Q: I am 27 years old and have a negative Rh factor – I am AA negative. I conceived once but had a D&C. I did not take the rhogram injection to stop antibodies from developing in my body. I want to conceive now. Do I still have a chance of getting pregnant? Is there something I have to do? I have done a hormone test and I was told I have high level of prolactin. Is this the cause?

A:The Rh (rhesus) factor is a protein (antigen) present on the surface of red blood cells (RBCs). As it was first discovered in the rhesus monkey, it has been so named. Individuals carrying this antigen are called Rh-positive (Rh+) while those lacking it are Rh-negative blood group type (Rh-). Rh incompatibility (or Rh disease) is a state in which a woman with Rh-negative blood group is exposed to Rh-positive RBCs leading to the formation of antibodies against this protein (called Rh antibodies). Once these antibodies are made in the mother, they cross the placenta into the developing baby’s circulation and destroy the baby’s RBCs, which are Rh +. This can occur when an Rh-negative woman is carrying an Rh-positive baby or if an Rh-negative woman receives blood transfusion containing Rh-positive cells. In either case, her immune system is exposed to the Rh antigen (which is ‘foreign’ to her body) and begins producing Rh antibodies. During pregnancy and delivery, red cells from the baby enter the mother’s circulation. If the exposure is significant, the mother gets sensitised and begins to produce antibodies. When these antibodies cross the placenta and enter the baby’s circulation, they encounter Rh + cells, which are then destroyed by these antibodies leading to anaemia and jaundice in the baby. Delivery is the usual time when sensitisation occurs and thus, first-born babies are usually unaffected, as antibodies have not yet formed in the mother. A subsequent pregnancy with an Rh-positive baby can give rise to anaemia in the baby as these antibodies destroy the baby’s RBCs. Each successive pregnancy poses a greater risk to the baby. It is postulated that even less than 1 ml of Rh-positive blood can induce antibody formation while several studies have shown that ~30% Rh-negative individuals never form antibodies despite exposure to Rh antigen. The problem of Rh incompatibility is of clinical importance only in a pregnant woman or if blood transfusion is required. These circulating antibodies in a woman’s blood are otherwise harmless. Most institutions give human anti-D immune globulin (Rh IgG) antenatally to Rh-negative pregnant women. If a woman has been already sensitised she needs to get the antibody titres estimated and be closely monitored during pregnancy. Babies born to such mothers too may require specialised neonatal care. The diagnostic evaluation includes maternal prenatal ABO and Rh typing, and an antibody screen. Depending on the results of the antibody screen, maternal antibody titres, and paternal and/or fetal RBC phenotyping are performed. If fetal RBC express the antigen against which maternal alloimmunisation has occurred, measuring serial maternal antibody titres and abdominal sonograms then follows the pregnancy. Pregnant mothers should have regular indirect antiglobulin tests. As a guide anti-D antibody levels < 0.2 mg/ml require no action while higher levels require action; levels > 2.0 mg/ml typically are associated with severe disease. Prevention of haemolytic disease of the newborn (HDN) is now carried out with anti-D Ig (intramuscular within 72 hours of delivery) in all d mothers giving birth to a D child. A Kleihauer test for fetal haemoglobin can be used as a guide for the dose of anti-D Ig to be administered.