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I. DEFINITION

ABO incompatibility is an immune system reaction that occurs when

blood from two different and incompatible blood types are mixed together.

1.

Hemolytic disease of the fetus and newborn is an immune reaction of the

mothers blood against the blood group factor on the fetus RBCs.2.

When RhoGAM (Rh immune globulin) became available in the 1960s to

treat isoimmunization in Rh-negative women, the incidence of hemolytic

disease in the fetus and newborn dropped significantly.

II. ASSESSMENT

1. Clinical manifestations

The hemolytic response in ABO incompatibility usually begins at birth witha resulting newborn jaundice.

Rh incompatibility may lead to:

o Hydramnios in the mother

o Excess bilirubin levels in the amniotic fluid.

o Varying degrees of hemolytic anemia (erythroblastosis) in the fetus.

If the condition is left unmanaged, 25% of affected infants may die

or suffer permanent brain damage.

III. PATHOPHYSIOLOGY

1.

This disorder occurs when the fetus has a blood group antigen that the

mother does not possess. The mothers body forms an antibody against

that particular blood group antigen, and hemolysis begins. The process of

antibody formation is called maternal sensitization.

2.

The fetus has resulting anemia from the hemolysis of blood cells. The fetus

compensates by producing large numbers of immature erythrocytes, a

condition known as erythroblastosis fetalis, hemolytic disease of the

newborn, or hydrops fetalis. Hydrops refers to the edema and fetalis refers

to the lethal state of the infant.

3.

In Rh incompatibility, the hemolysis usually begins in utero. It may notaffect the first pregnancy but all pregnancies that follow will experience

this problem. In ABO incompatibility, the hemolysis does not usually does

not usually begin until the birth of the newborn.

IV. LABORATORY RESULTS

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Laboratory and diagnostic study findings

The indirect Coombs test can aid in the search for agglutination of Rh-

positive RBCs to determine if antibodies are present.

Amniocentesis is used to determine optical density and estimate fetal

hemolysis. Spectrophotometer readings are made of the amniotic fluidcollected. The readings are obtained to determine fluid density. They are

plotted on a graph and correlated with gestational age. The amount of

bilirubin resulting from the hemolysis of red blood cells can then be

estimated.

An antibody titer should be drawn at the first prenatal visit on all Rh-

negative women. It should also be drawn at 28 and 36 weeks of

pregnancy and again at delivery or abortion. The normal value is 0. The

result is usually reported as a ratio; normal is 1:8. If the titer is absent or

minimal (1:8), no therapy is needed. A rising titer indicates the need for

RhoGAM and vigilant monitoring of fetal well-being.

V. MEDICAL MANAGEMENT

1. Phototherapy

2. Possible exchange transfusion

3. Administration of intravenous immunoglobulin

VI. NURSING MANAGEMENT

1. Administer RhoGAm to the unsensitized Rh-negative client as appropriate

Administer RhoGAM at 28 weeks gestation, even when titers are

negative, or after any invasive procedure, such as amniocentesis.

RhoGAM protects against the effects of early transplacental hemorrhage

(as recommended by the American College of Gynecologists).

When the Rh-negative mother is in labor, crossmatch for RhoGAM, which

must given within 72 hours of delivery of the newborn.

2. Provide management for the sensitized Rh-negative mother and Rh-

positive fetus.

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Focus management of the sensitized Rh-negative mother on close

monitoring of fetal well-being, as reflected by Rh titers, amniocentesis

results, and sonography.

If there is evidence of erythroblastosis, notify the perineal team of the

possibility for delivery of a compromised newborn.

3. Provide management for ABO incompatibility.

Phototherapy usually can resolve the newborn jaundice associated with

ABO incompatibility.

In addition, initiation of early feeding and exchange blood transfusions

may be immediate measures required to reduce indirect bilirubin levels.

Provide client and family teaching.

VII. NURSING DIAGNOSIS

1. Interrupted breast feeding r/t excessive bilirubin levels secondary to

breast milk jaundice

2. Risk for injury r/t effects of exchange transfusion

3. Pain r/t frequent heel sticks

VIII. 2 NURSING THEORIES W/ RATIONALE

1. Dorothea Orem - Self Care Deficit According to Orem, nurses have to supply care when the

patients cannot provide care to themselves. In relation to this, the infant affected by ABO

incompatibility is very vulnerable especially to jaundice. The nurse's provide phototherapy to the

infant.

2. Virginia Henderson Henderson's theory is defined as, "Assisting the individual, sick or well,

in the performance of those activities contributing to health or its recovery (or to peaceful death)

that an individual would perform unaided if he had the necessary strength, will or knowledge"

In this case, the nurse assists the mother and educates her on how to care for her child. Teach her

how to provide phototherapy independently, encourage breastfeeding, and provide healtheducation to the client and the family.