Rh Incompatibility:
This is off subject, but it has to do with the survival and welfare of babies, so it is close enough. Something has been brought to my attention.
As you should know, indeed as every educated person in the Western World should know, there is a disease which I shall call by an old name: Rh incompatibility.
The major blood types are A, B, AB and O. They are a matter of life and death in the case of transfusion. Basically the situation is this: most of your chromosomes come in pairs. There is a place, a locus, on each of one set of chromosomes for the A,B,O blood type. There are three possible forms of the gene, alleles, that can fit on this locus. Thus the gene types can be AA, AB (which is the same as BA), AO, BB, BO and OO. The genes produce sites on the cell membrane that surrounds each red blood cell. These sites are called antigens, so called because the body can produce antibodies to them. When a cell with an antigen is exposed to the corresponding antigen, the cell breaks open releasing the highly toxic hemoglobin the cell contains into the circulation and the cell is lost to the body as an oxygen carrying agent.
An A allele puts the A antibody on the cell; the B allele puts the B antibody on the cell. The O allele does not put a strong antigen on the cell. Thus the blood types corresponding to the six genotypes listed above are respectively A, AB, A, B, B, and O. The A antigen is a very strong one, meaning it evokes a very strong antibody response, and it is widely distributed in nature, so everyone is exposed to it, and anyone with type B or O reacts vigorously to blood of type A or AB. B is not quite so strong, but the same principle holds. A person with type A does not have antibodies against A because early in development the body does a sort of an inventory of the antigens it ordinarily has and normally will never mount a antibody attack on them. Other antigens it will mount an attack on after it has once been exposed, which in the case of type A is early in life. With something like the antigen on poison ivy, there is generally no reaction to a first exposure but there is a rash with subsequent exposure.
Thus, so far as the major blood types go, a person needing a transfusion generally gets his or her own blood type. If there is a problem, for instance if that type is not available or if time is very limited, it may be possible to use another blood type, for instance type 0. But if a person, lacking the A antigen, say a type O person, receives type A blood, there is a catastrophic reaction; all the transfused blood cells break down and the toxic hemoglobin does extensive damage.
In practice, unless in a dire emergency, the blood to be transfused is not only the same type as the recipient’s blood but is cross-matched by actually exposing samples of the two bloods to rule out a mismatch. There are many antigens other than A and B, and it is best to avoid any reaction, even a weak one.
Usually this much is of interest only to specialists in transfusion. However you ought to know your blood type. It could save your life. If there is a major catastrophe in which many have been injured and resources are stretched to the limit you might be asked, “What is your blood type?” If you do not know, it is possible to give you type O blood. It might make you sick, but it will probably not kill you. But if there is not enough type O to meet the needs you might bleed to death with the blood that could save you readily at hand. If you are type AB, you can be given blood of any type. Sadly it is true that more people in our society know their astrological sign, of no known medical significance, than know their blood type. Learn yours.
But there is another issue of blood type that is important to everybody. That is the Rh antigen or Rh factor as it is called. This is an antigen that either is or is not produced by a gene on a locus different from the ABO locus. There is an allele that makes it and one that either is absent or does not make it. If you were to take all the alleles in a white population and sort them out as either Rh positive – making the antigen – or negative and not making the antigen you would find that roughly 60% were positive and 40% were negative. Since it takes only one allele to make the antigen, in order to be Rh negative and not have the antigen you need two negative alleles, which happens with a frequency of 16%, maybe closer to 15% actually. You can have two Rh positive alleles, which happens about 36% if the time. So about 64% of the white population has at least one Rh negative allele. This is not a rare condition. Almost two out of three white Americans carry it.
The Rh antigen is a weak one. If you are Rh negative, that is if both of your chromosomes lack the allele that makes the antigen, and you have never had a transfusion or been pregnant, then it is very unlikely that you have antibodies against the Rh antigen. If you are Rh negative and have had a transfusion with Rh positive blood, then you have the antibody or you soon will.
If a woman who is Rh negative has a baby that is Rh positive, some of the babies blood will enter her circulation during childbirth. Then, unless modern medicine, and I mean medicine in the developed world for about the past fifty years, intervenes, she will develop an antibody against the Rh factor. The antibody against the A antigen does not enter the fetal circulation; apparently it is too big. But the antibody against the Rh factor is smaller and can cross the placenta and enter the fetal circulation. When it does so it breaks down fetal red blood cells. This has two unfortunate effects.
One effect is that the loss of the red blood cells in the fetus renders it anemic. It cannot supply the usual amount of oxygen to the tissues. It responds by increasing its cardiac output, but this can only go so far. Eventually, if the condition is serious enough, there is heart failure. You may have heard the term “dropsy” when reading older literature. That is hydrops or congestive heart failure. A weakened heart cannot pump blood to the kidneys vigorously enough for them to make a normal amount of urine. The person bloats, tissues swell and in the end the lungs fill with fluid and the person slowly drowns. This once was not rare. The term “death rattle” refers to the “rales” or crackling sound made by the wet lungs. When congestive heart failure strikes a fetus it is called hydrops fetalis. The fetus will not drown so long as the mother is able to provide oxygen across the placenta, but the fetus will still be oxygen starved. And the fetus can become bloated. Childbirth is difficult under the best of circumstances. It does not always work. If the fetus is bloated, it makes the chance of failure greater. Go back and look at the numbers I have given you and try to estimate how many otherwise healthy women, back in the days of big families and no modern medicine, died that way. With modern surgery nowadays it is usually, that’s usually mind you not necessarily always, possible to save the mother.
Another effect of breaking up red cells is to release hemoglobin into the circulation of the fetus. To a certain extent as long as the fetus has its circulation in contact with that of the mother across the placenta the hemoglobin is swept into the mother’s circulation where it is detoxified in her liver, converted into bile, conjugated and then excreted into her gastrointestinal tract. But after birth the breakdown of red blood cells continues, and the baby’s liver is not up to the task. The baby becomes jaundiced, overloaded with bile. Instead of turning yellow like a jaundiced adult, the newborn turns a sort of orange color. I am not sure, but I suspect that is because of the hemoglobin load. Even a normal infant will have a transient rise in bile levels, but in the case of Rh incompatibility the levels rise far above normal. Jaundice is hard enough on an adult, but the newborn does not have a mature blood-brain barrier. That is a mechanism that keeps things in the blood stream away from the brain, in this case bilirubin and hemoglobin. They are toxic and can destroy brain cells.
Even people who ought to know better have a sort of knee jerk reaction: Marry cousins and the children will be mentally handicapped. I once had a question on a genetics test as to whether there was any advantage of inbreeding. The answer was supposed to be a resounding, “NO.” But I said that yes, this would remove recessive deleterious genes from the population. I was graded wrong, and for once I went to the professor and objected. He honestly did not understand me. When he did he said, “Oh, I see. Have people inbreed so that recessive alleles are expressed and reduce the number of children that carry them. Then say, ‘Outbreed, everybody,’ and the number of deleterious genes has been reduced.” Close enough. Then he went sincere on me and said, “But our institutions are already so overloaded with the results of inbreeding that causes mental deficiency that it would be impossible.” In fact this was before modern medicine was available. Our institutions were overloaded with people of all ages who had been brain damaged by Rh incompatibility. More than half, probably something like ninety percent of people who could not survive without institutional care, were that way because of gene mixing. A judicious amount of inbreeding would have reduced that number to a small degree but I suspect more than the degree to which it would have caused an increase by bringing deleterious recessives together. There was really no excuse for a genetics professor not knowing that, but the truth had been suppressed presumably because it was not something people wanted to hear, much less believe.
So before Rh incompatibility was understood the situation was grim in the extreme.
There used to be whole wards full of babies brain damaged and dying of the condition. Nurses noticed that babies in cribs closer to the windows seemed to do better. It was finally realized that ultraviolet light, as from the sun, could reduce the jaundice and eventually putting ultraviolet lights in those baby’s cribs became part of standard treatment.
Finally somebody injected blood from a rhesus monkey into a rabbit and got an immune response. The antibody was called the rhesus factor, or Rh factor. Once it was found that 85% of the people tested had the factor it was realized that this was the cause of the syndrome. A blood test was given before people got married. If the man was Rh positive and the woman negative, a marriage license could not be obtained. To the extent that this law was effective, the condition simply vanished from the population and countless lives were saved, countless ruined brains avoided.
It was noticed that there were exceptions. If a woman of blood type O negative married a man who was AB positive, she could have baby after baby with no problem. That is because every baby was type A or B to both of which the mother had antibodies. When the cells with A antigens or B antigens got into the maternal circulation, they were immediately mopped up by the anti-A or anti-B antibodies and did not last long enough for the mother to develop an immune response to the Rh factor.
Then somebody had a very clever idea. If after the child was born those fetal red blood cells that had made their way into the mother’s circulation could be eliminated, then maybe she would not develop antibodies against them. The tool was right at hand. All that was required was a shot of the anti-Rh factor antibodies. The approach was tried and sure enough it worked pretty well. No it didn’t. It was a disaster. It worked pretty well if you compared the results with letting nature take her course. A disease that had been a constant horror time out of mind would have become rare. That’s a move in the right direction.
But that is not the proper comparison. The proper comparison is with the rule, “Don’t mix your Rh types.” And that rule is air tight. No mixed genes: no Rh incompatibility problems, at all, ever, not once, forever and ever, halleluiah. The injection sometimes fails.
And that, my friends, is something that affects all of us. Perhaps you think you are Rh positive so it doesn’t matter to you. If you are of European extraction even if you are Rh positive you probably still carry the negative allele. Go back and look at the numbers. Even if you are from a non-European background, from some population that has absolutely no Rh negative alleles whatsoever (and there isn’t one), you still have to interact with people who do come from a population with the allele. So it affects you.
Look: suppose I were to lose it. Suppose I were to steal a horse and a pistol and gallop through the town at night shooting out traffic lights screaming, “Don’t mix blood types, you murdering bastards!” I expect I would be convicted of enough crimes to make boring reading. I would spend a long time in jail. Yet what is the harm in it? Some danger, yes, but certainly there is not a chance in a hundred I would actually hurt somebody before I emptied the pistol. Some public property damage, yes. But the damage would be a trifle compared with the cost of extended and intense medical care. Mostly people would hate me because I forced them to take undignified precautions, like diving for the floor.
But suppose I find some lonely woman and my heart goes out to her. I introduce myself. Acquaintance grows to friendship. Friendship ripens to love. We marry, and I am the soul of kindness and fidelity. We are blessed with a child. But I did not take into account that I am Rh positive and she negative. We leave that up to the doctors. The doctors prescribe the classical treatment I described. We have a second child. But this time the treatment has not worked. The child is brain damaged. The chance of a complication is between one and two percent (Rhogam and Pregnancy Stealth Mercury Assault By Stephen C. Marini, D.C., PhC.) And the cost of the care is prodigious.
I do not go to jail. I get sympathy from all sides. This unavoidable tragedy all undeserved has crushed my happiness. No, it was not unavoidable. All I had to know was the facts I have just presented. My heedless behavior is in fact far worse than the wild ride would have been.
But how could I know? People don’t talk about it. It is not posted on placards in public lavatories. It is not the subject of annoying television announcements. There is no law requiring a blood test. There is not even a hysterical rider in the night. There is only silence until the stroke falls.
About ten years ago a lecturer mentioned that in the prior year twelve American babies had died of Rh incompatibility. Many more have been hurt.
But the law was changed. It seemed more important to tell everybody that they could marry whomever they liked. Mixing up the genes was thought to be good. But it isn’t good. It is disastrous, as I have been at pains to point out so many times.
So much you ought to know. So much I have known for decades. But now a new issue has emerged that I did not know until a friend pounded it though my thick skull.
There has been a change in the treatment. The doctors apparently felt a little uneasy about the frequency of the failure of their treatment. What they do now is, instead of waiting until the baby is born before giving the mother the shot of anti-Rh antibodies, they give the shot more than once. The first shot is given at twenty-six weeks into the pregnancy. That much I have been told and have been able to verify. What I have been told but have not verified is that this has reduced complications to less than one percent. I am sure somebody is feeling very smug.
But there are a couple of problems. The most spoken of is that there is usually a preservative in the shot. (Not always. I understand that there is mercury free medication available from Bayer Pharmaceuticals under their product name of BayRoh-D. This mercury free product has been available since 1996. Their number is 800-468-0894. Ibid.)
There are legal limits on how much toxic material is permitted. The margin of safety, before evident damage happens, is up to ten fold. So go figure. If a woman has two shots per pregnancy and is pregnant six times, then my arithmetic says the safety margin has been blown right away. And that’s just the mother.
What about the baby? The mercury (which is used as a preservative) might well bind at least loosely to the antibody being administered. In that case, it can cross the placenta and enter the fetal circulation. At twenty six weeks let’s say the critical part of the pregnancy, the fetus and placenta, weighs two pounds. If the mother weighs a hundred and twenty, then the fetus is getting sixty times the dose the mother gets. Some of the antibody may combine with fetal cells in the mother’s circulation, as intended, but the overwhelming bulk goes to the fetus and the mercury is then deposited there. I have read comforting words on the internet about the safety of the shot, but until that question is explicitly addressed I shall fear the worst.
The other problem is this. We are injecting an antibody, right? And this antibody can cross the placenta else there would never be any problem with incompatibility. So almost all of the red cells that are ruptured by the antibody are in the fetus. That is where the hemoglobin is released. The mother’s circulation will gradually clear the hemoglobin, but the immediate effect is that it is going to go right to the fetal brain, right past a really immature blood brain barrier, and fry it.
How much damage is done? I have no idea, but there is some. Suppose I were to start giving pregnant women a radioactive isotope that had the effect of destroying 10% of the cells in the fetal brain. It is unlikely that any clinical test would show a decline in function, but of course it would be there. I would expect that upon being released from jail I would be torn apart by an angry mob. I can imagine no way to estimate the amount of damage that is being done.
I don’t have good numbers. I can’t tell you how much IQ is lost or how often autism might result, if at all. But this idea of giving the shot while the woman is still pregnant worries me a great deal.
And it is all for nothing. You can’t safely just marry anybody. Blood type is at least a straw. Marrying the same blood type would only improve your chances of marrying an appropriate mate by a factor of eight. That’s something, anyway. That is where we ought to go, and then the entire issue of Rh incompatibility and the mayhem it wreaks simply goes away as a bonus.
So please talk about it. Send people to this web site. Get into arguments. The truth will not be laid out in full nor the population warned until voice is given.
M. Linton Herbert MD
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