The blood was transfused and the Rh conflict was eliminated. In utero

Intrauterine blood transfusion using control is the most effective method to date in the treatment of Rh conflict or hemolytic disease. This procedure is necessary when unborn child and mom have blood incompatibility.

There are intra-abdominal and intravascular transfusions. Intravascular is preferable, but it is performed after the twenty-second week of pregnancy. When difficulties arise before this period, intraperitoneal transfusion is used. The indication for transfusion is, as a rule, a fifteen percent or even more decrease in the total number of red blood cells. The procedure is repeated every three weeks, since hemolytic disease of the fetus reduces the hematocrit by one percent per day. In case of a complicated or progressive form, after the thirty-fourth week, a decision is made to carry out an early birth.

The procedure uses ultrasound guidance, when the doctor, using a catheter, penetrates the umbilical cord vein through the anterior abdominal wall, and then transfuses twenty to fifty milliliters of blood that has an Rh-negative factor to the fetus. When the fetal blood type is known, the same is used, and when it is unknown, blood 1(0) is used. This procedure weakens the body's immune response. expectant mother, since it reduces the number of Rh-positive red blood cells and will maintain the fetal hematocrit above critical levels.

You should know that intrauterine blood transfusion is quite dangerous procedure, both for the expectant mother and the fetus, so it is carried out under exceptional indications and only by an experienced doctor. Sometimes complications of an infectious nature, feto-maternal transfusion, compression of the umbilical vein, premature birth and possible intrauterine fetal death.

When pregnancy is just being planned, this procedure can be avoided by finding out the blood type, as well as the Rh factors of the woman and man. When the father is Rh positive and the mother is Rh negative, you need to undergo a set of preventive measures.

If you are undergoing such a complex procedure, you should not panic. Often the procedure goes well, and subsequently the children who have undergone it develop physically and psychologically normally.

"Rh conflict occurs in one out of 16 Rh-negative pregnant women, with next pregnancy- every fourth. Therefore, all pregnant women Rh negative blood monitoring is assigned anti-Rhesus antibodies in the blood - says Victoria Sergeevna Zhuravleva, obstetrician-gynelogist, Center for Healthy Motherhood. - For the first time, the amount of anti-Rhesus antibodies in the blood is determined in a pregnant woman during the initial appearance. If the results of the analysis do not cause any particular concern, it must be repeated at 20 weeks of pregnancy and then every four weeks.

Who is at risk for Rh conflict during pregnancy?

When registering with antenatal clinic, all pregnant women are determined by their group and Rhesus status. If a pregnant woman has Rh negative blood, the father of the child is prescribed the same test. If test results show that the father has Rh positive blood, the expectant mother is at risk for developing Rhesus conflict.

However, different rhesus blood in the child’s parents does not mean that an Rh conflict will certainly arise during pregnancy. The risk of developing Rh conflict increases if the previous pregnancy was artificially terminated, was ectopic pregnancy, spontaneous abortions. The lack of specific prophylaxis after the completion of previous pregnancies is another factor that predisposes to the occurrence of Rh conflict.

If there are no antibodies

In the absence of antibodies, all Rh-negative pregnant women undergo prophylactic administration of anti-Rhesus immunoglobulin at 28 weeks of pregnancy. If, during the next examination, anti-Rhesus antibodies are detected, the management tactics for the pregnant woman are revised.

Titers of anti-Rhesus antibodies are determined depending on their increase - every two or four weeks. Such pregnant women are advised to undergo more frequent ultrasound, namely up to 30 weeks once a month, after 30 weeks every two weeks to identify early ultrasound markers of the development of hemolytic disease of the fetus.

If hemolytic disease threatens

Hemolytic disease is a severe complication of Rh conflict during pregnancy. If there are high titers of anti-Rhesus antibodies or ultrasound signs of the development of hemolytic disease are detected, such a pregnant woman is sent to a specialized institution to determine the severity of hemolytic anemia in the fetus.

In a specialized institution, if indicated, amniocentesis is performed (examination amniotic fluid), cordocentesis - taking blood from the fetal umbilical cord through the anterior abdominal wall of a pregnant woman to determine the level of hemoglobin, group and Rh affiliation.

The main method of treatment is exchange blood transfusion intrauterine fetus. For this purpose, donor blood of the first group and Rh negative is used. This operation allows you to prolong pregnancy and save the baby from developing severe complications. The timing of delivery for pregnant women with Rhesus conflict is individual and depends on the degree of hemolytic anemia in the fetus and positive dynamics after replacement blood transfusion to the fetus.

For prophylactic purposes after childbirth, when a Rh-positive child is born, anti-Rhesus immunoglobulin is administered within 72 hours.”

When a couple decides to have a child, the man and woman are unlikely to think about possible development Rhesus conflict. The question of its occurrence usually arises already at the stage of pregnancy planning, but most often it is raised during the examination of a pregnant girl, when the presence of antibodies in the blood threatens the fetus. To warn her and prevent her from intrauterine death, termination of pregnancy or development various diseases after birth, an examination is first carried out, which includes determining the group and Rh factor of both parents. Then the doctor chooses a method of therapy. The most effective today is considered to be intrauterine blood transfusion to the fetus in case of Rhesus conflict.

Intrauterine blood transfusion involves the introduction of washed red blood cells with negative Rh factor straight into the fetal umbilical vein. Due to this, the normal function of these formed elements is achieved - the transfer of oxygen to organs and tissues, and the mother’s body will not recognize them as foreign.

If the expectant mother has blood group 1, alpha and beta antibodies circulate in her plasma. When the fetus receives group number 2 or 3, these same antibodies are sent to it in order to attack red blood cells. This situation of incompatibility of the blood of mother and child occurs in 2% of cases of union of a woman with group 1 and a representative of the stronger sex with any other.

Rhesus conflict is the most common. This is a condition in which the mother's red blood cells do not contain certain protein structures, while the baby's cells do. This determines high risk the occurrence of Rh conflict, which provokes many different diseases or damage to the fetus. At negative rhesus During pregnancy, these complications do not always develop, especially when it comes to the first fertilization.

Reasons for the development of Rh conflict and HDN

Danger awaits only when a woman has undergone a blood transfusion positive blood by rhesus, or were more early pregnancies ending in miscarriages and abortions.

Antibodies in a child’s blood may include:

• due to physiological childbirth;
• during caesarean section;
• with manual separation of the placenta;
• if delivery began after the placenta detached.

The development of Rh conflict and hemolytic disease of the newborn HDN can be caused by the mother’s exposure to viral processes, such as influenza, or against the background diabetes mellitus. A rather rare case of the formation of such a disease in a newborn is considered to be if an Rh-negative girl was born from an Rh-positive mother.

If this was not noted in the anamnestic history, but female body first encountered positive red blood cells, the production of antibodies occurs, which are called class M immunoglobulins. They are large protein molecules that do not enter the fetal bloodstream, therefore, they do not cause consequences.

Sensitization maternal body develops against the background of a second and/or subsequent pregnancy with a negative Rh factor. Then its bloodstream already contains antibodies that have a memory effect - immunoglobulins G. They have smaller size, so they easily penetrate the fetus. Under their influence, damage occurs to red blood cells that have a positive Rh antigen. This is the answer to the question “when does Rh conflict occur?”

The result of this process is hemolytic disease of the newborn, which manifests itself:

• decrease in the number of red blood cells;
• formation of the phenomena of anemia and fetal hypoxia;
• hypertrophy of organs, especially the liver and spleen;
• the brain, liver, heart suffer;
• Hypoglobulinemia is noted when the protein content in the plasma decreases, which is why there is a high probability of effusion in the cavities - pleural, pericardial, abdominal, between the membranes of the brain.

Hemolytic anemia in Rhesus conflict has serious complications, such as miscarriage and miscarriage. Therefore, doctors recommend taking preventive measures by determining the blood type of the parents in advance. There is a need to carry out regular diagnostics during pregnancy - ultrasound of the fetus, regular examinations and repeated blood tests to determine the increase in antibody titer.

Why is intrauterine blood transfusion necessary?

Due to the development of hemolytic disease of the fetus or newborn, hemolysis of red blood cells occurs. This is a condition in which they undergo destruction. The result of this process is anemia, in which the level of hemoglobin and the number of working red blood cells are significantly reduced, which leads to damage internal organs because they don't get enough oxygen. They begin to experience hypoxia.

During mild and medium degree The severity of the disease provokes jaundice, anemia or dropsy. In severe forms of hemolytic disease, the likelihood of intrauterine fetal death is high.

Previously, doctors used many various techniques in order to prevent such a process. However, they were characterized by questionable effectiveness. Today, fetal or intrauterine blood transfusion is used to treat hemolytic disease of the fetus, which occurs against the background of Rh conflict between mother and child.

It consists of delivering washed red blood cells to the fetus. Access is made through the umbilical cord (cordocentesis) under ultrasound guidance, after which a transfusion is performed. In some cases, this is the only step possible option, capable of saving the life of a child in case of Rhesus conflict.

Description of the intrauterine transfusion method

The technique of intrauterine blood transfusion to the fetus was proposed in the mid-twentieth century. Before that period, intraperitoneal transfusion was performed, when blood was poured directly into abdominal cavity fetus In 1982, when ultrasound examination became highly popular and its effectiveness was proven, it became possible to perform cordocentesis under its control.

This method of treatment is possible after the 22nd week of pregnancy. Doctors consider intrauterine transfusion to be preferable to intraperitoneal transfusion because the red blood cells go directly into the fetal bloodstream. Intraperitoneal transfusion is used until the 22nd week of pregnancy.

The manipulation is carried out in this way.

1. An ultrasound scan of the fetus is performed. Then, through the anterior abdominal wall of the expectant mother, using a special needle-catheter, the umbilical vein is punctured.
2. Then the transfusion is carried out small amount(20-50 ml) single-group Rh-negative blood.

It is extremely rare to resort to transfusion of group 1. This step is necessary when the fetal blood type cannot be determined. In this way, a weakening of the mother’s immune response is achieved due to a decrease in the number of red blood cells with a positive Rh antigen, and a decrease in the manifestations of anemia is also noted. Due to this, the general condition of the fetus improves, and pregnancy is extended by 2-3 weeks.

By determining the hematocrit, doctors determine the need for repeated blood transfusions. Usually the need arises 14-21 days after the first procedure. It is caused by a drop in the current volume of red blood cells by approximately 1% over 24 hours.

Manipulation can be performed up to 34 weeks of pregnancy. There is no need for the reason that upon reaching this period the fetus is considered viable. If hemolytic disease continues to attack with new strength, the issue of early preterm delivery is on the agenda. It could be like physiological birth, and the operation of cesarean section, the decision is made based on the individual indicators of the woman and the fetus.

Indications and contraindications

Carrying out intrauterine transfusion of washed red blood cells through cordocentesis is necessary for severe Rh conflicts, different groups blood, as well as severe immunological processes. All of them require transfusion. Indications for this manipulation are determined by performing an ultrasound:

• detection of hydrothorax, hydropericardium, ascites in the fetus;
• hepatomegaly;
• maternal polyhydramnios;
• expansion of the umbilical veins;
• increased blood flow velocity cerebral artery fetus;
• hypertrophy of the placenta;
• reduction in assessment points general condition fetus

Another test that determines the indications for the procedure is determining the titer of anti-Rhesus antibodies of the mother's body. If it tends to increase, then this serves as an indirect indication for intrauterine blood transfusion. It is important to note that it has less diagnostic value than the previous symptoms.

Among the contraindications, there are cases that do not fit the symptomatology of the indications - the presence of hemolytic disease of the fetus without the above clinical manifestations.

Methodology

The procedure for intrauterine blood transfusion has been known for a fairly long period of time, so today it has been well worked out by doctors. It is important to understand that it has certain risks, therefore such a step is regarded as one of last chances. It is best to prevent the formation of Rh conflict.

Hemotransfusion becomes possible after the 22nd week of pregnancy. By this time, its own circulatory system child, shaped elements. Transfusion involves replacing the baby's cells that have positive Rh proteins with those that are more suitable for the mother's. Due to this, doctors seem to establish contact between the maternal and child organisms in utero.

The manipulation involves infusion of the required blood type developing fetus through puncture of the umbilical vein - cordocentesis. The procedure is quite difficult to perform, since the fetus and its umbilical cord are constantly in motion, and it is not easy to catch the moment of puncture. For this purpose, ultrasound control is used, which allows you to track all movements. The duration of the blood transfusion is approximately an hour, but sometimes it takes longer.

After the end of the transfusion, the woman remains under the supervision of doctors for about a day, since there are long-term reactions after the injection of someone else's blood. It is usually well tolerated.

Will transfusion harm mother and baby?

Despite the fact that medicine has made a huge step forward today, it is necessary to be aware of everything possible risks manipulation. After all, intrauterine blood transfusion can be dangerous for both organisms at once - both mother and child.

To obtain a positive result, intrauterine transfusion should be performed only by a highly qualified specialist in compliance with all the rules of the technique, and you must also adhere to all indications.

Sometimes a complication of blood transfusion is the development of infectious processes. It is caused by non-compliance with all necessary rules, inaccurate insertion of the catheter. To others dangerous complication fetal blood loss is considered when the umbilical cord was pierced incorrectly. For the expectant mother, this situation threatens:

• the onset of premature birth;
• umbilical vein compression syndrome;
• fading pregnancy or miscarriage.

Doctors call hemorrhage into the uterus the most dangerous complication. This is extremely unpleasant situation, which poses a threat to the life of the expectant mother. If such a condition develops, then the only the right decision will surgery aimed at cleansing the uterine cavity. It is important to understand that saving a child’s life is almost impossible. This determines the complexity and responsibility of intrauterine blood transfusion.

Observation after transfusion

Usually the prognosis after such a blood transfusion is good. Almost all successful procedures end in the recovery of the fetus. Deviations from the norm occur in premature babies.

After the manipulation, the woman needs medical supervision for at least 24 hours, since long-term consequences of the manipulation are possible. She also undergoes an ultrasound to exclude blood loss into the uterine cavity, compression of the umbilical vein and other complications of the procedure.

Today, intrauterine blood transfusion to the fetus is the most effective method treatment of hemolytic disease of the fetus, which occurs due to incompatibility of the blood of mother and child.

According to statistics, Rh incompatibility occurs in 9.5-13% of all marriages, the frequency of hemolytic disease is about 1.5%. Of all Rh-sensitized women, 40-50% will have a fetus with mild or no hemolytic disease, 25-30% will have hemolytic disease requiring treatment in the early neonatal period, and only 20-25% will develop severe anemia. requiring invasive methods therapy and early delivery.

Today many married couples Those with a history of fetal loss with a severe form of hemolytic disease have the opportunity to carry and give birth to a child. Thanks to modern diagnostic methods and the latest equipment, specialists from the Republican Clinical Hospital annually perform intrauterine blood transfusions to the fetus. More details about the method in the interview Liliana Efimovna Teregulova.

— What is the method, and in what cases is its use advisable?

— Intrauterine blood transfusion to the fetus is the transfusion of blood products (erythrocytes and platelets) into the fetal umbilical cord vein. To do this, under ultrasound guidance, a puncture of the fetal umbilical cord vein is performed through the anterior abdominal wall and the wall of the uterus with a special, especially strong, rigid, atraumatic needle to determine the level of hemoglobin in the blood. After we receive a blood test, a transfusion of 100 to 250 ml is carried out under ultrasound guidance. freshly washed red blood cells. During the entire operation, fetal cardiac activity is constantly monitored. In addition, transfusion of a blood product helps to weaken the immune response of the pregnant woman by reducing the relative number of Rh-positive red blood cells and helps maintain the total volume of fetal red blood cells above the critical level, which can significantly improve the condition of the fetus.

Intrauterine blood transfusion to the fetus is carried out in cases where the pregnant woman has a Rhesus conflict; monthly we perform an ultrasound, which assesses the condition of the fetus, placenta and blood flow speed in the middle narrow artery. It is the speed of blood flow in the middle narrow artery that is a criterion for anemia. After making this diagnosis, we prepare the patient for intrauterine fetal blood transfusion.

It is worth noting that in a number of diseases, such as anemia, various forms immune conflict, including Rhesus conflict, anemia of non-immune origin, for example, parvovirus infection, as well as alloimmune thrombocytopenia - transfusion of blood products is the only method of treating and saving the fetus. Before the introduction of intrauterine blood transfusion, most fetuses with such anemia died, or, in best case scenario, became severely disabled as a result of the need for premature delivery. Most women with Rh conflicts, having given birth to several stillborn children, remained childless as a result.

— At what stage of pregnancy should it be carried out? this procedure?

— It all depends on the specific case. The moment the fetus is diagnosed with severe anemia, we immediately perform this operation. We typically perform intrauterine blood transfusions for the fetus between 18 and 33 weeks of pregnancy.

— After an intrauterine transfusion, how much time does the mother and fetus need to recover?

- Usually postoperative period is 1-2 days.

— When carrying out this treatment, there is a need for parallel administration medicines?

- No, there is no such need.

- In what cases is it necessary? rerun intrauterine transfusion?

— The number of repeat transfusions depends on the stage of pregnancy. There was a case in our practice where we performed this procedure on one patient 8 times. Regarding the duration of pregnancy, intrauterine blood transfusions can be performed repeatedly up to 34 weeks of pregnancy. This is due to the fact that it is at this time that the fetus becomes quite viable. For example, if after 34 weeks hemolytic disease of the fetus develops or its course becomes aggravated, the issue of early birth is decided. It could be like natural childbirth, so C-section- it all depends on the situation in each specific case.

- Can there beAre there any complications?

— Intrauterine blood transfusion is a procedure dangerous for both the mother and the fetus, so it must be performed experienced doctor according to strict indications. For example, a mother may develop a complication such as placental abruption, the fetus may experience large blood loss due to thrombocytonemia that often accompanies Rhesus conflict, and in rare cases intrauterine death fetus It is also worth considering that after this procedure, premature birth may occur.

Of course, it is difficult to say unambiguously what complications may develop in a particular case, but if the procedure is carried out in a qualified manner, everything usually goes well. If the intrauterine transfusion was successful and the desired result was achieved, all children grow and develop normally after birth. Deviations from normal development are noted only in strong premature babies With hemolytic disease and they are caused by prematurity.

- Is there a possibility that this treatment will not give positive results?

— In my practice, there have been no such cases. If the diagnosis is made correctly, we always get an adequate result.

Liliya Turullina