • Moderate: bilirubin in the blood is increased, but intoxication and complications have not been identified. In the first 5-11 hours after the birth of the baby, it manifests itself (depending on the Rh conflict or ABO conflict), in the first hour of life less than 140 g / l, bilirubin in the blood from the umbilical cord exceeds 60 μmol / l, the liver and spleen are enlarged.
  • Severe: edematous form of the disease, symptoms of nuclear jaundice, respiratory disorders and cardiac function.


Symptoms

Clinical symptoms are different in some form of pathology: edematous, anemic or icteric.

edematous

The edematous form, similarly called dropsy of the fetus, is the rarest, while the severity of the course of the disease surpasses all others. Here are its signs and symptoms:

  • The beginning of development is intrauterine;
  • High probability of miscarriage in the first trimester of pregnancy;
  • Less often - either later death of the fetus, or birth in a aggravated position with edema characteristic of this form, a deep deficiency of hemoglobin and erythrocytes in the bloodstream, with oxygen starvation and heart failure;
  • Great, almost waxy, pallor of the skin of an infant;
  • Sharp strengthening of muscles, reflex oppression;
  • Large abdomen due to enlargement of the liver and spleen;
  • Extensive tissue swelling.

anemic

The anemic form is the mildest possible. Her symptoms:

  • Can be recognized in the near future (up to four to five days) after the birth of a child;
  • Anemia progressively develops, the skin and mucous membranes turn pale, the abdomen increases;
  • In general, it does not greatly affect the well-being of the child.

icteric

The icteric form is the most common form. Her symptoms:

  • Tissues acquire a pronounced yellow tint due to hyperaccumulation of the yellow pigment bilirubin and its derivatives in the bloodstream;
  • deficit coloring pigment and red cells per unit volume of blood;
  • Significant enlargement of the spleen and liver in size.

The development of jaundice occurs soon after the birth of the baby, sometimes - after 24 hours. It progresses over time.

The skin and mucous membranes of the child become yellow, even orange. The severity of the course of the disease depends on how early it manifested itself. The more bilirubin accumulates in the blood, the more lethargy and drowsiness appears in the child. There is an inhibition of reflexes and a decrease in muscle tone.

On days 3-4, the concentration of toxic bilirubin becomes critical - more than 300 micromoles per liter.

Jaundice acquires a nuclear form when the subcortical nuclei of the brain are affected. This can be understood by the stiff neck and opisthotonus (convulsive posture with contraction of all muscles), the symptom of the "setting sun", a piercing brain cry. By the end of the week, the skin becomes greenish, the feces become colorless, and the rate of direct bilirubin increases.

Diagnostics

It is necessary to carry out prenatal diagnosis of the conflict between the immune system of the mother and the fetus. At risk are women with miscarriages, stillbirths, children who died on the first day from jaundice, if mothers did a blood transfusion without taking into account the Rh factor.

  • It is necessary to determine the Rh and ABO group of the child's parents. The mother with a negative, and the fetus with a positive Rh are at risk. The genotype of the father is checked with the prognosis of the Rh of future children. Women with I blood group are also in a dangerous position.
  • Check the dynamics of the titer of anti-Rhesus antibodies, if a woman has a negative Rh, at least three times during the gestation period.
  • Do a sampling of amniotic fluid at the 34th week, if there is a risk.
  • Mandatory ultrasound procedure for thickening of the placenta and polyhydramnios.

Postpartum diagnosis is also carried out on the basis of clinically manifested symptoms during childbirth and immediately after them, as well as laboratory indicators of the disease. A consultation with a pediatric hematologist is appointed, who will oversee the treatment if a pathology is detected.

Treatment

In severe forms of the disease, treatment is as follows:

  • Carry out a blood transfusion with replacement (they release "bad" blood and carry out a transfusion of donor blood);
  • Hemosorption is carried out - blood is passed through or resins capable of absorbing toxic substances;
  • A certain amount of blood is taken and plasma containing toxic components is removed from it.

A blood exchange transfusion helps to get rid of indirect bilirubin and harmful antibodies from the baby's blood and increase the number of red blood cells.

  • Be sure to read:

To carry out such a transfusion, blood with a negative Rh and the same ABO group as in an infant is used. Now they're trying not to spill whole blood, so as not to reduce the risk of transmitting HIV or hepatitis, but use either a mass of red blood cells with a negative Rh or plasma, depending on the group of the ABO system. This allows you to replace more than 94% of the baby's blood.

In case the disease is light form or carried out surgical treatment, do the following:

  • Intravenous glucose and protein-based preparations are infused;
  • Assign inducers of microsomal liver enzymes;
  • Vitamins C, E, group B, cocarboxylase, which improve the functioning of the liver and normalize metabolic processes.

If there is a syndromic thickening of bile, cholagogues are prescribed inside. If anemia is severe, an erythrocyte transfusion is done. In parallel, phototherapy is prescribed, that is, the child's body is irradiated with a fluorescent lamp of white or blue light. Indirect bilirubin, located in the skin, is oxidized, water-soluble components are formed from it, which are excreted naturally.


Complications and consequences

If the disease is severe forms, complications can be the most disappointing, despite treatment:

  • The fetus may die either during pregnancy or in the first week after birth;
  • The child may become disabled, including cerebral palsy;
  • May become completely deaf or blind;
  • Psychomotor disturbances can be observed;
  • May develop due to stagnation of bile;
  • Psychiatric disorders are often observed.

The red blood cells of the child may have differences in properties with those of the mother. If the placenta passes such red blood cells, they turn into foreign antigens, and the response is the production of antibodies by the mother's body. The penetration of antibodies into the body of the fetus can cause:

  • Hemolysis (breakdown of red blood cells);
  • Extremely dangerous jaundice.

Prevention

Prevention of hemolytic disease is divided into specific and nonspecific.

When registering for pregnancy, did you see “ABO, Rh-incompatibility” and “threat of HDN” in the card? How serious is this pathology and how it can affect the health and mental development of the baby, the symptoms and methods of treatment of hemolytic disease of the newborn - we turned to gynecologists and pediatricians for professional advice.

Hemolytic disease of the newborn(newborn jaundice, HDN) is a pathology of the hematopoietic system of infants, which occurs due to:

  • Rhesus conflict with the mother (Rh-conflict);
  • incompatibility of blood groups (ABO-conflict);
  • less often due to medications and impact negative factors during pregnancy.

In the presence of these risk factors, the mother's immune system "scans" the baby's blood cells as foreign agents. The production of antibodies begins, they penetrate the hematoplacental barrier and attack the blood segments of the child.

With a high level of antibodies in the mother's blood and the absence of medical correction, the fetus may die in the womb. In other cases, immediately after birth, the newborn has symptoms of HDN.

In the first hours after birth, a baby with HDN begins a massive breakdown of red blood cells. There is an increase in blood depot organs (spleen, liver), in the blood it increases sharply.

Enzymatic systems in newborns are immature, the liver does not function enough, which is why “bad”, indirect bilirubin, a breakdown product of red blood cells, accumulates in the baby’s blood. Indirect bilirubin is toxic, it damages cells cardiac myocardium crumbs, hepatocytes of the liver, most affecting nervous system child.

Doctors diagnose hemolytic disease of the newborn by the following signs:

  • the presence in the mother's exchange card of data on the possibility of Rh- or ABO-conflict with the fetus;
  • yellowing of the skin - immediately at birth or in the first 24-72 hours of life;
  • the baby is lethargic, eats poorly and sleeps a lot, often spits up after feeding;
  • uneven breathing;
  • congenital reflexes are reduced;
  • puffiness;
  • enlargement of the lymph nodes, heart, liver or spleen;
  • anemia, low level Gb (hemoglobin) in the blood;
  • a symptom of the "setting sun" - the child unnaturally lowers his eyes to the bottom.

In the first 3-5 days of a baby's life, an analysis for HDN can be taken directly from the umbilical vein. The trend of increasing bilirubin and the presence of edema provide information to doctors about the form of the disease and possible reason its occurrence, and also allow you to draw up the correct treatment regimen.

Why does hemolytic jaundice occur in infants?

Rhesus conflict occurs in an Rh-negative mother and an Rh-positive child. The first pregnancy in such cases, as a rule, proceeds without complications and a healthy baby is born. 2nd and 3rd pregnancies already require dispensary observation, because the risk of having a child with hemolytic disease rises to 85%.

ABO incompatibility most often detected in women with I (0) blood group, whose husbands are carriers of the II (A) and III (B) blood groups. With ABO incompatibility, even the first pregnancy may have a complication in the form of HDN.

Symptoms of hemolytic disorders in a baby with different incompatibilities differ in severity:

The severity of the disease largely depends on the options for the penetration of the mother's antibodies and the duration of their exposure to the fetus.

  1. Sometimes the mother's body synthesizes a small amount of antibodies, they do not penetrate the placental barrier, but affect the baby's blood only when passing through birth canal. In this case, hemolytic jaundice does not have serious consequences for the crumbs and disappears without a trace after several blue light procedures and vitamin therapy.
  2. Periodic "attack" of antibodies on hematopoietic system fetus, their high level throughout the entire period of pregnancy lead to more serious consequences: the birth of a macerated fetus, the development of an anemic, edematous or icteric form of HDN.

A severe form of hemolytic disease of the newborn is diagnosed immediately after childbirth: water with HDN is yellowish or greenish color, the child is born pale or icteric, traces of edema are visible on the body of the crumbs, the spleen and liver are enlarged.


Types of HDN

There are three forms of hemolytic disease of the newborn: edematous, anemic and icteric.

edematous form

It is the most severe: the baby's vital organs increase significantly in size even in the mother's womb. As a result, the baby is born with twice the normal weight, fluid can accumulate in the abdominal and pleural cavities, and the hemoglobin level in the blood drops to 35-50 g / l.

Icteric form of hemolytic disease

A consequence of the impact of antibodies on an already mature fetus. The baby is born full term visible signs diseases. Symptoms of jaundice in such children appear in the first 24-48 hours of life: there may be an increase in lymph nodes, spleen and liver, skin and visible mucous crumbs acquire a yellowish tint.

anemic form

It is easiest in newborns. A healthy baby is born, by the end of the 1st week of life, he may show signs of anemia - pale skin, a decrease in hemoglobin levels and an increase in the level of bilirubin in the blood.

More severe course disease is seen in premature infants. It is easier for the body of babies who have appeared on time to cope with the massive breakdown of red blood cells: all its systems are more mature and not so vulnerable to negative impact toxic indirect bilirubin.

Methods and drugs for the treatment of hemolytic disease

If your baby has been diagnosed with HDN, don't despair. With timely provision medical care all processes in it small organism will quickly return to normal and the risk of damage to the central nervous system will be eliminated.

Treatment of hemolytic disease is complex. It is aimed at removing antibodies and indirect bilirubin from the blood, as well as normalizing the functions of the kidneys and liver.

With Rhesus conflict breast-feeding, most likely, you will have to stop and offer the baby milk formulas for newborns. Also, with HDN, phenobarbital, methionine, prednisolone and intramuscular injections ATP.

Children with an icteric form of hemolytic disease undergo phototherapy sessions: under the influence of light, bilirubin breaks down into harmless substances.

In severe HDN, a blood transfusion is performed.

How to prevent the appearance of hemolytic disease of the newborn in a baby?

When we meet a loved one, the last thing that comes to mind is to ask about their blood type. But the mismatch of Rh factors is not a verdict! you can give birth healthy baby if you pay attention to the prevention of HDN. For this:

  • When registering with antenatal clinic Get your husband and I blood tested.
  • If you already know that there is an incompatibility, inform the gynecologist observing the pregnancy as soon as possible.
  • Control the level of antibodies in the blood - experts recommend undergoing such studies at least 3 times within 9 months of your "interesting" position.
  • Inform the gynecologist about the presence of aggravating factors - abortions, miscarriages and signs of CNS damage in older children.
  • Undergo an amniotic fluid test - amniocentesis.

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