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McCartin MP, Wool GD, Thomas SA, Panfil M, Schoenfeld D, Blumen IJ, Tataris KL, Thomas SH. Management Considerations for Air Medical Transport Programs Transfusing RhD-Positive Red Blood Cell-Containing Products to Females of Childbearing Potential. Air Med J 2024; 43:348-356. [PMID: 38897700 DOI: 10.1016/j.amj.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 06/21/2024]
Abstract
Recent years have seen increased discussion surrounding the benefits of damage control resuscitation, prehospital transfusion (PHT) of blood products, and the use of whole blood over component therapy. Concurrent shortages of blood products with the desire to provide PHT during air medical transport have prompted reconsideration of the traditional approach of administering RhD-negative red cell-containing blood products first-line to females of childbearing potential (FCPs). Given that only 7% of the US population has blood type O negative and 38% has O positive, some programs may be limited to offering RhD-positive blood products to FCPs. Adopting the practice of giving RhD-positive blood products first-line to FCPs extends the benefits of PHT to such patients, but this practice does incur the risk of future hemolytic disease of the fetus and newborn (HDFN). Although the risk of future fetal mortality after an RhD-incompatible transfusion is estimated to be low in the setting of acute hemorrhage, the number of FCPs who are affected by this disease will increase as more air medical transport programs adopt this practice. The process of monitoring and managing HDFN can also be time intensive and costly regardless of the rates of fetal mortality. Air medical transport programs planning on performing PHT of RhD-positive red cell-containing products to FCPs should have a basic understanding of the pathophysiology, prevention, and management of hemolytic disease of the newborn before introducing this practice. Programs should additionally ensure there is a reliable process to notify receiving centers of potentially RhD-incompatible PHT because alloimmunization prophylaxis is time sensitive. Facilities receiving patients who have had PHT must be prepared to identify, counsel, and offer alloimmunization prophylaxis to these patients. This review aims to provide air medical transport professionals with an understanding of the pathophysiology and management of HDFN and provide a template for the early management of FCPs who have received an RhD-positive red cell-containing PHT. This review also covers the initial workup and long-term anticipatory guidance that receiving trauma centers must provide to FCPs who have received RhD-positive red cell-containing PHT.
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Affiliation(s)
| | | | - Sarah A Thomas
- Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | - David Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Ira J Blumen
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Katie L Tataris
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
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2
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Jash A, Pridmore T, Collins JB, Hay AM, Hudson KE, Luckey CJ, Zimring JC. Complement C3 and marginal zone B cells promote IgG-mediated enhancement of RBC alloimmunization in mice. J Clin Invest 2024; 134:e167665. [PMID: 38618959 PMCID: PMC11014669 DOI: 10.1172/jci167665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/27/2024] [Indexed: 04/16/2024] Open
Abstract
Administration of anti-RhD immunoglobulin (Ig) to decrease maternal alloimmunization (antibody-mediated immune suppression [AMIS]) was a landmark clinical development. However, IgG has potent immune-stimulatory effects in other settings (antibody-mediated immune enhancement [AMIE]). The dominant thinking has been that IgG causes AMIS for antigens on RBCs but AMIE for soluble antigens. However, we have recently reported that IgG against RBC antigens can cause either AMIS or AMIE as a function of an IgG subclass. Recent advances in mechanistic understanding have demonstrated that RBC alloimmunization requires the IFN-α/-β receptor (IFNAR) and is inhibited by the complement C3 protein. Here, we demonstrate the opposite for AMIE of an RBC alloantigen (IFNAR is not required and C3 enhances). RBC clearance, C3 deposition, and antigen modulation all preceded AMIE, and both CD4+ T cells and marginal zone B cells were required. We detected no significant increase in antigen-specific germinal center B cells, consistent with other studies of RBC alloimmunization that show extrafollicular-like responses. To the best of our knowledge, these findings provide the first evidence of an RBC alloimmunization pathway which is IFNAR independent and C3 dependent, thus further advancing our understanding of RBCs as an immunogen and AMIE as a phenomenon.
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Affiliation(s)
- Arijita Jash
- University of Virginia School of Medicine, Charlottesville Virginia, USA
- Carter Immunology Center, University of Virginia, Charlottesville, Virginia, USA
| | - Thomas Pridmore
- University of Virginia School of Medicine, Charlottesville Virginia, USA
| | - James B. Collins
- University of Virginia School of Medicine, Charlottesville Virginia, USA
- Carter Immunology Center, University of Virginia, Charlottesville, Virginia, USA
| | - Ariel M. Hay
- University of Virginia School of Medicine, Charlottesville Virginia, USA
- Carter Immunology Center, University of Virginia, Charlottesville, Virginia, USA
| | - Krystalyn E. Hudson
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Chance John Luckey
- University of Virginia School of Medicine, Charlottesville Virginia, USA
| | - James C. Zimring
- University of Virginia School of Medicine, Charlottesville Virginia, USA
- Carter Immunology Center, University of Virginia, Charlottesville, Virginia, USA
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3
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Jourdren G, Berveiller P, Rousseau A. Practices for RhD alloimmunization prevention: a vignette-based survey of midwives. J Matern Fetal Neonatal Med 2021; 35:7629-7639. [PMID: 34433367 DOI: 10.1080/14767058.2021.1957822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Despite the availability guidelines to prevent RhD alloimmunization, severe hemolytic disease of fetus and newborn still occurs in high-income countries. The aim of the study was (1) To assess variations in practices for the prevention of RhD alloimmunization, and (2) to understand midwives' acceptance and appropriation of fetal RhD genotyping. METHODS Descriptive cross-sectional survey of French midwives from September 2017 through January 2018. Participants were asked to complete an internet-based questionnaire that included three clinical vignettes. They were questioned about their practices concerning early pregnancy visit by RhD-negative women, prevention of RhD alloimmunization in women with second-trimester metrorrhagia, and RhD fetal genotyping. RESULTS A total of 827 midwives completed the questionnaire. Only 21.1% reported that they practice all the preventive measures recommended in early pregnancy. In a situation at high risk of RhD alloimmunization during pregnancy, 97.2% of midwives would perform immunoprophylaxis. Nearly, all midwives reported providing information about RhD alloimmunization (92.4%) at the beginning of pregnancy, although only 11.3% offered both written and verbal information; at the time of systematic anti-D immunoprophylaxis (28 weeks), 78% provided information, but only 2.7% both verbally and in writing. Finally, only 50.8% of midwives preferred to include RhD fetal genotyping in routine prenatal prophylaxis. DISCUSSION This study showed significant variations in French midwives' practices to prevent RhD alloimmunization. Better dissemination of guidelines is needed to improve both consistent use of these practices and the quality of information delivered to RhD-negative pregnant women.
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Affiliation(s)
- Guenola Jourdren
- Midwifery Department, Versailles Saint Quentin University, Paris-Saclay University, Montigny-le-Bretonneux, France
| | - Paul Berveiller
- Department of Obstetrics and Gynecology, Poissy-Saint-Germain en Laye Hospital, Poissy, France.,INRAE, Paris Saclay University, UMR 1198 - BREED, RHuMA, Montigny-Le-Bretonneux, France
| | - Anne Rousseau
- Midwifery Department, Versailles Saint Quentin University, Paris-Saclay University, Montigny-le-Bretonneux, France.,Department of Obstetrics and Gynecology, Poissy-Saint-Germain en Laye Hospital, Poissy, France.,Paris-Saclay University, UVSQ, CESP, Equipe Epidémiologie clinique, Montigny-le-Bretonneux, France
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4
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Wind M, Gaasbeek AGA, Oosten LEM, Rabelink TJ, van Lith JMM, Sueters M, Teng YKO. Therapeutic plasma exchange in pregnancy: A literature review. Eur J Obstet Gynecol Reprod Biol 2021; 260:29-36. [PMID: 33713886 DOI: 10.1016/j.ejogrb.2021.02.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/24/2021] [Accepted: 02/25/2021] [Indexed: 01/13/2023]
Abstract
Therapeutic plasma exchange (TPE) is indicated as a treatment for a wide array of diseases, extensively addressed in the Guidelines of the American Society for Apheresis. In pregnancy, TPE is an uncommon event and application is largely based on extrapolation of efficacy and safety in a non-pregnant population. This review intends to describe the currently available experience of TPE in pregnancy to help clinicians recognise indications during pregnancy and to support current guideline recommendations with literature-based experiences. In order to identify the clinical indications for which TPE is applied in pregnant women, we performed a literature search including studies till November 2019, without a start date restriction. Data extraction included medical indication for TPE and safety of TPE in pregnant women. 279 studies were included for analysis. Nowadays, TPE is predominantly applied for thrombotic microangiopathies, lipid disorders and a variety of autoimmune diseases. The application of TPE during pregnancy remains largely empiric and relies on individual case reports in the absence of high-quality studies and definitive evidence-based guidelines. Safety profile of TPE during pregnancy appears to be comparable to application of TPE in non-pregnant patients. In conclusion, based on the limited evidence that we found in literature with a high risk of publication bias, TPE procedures can be used safely during pregnancy with the appropriate preparation and experience of a multidisciplinary team.
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Affiliation(s)
- M Wind
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
| | - A G A Gaasbeek
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - L E M Oosten
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - T J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - J M M van Lith
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - M Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Y K O Teng
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
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Visser GHA, Thommesen T, Di Renzo GC, Nassar AH, Spitalnik SL. FIGO/ICM guidelines for preventing Rhesus disease: A call to action. Int J Gynaecol Obstet 2021; 152:144-147. [PMID: 33128246 PMCID: PMC7898700 DOI: 10.1002/ijgo.13459] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022]
Abstract
The introduction of anti‐Rh(D) immunoglobulin more than 50 years ago has resulted in only a 50% decrease in Rhesus disease globally owing to a low uptake of this prophylactic approach. The International Federation of Gynecology and Obstetrics, International Confederation of Midwives, and Worldwide Initiative for Rhesus Disease Eradication have reviewed current evidence regarding the utility of anti‐Rh(D) immunoglobulin. Taking into account the effectiveness anti‐Rh(D), the new guidelines propose adjusting the dose for different indications and prioritizing its administration by indication. These FIGO/ICM guidelines review the evidence regarding the usefulness of anti‐Rh(D) immunoglobulin, prioritizing its administration by indication.
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Affiliation(s)
- Gerard H A Visser
- International Federation of Gynecology and Obstetrics, London, UK.,Worldwide Initiative for Rh Disease Eradication, New York, NY, USA
| | - Trude Thommesen
- Worldwide Initiative for Rh Disease Eradication, New York, NY, USA.,International Confederation of Midwives, The Hague, the Netherlands
| | | | - Anwar H Nassar
- International Federation of Gynecology and Obstetrics, London, UK
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Legler TJ. RhIg for the prevention Rh immunization and IVIg for the treatment of affected neonates. Transfus Apher Sci 2020; 59:102950. [PMID: 33004277 DOI: 10.1016/j.transci.2020.102950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rhesus D (RhD) negative pregnant women carrying an RhD positive fetus are at risk of developing anti-D during or after pregnancy. Anti-d-immunoglobulin (RhIg), which is mainly produced from special plasma donated in a few countries for the whole world, is able to prevent an anti-D alloimmunization. Through the introduction of ante- and postnatal anti-d-prophylaxis into clinical routine, the frequency of hemolytic disease of fetus and newborn decreased considerably. Postnatal prophylaxis from the beginning in the 1960s has been applied only to women who delivered an RhD positive newborn. Because the fetal RhD status can be determined with high sensitivity and accuracy from the mother's peripheral blood, targeted antenatal anti-d-prophylaxis is becoming a new standard procedure in more and more countries. Phototherapy and exchange transfusion are still the main pillars for the treatment of RhD hemolytic disease of the newborn. The efficacy of IVIg in the management of these neonates is not conclusive and cannot be recommended until a larger randomized, double-blind, placebo-controlled study is performed.
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Affiliation(s)
- Tobias J Legler
- Department of Transfusion Medicine, University Medical Center, Georg-August-University, Göttingen, Germany.
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Swift-Gallant A, Breedlove SM. O Gay New World: Ramifications of the Maternal Immune Hypothesis. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:39-41. [PMID: 29188406 DOI: 10.1007/s10508-017-1118-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/13/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Ashlyn Swift-Gallant
- Neuroscience Program and Departments of Psychology and Integrative Biology, Michigan State University, 293 Farm Lane, East Lansing, MI, 48824, USA
| | - S Marc Breedlove
- Neuroscience Program and Departments of Psychology and Integrative Biology, Michigan State University, 293 Farm Lane, East Lansing, MI, 48824, USA.
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Single-stranded DNA aptamer targeting and neutralization of anti-D alloantibody: a potential therapeutic strategy for haemolytic diseases caused by Rhesus alloantibody. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 16:184-192. [PMID: 27893356 DOI: 10.2450/2016.0123-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/26/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Rhesus (Rh) D antigen is the most important antigen in the Rh blood group system because of its strong immunogenicity. When RhD-negative individuals are exposed to RhD-positive blood, they may produce anti-D alloantibody, potentially resulting in delayed haemolytic transfusion reactions and Rh haemolytic disease of the foetus and newborn, which are difficult to treat. Inhibition of the binding of anti-D antibody with RhD antigens on the surface of red blood cells may effectively prevent immune haemolytic diseases. MATERIALS AND METHODS In this study, single-stranded (ss) DNA aptamers, specifically binding to anti-D antibodies, were selected via systematic evolution of ligands by exponential enrichment (SELEX) technology. After 14 rounds of selection, the purified ssDNA was sequenced using a Personal Genome Machine system. Haemagglutination inhibition assays were performed to screen aptamers for biological activity in terms of blocking antigen-antibody reactions: the affinity and specificity of the aptamers were also determined. RESULTS In addition to high specificity, the aptamers which were selected showed high affinity for anti-D antibodies with dissociation constant (Kd) values ranging from 51.46±14.90 to 543.30±92.59 nM. By the combined use of specific ssDNA aptamer 7 and auxiliary ssDNA aptamer 2, anti-D could be effectively neutralised at low concentrations of the aptamers. DISCUSSION Our results demonstrate that ssDNA aptamers may be a novel, promising strategy for the treatment of delayed haemolytic transfusion reactions and Rh haemolytic disease of the foetus and newborn.
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9
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Biscoe A, Kidson-Gerber G. Rare problems with RhD immunoglobulin for postnatal prophylaxis after large fetomaternal haemorrhage. Obstet Med 2016; 8:193-4. [PMID: 27512480 DOI: 10.1177/1753495x15597631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/02/2015] [Indexed: 11/17/2022] Open
Abstract
We report a case of unusually large fetomaternal haemorrhage in a RhD- patient; of symptomatic non-sustained haemolysis of fetal red cells in the maternal circulation with infusion of intravenous high-dose RhD immunoglobulin; and of a failure to prevent RhD alloimmunisation. The haemolytic reaction is not previously reported in this patient group and we suggest would be limited to patients where the number of fetal red cells in the circulation is high. We advocate caution in treatment and spaced dosing of RhD immunoglobulin where the required dose is high, and refer readers to the WinRhoSDF™ RhD immunoglobulin product information for their updated dosing recommendations. There is a need for better understanding of pathophysiology and RhD immunoglobulin effects, to further reduce alloimmunisation rates, and we support the reporting of prophylaxis failures to haemovigilance programmes as is in place in the United Kingdom.
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Affiliation(s)
- Amber Biscoe
- Department of Haematology, Prince of Wales Hospital, Sydney, Australia; Department of Haematology, South Eastern Area Laboratory Services, Randwick, Australia
| | - Giselle Kidson-Gerber
- Department of Haematology, Prince of Wales Hospital, Sydney, Australia; Department of Haematology, South Eastern Area Laboratory Services, Randwick, Australia; Royal Hospital for Women, Sydney, Australia
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Recommendations for the prevention and treatment of haemolytic disease of the foetus and newborn. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:109-34. [PMID: 25633877 DOI: 10.2450/2014.0119-14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Arnolda G, Nwe HM, Trevisanuto D, Thin AA, Thein AA, Defechereux T, Kumara D, Moccia L. Risk factors for acute bilirubin encephalopathy on admission to two Myanmar national paediatric hospitals. Matern Health Neonatol Perinatol 2015; 1:22. [PMID: 27057339 PMCID: PMC4823679 DOI: 10.1186/s40748-015-0024-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 09/07/2015] [Indexed: 11/10/2022] Open
Abstract
Background Jaundice is the commonest neonatal ailment requiring treatment. Untreated, it can lead to acute bilirubin encephalopathy (ABE), chronic bilirubin encephalopathy (CBE) or death. ABE and CBE have been largely eliminated in industrialised countries, but remain a problem of largely undocumented scale in low resource settings. As part of a quality-improvement intervention in the Neonatal Care Units of two paediatric referral hospitals in Myanmar, hospitals collected de-identified data on each neonate treated on new phototherapy machines over 13–20 months. The information collected included: diagnosis of ABE at hospital presentation; general characteristics such as place of birth, source of referral, and sex; and a selection of suspected causes of jaundice including prematurity, infection, G6PD status, ABO and Rh incompatibility. This information was analysed to identify risk factors for hospital presentation with ABE, using multiple logistic regression. Results Data on 251 neonates was recorded over 20 months in Hospital A, and 339 neonates over 13 months in Hospital B; the number of outborn neonates presenting with ABE was 32 (12.7 %) and 72 (21.2 %) respectively. In the merged dataset the final multivariate model identified the following independent risk and protective factors: home birth, ORadj = 2.3 (95 % CI: 1.04-5.4); self-referral, ORadj = 2.6 (95 % CI: 1.2-6.0); prematurity, ORadj = 0.40 (95 % CI: 0.18-0.85); and a significant interaction between hospital and screening status because screening positive for G6PD deficiency was a strong and significant risk factor at Hospital B (ORadj = 5.9; 95 % CI: 3.0-11.6), but not Hospital A (ORadj = 1.1; 95 % CI: 0.5-2.5). Conclusion The study identifies home birth, self-referral and G6PD screening status as important risk factors for presentation with ABE; prematurity was protective, but this is interpreted as an artefact of the study design. As operational research, there is likely to be substantial measurement error in the risk factor data, suggesting that the identified risk factor estimates are robust. Additional interventions are required to ensure prompt referral of jaundiced neonates to treatment facilities, with particular focus on home births and communities with high rates of G6PD deficiency.
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Affiliation(s)
- G Arnolda
- Thrive Networks, Oakland, CA USA ; School of Public Health & Community Medicine, Faculty of Medicine, University of New South Wales, Wales, NSW Australia
| | - H M Nwe
- Department of Paediatrics, University of Medicine (1), Yangon, Myanmar
| | - D Trevisanuto
- Amici della Neonatologia Trentina, Trento, Italy ; Children and Women's Health Department, Medical School University of Padua, Padua, Italy
| | - A A Thin
- Mandalay Children's Hospital (300), Mandalay, Myanmar
| | - A A Thein
- Department of Neonatology, University of Medicine (1), Yangon, Myanmar
| | - T Defechereux
- Department of Surgery, Liege University Hospital, Liege, Belgium
| | - D Kumara
- Thrive Networks, Oakland, CA USA
| | - L Moccia
- Thrive Networks, Oakland, CA USA ; Amici della Neonatologia Trentina, Trento, Italy
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12
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McBain RD, Crowther CA, Middleton P. Anti-D administration in pregnancy for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev 2015; 2015:CD000020. [PMID: 26334436 PMCID: PMC7061251 DOI: 10.1002/14651858.cd000020.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND During pregnancy, a Rhesus negative (Rh-negative) woman may develop antibodies when her fetus is Rhesus positive (Rh-positive). These antibodies may harm Rh-positive babies. OBJECTIVES To assess the effects of antenatal anti-D immunoglobulin on the incidence of Rhesus D alloimmunisation when given to Rh-negative women without anti-D antibodies. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials in Rh-negative women without anti-D antibodies given anti-D after 28 weeks of pregnancy, compared with no treatment, placebo or a different regimen of anti-D. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS We included two trials involving over 4500 women, comparing anti-D prophylaxis with no anti-D during pregnancy in this review. Overall, the trials were judged to be at moderate to high risk of bias. The quality of the evidence for pre-specified outcomes was also assessed using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.In regards to primary review outcomes, there did not appear to be a clear difference in the risks of immunisation when women who received anti-D at 28 and 34 weeks' gestation were compared with women who were not given antenatal anti-D: risk ratio (RR) for incidence of Rhesus D alloimmunisation during pregnancy was 0.42 (95% confidence interval (CI) 0.15 to 1.17, two trials, 3902 women; GRADE: low quality evidence); at birth of a Rh-positive infant the RR was 0.42 (95% CI 0.15 to 1.17, two trials, 2297 women); and within 12 months after birth of a Rh-positive infant the average RR was 0.39 (95% CI 0.10 to 1.62, two trials, 2048 women; Tau²: 0.47; I²: 39%; GRADE: low quality evidence). Neither of the trials reported on incidence of Rhesus D alloimmunisation in subsequent pregnancies.Considering secondary outcomes, in one trial, women receiving anti-D during pregnancy were shown to be less likely to register a positive Kleihauer test (which detects fetal cells in maternal blood) in pregnancy (at 32 to 25 weeks) (RR 0.60, 95% CI 0.41 to 0.88; 1884 women; GRADE: low quality evidence) and at the birth of a Rh-positive infant (RR 0.60, 95% CI 0.46 to 0.79; 1189 women; GRADE: low quality evidence). No clear differences were seen for neonatal jaundice (RR 0.26, 95% CI 0.03 to 2.30; 1882 infants; GRADE: very low quality evidence). Neither of the trials reported on adverse effects associated with anti-D treatment. AUTHORS' CONCLUSIONS Existing studies do not provide conclusive evidence that the use of anti-D during pregnancy benefits either mother or baby in terms of incidence of Rhesus D alloimmunisation during the pregnancy or postpartum, or the incidence of neonatal morbidity (jaundice) (low to very low quality evidence). However women receiving anti-D may be less likely to register a positive Kleihauer test in pregnancy and at the birth of a Rh-positive infant (low quality evidence). Fewer women who receive anti-D during pregnancy may have Rhesus D antibodies in a subsequent pregnancy, with benefits for the baby, however this needs to be tested in studies of robust design.
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Affiliation(s)
- Rosemary D McBain
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideAustralia5000
| | - Caroline A Crowther
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideAustralia5000
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
| | - Philippa Middleton
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideAustralia5000
- The University of AdelaideWomen's and Children's Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
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13
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Kacker S, Vassallo R, Keller MA, Westhoff CM, Frick KD, Sandler SG, Tobian AAR. Financial implications of RHD genotyping of pregnant women with a serologic weak D phenotype. Transfusion 2015; 55:2095-103. [PMID: 25808011 PMCID: PMC4739823 DOI: 10.1111/trf.13074] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/20/2015] [Accepted: 02/05/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemolytic disease of the fetus and newborn, classically caused by maternal-fetal incompatibility of the Rh blood group D antigen, can be prevented by RhIG prophylaxis. While prophylactic practices for pregnant women with serologic weak D phenotypes vary widely, RHD genotyping could provide clear guidance for management. This analysis evaluated the financial implications of using RHD genotyping to guide RhIG prophylaxis among pregnant females. STUDY DESIGN AND METHODS A Markov-based model was constructed to evaluate the costs of RHD genotyping for pregnant females with serologic weak D phenotypes to inform RhIG prophylaxis. Using a comparison strategy of managing these women conservatively as D-, direct medical costs were assessed over 10- and 20-year periods for a simulated population of US women. One-way and probabilistic sensitivity analyses were used to assess the robustness of conclusions. RESULTS Using base-case variables, RHD genotyping for pregnant women with serologic weak D phenotypes is expected to marginally reduce overall costs. RHD genotyping these patients, rather than conservatively managing them as D-, would be cost-saving when the cost of genotyping is below $256. Genotyping would decrease net costs among non-Hispanic Caucasian females (-$0.17/pregnancy), but would increase costs among non-Hispanic African Americans (+$0.51/pregnancy), non-Hispanic American Indian/Alaskans (+$0.10/pregnancy), and Hispanics (+$0.37/pregnancy). Incorporating RHD genotyping would not significantly impact costs among Asians and Hawaiians/Pacific Islanders. CONCLUSIONS Using RHD genotyping to guide RhIG prophylaxis among pregnant women with serologic weak D phenotypes may be clinically beneficial without increasing overall costs.
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Affiliation(s)
- Seema Kacker
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Ralph Vassallo
- National Molecular Laboratory, American Red Cross, Philadelphia, Pennsylvania
| | - Margaret A Keller
- National Molecular Laboratory, American Red Cross, Philadelphia, Pennsylvania
| | | | - Kevin D Frick
- Carey School of Business, Johns Hopkins University, Baltimore, Maryland
| | - S Gerald Sandler
- Department of Pathology and Laboratory Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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14
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Affiliation(s)
- Bjarte G Solheim
- Institute of Immunology, Oslo University Hospital - Rikshospitalet and University of Oslo, Oslo, Norway. ,
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15
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Fyfe TM, Ritchey MJ, Taruc C, Crompton D, Galliford B, Perrin R. Appropriate provision of anti-D prophylaxis to RhD negative pregnant women: a scoping review. BMC Pregnancy Childbirth 2014; 14:411. [PMID: 25491600 PMCID: PMC4265333 DOI: 10.1186/s12884-014-0411-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 12/02/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this scoping review was to review the literature on healthcare provider provision of anti-D prophylaxis to RhD negative pregnant women in appropriate clinical situations in various healthcare settings. METHODS A scoping review framework was used to structure the process. The following databases were searched: CINAHL (EBSCO), EBM Reviews (OvidSP), Embase (OvidSP), Medline (OvidSP), and Web of Science (ISI). In addition, hand searching of article references was conducted. The search yielded 301 articles. Thirty-five articles remained for review after screening. Two team members reviewed each article using a detailed data collection sheet. A third reviewer was utilized if discrepancies occurred amongst reviewers. RESULTS The review process yielded 18 included articles. The majority of the studies were conducted in the United Kingdom. Of the 18 studies, 15 were retrospective studies. The articles were largely conducted in one institution. The articles with a focus on routine antenatal provision of anti-D immunoglobulin found that it was given 80 to 90% of the time. Postpartum provision of anti-D immunoglobulin had significantly higher results of 95-100%. The review found that the delivery of anti-D immunoglobulin to RhD negative pregnant women during situations of potential sensitizing events was suboptimal. CONCLUSIONS The included articles examine the management of RhD negative pregnancies in various countries with existing national guidelines. The existing evidence indicates an opportunity for quality improvement in situations where potential sensitizing events are not at routine times in pregnancy, such as miscarriage or fetal demise early in pregnancy. Routine care for the prevention of RhD alloimmunization in pregnancy and postpartum appears to be fairly consistent. The paucity of recent literature in this area leads to a recommendation for further research.
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Affiliation(s)
- Trina M Fyfe
- Northern Medical Program, University of Northern British Columbia, 3333 University Way, Prince George, BC, V2N 4Z9, Canada.
| | - M Jane Ritchey
- Northern Health - Corporate Office Suite 600, 299 Victoria St., V2L 5B8, Prince George, BC, Canada.
| | - Christorina Taruc
- Northern Health - Corporate Office Suite 600, 299 Victoria St., V2L 5B8, Prince George, BC, Canada.
| | - Daniel Crompton
- Northern Health - Corporate Office Suite 600, 299 Victoria St., V2L 5B8, Prince George, BC, Canada.
| | - Brian Galliford
- Northern Health - Corporate Office Suite 600, 299 Victoria St., V2L 5B8, Prince George, BC, Canada.
| | - Rose Perrin
- Northern Health - Corporate Office Suite 600, 299 Victoria St., V2L 5B8, Prince George, BC, Canada.
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16
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Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, Silva DRAD, Downe S, Kennedy HP, Malata A, McCormick F, Wick L, Declercq E. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; 384:1129-45. [PMID: 24965816 DOI: 10.1016/s0140-6736(14)60789-3] [Citation(s) in RCA: 752] [Impact Index Per Article: 75.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.
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Affiliation(s)
- Mary J Renfrew
- Mother and Infant Research Unit, School of Nursing and Midwifery, College of Medicine, Dentistry and Nursing, University of Dundee, Dundee, UK.
| | - Alison McFadden
- Mother and Infant Research Unit, School of Nursing and Midwifery, College of Medicine, Dentistry and Nursing, University of Dundee, Dundee, UK
| | | | - James Campbell
- Instituto de Cooperación Social Integrare, Barcelona, Spain
| | - Andrew Amos Channon
- Division of Social Statistics and Demography, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Ngai Fen Cheung
- Midwifery Expert Committee of the Maternal and Child Health Association of China, Beijing, China
| | | | - Soo Downe
- School of Health, University of Central Lancashire, Preston, Lancashire, UK
| | | | - Address Malata
- Kamuzu College of Nursing University of Malawi, Lilongwe, Malawi
| | - Felicia McCormick
- Department of Health Sciences, University of York, Heslington West, York, UK
| | - Laura Wick
- Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Eugene Declercq
- Community Health Sciences, Boston University School of Public Health, Boston, MD, USA
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17
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Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, Sankar MJ, Blencowe H, Rizvi A, Chou VB, Walker N. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384:347-70. [PMID: 24853604 DOI: 10.1016/s0140-6736(14)60792-3] [Citation(s) in RCA: 866] [Impact Index Per Article: 86.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113,000 maternal deaths, 531,000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US$4·5 billion per year (US$0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6-2·1 million]), 33% of stillbirths (0·82 million [0·60-0·93 million]), and 54% of maternal deaths (0·16 million [0·14-0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5·65 billion (US$1·15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality--preterm, intrapartum, and infection-related deaths--by 58%, 79%, and 84%, respectively.
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Affiliation(s)
- Zulfiqar A Bhutta
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada; Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Jai K Das
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rajiv Bahl
- World Health Organization, Geneva, Switzerland
| | - Joy E Lawn
- Maternal, Adolescent Reproductive and Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK; Saving Newborn Lives, Save the Children, Washington, DC, USA; Research and Evidence Division, UK AID, London, UK
| | - Rehana A Salam
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Vinod K Paul
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Hannah Blencowe
- Maternal, Adolescent Reproductive and Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Arjumand Rizvi
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Victoria B Chou
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Neff Walker
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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18
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Cohen DN, Johnson MS, Liang WH, McDaniel HL, Young PP. Clinically significant hemolytic disease of the newborn secondary to passive transfer of anti-D from maternal RhIG. Transfusion 2014; 54:2863-6. [DOI: 10.1111/trf.12698] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 03/10/2014] [Accepted: 03/21/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel N. Cohen
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Mary S. Johnson
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Wayne H. Liang
- Department of Pediatrics; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Heather L. McDaniel
- Department of Pediatrics; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
- Division of Hematology and Oncology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Pampee P. Young
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
- Department of Medicine; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
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19
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Vecchio S, La Scala P, Perri L, Burgo T, Ferrise MA, Caparello S, Sofi S. Anti-D immunisation with permanent biological damage following inadequate post-amniocentesis prophylaxis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2008; 6:112-3. [PMID: 18946956 PMCID: PMC2626842 DOI: 10.2450/2008.0043-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 03/10/2008] [Indexed: 11/21/2022]
Affiliation(s)
- Sisto Vecchio
- U.O. Medicina Trasfusionale, Ospedale di Lamezia Terme, Italy.
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20
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Crowther C, Middleton P. Anti-D administration after childbirth for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev 2000; 1997:CD000021. [PMID: 10796089 PMCID: PMC7061351 DOI: 10.1002/14651858.cd000021] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The development of Rh immunisation and its prophylactic use since the 1970s has meant that severe Rhesus D (RhD) alloimmunisation is now rarely seen. OBJECTIVES The objective of this systematic review was to assess the effects of giving anti-D to Rhesus negative women, with no anti-D antibodies, who had given birth to a Rhesus positive infant. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register, MEDLINE (from 1966 to January 1999) and reference lists of relevant articles. Date of last search of Cochrane Controlled Trials Register: January 1999. SELECTION CRITERIA Randomised trials in Rhesus negative women without antibodies who were given anti-D immunoglobulin postpartum compared with no treatment or placebo. DATA COLLECTION AND ANALYSIS Assessments of inclusion criteria, trial quality and data extraction were done by each author independently. Initial analyses included all trials. Other analyses assessed the effect of trial quality, ABO compatibility and dose. MAIN RESULTS Six eligible trials compared postpartum anti-D prophylaxis with no treatment or placebo. The trials involved over 10,000 women, but trial quality varied. Anti-D lowered the incidence of RhD alloimmunisation six months after birth (relative risk 0.04, 95% confidence interval 0.02 to 0.06), and in a subsequent pregnancy (relative risk 0.12, 95% confidence interval 0. 07 to 0.23). These benefits were seen regardless of the ABO status of the mother and baby and when anti-D was given within 72 hours of birth. Higher doses (up to 200 micro grams) were more effective than lower doses (up to 50 micro grams) in preventing RhD alloimmunisation in a subsequent pregnancy. REVIEWER'S CONCLUSIONS Anti-D, given within 72 hours after childbirth, reduces the risk of RhD alloimmunisation in Rhesus negative women who have given birth to a Rhesus positive infant. However the evidence on the optimal dose is limited.
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Affiliation(s)
- C Crowther
- Department of Obstetrics and Gynaecology, University of Adelaide, Women's and Children's Hospital, King William Road, Adelaide, South Australia, Australia, SA 5006.
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