1
|
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.
Collapse
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
| |
Collapse
|
2
|
Prabhu M, Louis JM, Kuller JA. Society for Maternal-Fetal Medicine Statement: RhD immune globulin after spontaneous or induced abortion at less than 12 weeks of gestation. Am J Obstet Gynecol 2024; 230:B2-B5. [PMID: 38417536 DOI: 10.1016/j.ajog.2024.02.288] [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: 03/01/2024]
Abstract
Guidelines for the management of first-trimester spontaneous and induced abortion vary in terms of rhesus factor D (RhD) testing and RhD immune globulin (RhIg) administration. These existing guidelines are based on limited data that do not convincingly demonstrate the safety of withholding RhIg for first-trimester abortions or pregnancy losses. Given the adverse fetal and neonatal outcomes associated with RhD alloimmunization, prevention of maternal sensitization is essential in RhD-negative patients who may experience subsequent pregnancies. In care settings in which RhD testing and RhIg administration are logistically and financially feasible and do not hinder access to abortion care, we recommend offering both RhD testing and RhIg administration for spontaneous and induced abortion at <12 weeks of gestation in unsensitized, RhD-negative individuals. Guidelines for RhD testing and RhIg administration in the first trimester must balance the prevention of alloimmunization with the individual- and population-level harms of restricted access to abortion.
Collapse
|
3
|
Kjær M, Geisen C, Akkök ÇA, Wikman A, Sachs U, Bussel JB, Nielsen K, Walles K, Curtis BR, Vidarsson G, Järås K, Skogen B. Strategies to develop a prophylaxis for the prevention of HPA-1a immunization and fetal and neonatal alloimmune thrombocytopenia. Transfus Apher Sci 2019; 59:102712. [PMID: 31948915 DOI: 10.1016/j.transci.2019.102712] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Indexed: 01/20/2023]
Abstract
Anti-HPA-1a-antibodies are the main cause of fetal and neonatal alloimmune thrombocytopenia (FNAIT) which may result in intracranial hemorrhage (ICH) and death among fetuses and newborns. Advances in understanding the pathogenesis of FNAIT and proof of concept for prophylaxis to prevent immunization suggest that development of hyperimmune anti-HPA-1a IgG aimed at preventing immunization against HPA-1a and FNAIT is feasible. Anti-HPA-1a IgG can be obtained either by isolating immunoglobulin from already-immunized women or by development of monoclonal anti-HPA-1a antibodies. Here we discuss recent advances that may lead to the development of a prenatal and postnatal prophylactic treatment for the prevention of HPA-1a-associated FNAIT and life-threatening FNAIT-induced complications.
Collapse
Affiliation(s)
- Mette Kjær
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway; Finnmark Hospital Trust, Hammerfest, Norway.
| | | | | | | | | | - James B Bussel
- Dept of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | | | | | | | | | | | - Bjørn Skogen
- Department of Medical Biology, UiT- The Artic University of Norway, Tromsø, Norway
| |
Collapse
|
4
|
Hollenbach SJ, Cochran M, Harrington A. "Provoked" feto-maternal hemorrhage may represent insensible cell exchange in pregnancies from 6 to 22 weeks gestational age. Contraception 2019; 100:142-146. [PMID: 30980826 DOI: 10.1016/j.contraception.2019.03.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 03/20/2019] [Accepted: 03/20/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To quantify spontaneous and provoked fetal to maternal cell exchange in the first half of pregnancy. Transfer of fetal red blood cells (FRBCs) into the maternal circulation during the first half of pregnancy is poorly characterized but of clinical relevance for miscarriage management and invasive procedures. STUDY DESIGN Prospective, descriptive cohort study of women presenting for surgical termination of pregnancy with sonographically confirmed gestational age (GA). Pre-procedural and post-procedural blood samples were collected to characterize both spontaneous (pre) and provoked (post) cell exchange with analysis via flow cytometry to quantify FRBC count. RESULTS A total of 100 patients at 6-22 weeks GA contributed 200 matched pre- and post-procedural samples. FRBCs were identified in 69 patients including 4 who exhibited FRBCs pre-procedure only and 9 post-procedure only, for a total of 65 patients having post-procedural FRBCs. Of patients with FRBCs following their procedure, the majority (n=56, 86%) also exhibited evidence of cells before the procedure with just 9 patients (14%) exhibiting FRBCs only after. No dose-response relationship was appreciable between GA and FRBC count. CONCLUSION After experiencing disruption of the placenta with instrumentation, roughly two thirds of patients had detectable FRBCs in maternal circulation following their procedure but-among those that did-the majority also exhibited cell presence prior to the procedure. This leads to further questions regarding the relationship between risk events and alloimmunization potential in previable pregnancies as the rate of spontaneous transplacental cell exchange may be underappreciated and the magnitude of provoked transfer may be overestimated. IMPLICATIONS The relationship between feto-maternal hemorrhage risk events and alloimmunization potential in previable pregnancies has previously been poorly characterized but these data reveal spontaneous transplacental cell exchange may be underappreciated and the magnitude of provoked transfer may be overestimated.
Collapse
Affiliation(s)
| | | | - Amy Harrington
- The University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
5
|
Sullivan IJ, Ralph CJ. Obstetric intra-operative cell salvage and maternal fetal red cell contamination. Transfus Med 2018; 28:298-303. [PMID: 29377380 DOI: 10.1111/tme.12510] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 05/17/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The significance of fetal red blood cell (RBC) contamination in obstetric intra-operative cell salvage is not fully known. It is unclear if we re-infuse a larger volume of fetal RBCs into the maternal circulation than the amount that occurs secondary to transplacental haemorrhages is unclear. We also do not know if there is a critical volume required to cause alloimmunisation or if larger volumes increase the risk. OBJECTIVES The aim of this study is to provide data on the level of fetal RBC contamination in the maternal circulation prior to delivery and immediately post-partum and to compare these levels to those found in processed cell-salvaged blood. METHODS In the first part of this study, we quantified the levels of fetal RBCs circulating in women immediately prior to delivery. This was then repeated with a separate group measuring the levels of fetal RBCs pre- and post-delivery. RESULTS We found that 37% of women had fetal cells detected in their circulation, median 0·00 mL (IQR 0-0·24; average 0·3 mL, maximum 4·56 mL). Fetal RBCs were present pre-delivery (maximum 0·66 mL) in 16% of women, increasing to 53% post-delivery (median 0·66 mL; IQR 0·22-2·20, maximum 21·20 mL). CONCLUSIONS We have shown that fetal RBCs are present in the maternal circulation throughout pregnancy and that the volumes are comparable to that obtained from intra-operative salvage, with contamination amounts of up to 19 mL. At the Royal Cornwall Hospital, our experience and evidence supports offering intra-operative salvage to all women, and we have not noted an increase in antibody formation, compared to allogeneic transfusion.
Collapse
Affiliation(s)
- I J Sullivan
- Department of Blood Transfusion, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - C J Ralph
- Department of Anaesthesiology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| |
Collapse
|
6
|
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]
|
7
|
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.
Collapse
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
| | | |
Collapse
|
8
|
Bernardo L, Yu H, Amash A, Zimring JC, Lazarus AH. IgG-Mediated Immune Suppression to Erythrocytes by Polyclonal Antibodies Can Occur in the Absence of Activating or Inhibitory Fcγ Receptors in a Full Mouse Model. THE JOURNAL OF IMMUNOLOGY 2015; 195:2224-30. [PMID: 26188060 DOI: 10.4049/jimmunol.1500790] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/22/2015] [Indexed: 01/01/2023]
Abstract
Polyclonal anti-D has been used to prevent RhD-negative mothers from becoming immunized against RhD positive fetal erythrocytes, and this mechanism has been referred as Ab or IgG-mediated immune suppression (AMIS). Although anti-D has been highly successful, the inhibitory mechanisms remain poorly understood. Two major theories behind AMIS involve the binding of IgG to activating or inhibitory FcγR, which can induce either erythrocyte clearance or immune inhibition, respectively. In this work, we explored the absolute role of activating and inhibitory FcγR in the AMIS mechanism using the HOD mouse model of RBC immunization. HOD mice contain a RBC-specific recombinant protein composed of hen egg lysozyme (HEL), OVA and human transmembrane Duffy Ag, and erythrocytes from HOD mice can stimulate an immune response to HEL. To assess the contribution of activating and inhibitory FcγR to AMIS, C57BL/6 versus FcRγ-chain(-/-) or FcγRIIB(-/-) mice were used as recipients of HOD-RBC alone or together with anti-HEL Abs (i.e., AMIS) and the resulting immune response to HEL evaluated. We show that anti-HEL polyclonal Abs induce the same degree of AMIS effect in mice lacking these IgG binding receptors as compared with wild-type mice. In agreement with this, F(ab')2 fragments of the AMIS Ab also significantly reduced the Ab response to the HOD cells. In conclusion, successful inhibition of in vivo Ab responses to HOD-RBC by polyclonal IgG can occur independently of activating or inhibitory FcγR involvement. These results may have implications for the understanding of RhD prophylaxis.
Collapse
Affiliation(s)
- Lidice Bernardo
- Canadian Blood Services, Ottawa, Ontario K1G 4J5, Canada; Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada
| | - Honghui Yu
- Canadian Blood Services, Ottawa, Ontario K1G 4J5, Canada; Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada; Department of Anesthesiology, Tongji Hospital, Huazhong University of Science and Technology, 430030 Wuhan, China
| | - Alaa Amash
- Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada
| | - James C Zimring
- Bloodworks Northwest Research Institute, South Lake Union, Seattle, WA 98102
| | - Alan H Lazarus
- Canadian Blood Services, Ottawa, Ontario K1G 4J5, Canada; Department of Laboratory Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada; Department of Medicine, University of Toronto, Toronto, Ontario M5S 1A1, Canada; and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A1, Canada
| |
Collapse
|
9
|
Is cell salvaged vaginal blood loss suitable for re-infusion? Int J Obstet Anesth 2014; 24:103-10. [PMID: 25659518 DOI: 10.1016/j.ijoa.2014.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 10/28/2014] [Accepted: 12/03/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Haemorrhage is one of the commonest causes of maternal critical care admission. Cell salvage used during caesarean section can contribute to a reduction in allogeneic blood consumption. This study sought to provide a practical method to salvage blood lost after vaginal delivery and a description of the constituents before and after washing. METHODS Blood lost after vaginal delivery was collected from 50 women and washed in a cell salvage machine. No blood was re-infused to any patient in this study. The following measurements were made pre- and post-wash: haemoglobin (haematocrit), alpha-fetoprotein, albumin, lactate dehydrogenase, plasma free haemoglobin, heparin concentration, fetal red cells and identification of bacterial species and colony-forming units (cfu). RESULTS Median haemoglobin concentration post-wash was 15.4 g/dL. Alpha-fetoprotein, lactate dehydrogenase and albumin concentrations were significantly reduced post-wash (<1 KU/L, 183 IU/L, 0.011 g/L, respectively; P <0.001). Median fetal red cell level post-wash was 0.15 mL [range 0-19 mL]. Median bacterial contamination concentration post-wash was 2 cfu/mL, with a median total count of 303 cfu. CONCLUSIONS Vaginal blood can be collected efficiently with little disruption to patient management. The amounts of haemolysis and washout of non-red cell blood components are consistent with results in our cell salvage quality assurance programme for caesarean section and non-obstetric surgery. Although bacteria are detectable in all the post-wash and post-filter samples, the median residual contamination is similar to that found with cell salvage in caesarean section, and if re-infused would result in a circulating bacteraemia of <1 cfu/mL; this is similar to that seen with dental procedures (0.3-4.0 cfu/mL) and is thought to be clinically insignificant.
Collapse
|
10
|
Karanth L, Jaafar SH, Kanagasabai S, Nair NS, Barua A. Anti-D administration after spontaneous miscarriage for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev 2013:CD009617. [PMID: 23543581 DOI: 10.1002/14651858.cd009617.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND During pregnancy, a Rhesus-negative (Rh-negative) woman may develop antibodies if her fetus is Rh-positive, which can cause fetal morbidity or mortality in following pregnancies, if untreated. OBJECTIVES To assess the effects of administering anti-D immunoglobulin (Ig) after spontaneous miscarriage in a Rh-negative woman, with no anti-D antibodies. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2012). SELECTION CRITERIA Randomised controlled trials (RCT) in Rh-negative women without antibodies who were given anti-D Ig following spontaneous miscarriage compared with no treatment or placebo treatment following spontaneous miscarriage as control. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and trial quality. Two review authors extracted data and checked it for accuracy. MAIN RESULTS We included one RCT, involving 48 women who had a miscarriage between eight to 24 weeks of gestation. Of the 19 women in the treatment group, 14 had therapeutic dilatation & curettage (D&C) and five had spontaneous miscarriage; of the 29 women in the control group, 25 had therapeutic D&C and four had spontaneous miscarriage. The treatment group received 300 µg anti-D Ig intramuscular injection and were compared with a control group who received 1 cc homogenous gamma globulin placebo.This review's primary outcomes (development of a positive Kleihauer Betke test (a test that detects fetal cells in the maternal blood; and development of RhD alloimmunisation in a subsequent pregnancy) were not reported in the included study.Similarly, none of the review's secondary outcomes were reported in the included study: the need for increased surveillance for suspected fetal blood sampling and fetal transfusions in subsequent pregnancies, neonatal morbidity such as neonatal anaemia, jaundice, bilirubin encephalopathy, erythroblastosis, prematurity, hypoglycaemia (low blood sugar) in subsequent pregnancies, maternal adverse events of anti-D administration including anaphylactic reaction and blood-borne infections.The included study did report subsequent Rh-positive pregnancies in three women in the treatment group and six women in the control group. However, due to the small sample size, the study failed to show any difference in maternal sensitisation or development of Rh alloimmunisation in the subsequent pregnancies. AUTHORS' CONCLUSIONS There are insufficient data available to evaluate the practice of anti-D administration in an unsensitised Rh-negative mother after spontaneous miscarriage. Thus, until high-quality evidence becomes available, the practice of anti-D Immunoglobulin prophylaxis after spontaneous miscarriage for preventing Rh alloimmunisation cannot be generalised and should be based on the standard practice guidelines of each country.
Collapse
Affiliation(s)
- Laxminarayan Karanth
- Department of Obstetrics and Gynecology, Melaka Manipal Medical College, Melaka, Malaysia.
| | | | | | | | | |
Collapse
|
11
|
Crowther CA, Middleton P, McBain RD. Anti-D administration in pregnancy for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev 2013:CD000020. [PMID: 23450526 DOI: 10.1002/14651858.cd000020.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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 (30 September 2012). 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 trial eligibility and risk of bias and extracted the data. MAIN RESULTS Two trials with moderate to high risk of bias, involving over 4500 women, compared anti-D prophylaxis with no anti-D during pregnancy. When women received anti-D at 28 and 34 weeks' gestation, risks of immunisation were not significantly different than for women not given antenatal anti-D: risk ratio (RR) of immunisation during pregnancy was 0.42 (95% confidence interval (CI) 0.15 to 1.17); after the birth of a Rh-positive infant the RR was 0.42 (95% CI 0.15 to 1.17); and within 12 months after birth of a Rh-positive infant the RR was 0.39 (95% CI 0.10 to 1.62).However, women receiving anti-D during pregnancy were significantly less likely to register a positive Kleihauer test (which detects fetal cells in maternal blood) in pregnancy (RR 0.60, 95% CI 0.41 to 0.88) and at the birth of a Rh-positive infant (RR 0.60, 95% CI 0.46 to 0.79). No data were available for the risk of Rhesus D alloimmunisation in a subsequent pregnancy. No significant differences were seen for neonatal jaundice, and no adverse effects were reported in either trial. AUTHORS' CONCLUSIONS The risk of Rhesus D alloimmunisation during or immediately after a first pregnancy is about 1%. Administration of 100 µg (500 IU) anti-D to women in their first pregnancy can reduce this risk to about 0.2% without, to date, any adverse effects. Although unlikely to confer benefit in the current pregnancy, fewer women may have Rhesus D antibodies in any subsequent pregnancy, but the effects of this needs to be tested in studies of robust design.
Collapse
Affiliation(s)
- Caroline A Crowther
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University ofAdelaide, Adelaide, Australia.
| | | | | |
Collapse
|
12
|
Tiller H, Killie MK, Chen P, Eksteen M, Husebekk A, Skogen B, Kjeldsen-Kragh J, Ni H. Toward a prophylaxis against fetal and neonatal alloimmune thrombocytopenia: induction of antibody-mediated immune suppression and prevention of severe clinical complications in a murine model. Transfusion 2012; 52:1446-57. [DOI: 10.1111/j.1537-2995.2011.03480.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
13
|
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
|
14
|
Recombinant human erythropoietin in the prevention of late anemia in intrauterine transfused neonates with Rh-isoimmunization. J Pediatr Hematol Oncol 2010; 32:e95-101. [PMID: 20216236 DOI: 10.1097/mph.0b013e3181cf444c] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The majority of neonates with Rh-isoimmunization develops late anemia between the second and the sixth week of life. We report the effectiveness of recombinant human erythropoietin (rHuEPO) in preventing late anemia in 25 intrauterine and nonintrauterine-transfused neonates. The neonates were treated from 11+/-4 days after birth to 26+/-14 days (400 U/kg/d of rHuEpo, administered subcutaneously). During rHuEpo therapy, vitamin E, calcium folinate, and iron maltose were administered intramuscularly on a daily basis. Hematocrit, platelet, and neutrophil counts did not differ significantly before and after 21-days therapy. However, average values for reticulocyte showed a significant increase. The hematocrit values in the non-intrauterine transfusion (IUT) group increased progressively from the beginning to the end of the treatment, whereas that in the IUT group remained stable. Reticulocyte count increased during treatment in both groups, but it was significantly elevated in the non-IUT group only. Moreover, we observed that only neonates transfused with IUTs needed transfusions before and after treatment. This study suggests the effectiveness of rHuEpo therapy in the treatment of neonates with Rh-isoimmunization and it highlights how IUTs decrease the neonatal response efficacy. Larger, better if multicentric, randomized controlled trial are needed to definitely state whether rHuEPO safely decreases the incidence of late onset anemia.
Collapse
|
15
|
Liumbruno GM, D'Alessandro A, Rea F, Piccinini V, Catalano L, Calizzani G, Pupella S, Grazzini G. The role of antenatal immunoprophylaxis in the prevention of maternal-foetal anti-Rh(D) alloimmunisation. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2010; 8:8-16. [PMID: 20104273 PMCID: PMC2809506 DOI: 10.2450/2009.0108-09] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 08/06/2009] [Indexed: 11/21/2022]
|
16
|
Cardo L, García BP, Alvarez FV. Non-invasive fetal RHD genotyping in the first trimester of pregnancy. Clin Chem Lab Med 2010; 48:1121-6. [DOI: 10.1515/cclm.2010.234] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
17
|
Ben-David G, Sheiner E, Levy A, Erez O, Mazor M. An increased risk for non allo-immunization related intrauterine fetal death in RhD-negative patients. J Matern Fetal Neonatal Med 2008; 21:255-9. [PMID: 18330822 DOI: 10.1080/14767050801928804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate immediate perinatal outcome of RhD-negative patients carrying RhD-positive fetuses who received antenatal Rh immunoglobulin for the prevention of RhD-mediated hemolytic disease of the fetus and newborn. METHODS A retrospective population-based analysis was conducted comparing pregnancies of all RhD-negative women who received antenatal Rh immunoglobulin prophylaxis (anti-D), to RhD-positive parturients, during the years 1988-2003. All women were RhD-negative without evidence of RhD sensitization. Patients received anti-D during the 28-30th week of pregnancy, and an additional dosage within 72 hours following delivery after confirmation of the newborn's RhD status. RESULTS Of 145,437 deliveries during the study period, 6.8% were of RhD-negative women (n = 9961). Perinatal mortality rate was significantly higher among the RhD-negative women who received antenatal prophylaxis rhesus immunoglobulin as compared with the controls (17/1000 vs. 12/1000, OR = 1.3, 95%CI 1.2-1.6; p < 0.001). This higher mortality rate was related to a higher rate of intrauterine fetal demise (IUFD) (10/1000 vs. 6/1000, OR = 1.5, 95%CI 1.2-1.9; p < 0.001). The association remained significant after controlling for RhD isoimmunization leading to hydrops fetalis, using the Mantel-Haenszel technique (weighted OR = 1.3; 95% CI 1.1-1.5; p = 0.001). The rate of RhD isoimmunization was 0.6% (n = 58). Using a multivariable analysis with IUFD as the outcome variable, controlling for known confounders for fetal demise, RhD-negative status was an independent risk factor for IUFD. CONCLUSION RhD-negative women carrying RhD-positive newborns are at an increased risk for IUFD despite Rh immunoprophylaxis.
Collapse
Affiliation(s)
- Gila Ben-David
- Department of Obstetrics and Gynecology, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | | | | | | | | |
Collapse
|
18
|
Brinc D, Le-Tien H, Crow AR, Siragam V, Freedman J, Lazarus AH. Immunoglobulin G-mediated regulation of the murine immune response to transfused red blood cells occurs in the absence of active immune suppression: implications for the mechanism of action of anti-D in the prevention of haemolytic disease of the fetus and newborn? Immunology 2008; 124:141-6. [PMID: 18266717 DOI: 10.1111/j.1365-2567.2008.02807.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Anti-D has been widely and effectively used in Rhesus blood group D negative mothers for the prevention of haemolytic disease of the fetus and newborn; its mechanism of action however, often referred to as antibody-mediated immune suppression (AMIS), remains largely unresolved. We investigated, in a murine model, whether active immune suppression or clonal deletion mediated by anti-red blood cell (RBC) immunoglobulin G (IgG) could explain the phenomenon of AMIS. Transfusion of IgG-opsonized foreign RBCs (i.e. AMIS) strongly attenuated antibody responses compared to transfusion of untreated foreign RBCs. When the AMIS-mice were subsequently transfused with untreated RBCs, no immune suppression was observed at 5 and 35 days after AMIS induction; in fact, the mice responded to retransfusion with untreated RBCs in a manner that was characteristic of a secondary immune response. When IgG-opsonized RBCs were transfused concurrently with untreated RBCs, a dose-dependent reduction of the antibody response was observed. This work suggests that the attenuation of the antibody responsiveness by anti-RBC IgG is not associated with active immune suppression or clonal deletion at either the T-cell or B-cell level; rather, the effect appears more characteristic of B-cell unresponsiveness to IgG-opsonized RBCs. These results may have implications for the understanding of the mechanism of action of anti-D in haemolytic disease of the fetus and newborn.
Collapse
Affiliation(s)
- Davor Brinc
- Canadian Blood Services, Toronto, ON, Canada
| | | | | | | | | | | |
Collapse
|
19
|
Ryan MJ, Joyce S, O'Brien N, Lynch E, Burke G, Cahill MR. The issue of anti-D: an integrated seamless approach from recognition of need to bedside administration. Ir J Med Sci 2005; 174:58-63. [PMID: 16285341 DOI: 10.1007/bf03169150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The appropriate and timely administration of Anti-D immunoglobulin to Rhesus (D) negative women who have delivered Rhesus (D) positive babies is a vital part of obstetric care. Anti-D has an especially high profile in Ireland because of the tragic inadvertent transmission of Hepatitis C to Irish women in past decades. AUDIT We have reviewed our policy and procedures pertaining to the administration of Anti-D for sensitising events during pregnancy and postnatally, in the Mid-Western Health Board in 1999/2000. As a result, major changes were made in the storage, issue, recording and administration of Anti-D. New procedures in the transfusion laboratory and in the maternity hospital have been accepted by scientists and midwives and supported by haematology and obstetric medical staff. The pharmacy and haematology laboratory no longer have a role in this programme. IMPLEMENTATION OF MULTI-DISCIPLINARY CHANGE MANAGEMENT: As a result of these changes, the storage, issuing and tracking of Anti-D has become the responsibility of the hospital blood bank. Measurement offoeto-maternal haemorrhage (FMH) is now the responsibility of bio medical scientists in blood bank, utilising both flow cytometry (increasingly recognised as the gold standard method) and the Kleihauer method (Kleihauer-Betke). The programme has moved from a doctor-administered IV Anti-D Ig, to a midwife-administered IM preparation. Prescription remains the responsibility of the doctor. These changes are facilitated by the protocol guided issue of the appropriate dose of Anti-D Ig by bio medical scientists to midwives. The issue of the Anti-D Ig occurs simultaneously with issue of results of mother and baby's serology testing and estimation of volume of FMH. These major changes have been guided by audit and needs assessment and require close liaison between medical, nursing and laboratory scientific staff in haematology, transfusion and obstetrics. CRITICAL INCIDENT AUDIT-CASE REPORT: Before new procedures became official policy, a critical incident audit allowed us to pilot our protocol and to revise it using draft new procedures. In this critical incident we describe successful management of a patient with a large foeto-maternal haemorrhage. This incident supported the need for the procedural enhancements already underway. This critical incident re-emphasised the need for the planned systems improvements to be introduced quickly.
Collapse
Affiliation(s)
- M J Ryan
- Dept of Haematology, Mid-Western Regional Hospital & Regional Maternity Hospital, Limerick
| | | | | | | | | | | |
Collapse
|
20
|
Chilcott J, Tappenden P, Lloyd Jones M, Wight J, Forman K, Wray J, Beverley C. The economics of routine antenatal anti-D prophylaxis for pregnant women who are rhesus negative. BJOG 2004; 111:903-7. [PMID: 15327602 DOI: 10.1111/j.1471-0528.2004.00226.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the economics of routine antenatal anti-D prophylaxis in the prevention of haemolytic disease of the newborn, in support of the NICE appraisals process. DESIGN Cost effectiveness analysis. SETTING UK NHS. POPULATION/SAMPLE Pregnant women who are RhD-negative. METHODS A model was constructed to estimate the incremental cost effectiveness and cost utility of: (1) offering routine antenatal anti-D prophylaxis to all pregnant women who are RhD-negative; (2) offering routine antenatal anti-D prophylaxis to RhD-negative primigravidae, compared with conventional management alone. Effectiveness estimates were derived from a meta-analysis of two UK community-based studies. Costs were derived from published sources and NHS product lists. Threshold analysis was conducted to reflect the social value of routine antenatal anti-D prophylaxis through incorporating valuations of parental grief and fetal/neonatal loss. MAIN OUTCOME MEASURES Cost per life year gained and cost per quality adjusted life year (QALY) gained. RESULTS The cost per life year gained is in the range pound 5,000- pound 15,000. The inclusion of long term neurodevelopmental problems results in a cost utility ranging between pound 11,000 and pound 52,000 per QALY gained. Threshold analysis suggests that if fetal loss, parental grief and subsequent high intervention pregnancy are valued at greater than 9 QALYs, the comprehensive policy would be more attractive than the primigravidae policy, assuming a maximum acceptable threshold of pound 30,000 per QALY. CONCLUSION Routine antenatal anti-D prophylaxis provides a cost effective intervention for preventing haemolytic disease of the newborn in the pregnancies of women who are RhD-negative.
Collapse
Affiliation(s)
- Jim Chilcott
- School of Health and Related Research (ScHARR), University of Sheffield, UK
| | | | | | | | | | | | | |
Collapse
|
21
|
Rudensky B, Mazaki E, Na'amad M, Samueloff A. Lack of anti-D in women at birth following antepartum immune globulin prophylaxis. Eur J Obstet Gynecol Reprod Biol 2003; 107:45-6. [PMID: 12593893 DOI: 10.1016/s0301-2115(02)00310-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Antepartum prophylaxis using Rh immune globulin suppresses maternal immunization to transplacental transfer of Rh-positive fetal cells, and, theoretically, to be effective, anti-D should be detectable until birth. We used a sensitive gel technique to quantitatively detect the serum concentration of anti-D at birth in 150 women who had received 300 microg of Rh immune globulin at 28 weeks gestation. Our method, which was sensitive enough to detect 20-25 microg, the recommended residual amount at birth, was positive in only 21% total, and in only 13% of women at term. Fifty-seven percent of women with premature births had above the recommended level of anti-D.
Collapse
Affiliation(s)
- Bernard Rudensky
- Laboratory of Immunohaematology, Shaare Zedek Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Jerusalem 91031, Israel.
| | | | | | | |
Collapse
|
22
|
Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003; 41:123-33. [PMID: 12514693 DOI: 10.1067/mem.2003.13] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
MESH Headings
- Abdominal Injuries/diagnosis
- Abdominal Injuries/therapy
- Abortifacient Agents, Nonsteroidal/administration & dosage
- Abortifacient Agents, Nonsteroidal/adverse effects
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/therapy
- Abortion, Threatened/diagnosis
- Abortion, Threatened/therapy
- Chorionic Gonadotropin/blood
- Diagnosis, Differential
- Emergency Service, Hospital
- Female
- Follow-Up Studies
- Humans
- Immunoglobulin D
- Methotrexate/administration & dosage
- Methotrexate/adverse effects
- Pregnancy
- Pregnancy Complications/diagnosis
- Pregnancy Complications/therapy
- Pregnancy, Ectopic/blood
- Pregnancy, Ectopic/diagnosis
- Pregnancy, Ectopic/diagnostic imaging
- Retrospective Studies
- Rh-Hr Blood-Group System
- Time Factors
- Ultrasonography
Collapse
|
23
|
Greiss MA, Armstrong-Isher SS, Perera WS, Brown PM, Urbaniak SJ. Semiautomated data analysis of flow cytometric estimation of fetomaternal hemorrhage in D- women. Transfusion 2002; 42:1067-78. [PMID: 12385420 DOI: 10.1046/j.1537-2995.2002.00159.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Accurate and reliable measurement of the volume of fetal D+ cells in D- women is required for adequate anti-D prophylaxis. A semiautomated flow cytometry assay based on a standardized calibration curve that was created with simulated fetomatemal hemorrhage (FMH) mixtures was developed. STUDY DESIGN AND METHODS A calibration range of 0.083- to 2-percent D+ cells in the D-RBC mixtures (2-44 mL calculated FMH) was analyzed by use of a flow cytometer (XL-MCL, Coulter Electronics Ltd). Linear regression analysis of the calibration curve data with computer software (Excel, Microsoft) allowed semiautomated determination of the FMH volume. To optimize the assay, fresh versus frozen and thawed RBCs, RBCs from adults who are heterozygous for D or cord RBCs, and indirect- or direct-labeling techniques were evaluated by use of MoAbs. RESULTS Fresh RBCs from adults heterozygous for D were chosen for routine use, although equivalent calibration curves were obtained with all cells tested (n = 12 calibration assays; r2 = 0.999; mean SD, 14%). A monoclonal anti-D reagent (Therad 10, Diagnostics Scotland) worked well in both indirect-(anti-IgG F(ab)-FITC) and direct-(anti-D-FITC) labeling methods compared to the use of BRAD-3 FITC. In routine practice, the FMH volumes obtained were mainly lower than those obtained in the Kleihauer Betke test when there was less than 4 mL of FMH. CONCLUSION Semiautomated data acquisition and calibration curve analysis represents a further step toward standardization of flow cytometry for accurate FMH quantification and facilitates evaluation and control of day-to-day variations between laboratories, flow cytometers, and operators.
Collapse
Affiliation(s)
- M A Greiss
- Department of Medicine and Therapeutics, University of Aberdeen, UK.
| | | | | | | | | |
Collapse
|
24
|
Abstract
OBJECTIVE To review the literature on current perspectives and treatment of RhD isoimmunization. DATA SOURCES A search was conducted on MEDLINE and CINAHL, and supplemental articles/ bulletins were obtained from cited references and the Web site of the American College of Obstetricians and Gynecologists. Recent texts also were reviewed. Key search words: isoimmunization, Rho (d) immune globulin, fetal erythroblastosis, intrauterine blood transfusions, alloimmunization. STUDY SELECTION Articles and comprehensive works from indexed journals in the English language relevant to key words and published after 1995 were evaluated. Historically relevant periodicals and texts were also reviewed and selected. DATA EXTRACTION Data were extracted and organized under the following headings: testing of the antepartum patient, antepartum treatment of isoimmunization, testing of the postpartum patient, anti-D immune globulin, antepartum anti-D immune globulin prophylaxis, other antepartum and obstetric indications for anti-D immune globulin administration, postpartum anti-D immune globulin prophylaxis, nursing implications, and future possibilities. DATA SYNTHESIS RhD isoimmunized pregnancies continue to contribute to worldwide perinatal and neonatal morbidity and mortality. This review describes the basic knowledge necessary to care for these pregnancies and the current management modalities. CONCLUSIONS The management options for RhD compromised gestations continue to evolve almost as quickly as technological advances are made. Multiple areas of research in this field have surfaced, and nurses can become valuable members of these research teams. The literature also indicates that with the available knowledge and resources, the current rate of RhD isoimmunization can be further decreased with closer adherence to proposed management guidelines by all health care professionals.
Collapse
Affiliation(s)
- J L Neal
- The Ohio State University, Columbus, USA.
| |
Collapse
|
25
|
Abstract
When an RhD negative mother is exposed to the RhD positive red cells (usually as transplacental haemorrhage), she develops allo-anti-D which crosses the placenta and then results in the destruction of fetal red cells. Clinical manifestations of RhD haemolytic disease (HDN) range from asymptomatic mild anaemia to hydrops fetalis or stillbirth associated with severe anaemia and jaundice. HDN was a significant cause of fetal mortality and morbidity until the introduction of amniocentesis, intrauterine transfusion, controlled early delivery and exchange transfusion in the management of severely alloimmunised women and their fetuses. The objective of monitoring alloimmunised women is to identify fetal anaemia and prevent the development of life-threatening hydrops. Evaluation involves assessing the history of previous pregnancies; serial estimation of maternal anti-D levels; serial ultrasound measurements; serial amniocentesis; fetal blood sampling, and intrauterine transfusion when indicated. Diagnostic genotyping by DNA-based methods can identify at-risk RhD positive fetuses early in gestation. Identification of transplacental haemorrhage (TPH) as the stimulus for anti-D antibody production led to the development of anti-D immunoglobulin prophylaxis for at-risk RhD negative women who are not already alloimmunised. Prevention includes administration of anti-D immunoglobulin for any event associated with TPH during pregnancy, and at delivery of an RhD positive infant. Prophylactic routine administration of anti-D immunoglobulin at 28 (and 34) weeks gestation, in addition to the above, has reduced alloimmunisation to <1% of RhD negative women carrying an RhD positive fetus.
Collapse
Affiliation(s)
- S J Urbaniak
- Department of Medicine and Therapeutics, Aberdeen University, UK
| | | |
Collapse
|
26
|
Abstract
BACKGROUND A woman may develop Rh-negative antibodies during her first pregnancy when her fetus is Rh-positive. Antibodies develop most frequently after the 28th week of gestation. OBJECTIVES The objective of this review was to asses the effects of giving antenatal anti-D immunoglobulin at 28 weeks or more of pregnancy on the incidence of RhD alloimmunisation when given to Rhesus negative mothers without anti-D antibodies. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register, Cochrane Controlled Trials Register, and bibliographies. Date of last search: December 1998. SELECTION CRITERIA Randomised trials in Rhesus negative women without anti-D antibodies given anti-D after 28 weeks of pregnancy, compared with no treatment or placebo. DATA COLLECTION AND ANALYSIS Data were extracted by one reviewer and double entered. MAIN RESULTS Two eligible trials, which involved over 4500 women, compared anti-D prophylaxis with no treatment. Although the data suggested, when women receive anti-D at 28 and 34 weeks gestation, a reduced incidence of immunisation during pregnancy (0R O.44, 95% CI 0.18-1.12), after the birth of a Rhesus positive infant (OR 0.44, 95% CI 0.18-1.12), and within 12 months after birth of a Rhesus positive infant (OR 0.44, 95% CI 0.19-1.01), none of these differences were statistically significant. In the trial, which used the larger dose of anti-D (100ug; 500IU), there was a clear reduction in the incidence of immunisation at 2-12 months following birth in women who had received Anti-D at 28 and 34 weeks (OR 0.22 95% CI 0.05-0.88). No data were available for the risk of RhD alloimmunisation in a subsequent pregnancy. No differences were observed in the incidence of neonatal jaundice. REVIEWER'S CONCLUSIONS The risk of RhD alloimmunisation during or immediately after a first pregnancy is about 1.5%. Administration of 100ug (500IU) anti-D at 28 weeks and 34 weeks gestation to women in their first pregnancy can reduce this risk to about 0.2% without, to date, any adverse effects. Although such a policy is unlikely to confer benefit or improve outcome in the present pregnancy, fewer women will have Rhesus D antibodies in their next pregnancy. Adoption of such a policy will need to consider the costs of prophylaxis against the costs of care for women who become sensitised and their affected infants, and local adequacy of supply of anti-D gammaglobulin.
Collapse
Affiliation(s)
- C A Crowther
- Department of Obstetrics and Gynaecology, University of Adelaide, Women's and Children's Hospital, King William Road, Adelaide, South Australia, Australia, SA 5006.
| | | |
Collapse
|