Health of pregnant women
Every woman who gets registered in a women's consultation determines the blood group and the so-called Rh factor. Are also interested in the Rh factor of the child's father. What is Rhesus-conflict and Rh-factor in general? Why all these tests are needed and why are "Rh-negative" pregnant women causing close attention of obstetrician-gynecologists?
Alexander Ivanov obstetrician-gynecologist, head. gynecological department of the multi-field day hospital of polyclinic № 5, Ulyanovsk
Rhesus factor is an ordinary protein on the surface of red blood cells - red blood cells. It is named so because it was first discovered in rhesus monkeys. And then it was found in people ...
85% of us have it, 15% do not. Those who have this protein, are called Rh-positive. Who does not - Rh-negative. The presence or absence of Rh factor is not good and not bad - just like a blood group: some have it first, others have a second, etc. This is a genetic feature of the body, not talking about any violations.
How does Rh disease develop?
So why in pregnancy at this rate suddenly begin to pay attention, especially if the future mother is Rh-negative? In this case, the rhesus-belonging of the father of the unborn child is determined. If its rhesus is also negative, then you do not have to worry. If the father of the future baby is Rh-positive, the pregnant woman gives additional tests.
The fact is that such women can develop Rh-conflict. It is observed in less than 1% of pregnant women. And yet this problem is serious enough. In such a married couple, the probability of having a Rh-positive baby is 75%. And the body of the Rh-negative mother can enter into a fight with her own child. In the body of the mother, special proteins are formed - the so-called antibodies, which are normally designed to protect the body from all kinds of infections and aggressors. In this case, an innocuous protein located on the surface of red blood cells (red blood cells carrying oxygen) is perceived as an aggressor in the womb of the mother. Together with the protein, red blood cells perish, on the membrane of which it is located. If antibodies are produced a lot, it leads to unpleasant consequences - the development of hemolytic disease of the fetus; the more red blood cells of the fetus is destroyed, the more the baby suffers.
What happens in the mother's body, why does her immune system react so to her own child?
Here it is necessary to recall what happens at conception: the child receives half of the genes from the father, half from the mother. Strictly speaking, for the mother's organism, it is half foreign, and the immune system simply must attack it and destroy it. However, this does not happen in the norm. Nature, having given warm-blooded abilities to give birth to similar ones, but somewhat different, took care to separate one organism from another in the earliest stages. Normally, the blood of the mother and child does not touch. On the border between two independent organisms there is a placental barrier - a thin barrier from the cells, which, like vigilant customs officers, strictly control the passage of substances from mother to fetus and back. And only low-molecular substances pass. Amino acids - building material, glucose - energy, oxygen - always please. But the proteins that can prove to be antibodies - stop, stop, stop. In addition, near the placental barrier due to the hormones that support pregnancy, the activity of immunocompetent cells itself is decreased.
But also from the child to the mother, too, nothing does penetrate anything that could cause an immune response and conflict. All these "foreign bodies" are delayed by the same placental barrier. Therefore, during the first pregnancy, Rhesus-conflict develops rarely, if there are no diseases that can damage the placental barrier and cause the child's proteins to enter the bloodstream of the mother.
However, there are situations where the Rh-positive factor nevertheless penetrates the mother's blood and causes an immune response. This can happen with abortion, miscarriage, cesarean section, ectopic pregnancy, transfusion of plasma containing anti-rhesus antibodies, placental trauma, infectious diseases accompanied by placental damage, and even with normal births. There is a so-called sensitization of the female organism: the immune system received a sample of foreign protein, prepared for it antibodies - cells that selectively destroy only this protein. And organized an attack. Or I left the sample in case of a second meeting, when it will be possible to quickly "fix the release" of antibodies. However, this happens, apparently, only with massive ingress of foreign blood. Because the norm in the body of the mother still gets a small amount of red blood cells of the fetus, but no sensitization occurs.
So, the antibodies are ready. They get to the destination - in the blood of the fetus. Once there, the antibodies destroy this very Rh-protein, which is on the surface of red blood cells, thereby destroying them (the so-called hemolysis); as a result of hemolytic disease of the fetus. When destroyed, bilirubin is released into the bloodstream, which has a toxic effect on the fetus. In addition, the destroyed red blood cells can not perform their basic function - to carry oxygen and nutrients, which leads to oxygen starvation and impaired fetal development.
Forms of hemolytic disease
Depending on the severity of hemolytic disease, several of its forms are distinguished: anemic, icteric and edematous - the heaviest.
When anemic form only the quantity of erythrocytes and, accordingly, hemoglobin decreases. Anemia (anemia) in this case is associated with a violation of the synthesis of red blood cells in the bone marrow. The prognosis for this form of the disease is favorable.
The most common is the so-called icteric, at which jaundice develops in the skin of the fetus: the skin is stained with bilirubin, which is formed during the breakdown of red blood cells. In most cases, with timely proper treatment, this form also passes without consequences for the child.
Edema form, как уже было сказано, наиболее тяжелая. В этом случае у плода к желтухе добавляется водянка. Кожные покровы становятся не желтушными, а бледными, отечными, в брюшной полости скапливается жидкость. When диагностике отечной формы неоценимую помощь оказывает УЗИ плода, возможно выявление этой формы еще во внутриутробном периоде. Состояние женщины при этом обычно не изменяется — она может чувствовать себя прекрасно.
Diagnosis of Rhesus Conflict
How to recognize this attack and how to fight it? First of all, early registration with a woman's consultation is necessary. The process of sensitization and immune response can begin with the 9-10th week of pregnancy, when the formation of the Rh factor begins on the erythrocytes of the embryo and an immune response becomes possible. In the antenatal clinic the pregnant woman will give a blood test with the definition of group affiliation and Rh factor. If the woman's blood turns out to be Rh-negative, and her husband's blood is Rh-positive, a blood test for the antiresus antibodies will be regularly performed. The very presence of antiresusive antibodies is not yet a tragedy, with the regular delivery of analyzes, the change in their number will be tracked, and in case of their increase the doctor will prescribe the appropriate treatment.
Normally, the titer (amount) of antibodies is determined up to 32 weeks - once a month, from 32 to 35 weeks - once in 2 weeks, then - once a week.
However, the antibody titer is not always a reliable indicator. It happens that with a high titer the fetus's condition remains stable, and it happens that with low antibody titers, severe forms of hemolytic disease of the fetus develop. At present, other methods of investigation are widely used to determine the severity of the disease and fetal condition-for example, ultrasound can detect changes in the liver and spleen of the fetus, which is one of the diagnostic criteria. Conduct CTG - record heart rate to determine the degree of suffering of the fetus.
When необходимости в крупных научных центрах могут провести амниоцентез: плодный пузырь прокалывается через шейку матки или брюшную стенку под контролем УЗИ, делается забор амниотической жидкости. Появление антител в околоплодных водах свидетельствует о тяжелом течении гемолитической болезни.
According to the indications, it is possible to conduct a cordocentesis - under the control of ultrasound, pierce the umbilical cord of the fetus with the purpose of blood sampling. Blood group, antibody titer, biochemical parameters, sex of the child, which in this case is of prognostic value are also determined: it is noticed that in girls the unfavorable outcome of the disease is observed in 2 times less often.
Treatment проводится строго индивидуально, в зависимости от выраженности процесса. Желательно наблюдение резус-сенсибилизированных беременных (тех, у кого есть антитела) в специальных перинатальных центрах. На сроках беременности 8—10, 24, 28 и 32 недели рекомендована госпитализация в стационар, обследование и специальное лечение. Проводят так называемую десенсибилизирующую терапию, направленную на снижение образования антител в крови; для этого используют различные медикаменты, а также гемосорбцию. С помощью гемосорбции удаляют антитела — кровь матери пропускают через специальную колонку с фильтрами, на которых оседают токсические вещества
and most of the antibodies. The plasmapheresis method is also used, when a small part of the blood is taken from the woman, the plasma is removed together with the antibodies, and the washed red blood cells along with the physiological solution are poured back. This procedure is carried out several times.
Widely used drugs that enhance blood flow in the placenta, improve the nutrition of the fetus, introduce various energy substrates for fetal nutrition. The method of hyperbaric oxygenation is used - in the pressure chamber oxygen is supplied under pressure, which increases its content in the blood of the mother and, accordingly, the fetus.
Currently, in large cities, there are perinatal centers, in large centers there are even departments that are fully engaged in this problem and have accumulated a wealth of experience in the treatment of this pathology.
When уровне развития современной техники применяется, например, метод заменного переливания крови плода, когда пуповину плода под контролем УЗИ прокалывают специальной иглой и проводят переливание крови еще до рождения ребенка! Сущность метода состоит в том, чтобы заменить кровью донора кровь плода, содержащую неполноценные эритроциты, антитела, продолжающие атаковать свои мишени уже даже вне материнского организма, и тот же билирубин — продукт распада гемоглобина. Кровь донора дает организму плода передышку, временно выполняя функции его собственной крови. А затем организм ребенка успевает выработать достаточное для нормальной жизнедеятельности количество эритроцитов.
В случае тяжелого течения заболевания и неэффективности лечения решается вопрос о досрочном родоразрешении. When подготовленной шейке матки и отсутствии сопутствующей патологии роды проводят естественным путем, в иных случаях проводят операцию кесарева сечения.
После родов за ребенком ведется тщательное наблюдение. У него берут анализы крови, следят за изменением уровня гемоглобина и билирубина. When распаде эритроцитов уровень гемоглобина снижается, а билирубина, соответственно, повышается. Для улучшения состояния плода, ускорения выведения билирубина проводят внутривенное введение глюкозы, белоксодержащих растворов. Ребенку дают препараты, усиливающие активность печени, за счет чего ускоряется выведение билирубина из крови.
But to date, the most effective method of treating a hemolytic disease of a newborn is a replacement blood transfusion, which is performed when there are appropriate indications. Separately, it should be said about feeding. Children with hemolytic disease milk mother can begin to feed from the 7-10th day of life, since milk can contain antibodies. And during this time, their number is decreasing. Before that, children are on artificial feeding. Children who received timely treatment, further develop well.
Once again, it should be recalled that pregnancy in Rh-negative mothers with a Rh-positive father is not a reason for panic and the expectation of the inevitable development of Rh-conflict. Just the norm for her should be a regular visit to the doctor, examination and reasonable behavior, which, however, is not out of place for anyone who is preparing to become a mother.
Prevention is necessary!
At present, the only reliable method of preventing Rh-sensitization is the introduction of antiresusive globulin. It is administered to the Rh-negative mothers who gave birth to the Rh-positive child within the first 24 hours - it is highly desirable to do this in the first 2 hours after delivery. Currently, globulin is also used during pregnancy.
It should be remembered that each subsequent pregnancy increases the possibility of immunizing a woman by 10%.
It is very undesirable to have abortions in primordial women with Rh-negative blood. However, if all this happened, after an artificial or spontaneous abortion or after an ectopic pregnancy, such women are injected with an antiresusive immunoglobulin. Its introduction is made no later than 72 hours after the intervention. The drug blocks the sensitization of the woman's body and reduces the number of problems in the future.
What can I recommend to a woman to avoid possible complications? Early appearance in the women's consultation, timely and correct delivery of tests, accurate and accurate implementation of medical recommendations will help the future mother to maintain the health of her baby.