Clinical aspects of rhesus isoimmunization

The object of this Thesis is to present and discuss various aspects of Management and Prevention of Rhesus isoimmunization within a County Obstetric Service which caters for a population of 600,000. The work presented was carried out over the years 1958 - 1968, partly within the County Obstetric Service and partly with the Regional Transfusion Centre. The first chapter traces the history of Rhesus isoimmunization starting in 1959 with the beginning of the elucidation of the Rhesus factor and its connection with the syndrome of erythroblastosis foetalis. The advances in the knowledge of this factor and its effect are followed throughout the subsequent years. The management of pregnancy and treatment of the newborn are also followed from early induction of labour based on antibody titre and original exchange transfusion of the baby to the present day assessment by liquor amnii bilirubin content and treatment of the severely affected baby by intra-uterine transfusion. The early attempts at amelioration of the effects of isoimmunization during pregnancy are described and followed to the present use of anti Rh. (D) gamma globulin to prevent the sensitization of the Rhesus negative mother to the Rhesus factor. The second chapter describes how the pattern of management has evolved over the past eleven years. First came the establishment of special clinics for sensitized patients, followed by the introduction of the diagnostic aid of amniocentesis. This chapter includes a broad picture of the material studied, including tables detailing type of antibody found, frequency of antibody, ABO relationship of parents and baby and parity. The overall results are presented as representing the three periods:- (1) pre Rhesus clinic (2) Rhesus clinic and (3) Rhesus clinic plus amniocentesis and show how the perinatal mortality has improved, reflecting the improvement in antenatal The third chapter contains a detailed review; of the use of liquor amnii bilirubin content in the prediction of the severity of erythroblastosis of the foetus. The technique and risks of amniocentesis are fully described. One hundred and seventy three cases are presented in detail and correlation made between the liquor amnii prediction and the condition of the baby at birth as judged by the cord haemoglobin and bilirubin. These correlations were not always found to be satisfactory and a better correlation was found between liquor amnii prediction and a suggested Cord Blood Factor obtained from the ratio cord haemoglobin in gms.% divided by the cord bilirubin in mgm.%. (These results are presented in tabular and diagrammatic form). The fourth chapter gives a detailed review of the use of intrauterine transfusion of the foetus from the original paper describing this procedure to the present time. The selection of cases, risks to mother and foetus and the present status of intra-uterine transfusion are considered. Twenty-six pregnancies so treated are fully discussed in detail and the survival rate is shown to be similar to the various published series. The various operative techniques are fully discussed and a short joint publication on technique is included. The cause of perinatal mortality is given when possible for the babies which did not survive. The final chapter deals with the prevention of Rhesus isoimmunization. It describes the early attempts to ameliorate the effects of immunization on the foetus and later the recent work on prevention of isoimmunization by the use of anti Rh. (D) gamma globulin. The background and experimental work in this field is described. The sources of raw material necessary to prepare anti Rh. (D) gamma globulin are considered and experience in the use of plasmapheresis to obtain this material is described. A series of cases treated with anti Rh. (D) gamma globulin before the general introduction of anti Rh. (D) gamma globulin is presented and the practical difficulties of administration discussed. The results of its use in a v;ider series is also presented. The relevant literature has been reviewed in all chapters and references are shown at the end of each chapter