Hemolytic disease in an infant. Basic methods of treatment. Diagnosis of hemolytic jaundice of the newborn

Hemolytic disease newborns (another name for erythroblastosis) occurs due to incompatibility maternal blood with fetal blood due to a number of factors. The disease is very serious, since it often develops during the prenatal period and can become various shapes, but the result of the neglected condition is the same - hemolysis of red blood cells and death of the fetus (or newborn).

Red blood cell hemolysis is the destruction of the red blood cell membrane, releasing hemoglobin into the plasma. This process itself is normal, because after 120 days it ends life cycle red blood cell However, if, under certain circumstances, pathological destruction occurs, the entire mechanism of the circulatory system is disrupted. Released hemoglobin in large quantities when released into the plasma is poisonous, since it overloads the body with a high content of bilirubin, iron, etc. In addition, it leads to the development of anemia.

If too much bilirubin is released in a toxic form, the organs involved in its transformation and excretion suffer.

Free bilirubin from the blood enters the liver, where it is conjugated, in other words, neutralized. But when there is a lot of it, the liver simply does not have time to process it a large number of. As a result, the neurotoxic form of this special pigment wanders from one organ to another, slowing down oxidative processes and causing destructive changes in tissues and organs at the cellular level, including their destruction.

At concentrations above 340 µmol/L, bilirubin passes through the blood-brain barrier, changing brain structures. For premature babies, a concentration of 200 µmol/l is sufficient. This is how bilirubin encephalopathy develops, poisoning the brain and leading to subsequent disability.

The disease is also characterized by so-called extramedullary hematopoiesis - processes in which blood is not formed in the tissues bone marrow, and in other organs: liver, spleen, lymph nodes. Because of this, the above-mentioned organs become enlarged, along with a lack of important microelements such as zinc, cobalt, iron and copper. Erythrocyte breakdown products “settle” in the cells of the pancreas, kidneys and other organs.

Reasons for the development of hemolysis

The progression of hemolytic disease of newborns, as a rule, is caused by incompatibility of the blood of mother and baby due to the Rh factor or due to an ABO conflict. But even with such established genetic combinations (we will now consider the essence of the problem in detail), hemolysis of red blood cells occurs in no more than 6 cases out of 100. This means that it makes sense to fight for the child’s life, and effective treatment methods exist. Let's talk in more detail about common blood incompatibilities.

ABO system conflict

As you know, according to the ABO system, there are 4 combinations that make up 4 blood groups. So, if the mother has blood type O (I), and the unborn child has II or III, an antigen-antibody immunoconflict is possible. Although it is generally accepted that “enmity” according to the ABO system occurs more often than Rhesus conflict, hemolytic disease of newborns in in this case It passes much more easily, and sometimes is barely noticeable, so it is not always diagnosed.

Rhesus conflict

The Rh factor can be either positive or negative, and is designated Rh+ and Rh-, respectively. The presence or absence of this factor (a certain antigen D on the surface of red blood cells) does not in any way affect the health of its owner and life itself, with the exception of one situation: if we are not talking about a woman with Rh negative who got married and wants to have children from an Rh-positive father. Then the risk of complicated pregnancies and pregnancy increases.

Rh conflict manifests itself when a woman’s blood is Rh-negative, but her unborn child’s blood is Rh-positive. Where does such hostility come from? The moment the Rh-positive blood of the fetus enters the bloodstream of the Rh-negative mother, the woman’s immune system sounds an alarm about the invasion of “strangers”, since her body is not familiar with the Rh protein. Antibodies are produced aimed at destroying the “enemy”, which turns out to be... the blood of your own child!

The first pregnancy usually goes without complications, since the mother’s immune system is not yet sensitized and antibodies are produced in small quantities. But there are situations in which the risk of Rh conflict is high. These include:

• second and subsequent births (each time the risk of conflict increases);
• ectopic pregnancy;
• the first pregnancy ended in miscarriage or abortion;
• transfusion of previously Rh-positive blood, and the statute of limitations does not play any role.

There are situations when mother and child become “blood enemies”

The consolation is that 85% of white people have Rh positive.

Nature of the disease and symptoms

There are several forms of hemolytic disease of newborns:

1. Anemic. The most favorable in relation to the severity of the disease, since it has minimal damaging effects on the fetus. Anemia, as a rule, is not diagnosed immediately, but only 15-20 days after birth. They turn pale skin, the level of unconjugated bilirubin is increased, but overall the child’s condition is satisfactory and responds well to treatment.
2. Edema. The most severe variant of the disease, occurring in 2% of cases. Development begins in the womb and often ends in the death of the child. If he manages to survive, the condition is very serious: anemia is pronounced, the borders of the heart, spleen, liver and other organs are enlarged, and there is a deficiency of albumin. The body weight of a newborn is 2 times higher than normal. The subcutaneous fat tissue is swollen, and the child is often born with pleurisy, pericarditis, and ascites.
3. Jaundice. It occurs against the background of bilirubin intoxication and is characterized by a rich icteric tint of the skin, which is visible immediately at birth or after 24 hours. The severity of the disease is judged by how quickly jaundice appears. The birth of a baby most often occurs from premature birth. In the case of kernicterus, convulsions, vomiting, frequent regurgitation are observed, the newborn is lethargic, and the sucking reflex is poorly developed. With bilirubin encephalopathy, the central nervous system suffers, which subsequently affects mental development baby.

Diagnostics

When registering a pregnant woman, her blood type and Rh factor are first determined. Future mothers with negative Rh are under special, close attention of obstetricians. The future father undergoes the same examination. The woman is asked in detail about previous pregnancies, how they proceeded, whether there were miscarriages, terminations of pregnancy, etc.

A pregnant woman must be examined on time and take the necessary tests

Rh-negative mothers have their blood drawn at least three times during pregnancy to determine the titer of anti-Rhes antibodies. If there is a suspicion of an immunoconflict, amniocentesis is performed (a method for examining amniotic fluid), through which data on the optical density of fetal bilirubin and the concentration of other elements is obtained). Sometimes they resort to cordocentesis.

Carrying out an ultrasound examination, Special attention pay attention to possible thickening of the placenta, the rate of its growth, the presence of polyhydramnios, ascites, expansion of the boundaries of the liver and spleen. All this together may indicate swelling of the placenta and the development of hemolytic disease. Cardiotocography allows one to evaluate cardiac activity and identify possible hypoxia.

After birth, diagnosis of the disease is based on visible manifestations (jaundice of the integument, anemic conditions) and on these test results over time. For example, the content of bilirubin and hemoglobin in cord blood, the presence (or absence) of erythroblasts.

Treatment

The main goal for hemolytic manifestations is antitoxic therapy, that is, the removal of toxic substances from the baby’s body, in particular, free bilirubin.

Phototherapy is very effective. The method is based on observations that, under the influence of daylight, the yellowness of the skin (a sign of hyperbilirubinemia) is significantly reduced due to the breakdown and excretion of unconjugated bilirubin.

To carry out the procedure, fluorescent lamps with blue, white and blue-white light are used. When prescribing phototherapy sessions, they take into account not only the bilirubin level, but also body weight, as well as the age of the newborn. During the session, the baby is either in a special heated crib or in an incubator. Every 8-12 hours, blood is drawn for laboratory monitoring of bilirubin.

After the widespread use of phototherapy began, the need for replacement blood transfusions decreased by 40%, the nursing time for children with jaundice was reduced, and complications became an order of magnitude less.

Treatment also includes normalizing liver function through the introduction of vitamins B, E, C, and cocarboxylase. They improve metabolic processes. Choleretic drugs help fight bile thickening, and cleansing enemas and the use of activated charcoal slows down the absorption of bilirubin in the intestine. General detoxification infusion therapy is carried out.

Phototherapy is very effective method in the fight against jaundice in newborns

IN difficult situations(development of anemia) treatment is carried out promptly, with the help of exchange transfusion of blood or its components, for example, red blood cells. In this case, the Rh affiliation of the fetus is taken into account.

Is it possible to breastfeed?

Previously, breastfeeding children in the presence of Rh conflict or hemolytic disease was prohibited; later, a child was allowed to be breastfed only 2 weeks after birth. It was believed that anti-Rh antibodies contained in milk could harm the baby. Now it has been proven that when they get into gastric tract, are subject to destruction under the influence of hydrochloric acid and enzymes, therefore they cannot enter the bloodstream and, therefore, do harm.

Forecasts

It is difficult to say how hemolytic manifestations will affect the child in the future; it all depends on the severity of the disease. In the most unfavorable cases, there is a subsequent delay in development, cerebral palsy in different manifestations. In simpler situations, the hepatobiliary system suffers due to high load to it, the baby is prone to allergies, special reactions to vaccination, possible development of strabismus, and hearing problems.

Prevention

Preventive measures can be divided into two stages.

When a woman is not sensitized

That is, her Rh-negative blood has not previously encountered Rh-positive antigens. Such a mother should treat her first pregnancy with trepidation, since she has the highest chances of a favorable outcome. She is strongly discouraged from having abortions and blood transfusions. In the third trimester, a blood test is done several times to detect antibodies.

When a woman is sensitized

During the first 24 hours after the first birth and the birth of an Rh-positive baby, immunoglobulin is administered, the purpose of which is to prevent the formation of Rh antibodies in the mother's blood. A similar procedure is also done after:

• ectopic pregnancy;
• abortions;
• transfusion of Rh-positive blood;
• specific diagnostics in the fetus: amniocentesis, chorionic villus biopsy, cordocentesis.

Another prevention option is specific hyposensitization. Its essence is as follows: a skin flap from the husband (Rh +) is transplanted to the wife (with Rh -) and then the antibodies “switch” their attention to the graft, thereby reducing the likelihood of hemolysis of fetal red blood cells.

As you can see, hemolytic disease has serious consequences. For this reason, it is extremely important for a woman with Rh-negative blood to remember her Rh status and take a responsible approach to the issues of motherhood and childbearing. If the obstetrician-gynecologist says that you need to take additional tests, it is better to do this so that the situation does not get out of control. Not less important timely treatment. Then the risk of developing hemolysis of red blood cells with all the ensuing consequences will be minimized.

Hemolytic disease is a disease that is caused by incompatibility of the blood of the mother and the unborn baby for various antigens. There is also incompatibility based on the Rh factor. This often happens when the mother and fetus have different Rh factors (for example, the mother is positive, the fetus is negative, or vice versa). In case of group incompatibility, 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 newborns can also develop due to incompatibility of other blood antigens, but this happens extremely rarely.

What are the reasons?

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

Hemolytic disease of the newborn. Symptoms

To date, three forms of this have been studied. insidious disease: edematous, icteric and anemic. Considered the most difficult edematous form, with it, children are born premature or die immediately after birth. Wherein appearance the newborn has a characteristic appearance: moon-shaped face, waxy pallor, sometimes cyanosis or jaundice, subcutaneous tissue edematous. There is free fluid in the pleural, abdominal, and pericardial cavities, sometimes bruises and petechiae. The baby's liver and spleen are enlarged. There is a decrease in red blood cells and hemoglobin in the blood, as well as leukocytosis, erythroblastosis, and reticulocytosis.

Hemolytic can be mild, moderate and severe. It is characterized by the appearance of jaundice immediately after the birth of the fetus or several hours later. In this case, even amniotic fluid can be colored yellow. Hemolytic jaundice in an infant increases very quickly, the liver and spleen enlarge, and there is a tendency to bleeding. Such babies are born lethargic, do not breastfeed well, and all their physiological reflexes may be reduced. The level of bilirubin in the blood increases and reaches its maximum on the third to fifth day. If the child is not treated at this point, tonic convulsions and tremors of the limbs develop. The tone of the extensor muscles of the arms is considered characteristic of this type of disease, while general hypotension increases.

Anemic form is the mildest manifestation of this disease. With it, an enlargement of the liver and spleen is observed, and 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 newborn’s body, removal of breakdown products of red blood cells, antibodies and bilirubin. All this is done in order to stop the baby’s hemolysis after birth. During this period, the child is advised to drink plenty of fluids, vitamins, enterosrbents, and detoxification solutions. Severe anemia is an indication for exchange transfusion.

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

erythroblastosis fetalis

Hemolytic disease of the newborn occurs when a child inherits an Rh factor or blood type from the father that is incompatible with the mother's blood. The conflict leads to massive breakdown of red blood cells and severe complications, including the death of the body over the next few hours/days. But it is now possible to treat hemolytic disease of newborns, as well as prevent it. In the ICD-10 system, this disease is assigned code P55.

The etiology (cause) of the phenomenon in which antibodies incompatible with its blood from the mother’s body enter the fetal blood lies in heredity and its laws. But sometimes episodes from her past can also lead to the appearance of such proteins in a mother, for example, if she has a history of repeated blood transfusions. Or if the blood was transfused once, but it did not suit her well (say, it was selected without taking into account Rh). Similar factors risk is rarely taken into account by parents, as well as the compatibility of their blood groups. Meanwhile, they can create situations where the family already has a child, and everything is fine with him, and the second suddenly starts a pathological process.

When can pathology occur?

The causes of hemolytic disease of newborns can be different, and it is not always a matter of the laws of genetics. So, its appearance can be expected in the following cases.

• If the mother is Rh negative and the child is positive. The Rh factor (special blood proteins inherited from our tailed ancestors) is either present in the blood or it is not. It tends to be inherited. This means that if at least one of the grandparents has it, the child can inherit Rh positive from them, even if both of his parents are Rh negative. Thus, the greatest danger to the unborn fetus is the Rh-negative mother. After all, the likelihood that Rh positive will be passed on to her baby from one of her ancestors is much higher than the likelihood that this will not happen.
• If there is a blood type conflict. Now medicine distinguishes not three, but four blood groups, where the fourth has simultaneously the characteristics of the third and second groups. Domestic system markings indicate them with Latin numerals. And in Western and American medicine the so-called AB0 system. In it, group I is designated as zero, group II is designated by the letter “A”, and group III is designated by the letter “B”. Group IV, as representing a “hybrid” of groups II and III, is designated as “AB”. The mechanism of development or pathogenesis of hemolytic disease according to the blood group of newborns lies in the incompatibility of certain proteins characteristic of a particular group. Of these combinations, group 0 (that is, I) is in the mother versus group A or B (II or III) in the child.
• If you have acquired hypersensitivity in the past. That is, blood with the opposite rhesus entered the mother’s body and the corresponding antibodies were formed. This could have happened during a transfusion. donated blood; abortion or miscarriage (blood may be mixed); amniotic fluid/chorionic villus biopsy.

Only a blood test can determine the blood type and Rh factor in the mother and fetus, as well as answer the question of whether the mother has Rh antibodies. All these processes, including the production of antibodies to the blood of another group, are asymptomatic, the mother does not subjectively feel them, and therefore does not experience anxiety.

Manifestations of different forms of hemolytic disease of newborns

This conflict of blood cells between a mother and her baby also has another name - erythroblastosis fetalis. But in reality, this term reflects one of the consequences of the massive destruction of red blood cells. It means that a large number of immature red blood cells are present in the patient’s blood - the result increased activity bone marrow, which is in a hurry to replace adult blood cells dying under the influence of any factors. These immature red blood cells are called reticulocytes. Erythroblastosis occurs in all cases of massive breakdown of red blood cells, regardless of its cause.

And in the classification of hemolytic disease, three main forms of the course are distinguished. Not only the picture of her symptoms, but also the prognosis for the child’s survival/recovery depends on them.

• Edema form. Fortunately, it is the rarest, occurring during the gestation period. 99% of children suffering from it die before birth or soon after it, since their condition at the time of birth is extremely severe, and it is almost impossible to independently supply tissues with oxygen. The newborn has large-scale edema, the liver is sharply enlarged, reflexes are almost absent, and there is heart failure (in addition to respiratory failure). Onset of hemolytic disease early stages pregnancy often ends in miscarriage.
• Jaundice form. It is more widespread than others and manifests itself within the next 24 hours after birth, since “incest” here occurs only during childbirth. It can also be very difficult and end in death, but in most cases this scenario can be avoided. Jaundice and anemia may persist in the child for several months.
• Anemic form. It also occurs during the first days or 2-3 weeks after birth. In general, with it, the newborn behaves almost like healthy child. The only symptoms that may be observed are some lethargy, pallor, an enlarged liver and spleen, and decreased appetite. Timely treatment can shorten the entire period of anemic hemolytic disease to a month.

Edema

The most dangerous form Hemolytic disease of the newborn begins during pregnancy, so early signs can be detected in the mother rather than in the fetus.

• Mom. The level of bilirubin in the blood increases. Bilirubin is a brown organic dye that gives the characteristic color to bile, stool and urine. It is formed when the liver processes old red blood cells. And even more precisely, with the breakdown of the red glandular protein hemoglobin in their composition. An increase in the concentration of bilirubin in the blood colors yellow all tissues, including the mucous membranes of the mouth and eyeballs. This phenomenon is called jaundice, and it indicates the accelerated destruction of red blood cells directly in the bloodstream, so large-scale that the liver simply does not have time to filter out all the bilirubin released.
• In the fetus. A huge belly and tissue swelling are recorded. A CT scanner is usually more useful than an ultrasound machine for detecting such signs. They are deliberately sought for when hemolytic disease is suspected. For example, if the concentration of bilirubin in the mother’s blood increases or her blood is sensitized by the Rh factor. In addition, increased monitoring is required in cases where the chances of incompatibility of the blood group or Rhesus of the fetus and mother are very high.

After birth, diagnosis of hemolytic disease in a newborn born child in the edematous form is not difficult, since it is clearly indicated:

• huge belly;
• signs of oxygen starvation;
• large-scale swelling throughout the body;
• pallor of the skin and mucous membranes;
• flaccid muscle tone;
• decreased reflexes;
• pulmonary and heart failure;
• critically low blood hemoglobin levels.

Jaundice

Main symptom icteric form indicated in its title. True, in this case it is necessary differential diagnosis hemolytic disease of newborns with other pathologies accompanied by jaundice: viral hepatitis, malaria, bone marrow/blood/liver cancer. And in addition to jaundice, it manifests itself in three groups of symptoms.

1. Enlarged liver and spleen. This happens in the first two to three days after birth.
2. Drowsiness, lethargy of behavior and reflexes. These are signs of brain hypoxia, associated with the inability of the blood to provide it with oxygen due to a reduction in the number of “functional” red blood cells in the blood.
3. Discoloration of stool. It occurs against the background of darkening of urine, gases and regurgitation after eating. All these signs are explained by cholestasis - retention of bile in the gallbladder (in this case, due to its thickening with excess bilirubin).

The severe course of the icteric form may also be accompanied by bulging fontanelles on the newborn’s skull, convulsions, throwing the head up and a “brain” cry - monotonous, piercing and continuous. Such signs indicate the onset of so-called bilirubin encephalopathy (kernicterus, as it affects the nuclei of the brain).

The essence of this process is toxic effect free bilirubin onto cortical cells, since this substance can penetrate the blood-brain barrier (the brain’s own protective system against foreign components carried by the bloodstream). A child in such a state may stop breathing, lose facial expressions, and develop a sharp reaction to even the weakest stimuli.

Anemic

This form is manifested only by a slight enlargement of the liver and spleen, moderate hypoxia (lack of oxygen), which forces the baby to move less and sleep more often. His skin may be paler than usual, but this symptom also has an erased character.

Hemolytic disease of the newborn has one interesting feature. The fact is that when mother and child are incompatible only by the Rh factor, it is usually more severe than when there is incompatibility only by blood type or by both indicators at the same time. Moreover, if the conflict comes down to different rhesuses, in the case of one pregnancy it may appear, but not with the next, and vice versa. But a blood type conflict always manifests itself immediately and cannot be corrected in the future.

Therapy

The basic principle of treatment for hemolytic disease of newborns is to completely replace the child’s own blood with donor blood. It is carried out if the disease has occurred, progresses and threatens his life. Donor blood transfusion can be performed:

• before birth (via the umbilical vein),
• after the birth of the child.

Blood has to be transfused that is identical both in group (a compatible group will not work here - you need the same one as the child had) and in Rhesus. This means that while the fetus is in the womb, the mother’s body will continue to fight new blood cells just as actively as it did with the old ones.

Emergency care for a baby who is born with signs of hemolytic disease should be provided within the next few hours. It usually involves a combination of blood transfusion followed by stimulation of the heart and lungs. In the future, the baby only needs:

• standard nursing care;
• presence of mother;
• a few more blood biochemistry tests.

Biochemistry is done at intervals of 7-15 days, but it is needed to track changes indicating rejection of donor blood for other reasons that are no longer related to hemolytic disease.

Treatment with traditional medicine

Treatment of hemolytic disease in newborns using methods alternative medicine unacceptable and directly threatens their lives.

• Homeopathy. It is not popular even among healers, since we are talking not about folk, but about the author’s technique. And reviews about it from scientists are also negative.
• Herbal treatment. In this case, it is acceptable in theory (say, a course of choleretic drugs like corn silk). But in practice, it can make a child allergic for life, since all plants are allergens. Meanwhile, the baby's immune defense has not yet learned proper operation. Plus, she had only recently been in a situation where she was either suppressed by her mother’s immunity, or she herself had to deal with completely new blood and foreign antibodies in its composition.

Therefore, only non-toxic (!) medicinal plants are conditionally suitable for use. Their course can be carried out no earlier than a month after the disappearance of all symptoms of the disease, and it should not last more than a week. Herbs should be used at a minimum - one or two, and it is better to avoid making multi-component mixtures.

Prevention

Prevention of hemolytic disease in infants involves preventing the formation of Rh antibodies in the mother before and during pregnancy. Such measures are carried out if it is not available at the time of the start of the procedure, since, otherwise, preventive measures will no longer work.

In other words, preventing such conflicts begins and ends with the mother’s body. The only way To avoid them if there is a discrepancy between the baby’s Rh and/or blood group, lies in the timely administration of anti-Rhesus immunoglobulin.

The point of the procedure is that immunoglobulins capture Rh proteins from the blood of a “positive” baby, without letting them pass into the “negative” blood. circulatory system moms. If there is no mixing of blood different types, antibodies to the baby’s blood will not form in the mother’s blood.

Long-term consequences

The immediate complications of hemolytic disease in a newborn child largely coincide with its symptoms. These include liver/gallbladder diseases, developmental delays, and cardiovascular pathologies. And in the future, there may be consequences of hemolytic disease of newborns associated with the effects of red blood cell destruction products (billirubin) on the brain:

• Cerebral palsy (cerebral palsy);
• deafness, blindness and other sensory impairments;
• developmental delay and decreased intelligence;
• epilepsy.

The basis of the metabolic system is blood circulation and the work of filtering organs - the liver, spleen and kidneys. Hemolytic disease of newborns can cause serious complications in them. If they exist, in the future you need to beware of any prescriptions for your child (medical and folk) medicines. Therefore, children who have had it are prohibited from most standard childhood vaccinations, including the so-called. BCG (vaccination against tuberculosis). They should be avoided for at least three months after treatment.

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Girls, get acquainted with the information. Many people know that there is a conflict regarding the Rh factor. But for some reason, few people know that there is also a blood type conflict. Unfortunately, the antenatal clinic is silent about this.

Having registered at the antenatal clinic, every pregnant woman receives a lot of referrals for tests, among which there is a mandatory test to determine the blood group and Rh of both spouses. In most cases, everyone is concerned about the presence or absence of this very Rh factor, since everyone knows about the likelihood of the development of Rh conflict in mother and child. At the same time, few people are aware of the existing possibility of an immunological conflict between blood groups.
Why does an immunological conflict occur?
The first blood group does not contain antigens A and B in erythrocytes, but there are α and β antibodies. All other groups have such antigens, and therefore the first blood group, having encountered antigens A or B that are foreign to it, begins to “enmity” with them, destroying red blood cells containing these antigens. It is this process that is the immunological conflict in the AB0 system.
Who should be afraid of a blood type conflict?
Theoretically, this problem can arise if the mother and the unborn baby have different blood types:
a woman with blood group I or III - a fetus with type II;
a woman with blood group I or II - a fetus with III;
a woman with group I, II or III - a fetus with IV.
The most dangerous combination is considered to be if a woman with blood group I carries a child with blood group II or III. It is this situation that most often leads to the development of all signs of conflict between mother and fetus and the occurrence of hemolytic disease in the newborn. Women at risk also include:
have received blood transfusions in the past;
survivors of several miscarriages or abortions;
who previously gave birth to a child who developed hemolytic disease or mental retardation.
The possibility of developing a group immunological conflict according to the AB0 system exists in married couples having the following combinations of blood groups:
woman with group I + man with group II, III or IV;
woman with group II + man with group III or IV;
woman with III + man with II or IV.

What contributes to the development of conflict?
A properly functioning and healthy placenta protects against the development of blood group conflict. Its special structure does not allow the blood of the mother and fetus to mix, in particular, due to the placental barrier. However, this can still happen if the integrity of the blood vessels of the placenta is violated, its detachment and other damage or, most often, during childbirth. Fetal cells that enter the maternal bloodstream, if they are foreign, cause the production of antibodies that have the ability to penetrate the fetal body and attack its blood cells, resulting in hemolytic disease. The toxic substance bilirubin, formed as a result of such exposure in large quantities, can damage the child’s organs, mainly the brain, liver and kidneys, which can have serious consequences for the physical and mental health of the baby.
Manifestations of group conflict, its treatment and prevention
A pregnant woman will not experience any signs of developing a blood group conflict. A blood test will help you find out about its occurrence, which will show a high titer of antibodies in the woman’s blood. With the development of hemolytic disease of the fetus and newborn, the following may be observed:
swelling,
jaundice,
anemia,
enlargement of the spleen and liver.
Prevention serious complications is to regularly donate blood for analysis and identify specific antibodies in it - hemolysins. If they are found, the pregnant woman is placed under observation. If, as a result of repeated tests, the antibody titer continues to rise steadily and the fetal condition worsens, then premature delivery or intrauterine blood transfusion to the fetus may be required.
Some gynecologists regularly prescribe a test for group antibodies to pregnant women with the first blood group if there are prerequisites for this. In fact, this happens very rarely, due to the fact that a conflict in the AB0 system usually does not entail serious consequences and causes jaundice only in an already born child, with virtually no effect on the fetus in the womb. Therefore, there are no such mass studies as during the pregnancy of an Rh-negative woman.
Hemolytic disease of the newborn requires mandatory treatment to avoid the development of severe complications. The more pronounced the symptoms, the more intense the conflict, to confirm which a blood test is performed. increased content bilirubin. The purpose of treatment is to remove antibodies, damaged red blood cells and excess bilirubin from the child’s blood, for which phototherapy and more are performed. symptomatic treatment. If this does not help, or the level of bilirubin in the blood increases very quickly, then they resort to the procedure of blood transfusion to the newborn.
Future parents who are at risk of developing such a conflict need to know that, firstly, the likelihood of a real blood group conflict occurring in practice is very small, and secondly, it most often occurs much easier than Rh conflict, and cases of severe are relatively rare, therefore conflict according to the AB0 system is considered less dangerous for the baby’s health.

Hemolytic disease of the newborn (HDN) – pathological condition child (fetus), which is accompanied by the breakdown (hemolysis) of red blood cells due to the incompatibility of its blood with the mother’s blood in terms of erythrocyte antigens.

general information

Red blood cells are red cells that are shaped elements human blood. They perform very important function: deliver oxygen from the lungs to the tissues and carry out reverse transport of carbon dioxide.

On the surface of red blood cells there are agglutinogens (antigen proteins) of two types A and B, and the blood plasma contains antibodies to them - agglutinins α and ß - anti-A and anti-B, respectively. Various combinations of these elements serve as the basis for distinguishing four groups according to the AB0 system:

• 0(I) – both proteins are absent, there are antibodies to them;
• A (II) – there is protein A and antibodies to B;
• B (III) – there is protein B and antibodies to A;
• AB (IV) – there are both proteins and no antibodies.

There are other antigens on the membrane of red blood cells. The most significant of them is antigen D. If it is present, it is considered that the blood has positive Rh factor(Rh+), and in the absence - negative (Rh-).

The blood group according to the ABO system and the Rh factor is of great importance during pregnancy: conflict between the blood of mother and child leads to agglutination (gluing) and subsequent destruction of red cells, that is, to hemolytic disease of the newborn. It is found in 0.6% of children and without adequate therapy leads to serious consequences.

Causes

The cause of hemolytic disease of newborns is a conflict between the blood of the child and the mother. It occurs under the following conditions:

• a woman with Rh-negative (Rh-) blood develops a Rh-positive (Rh+) fetus;
• the expectant mother’s blood belongs to group 0(I), and the child’s blood belongs to A(II) or B(III);
• there is a conflict regarding other antigens.

In most cases, HDN develops due to Rh conflict. There is an opinion that incompatibility according to the AB0 system is even more common, but due to mild course pathologies are not always diagnosed.

Rh conflict provokes hemolytic disease of the fetus (newborn) only under the condition of previous sensitization (increased sensitivity) of the body of matter. Sensitizing factors:

• transfusion of Rh+ blood to a woman with Rh-, regardless of the age at which it was performed;
• previous pregnancies, including those terminated after 5-6 weeks - the risk of developing tension-type headache increases with each subsequent birth, especially if they were complicated by placental abruption and surgical interventions.

In case of hemolytic disease of newborns with blood group incompatibility, sensitization of the body occurs in Everyday life– when consuming certain products, during vaccination, as a result of infections.

Another factor that increases the risk of pathology is a violation of the barrier functions of the placenta, which occurs as a result of the presence chronic diseases in a pregnant woman poor nutrition, bad habits and so on.

Pathogenesis

The pathogenesis of hemolytic disease of newborns is associated with the fact that the woman’s immune system perceives blood elements (erythrocytes) of the fetus as foreign agents and produces antibodies to destroy them.

In case of Rh-conflict, Rh-positive erythrocytes of the fetus penetrate into the blood of the mother with Rh-. In response, her body produces anti-Rhesus antibodies. They pass through the placenta, enter the baby’s blood, bind to receptors on the surface of his red blood cells and destroy them. At the same time, the amount of hemoglobin in the fetal blood significantly decreases and the level of unconjugated (indirect) bilirubin increases. This is how anemia and hyperbilirubinemia (hemolytic jaundice of newborns) develop.

Indirect bilirubin is a bile pigment that has a toxic effect on all organs - kidneys, liver, lungs, heart, and so on. At high concentration it is able to penetrate the barrier between the bloodstream and nervous systems and damage brain cells, causing bilirubin encephalopathy (kernicterus). The risk of brain damage from hemolytic disease of the newborn increases if:

• reducing the level of albumin - a protein that has the ability to bind and neutralize bilirubin in the blood;
• hypoglycemia – glucose deficiency;
• hypoxia – lack of oxygen;
• acidosis - increased blood acidity.

Indirect bilirubin damages liver cells. As a result, the concentration of conjugated (direct, neutralized) bilirubin in the blood increases. Insufficient development in a child bile ducts leads to poor excretion, cholestasis (stagnation of bile) and hepatitis.

Due to severe anemia in hemolytic disease of the newborn, foci of extramedullary (extramedullary) hematopoiesis may occur in the spleen and liver. As a result, these organs enlarge, and erythroblasts—immature red blood cells—appear in the blood.

The products of hemolysis of red blood cells accumulate in organ tissues, metabolic processes are violated, and there is a shortage of many minerals– copper, cobalt, zinc, iron and others.

The pathogenesis of HDN in blood group incompatibility is characterized by a similar mechanism. The difference is that proteins A and B mature later than D. Therefore, the conflict poses a danger to the baby towards the end of pregnancy. In premature babies, red blood cell breakdown does not occur.

Symptoms

Hemolytic disease of newborns occurs in one of three forms:

• icteric – 88% of cases;
• anemic – 10%;
• edematous – 2%.

Signs of the icteric form:

• jaundice - a change in the color of the skin and mucous membranes as a result of the accumulation of bilirubin pigment;
• decreased hemoglobin (anemia);
• enlargement of the spleen and liver (hepatosplenomegaly);
• lethargy, decreased reflexes and muscle tone.

In case of Rhesus conflict, jaundice occurs immediately after birth, in the ABO system - on the 2-3rd day. The skin tone gradually changes from orange to pale lemon.

If the level of indirect bilirubin in the blood exceeds 300 µmol/l, nuclear hemolytic jaundice may develop in newborns on days 3-4, which is accompanied by damage to the subcortical nuclei of the brain. Kernicterus is characterized by four stages:

• Intoxication. It is characterized by loss of appetite, monotonous screaming, motor weakness, and vomiting.
• Nuclear damage. Symptoms - tension in the neck muscles, a sharp cry, swelling of the fontanel, tremors, (posture with arching of the back), disappearance of some reflexes, .
• Imaginary well-being (improved clinical picture).
• Complications of hemolytic disease of the newborn. Appear at the end of the 1st – beginning of the 5th month of life. Among them are paralysis, paresis, deafness, cerebral palsy, developmental delay, and so on.

On days 7-8 of hemolytic jaundice, newborns may experience signs of cholestasis:

• stool discoloration;
• greenish-dirty skin tone;
• darkening of urine;
• an increase in the level of direct bilirubin in the blood.

In anemic form clinical manifestations hemolytic disease of newborns include:

• anemia;
• pallor;
• hepatosplenomegaly;
• slight increase or normal level bilirubin.

The anemic form is characterized most light current– the child’s general well-being is almost unaffected.

The edematous variant (intrauterine hydrops) is the most severe form of HDN. Signs:

• pallor and severe swelling skin;
• big belly;
• marked enlargement of the liver and spleen;
• muscle flaccidity;
• muffled heart sounds;
• breathing disorders;
• severe anemia.

Edema hemolytic disease of the newborn leads to miscarriages, stillbirths and death of children.

Diagnostics

Diagnosis of tension-type headache is possible in the prenatal period. It includes:

1. Collecting anamnesis - clarifying the number of previous births, miscarriages and transfusions, finding out information about the health status of older children,
2. Determination of the Rh factor and blood group of the pregnant woman, as well as the father of the child.
3. Mandatory detection of anti-Rh antibodies in the blood of a woman with Rh- at least 3 times during the period of bearing a child. Sharp fluctuations in numbers are considered a sign of conflict. In case of incompatibility with the AB0 system, the titer of allohemagglutinins is monitored .
4. Ultrasound scan - shows thickening of the placenta, polyhydramnios, enlargement of the fetal liver and spleen.

At high risk For hemolytic disease of the newborn, amniocentesis is performed at 34 weeks - amniotic fluid is taken through a puncture in the bladder. In this case, the density of bilirubin, the level of antibodies, glucose, iron and other substances are determined.

After birth, the diagnosis of HDN is made based on clinical symptoms And laboratory research. A blood test shows:

• bilirubin level is above 310-340 µmol/l immediately after birth and its increase by 18 µmol/l every hour;
• hemoglobin concentration below 150 g/l;
• a decrease in the number of red blood cells with a simultaneous increase in erythroblasts and reticulocytes (immature forms of blood cells).

A Coombs test is also performed (shows the amount incomplete antibodies) and monitors the level of anti-Rhesus antibodies and allohemagglutinins in the mother’s blood and breast milk. All indicators are checked several times a day.

Hemolytic disease of newborns is differentiated from anemia, severe asphyxia, intrauterine infection, physiological jaundice and other pathologies.

Treatment

Treatment of severe hemolytic disease of newborns in the prenatal period is carried out by transfusion of red blood cells into the fetus (through the umbilical cord vein) or with the help of exchange blood transfusion (BRT).

ZPK is a procedure for alternately removing the child’s blood in small portions and introducing donor blood. It removes bilirubin and maternal antibodies while replenishing lost red blood cells. Today for ZPK it is not used whole blood, but red blood cells mixed with frozen plasma.

Indications for PCP for full-term infants diagnosed with hemolytic jaundice of newborns:

• bilirubin in the umbilical cord blood is above 60 µmol/l and this indicator increases by 6-10 µmol/l every hour, the level of pigment in the peripheral blood is 340 µmol/l;
• hemoglobin is below 100 g/l.

In some cases, the procedure is repeated after 12 hours.

Other methods used for treatment of tension-type headache newborns:

• hemosorption - filtration of blood through sorbents that cleanse it of toxins;
• plasmapheresis – removal of part of the plasma along with antibodies from the blood;
• administration of glucocorticoids.

Treatment of tension-type headache in mild to moderate cases, as well as after PCD or blood cleansing includes medications and phototherapy.

Medicines used for hemolytic disease of the newborn:

• protein preparations and glucose intravenously;
• liver enzyme inducers;
• vitamins that improve liver function and activate metabolic processes - E, C, group B;
• choleretic agents in case of thickening of bile;
• transfusion of red blood cells;
• sorbents and cleansing enemas.

Phototherapy is a procedure for irradiating a child’s body with a fluorescent lamp with white or blue light, during which indirect bilirubin found in the skin is oxidized and then excreted from the body.

Attitudes towards breastfeeding during HDN in newborns are ambiguous. Previously, it was believed that a baby could be put to the breast only 1-2 weeks after birth, since by this time there were no antibodies in the milk. Today, doctors are inclined to start breastfeeding from the first days, since anti-Rh antibodies are destroyed in the baby’s stomach.

Forecast

The consequences of hemolytic disease of newborns depend on the nature of the course. A severe form can lead to the death of a child in recent months pregnancy or within a week after birth.

If bilirubin encephalopathy develops, complications such as:

• cerebral paralysis;
• deafness, blindness;
• developmental delay.

Previous hemolytic disease of newborns at an older age provokes a tendency to frequent illnesses, inadequate reactions to vaccination, allergies. Adolescents experience decreased performance, apathy, and anxiety.

Prevention

Prevention of hemolytic disease of newborns is aimed at preventing sensitization of women. The main measures are blood transfusions only taking into account the Rh factor, preventing abortions, and so on.

Since the main sensitizing factor for Rh conflict is previous births, within 24 hours after the birth of the first child with Rh+ (or after an abortion), the woman must be administered a drug with anti-D immunoglobulin. Thanks to this, fetal red blood cells are quickly removed from the mother’s bloodstream and do not provoke the formation of antibodies in subsequent pregnancies. An insufficient dose of the drug or its late administration significantly reduces the effectiveness of the procedure.

Prevention of HDN during pregnancy when Rh sensitization is detected includes:

• nonspecific hyposensitization - administration of detoxification, hormonal, vitamin, antihistamine and other drugs;
• hemosorption, plasmapheresis;
• specific hyposensitization - transplantation of a skin flap from the husband;
• PCP at 25-27 weeks followed by emergency delivery.