Management of a Baby Born to an Rh-Negative Mother

1. Immediate Steps at Birth

• Cord blood sampling for:
  • Blood group and Rh type of the baby
  • Direct Coombs test (DCT) / Direct antiglobulin test (DAT) - positive if maternal antibody is coating the baby's red cells
  • Hemoglobin/hematocrit, reticulocyte count
  • Total serum bilirubin
• Clinical assessment for pallor, jaundice, hepatosplenomegaly, respiratory distress, or signs of hydrops fetalis (severe cases can present with generalized edema, ascites, and high-output cardiac failure).
• Note whether the mother received antenatal interventions (serial anti-D titers, middle cerebral artery Doppler velocity monitoring, or intrauterine transfusion), since a severely affected fetus may already be anemic at delivery.

2. Grading Severity

• Mild disease: only jaundice, no significant anemia - manage with phototherapy and monitoring.
• Moderate disease: anemia + jaundice, no hydrops.
• Severe disease: hydrops fetalis, severe anemia, marked hyperbilirubinemia - needs immediate intensive care.

3. Hyperbilirubinemia Management

• Serial bilirubin monitoring (often every 4-6 hours initially) since bilirubin can rise rapidly from ongoing hemolysis.
• Phototherapy: started early and aggressively if bilirubin is rising fast or approaching exchange thresholds, using hour-specific/age-specific nomograms specific to hemolytic disease (lower thresholds than for non-hemolytic jaundice given kernicterus risk).
• IVIG (intravenous immunoglobulin): can reduce the need for exchange transfusion by blocking Fc receptor-mediated hemolysis in DCT-positive, actively hemolyzing infants.
• Exchange transfusion: indicated for severe/rapidly rising bilirubin unresponsive to phototherapy, cord bilirubin markedly elevated, or signs of impending kernicterus. Double-volume exchange transfusion removes bilirubin-coated red cells, circulating antibody, and unconjugated bilirubin, and corrects anemia simultaneously. Rh-negative, ABO-compatible blood (crossmatched against maternal serum) is used.
• Watch closely for kernicterus (bilirubin encephalopathy) - lethargy, poor feeding, hypertonia/opisthotonus progressing to choreoathetosis and sensorineural hearing loss if untreated - Bradley and Daroff's Neurology in Clinical Practice.

4. Anemia Management

• Ongoing hemolysis can cause anemia for weeks after birth even after bilirubin stabilizes.
• Monitor hemoglobin/reticulocyte counts regularly for 2-3 months.
• Top-up (simple) packed red cell transfusion if hemoglobin falls significantly or the infant is symptomatic (poor feeding, tachycardia, poor weight gain) - late anemia is common because maternal antibody persists in the infant's circulation for weeks.
• Recombinant erythropoietin has been used adjunctively in some late anemia cases to reduce transfusion need, though evidence is limited.

5. Supportive/General Care

• Monitor glucose (hemolysis and hepatosplenomegaly can predispose to hypoglycemia), hydration, and temperature.
• In hydrops fetalis: may need respiratory support/ventilation, careful correction of fluid and electrolyte disturbances, treatment of associated thrombocytopenia or coagulopathy, and drainage of effusions/ascites if compromising respiration.
• Hepatosplenomegaly and thrombocytopenia should be monitored; severe cases can develop a bleeding diathesis.

6. Follow-up

• Continue outpatient hemoglobin and bilirubin checks after discharge given risk of late-onset anemia.
• Hearing screening given kernicterus risk with prior significant hyperbilirubinemia.
• Neurodevelopmental follow-up in infants who had severe disease or required exchange transfusion.

Related Maternal Point (context)

Recent Evidence Note