37例母儿Rh D血型不合孕妇和新生儿的临床分析

Pregnancy management and outcomes of maternal-fetal Rh D incompatibility:analysis of 37 cases

目的 分析母儿RhD血型不合的孕期管理,妊娠结局及新生儿情况。方法 回顾性分析2013-2017年本院收治的37例母儿Rh血型不合孕妇及其新生儿临床资料,26例孕期已行抗D抗体检测,37例分娩前已行彩超检查。根据新生儿出生后是否行换血治疗将孕妇及其新生儿分为换血组和未换血组。结果 （1）孕期抗D效价为≥1∶512者,换血组有11例（84. 6%）明显高于未换血组（3例,占23. 1%）（P=0. 002）;（2）换血组有5例（31. 3%）超声疑诊胎儿溶血[胎儿多浆膜腔积液1例、胎儿三尖瓣重度反流伴胎儿大脑中动脉收缩期峰值流速（middle cerebral artery peak systolic velocity,MCA-PSV）增快1例、羊水增多1例、MCA-PSV增快2例],未换血组中有1例（4. 8%）为胎儿MCA-PSV增快,两者相比差异有统计学意义（P=0. 03）;（3）除2例孕妇因高度疑诊胎儿溶血行剖宫产,其余手术指征均为产科指征;（4）换血组新生儿出生后血红蛋白水平明显低于未换血组（P 〈0. 05）,换血组有2例新生儿放弃治疗,其余均治愈出院。结论 已发生同种免疫的Rh阴性妇女孕期应关注胎儿MCA-PSV及其他胎儿贫血的异常超声指标;孕期定期监测抗D抗体,如抗D抗体≥1∶512新生儿出生后换血概率较高,应及时做好换血准备;孕妇已发生同种免疫不是阴道分娩禁忌证。

Objective To analyze the pregnancy management and pregnancy and neonatal outcomes of maternal-fetal RhD incompatibility. Methods We retrospectively analyzed the clinical data of 37 pairs of pregnant women and their newborns with RhD incompatibility between January 1, 2013 and December 12, 2017. Anti-D antibody was deteeted in 26 cases and color-Doppler ultrasound examinations were performed in all the 37 cases during pregnancy. The clinical data were compared between the cases where the neonates required blood exchange transfusion therapy and those without blood exchange transfusion. Results In the blood exchange group, 11 （84.6%） pregnant women had an anti-D antibody titer exceeding 1： 512, a rate significantly higher than that in cases without blood exchange （3 cases, 23.1% ; P = 0. 002）. Ultrasound examinations detected fetal abnormalities in 5 cases （31.3%） in blood exchange group, including l case of cavity effusion, 1 case of severe tricuspid reflux with increased middle cerebral artery peak systolic velocity （MCA-PSV） , 2 cases of increased amniotic fluid, and 2 cases of increased MCA-PSV; in comparison, only 1 case （4.8%） in the group without blood exchange was found to have fetal abnormality （increased MCA- PSV） , showing a significant difference in the rate of fetal abnormalities between the 2 groups （ P = 0.03 ）. With the exception of 2 pregnant women who underwent cesarean section for highly suspected fetal hemolysis, all the other women had obstetric indications. In the blood exchange group, the hemoglobin level of the neonates was significantly lower than that in the cases without blood exchange （P 〈 0.05 ）. Two neonates in the blood exchange group gave up further treatment, and all the other neonates were cured and discharged uneventfully. Conclusions For Rh-negative women with ongoing pregnancy and confirmed allogeneic immunization, concerns should be raised for abnormal ultrasound findings of fetal MCA-PSV and fetal anemia. A high anti-D antibody titer over 1：512 during pregnancy suggests a high likeliness of subsequent neonatal exchange transfusion. RhD incompatibility is not a contraindication for vaginal delivery.