Gebelikte RH D Alloimmunizasyonu
Özet
Gebeliklerde RhD alloimmünizasyonu, RhD-negatif annelerin RhD-pozitif fetal kırmızı kan hücrelerine maruz kalmasıyla anti-D antikorları geliştirmesi durumudur. Bu antikorlar plasentayı geçerek fetüste anemi, hidrops fetalis ve fetüs ile yenidoğanın hemolitik hastalığına (HDFN) yol açabilir. Genellikle doğum veya gebelik sırasındaki fetomaternal kanamalar maternal bağışıklık yanıtını tetikler. Yönetim sürecinde, ilk doğum öncesi viziyette kan grubu tiplemesi ve antikor taraması (indirek Coombs testi) yapılmalı, 28. haftada ve doğumda tekrarlanmalıdır. Fetal RhD genotipini belirlemek için hücresiz DNA (cfDNA) testlerinden yararlanılır. Antikor titresi kritik seviyeye (16 veya 32) ulaştığında, fetal anemiyi öngörmek için orta serebral arter tepe sistolik hız (MCA-PSV) Doppler ultrasonografisi uygulanır. MCA-PSV değerinin 1.5 MoM'un üzerinde olması ciddi fetal anemi riski taşır ve gestasyonel yaşa göre intrauterin transfüzyon veya doğum planlaması gerektirir. Önleme stratejisi olarak, duyarlılaşmamış tüm Rh-negatif kadınlara 28. gebelik haftasında ve Rh-pozitif bebek doğumundan sonraki 72 saat içinde 300 µg anti-D immün globulin rutin olarak uygulanmalıdır. Ayrıca kürtaj, dış gebelik, amniyosentez ve koryonik villus örneklemesi gibi invaziv girişimler veya travmalar sonrasında da haftaya uygun dozda profilaksi yapılmalıdır.
RhD alloimmunization in pregnancy occurs when RhD-negative mothers develop anti-D antibodies following exposure to RhD-positive fetal red blood cells. These antibodies can cross the placenta, leading to fetal anemia, hydrops fetalis, and hemolytic disease of the fetus and newborn (HDFN). Maternal immune responses are generally triggered by fetomaternal hemorrhages during delivery or pregnancy complications. In terms of management, blood typing and antibody screening (indirect Coombs test) must be performed at the initial prenatal visit and repeated at approximately 28 weeks of gestation and delivery. Cell-free DNA (cfDNA) testing is utilized to determine the fetal RhD genotype. Once the antibody titer reaches a critical level (16 or 32), middle cerebral artery peak systolic velocity (MCA-PSV) Doppler ultrasonography is applied to predict severe fetal anemia. An MCA-PSV value above 1.5 MoMs indicates a risk for severe anemia, necessitating either intrauterine transfusion or planned delivery depending on gestational age. For prevention, a routine dose of 300 µg anti-D immune globulin should be administered to all non-sensitized Rh-negative women at 28 weeks of gestation and within 72 hours after delivering an Rh-positive infant. Furthermore, appropriate doses of prophylaxis are mandatory following invasive procedures or traumas, such as abortion, ectopic pregnancy, amniocentesis, and chorionic villus sampling.
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