Rh incompatibility occurs when a pregnant woman has Rh-negative blood and the fetus has Rh-positive blood.

• Rh incompatibility can result in destruction of the fetus's red blood cells, sometimes causing anemia that can be severe.
• The fetus is checked periodically for evidence of anemia.
• If anemia is suspected, the fetus is given blood transfusions.
• To prevent problems in the fetus, doctors give injections to women with Rh-negative blood late in the pregnancy, after delivery, and after certain procedures.

The fetus of a woman with Rh-negative blood may have Rh-positive blood if the father has Rh-positive blood. In about 13% of marriages in the United States, the man has Rh-positive blood and the woman has Rh-negative blood.

Did You Know... Rh incompatibility does not cause problems in a first pregnancy.

The Rh factor is a molecule on the surface of red blood cells in some people. Blood is Rh-positive if red blood cells have the Rh factor and Rh-negative if they do not. Problems can occur if the fetus's Rh-positive blood enters the bloodstream of a woman with Rh-negative blood. The woman's immune system may recognize the fetus's red blood cells as foreign and produce antibodies, called Rh antibodies, to destroy Rh-positive blood cells. The production of these antibodies is called Rh sensitization.

During a first pregnancy, Rh sensitization is unlikely because no significant amount of the fetus's blood is likely to enter the woman's bloodstream until delivery. So the fetus or newborn rarely has problems. However, a woman becomes sensitized during delivery. Once she is sensitized, problems are more likely with each subsequent pregnancy when the fetus's blood is Rh-positive. In each pregnancy, the woman produces Rh antibodies earlier and in larger amounts.

If Rh antibodies cross the placenta to the fetus, they may destroy some of the fetus's red blood cells. If red blood cells are destroyed faster than the fetus can produce new ones, the fetus can develop anemia. Such destruction is called hemolytic disease of the fetus (erythroblastosis fetalis) or of the newborn (erythroblastosis neonatorum—see Problems in Newborns: What Is Hemolytic Disease of the Newborn?). In severe cases, the fetus may die. Miscarriage can occur.

Diagnosis

At the first visit to a doctor during a pregnancy, women are screened to determine whether they have Rh-positive or Rh-negative blood. If they have Rh-negative blood, their blood is checked for Rh antibodies and the father's blood type is determined. If he has Rh-positive blood, Rh sensitization is a risk. In such cases, the woman's blood is checked for Rh antibodies periodically during the pregnancy. The pregnancy can proceed as usual as long as no antibodies are detected.

If antibodies are detected, steps may be taken to protect the fetus, depending on how high the antibody level is. Doppler ultrasonography may be done periodically to evaluate blood flow in the fetus's brain. If it is abnormal, the fetus may have anemia. Then doctors anesthetize an area of skin over the woman's abdomen and use either of the following tests to check for anemia:

• Amniocentesis: A needle is inserted through the skin of the abdomen to withdraw fluid from the membranes that contain the fetus (amniotic sac). The level of bilirubin (a yellow pigment resulting from the normal breakdown of red blood cells) is measured in the fluid sample. If this level is high, anemia is likely.
• Percutaneous umbilical blood sampling: A needle is inserted through the abdomen into the umbilical cord. Blood from the fetus is then withdrawn and analyzed.

Prevention

As a precaution, women who have Rh-negative blood are given an injection of Rh antibodies at 28 weeks of pregnancy and within 72 hours after delivery of a baby who has Rh-positive blood, even after a miscarriage or an abortion. They are also given an injection after any episode of vaginal bleeding and after amniocentesis or chorionic villus sampling. The antibodies given are called Rh₀(D) immune globulin. This treatment destroys any red blood cells from the baby that may have entered the woman's bloodstream. Thus, there are no red blood cells from the baby to trigger the production of antibodies by these women, and subsequent pregnancies are usually not endangered.

Treatment

If anemia is suspected, the fetus is given a blood transfusion. Usually, additional transfusions are given until the fetus is mature enough to be safely delivered. Then labor is induced. The baby may need additional transfusions after birth. Sometimes no transfusions are needed until after birth.

Last full review/revision December 2008 by Edmund F. Funai, MD