Third Pregnancy for a Mother after Two Stillbirths: Role of Rh Antigens

Background: Hemolytic disease of the foetus and newborn(HDFN)due to Rhesus(Rh) incompatibility is estimated around 276 per 100.000 live births worldwide and 50% will either die or develop brain damage.In comparison,the prevalence in developed countries has been reduced to 2.5 per 100.000 live births,due to both higher quality diagnostics and perinatal treatment.The commonest antigen of the Rh blood group system responsible for this disease is Rh(D).However, the group counts over 50 other antigens that are gaining ground because of successful mitigation provoked by anti-Rh(D) immunoglobulin.

Aim: Demonstrate the importance of testing for other Rh antibodies besides anti-Rh(D) throughout pregnancy,when indirect Coombs is found positive.

Methods: We present a healthy 22-year-old refugee who presented in our hospital during her 3rd pregnancy, after two full-term stillbirths.She was O Rh(+).The pregnancy follow-up was insufficiently recorded, yet there had been an indirect Coombs on the 28th week that was negative and no anti-Rh(D) immunoglobulin was administered.During standard testing,a new indirect Coombs was performed and it was found positive.Both anti-Rh(c) and anti-Rh(E) were positive,while anti-Rh(D)was negative,and a cesarean section was immediately performed during the 37th week of gestation,even though there were no signs of hydrops fetalis and cardiotocography was normal.

Results: A female neonate was born (APGARscore at 1min:9/10 and at 10min:10/10) with birth weight of 2.610g and remarkable clinical examination.Cord blood hemoglobin was 14.7g/dl and direct Coombs was negative.On the 3rd day of life she was discharged with Hgb:16.8g/dl and no signs of jaundice or hemolysis (bilirubin:10,55mg/dl, SGOT:30U/L,SGPT:10U/L).

Conclusions: Rh incompatibility is very common and it has to do with more than just Rh(D).Less known antigens of the group should also be evaluated as they can also have severe impact on the newborn causing hyperbilirubinemia or even kernicterus and on the fetus causing portal hypertension,cardiac failure,hydrops fetalis and even fetal death.