1
|
Clausen FB. Antenatal RHD screening to guide antenatal anti-D immunoprophylaxis in non-immunized D- pregnant women. Immunohematology 2024; 40:15-27. [PMID: 38739027 DOI: 10.2478/immunohematology-2024-004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
In pregnancy, D- pregnant women may be at risk of becoming immunized against D when carrying a D+ fetus, which may eventually lead to hemolytic disease of the fetus and newborn. Administrating antenatal and postnatal anti-D immunoglobulin prophylaxis decreases the risk of immunization substantially. Noninvasive fetal RHD genotyping, based on testing cell-free DNA extracted from maternal plasma, offers a reliable tool to predict the fetal RhD phenotype during pregnancy. Used as a screening program, antenatal RHD screening can guide the administration of antenatal prophylaxis in non-immunized D- pregnant women so that unnecessary prophylaxis is avoided in those women who carry a D- fetus. In Europe, antenatal RHD screening programs have been running since 2009, demonstrating high test accuracies and program feasibility. In this review, an overview is provided of current state-of-the-art antenatal RHD screening, which includes discussions on the rationale for its implementation, methodology, detection strategies, and test performance. The performance of antenatal RHD screening in a routine setting is characterized by high accuracy, with a high diagnostic sensitivity of ≥99.9 percent. The result of using antenatal RHD screening is that 97-99 percent of the women who carry a D- fetus avoid unnecessary prophylaxis. As such, this activity contributes to avoiding unnecessary treatment and saves valuable anti-D immunoglobulin, which has a shortage worldwide. The main challenges for a reliable noninvasive fetal RHD genotyping assay are low cell-free DNA levels, the genetics of the Rh blood group system, and choosing an appropriate detection strategy for an admixed population. In many parts of the world, however, the main challenge is to improve the basic care for D- pregnant women.
Collapse
Affiliation(s)
- Frederik B Clausen
- Laboratory of Blood Genetics, Department of Clinical Immunology, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
2
|
Fung-Kee-Fung K, Wong K, Walsh J, Hamel C, Clarke G. Directive clinique n o 448 : Prévention de l'allo-immunisation Rhésus D. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102448. [PMID: 38553006 DOI: 10.1016/j.jogc.2024.102448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
|
3
|
Fung-Kee-Fung K, Wong K, Walsh J, Hamel C, Clarke G. Guideline No. 448: Prevention of Rh D Alloimmunization. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102449. [PMID: 38553007 DOI: 10.1016/j.jogc.2024.102449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
OBJECTIVE This guideline provides recommendations for the prevention of Rh D alloimmunization (isoimmunization) in pregnancy, including parental testing, routine postpartum and antepartum prophylaxis, and other clinical indications for prophylaxis. Prevention of red cell alloimmunization in pregnancy with atypical antigens (other than the D antigen), for which immunoprophylaxis is not currently available, is not addressed in this guideline. TARGET POPULATION All Rh D-negative pregnant individuals at risk for Rh D alloimmunization due to potential exposure to a paternally derived fetal Rh D antigen. OUTCOMES Routine postpartum and antepartum Rh D immunoprophylaxis reduces the risk of Rh D alloimmunization at 6 months postpartum and in a subsequent pregnancy. BENEFITS, HARMS, AND COSTS This guideline details the population of pregnant individuals who may benefit from Rho(D) immune globulin (RhIG) immunoprophylaxis. Thus, those for whom the intervention is not required may avoid adverse effects, while those who are at risk of alloimmunization may mitigate this risk for themselves and/or their fetus. EVIDENCE For recommendations regarding use of RhIG, Medline and Medline in Process via Ovid and Embase Classic + Embase via Ovid were searched using both the trials and observational studies search strategies with study design filters. For trials, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects via Ovid were also searched. All databases were searched from January 2000 to November 26, 2019. Studies published before 2000 were captured from the grey literature of national obstetrics and gynaecology specialty societies, luminary specialty journals, and bibliographic searching. A formal process for the systematic review was undertaken for this update, as described in the systematic review manuscript published separately. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the SOGC's modified GRADE approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE The intended users of this guideline include prenatal care providers such as obstetricians, midwives, family physicians, emergency room physicians, and residents, as well as registered nurses and nurse practitioners. TWEETABLE ABSTRACT An updated Canadian guideline for prevention of Rh D alloimmunization addresses D variants, cffDNA for fetal Rh type, and updates recommendations on timing of RhIG administration. SUMMARY STATEMENTS RECOMMENDATIONS.
Collapse
|
4
|
Jajosky RP, Patel KR, Allen JWL, Zerra PE, Chonat S, Ayona D, Maier CL, Morais D, Wu SC, Luckey CJ, Eisenbarth SC, Roback JD, Fasano RM, Josephson CD, Manis JP, Chai L, Hendrickson JE, Hudson KE, Arthur CM, Stowell SR. Antibody-mediated antigen loss switches augmented immunity to antibody-mediated immunosuppression. Blood 2023; 142:1082-1098. [PMID: 37363865 PMCID: PMC10541552 DOI: 10.1182/blood.2022018591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 05/01/2023] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Abstract
Antibodies against fetal red blood cell (RBC) antigens can cause hemolytic disease of the fetus and newborn (HDFN). Reductions in HDFN due to anti-RhD antibodies have been achieved through use of Rh immune globulin (RhIg), a polyclonal antibody preparation that causes antibody-mediated immunosuppression (AMIS), thereby preventing maternal immune responses against fetal RBCs. Despite the success of RhIg, it is only effective against 1 alloantigen. The lack of similar interventions that mitigate immune responses toward other RBC alloantigens reflects an incomplete understanding of AMIS mechanisms. AMIS has been previously attributed to rapid antibody-mediated RBC removal, resulting in B-cell ignorance of the RBC alloantigen. However, our data demonstrate that antibody-mediated RBC removal can enhance de novo alloimmunization. In contrast, inclusion of antibodies that possess the ability to rapidly remove the target antigen in the absence of detectable RBC clearance can convert an augmented antibody response to AMIS. These results suggest that the ability of antibodies to remove target antigens from the RBC surface can trigger AMIS in situations in which enhanced immunity may otherwise occur. In doing so, these results hold promise in identifying key antibody characteristics that can drive AMIS, thereby facilitating the design of AMIS approaches toward other RBC antigens to eliminate all forms of HDFN.
Collapse
Affiliation(s)
- Ryan P. Jajosky
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Glycomics Center, Harvard Medical School, Boston, MA
| | - Kashyap R. Patel
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jerry William L. Allen
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Patricia E. Zerra
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Satheesh Chonat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Diyoly Ayona
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Cheryl L. Maier
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Dominique Morais
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Shang-Chuen Wu
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
| | - C. John Luckey
- Department of Pathology, University of Virginia, Charlottesville, VA
| | - Stephanie C. Eisenbarth
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John D. Roback
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Ross M. Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Cassandra D. Josephson
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Department of Hematology and Oncology, Johns Hopkins University All Children's Hospital, St. Petersburg, FL
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Departments of Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John P. Manis
- Department of Laboratory Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Li Chai
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jeanne E. Hendrickson
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Krystalyn E. Hudson
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York City, NY
| | - Connie M. Arthur
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Glycomics Center, Harvard Medical School, Boston, MA
| | - Sean R. Stowell
- Department of Pathology, Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Glycomics Center, Harvard Medical School, Boston, MA
| |
Collapse
|
5
|
Blomme S, Nollet F, Rosseel W, Bogaard N, Devos H, Emmerechts J, Cauwelier B. Routine noninvasive prenatal screening for fetal Rh D in maternal plasma—A 2‐year experience from a single center in Belgium. Transfusion 2022; 62:1103-1109. [DOI: 10.1111/trf.16868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Siska Blomme
- Department of Laboratory Medicine AZ Sint‐Jan Hospitals Brugge‐Oostende Brugge Belgium
| | - Friedel Nollet
- Department of Laboratory Medicine AZ Sint‐Jan Hospitals Brugge‐Oostende Brugge Belgium
| | - Wesley Rosseel
- Department of Laboratory Medicine AZ Sint‐Jan Hospitals Brugge‐Oostende Brugge Belgium
| | - Natalie Bogaard
- Department of Laboratory Medicine AZ Sint‐Jan Hospitals Brugge‐Oostende Brugge Belgium
| | - Helena Devos
- Department of Laboratory Medicine AZ Sint‐Jan Hospitals Brugge‐Oostende Brugge Belgium
| | - Jan Emmerechts
- Department of Laboratory Medicine AZ Sint‐Jan Hospitals Brugge‐Oostende Brugge Belgium
| | - Barbara Cauwelier
- Department of Laboratory Medicine AZ Sint‐Jan Hospitals Brugge‐Oostende Brugge Belgium
| |
Collapse
|
6
|
Gajic-Veljanoski O, Li C, Schaink AK, Guo J, Shehata N, Charames GS, de Vrijer B, Clarke G, Pechlivanoglou P, Okun N, Kandel R, Dooley J, Higgins C, Ng V, Sikich N. Cost-effectiveness of noninvasive fetal RhD blood group genotyping in nonalloimmunized and alloimmunized pregnancies. Transfusion 2022; 62:1089-1102. [PMID: 35170037 DOI: 10.1111/trf.16826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND We sought to determine the cost-effectiveness of noninvasive fetal RhD blood group genotyping in nonalloimmunized and alloimmunized pregnancies in Canada. STUDY DESIGN AND METHODS We developed two probabilistic state-transition (Markov) microsimulation models to compare fetal genotyping followed by targeted management versus usual care (i.e., universal Rh immunoglobulin [RhIG] prophylaxis in nonalloimmunized RhD-negative pregnancies, or universal intensive monitoring in alloimmunized pregnancies). The reference case considered a healthcare payer perspective and a 10-year time horizon. Sensitivity analysis examined assumptions related to test cost, paternal screening, subsequent pregnancies, other alloantibodies (e.g., K, Rh c/C/E), societal perspective, and lifetime horizon. RESULTS Fetal genotyping in nonalloimmunized pregnancies (at per-sample test cost of C$247/US$311) was associated with a slightly higher probability of maternal alloimmunization (22 vs. 21 per 10,000) and a reduced number of RhIG injections (1.427 vs. 1.795) than usual care. It was more expensive (C$154/US$194, 95% Credible Interval [CrI]: C$139/US$175-C$169/US$213) and had little impact on QALYs (0.0007, 95%CrI: -0.01-0.01). These results were sensitive to the test cost (threshold achieved at C$88/US$111), and inclusion of paternal screening. Fetal genotyping in alloimmunized pregnancies (at test cost of C$328/US$413) was less expensive (-C$6280/US$7903, 95% CrI: -C$6325/US$7959 to -C$6229/US$7838) and more effective (0.19 QALYs, 95% CrI 0.17-0.20) than usual care. These cost savings remained robust in sensitivity analyses. DISCUSSION Noninvasive fetal RhD genotyping saves resources and represents good value for the management of alloimmunized pregnancies. If the cost of genotyping is substantially decreased, the targeted intervention can become a viable option for nonalloimmunized pregnancies.
Collapse
Affiliation(s)
- Olga Gajic-Veljanoski
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Chunmei Li
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Alexis K Schaink
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Jennifer Guo
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Nadine Shehata
- Mount Sinai Hospital (Division of Hematology), and Department of Medicine, Department of Laboratory Management and Evaluation, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George S Charames
- Mount Sinai Hospital (Department of Pathology and Laboratory Medicine), and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Barbra de Vrijer
- Western University, Schulich School of Medicine and Dentistry/Department of Obstetrics and Gynaecology, and London Health Sciences Centre, London, Ontario, Canada
| | - Gwen Clarke
- Laboratory Services, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nanette Okun
- Sunnybrook Health Sciences Centre (Maternal-Fetal Medicine Division), and Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Rita Kandel
- Mount Sinai Hospital (Department of Pathology and Laboratory Medicine), and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Dooley
- Department of Family Medicine, The Northern Ontario School of Medicine and Sioux Lookout Menoyawin Health Centre, Sioux Lookout, Ontario, Canada
| | - Caroline Higgins
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Vivian Ng
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Nancy Sikich
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| |
Collapse
|
7
|
Thorpe R, Kruse SP, Masser BM. It is about who you know (and how you help them): Insights from staff and donors about how to recruit and retain a panel of committed anti-D donors. Vox Sang 2022; 117:664-670. [PMID: 35001388 DOI: 10.1111/vox.13242] [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: 09/23/2021] [Revised: 12/06/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Maintaining a panel of committed anti-D donors is crucial for the production of anti-D immunoglobulin to prevent haemolytic disease of the foetus and newborn. Given low numbers of donors in the Australian panel, there is a need to better understand motivators and barriers specific to anti-D donors. MATERIALS AND METHODS A qualitative approach was used to gather perspectives of staff and current anti-D donors in Australia. Focus groups were held with staff involved with the anti-D programme. An asynchronous online discussion forum and interviews were conducted with donors. All data were coded using deductive and inductive thematic analysis. RESULTS Staff stressed the importance of recruiting donors who met their own informal criteria as well as the formal selection criteria in order to maximize the chances of donors committing to making regular plasma donations. In contrast, donors were motivated by having a personal connection to anti-D, the recipient group and being eligible to join the programme. Support from staff and understanding the value of their donations also helped donors overcome concerns about the risks of joining the programme and reduced barriers to remaining in the programme. CONCLUSION Anti-D donors in Australia are motivated by multiple factors, including knowing who the recipient is, and dedicated staff are integral to building donors' commitment through education and support. Findings suggest the current approach to recruitment could be broadened to include all donors who meet formal selection criteria, with retention enhanced by reinforcing and rewarding the motives identified by donors for donating.
Collapse
Affiliation(s)
- Rachel Thorpe
- Clinical Services and Research, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia.,Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sarah P Kruse
- Clinical Services and Research, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia
| | - Barbara M Masser
- Clinical Services and Research, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia.,Australian Red Cross Lifeblood Chair in Donor Research, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
8
|
Gajic-Veljanoski O, Li C, Schaink AK, Guo J, Higgins C, Shehata N, Okun N, de Vrijer B, Pechlivanoglou P, Ng V, Sikich N. Noninvasive Fetal RhD Blood Group Genotyping: A Systematic Review of Economic Evaluations. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:1416-1425.e5. [PMID: 34390866 DOI: 10.1016/j.jogc.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Noninvasive fetal rhesus D (RhD) blood group genotyping may prevent unnecessary use of anti-D immunoglobulin (RhIG) in non-alloimmunized RhD-negative pregnancies and can guide management of alloimmunized pregnancies. We conducted a systematic review of the economic literature to determine the cost-effectiveness of this intervention over usual care. DATA SOURCES Systematic literature searches of bibliographic databases (Ovid MEDLINE, Embase, and Cochrane) until February 26, 2019, and auto-alerts until October 30, 2020, and of grey literature sources were performed to retrieve all English-language studies. STUDY SELECTION We included studies done in serologically confirmed non-alloimmunized or alloimmunized RhD-negative pregnancies, comparing costs and effectiveness of the intervention versus usual care. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted data from the eligible studies and assessed their methodological quality (risk of bias) using the Quality of Health Economic Studies (QHES) and Drummond tools. We narratively synthesized findings. Our review included 8 economic studies that evaluated non-invasive fetal RhD genotyping followed by targeted RhIG prophylaxis in non-alloimmunized pregnancies. Five studies further considered a subsequent alloimmunized pregnancy. The cost-effectiveness of the intervention versus usual care (e.g., universal RhIG or prophylaxis conditional on results of paternal testing) for non-alloiummunized pregnancies was inconsistent. Two studies indicated greater benefits and lower costs for the intervention, and another 2 suggested a trade-off. In 4 studies, the intervention was less effective and costlier than alternatives. Three studies were determined to be of high quality by both tools. Two of these studies favoured the intervention, and one assessed benefits in quality-adjusted life-years. No study clearly examined the cost-effectiveness of repetitive use of fetal genotyping in multiple non-alloimmunized or alloimmunized pregnancies. The cost of genotyping was the most influential parameter. CONCLUSION The cost-effectiveness of noninvasive fetal RhD genotyping for non-alloimmunized pregnancies varies between studies. Potential savings from targeted management of alloimmunized pregnancies requires further research.
Collapse
Affiliation(s)
- Olga Gajic-Veljanoski
- Ontario Health (Health Technology Assessment, Clinical Institutes and Quality Programs), Toronto, ON.
| | - Chunmei Li
- Ontario Health (Health Technology Assessment, Clinical Institutes and Quality Programs), Toronto, ON
| | - Alexis K Schaink
- Ontario Health (Health Technology Assessment, Clinical Institutes and Quality Programs), Toronto, ON
| | - Jennifer Guo
- Ontario Health (Health Technology Assessment, Clinical Institutes and Quality Programs), Toronto, ON
| | - Caroline Higgins
- Ontario Health (Health Technology Assessment, Clinical Institutes and Quality Programs), Toronto, ON
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, and Division of Hematology, Mount Sinai Hospital, Toronto, ON
| | - Nanette Okun
- Sunnybrook Health Sciences Centre, and Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Barbra de Vrijer
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Vivian Ng
- Ontario Health (Health Technology Assessment, Clinical Institutes and Quality Programs), Toronto, ON
| | - Nancy Sikich
- Ontario Health (Health Technology Assessment, Clinical Institutes and Quality Programs), Toronto, ON
| |
Collapse
|
9
|
Schwab ME, Schmidt CN, Gonzalez-Velez JM, Bakhtary S. Racial/ethnic disparities among women receiving intrauterine transfusions for alloimmunization at a single fetal treatment center. Transfusion 2021; 61:2019-2024. [PMID: 33745158 DOI: 10.1111/trf.16379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 01/18/2023]
Abstract
Disparities are prevalent in numerous areas of healthcare. We sought to investigate whether there were racial/ethnic disparities among pregnant women with the most severe form of alloimmunization who require intrauterine transfusions (IUT). We reviewed patients who underwent IUT for alloimmunization at a single fetal treatment center between 2015 and 2020. This "IUT cohort" was compared to an "Alloimmunization cohort": patients seen at our institution with a diagnosis of alloimmunization during pregnancy, who did not receive IUT. We collected maternal demographics including self-identified race/ethnicity and primary language, transfusion, and antibody characteristics. The cohorts were compared using unpaired t-tests, Mann-Whitney tests, and Fischer's exact tests, as appropriate. The IUT cohort included 43 patients and the alloimmunization cohort included 1049 patients. Compared to the alloimmunization cohort, there were significantly more patients of Latina descent in the IUT cohort (23.3% vs. 3.4%, p < .0001), and more non-English speakers (18.6% vs. 4.6%, p = .001). Twenty-one percent (9/43) of patients had immigrated to the United States, all of whom had pregnancies or miscarriages in their country of origin. A third of patients had new antibodies identified on serial screens during the current pregnancy. Significantly more women of Latina ethnicity and non-English speakers required IUTs compared to the cohort of women with alloimmunization. Insufficient access to care prior to arriving in the United States and among racial and ethnic minorities in the United States may contribute to these findings. Providers should be cognizant of potential, racial, and ethnic inequalities among women receiving intrauterine transfusions.
Collapse
Affiliation(s)
- Marisa E Schwab
- Fetal Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Christina N Schmidt
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Juan M Gonzalez-Velez
- Fetal Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
10
|
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.
Collapse
Affiliation(s)
- Tobias J Legler
- Department of Transfusion Medicine, University Medical Center, Georg-August-University, Göttingen, Germany.
| |
Collapse
|
11
|
Moise KJ, Hashmi SS, Markham K, Argoti PS, Bebbington M. Cell free fetal DNA to triage antenatal rhesus immune globulin: Is it really cost-effective in the United States? Prenat Diagn 2019; 39:238-247. [PMID: 30610742 DOI: 10.1002/pd.5415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To compare the efficacy and costs of three different strategies of antenatal rhesus immune globulin (RhIG) administration in a US population. METHODS A decision tree analysis was undertaken for universal antenatal RhIG administration based on RhD serologic paternity testing, universal administration without paternity, and selective antenatal RhIG administration using cell free fetal DNA (cfDNA) for RHD fetal typing. Rates of alloimmunization were calculated. Charges were determined for laboratory testing and obstetrical and neonatal treatments for the first pregnancy and cases of alloimmunization in the following pregnancy. RESULTS The largest number of new RhD alloimmunization cases resulted from a strategy of universal RhIG that included paternity. Fewer cases resulted from a selective strategy; the least number of cases were associated with a universal approach that discounted paternity. When the costs of first pregnancies and alloimmunized second pregnancies were combined, a universal strategy that excludes paternity had the least costs followed by a selective strategy followed by a universal strategy that included paternity. CONCLUSION The use of cfDNA to determine the selective use of antenatal RhIG would not be cost-effective in the United States. Universal antenatal RhIG without paternity is more effective in preventing new cases of alloimmunization than the current ACOG guideline.
Collapse
Affiliation(s)
- Kenneth J Moise
- Department of Obstetrics, Gynecology and Reproductive Medicine, Division of Maternal-Fetal Medicine, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Syed Shahrukh Hashmi
- Department of Pediatrics, Pediatric Research Center, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kara Markham
- Department of Obstetrics and Gynecology, Ohio State University College of Medicine, Columbus, OH, USA
| | - Pedro S Argoti
- Department of Obstetrics, Gynecology and Reproductive Medicine, Division of Maternal-Fetal Medicine, University of Texas School of Medicine at Houston, Houston, TX, USA
| | - Michael Bebbington
- Department of Obstetrics, Gynecology and Reproductive Medicine, Division of Maternal-Fetal Medicine, University of Texas School of Medicine at Houston, Houston, TX, USA
| |
Collapse
|
12
|
Clausen FB. Lessons learned from the implementation of non-invasive fetalRHDscreening. Expert Rev Mol Diagn 2018; 18:423-431. [DOI: 10.1080/14737159.2018.1461562] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Frederik Banch Clausen
- Laboratory of Blood Genetics, Department of Clinical Immunology, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
13
|
Aitken SL, Tichy EM. Rh(O)D immune globulin products for prevention of alloimmunization during pregnancy. Am J Health Syst Pharm 2015; 72:267-76. [PMID: 25631833 DOI: 10.2146/ajhp140288] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The pharmacologic properties of Rhesus (Rh) immune globulin (RhIG) and clinical data on its effectiveness in preventing Rh-antigen alloimmunization in pregnant women are reviewed. SUMMARY RhIG is a human plasma derivative that targets red blood cells (RBCs) positive for Rh(O) antigen (also called D antigen). In the United States and other countries, the widespread use of RhIG has markedly reduced the occurrence of hemolytic disease of the fetus and newborn (HDFN), a devastating condition caused by D-antigen sensitization of a pregnant woman via exposure to fetal RBCs (usually during detachment of the placenta in labor) that results in a maternal immune response leading to severe hemolysis in the fetus. Routine administration of RhIG at 26-30 weeks' gestation and again within 72 hours of delivery has been shown to be highly effective in preventing maternal Rh alloimmunization, with very low rates of D-antigen sensitization (in the range of 0-2.2%) reported in multiple studies of at-risk women. The four RhIG products currently available in the United States have common clinical indications but differ in certain attributes. Pharmacists can play an important role in guiding other clinicians on the rationale for the use of RhIG, important differences between products, and appropriate timing of RhIG therapy. CONCLUSION Routine administration of RhIG to women at risk for Rh alloimmunization is clinically effective and has made HDFN a rare clinical event. The available RhIG products are not the same and should be carefully reviewed to ensure that they are administered safely.
Collapse
Affiliation(s)
- Samuel L Aitken
- Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist in Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston. Eric M. Tichy, Pharm.D., FCCP, BCPS, is Senior Clinical Pharmacy Specialist, Solid Organ Transplantation, and Director, Postgraduate Year 2 Residency, Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, CT
| | - Eric M Tichy
- Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist in Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston. Eric M. Tichy, Pharm.D., FCCP, BCPS, is Senior Clinical Pharmacy Specialist, Solid Organ Transplantation, and Director, Postgraduate Year 2 Residency, Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, CT.
| |
Collapse
|
14
|
Banch Clausen F, Steffensen R, Christiansen M, Rudby M, Jakobsen MA, Jakobsen TR, Krog GR, Madsen RD, Nielsen KR, Rieneck K, Sprogøe U, Homburg KM, Baech J, Dziegiel MH, Grunnet N. Routine noninvasive prenatal screening for fetalRHDin plasma of RhD-negative pregnant women-2 years of screening experience from Denmark. Prenat Diagn 2014; 34:1000-5. [DOI: 10.1002/pd.4419] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/12/2014] [Accepted: 05/19/2014] [Indexed: 12/20/2022]
Affiliation(s)
- F. Banch Clausen
- Department of Clinical Immunology; Copenhagen University Hospital; Copenhagen Denmark
| | - R. Steffensen
- Department of Clinical Immunology; Aalborg University Hospital; Aalborg Denmark
| | - M. Christiansen
- Department of Clinical Immunology; Aarhus University Hospital; Skejby Aarhus Denmark
| | - M. Rudby
- Department of Clinical Immunology; Naestved Hospital; Naestved Denmark
| | - M. A. Jakobsen
- Department of Clinical Immunology; Odense University Hospital; Odense Denmark
| | - T. R. Jakobsen
- Department of Obstetrics and Gynecology; Copenhagen University Hospital; Copenhagen Denmark
| | - G. R. Krog
- Department of Clinical Immunology; Copenhagen University Hospital; Copenhagen Denmark
| | - R. D. Madsen
- Department of Clinical Immunology; Aarhus University Hospital; Skejby Aarhus Denmark
| | - K. R. Nielsen
- Department of Clinical Immunology; Aalborg University Hospital; Aalborg Denmark
| | - K. Rieneck
- Department of Clinical Immunology; Copenhagen University Hospital; Copenhagen Denmark
| | - U. Sprogøe
- Department of Clinical Immunology; Odense University Hospital; Odense Denmark
| | - K. M. Homburg
- Department of Clinical Immunology; Naestved Hospital; Naestved Denmark
| | - J. Baech
- Department of Clinical Immunology; Aalborg University Hospital; Aalborg Denmark
| | - M. H. Dziegiel
- Department of Clinical Immunology; Copenhagen University Hospital; Copenhagen Denmark
| | - N. Grunnet
- Department of Clinical Immunology; Aarhus University Hospital; Skejby Aarhus Denmark
| |
Collapse
|
15
|
Cost–Benefit Analysis of Indirect Antiglobulin Screening in Rh(D)-Negative Women at 28 Weeks of Gestation. Obstet Gynecol 2014; 123:938-945. [DOI: 10.1097/aog.0000000000000224] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Costs and Clinical Outcomes of Noninvasive Fetal RhD Typing for Targeted Prophylaxis. Obstet Gynecol 2013; 122:579-85. [DOI: 10.1097/aog.0b013e31829f8814] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Szczepura A, Osipenko L, Freeman K. A new fetal RHD genotyping test: costs and benefits of mass testing to target antenatal anti-D prophylaxis in England and Wales. BMC Pregnancy Childbirth 2011; 11:5. [PMID: 21244652 PMCID: PMC3034710 DOI: 10.1186/1471-2393-11-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 01/18/2011] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Postnatal and antenatal anti-D prophylaxis have dramatically reduced maternal sensitisations and cases of rhesus disease in babies born to women with RhD negative blood group. Recent scientific advances mean that non-invasive prenatal diagnosis (NIPD), based on the presence of cell-free fetal DNA in maternal plasma, could be used to target prophylaxis on "at risk" pregnancies where the fetus is RhD positive. This paper provides the first assessment of cost-effectiveness of NIPD-targeted prophylaxis compared to current policies. METHODS We conducted an economic analysis of NIPD implementation in England and Wales. Two scenarios were considered. Scenario 1 assumed that NIPD will be only used to target antenatal prophylaxis with serology tests continuing to direct post-delivery prophylaxis. In Scenario 2, NIPD would also displace postnatal serology testing if an RhD negative fetus was identified. Costs were estimated from the provider's perspective for both scenarios together with a threshold royalty fee per test. Incremental costs were compared with clinical implications. RESULTS The basic cost of an NIPD in-house test is £16.25 per sample (excluding royalty fee). The two-dose antenatal prophylaxis policy recommended by NICE is estimated to cost the NHS £3.37 million each year. The estimated threshold royalty fee is £2.18 and £8.83 for Scenarios 1 and 2 respectively. At a £2.00 royalty fee, mass NIPD testing would produce no saving for Scenario 1 and £507,154 per annum for Scenario 2. Incremental cost-effectiveness analysis indicates that, at a test sensitivity of 99.7% and this royalty fee, NIPD testing in Scenario 2 will generate one additional sensitisation for every £9,190 saved. If a single-dose prophylaxis policy were implemented nationally, as recently recommended by NICE, Scenario 2 savings would fall. CONCLUSIONS Currently, NIPD testing to target anti-D prophylaxis is unlikely to be sufficiently cost-effective to warrant its large scale introduction in England and Wales. Only minor savings are calculated and, balanced against this, the predicted increase in maternal sensitisations may be unacceptably high. Reliability of NIPD assays still needs to be demonstrated rigorously in different ethnic minority populations. First trimester testing is unlikely to alter this picture significantly although other emerging technologies may.
Collapse
Affiliation(s)
- Ala Szczepura
- Warwick Medical School, University of Warwick, Coventry, UK.
| | | | | |
Collapse
|
18
|
Land KJ, Lasarre M, Straley M. Worried that your laboratory doesn't measure up? Arch Pathol Lab Med 2009; 133:343-5. [PMID: 19260738 DOI: 10.5858/133.3.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2008] [Indexed: 11/06/2022]
|