Deaths from Rh haemolytic disease in England and Wales in 1988 and 1989

Routine antenatal Rhesus D immunoglobulin prophylaxis: the results of a prospective 10 year study

OBJECTIVE

To assess the clinical and financial impact, and identify the problems, of providing routine antenatal RhD immunoglobulin prophylaxis for Rhesus D negative nulliparae.

DESIGN

A retrospective (1980-1986) and prospective (1987-1996) comparison between two similar populations, one population with nulliparae offered routine RhD immunoglobulin 500 IU prophylaxis at 28 and 34 weeks of gestation part way through the study period, and the other population not offered prophylaxis at any time.

SETTING

Obstetric units in two counties (three health districts) with similar annual numbers of maternities and the Regional Blood Transfusion Service antenatal serology laboratory.

PARTICIPANTS

Non-sensitised Rhesus D negative pregnant nulliparae.

INTERVENTIONS

Intramuscular RhD immunoglobulin 500 IU at 28 and 34 weeks of gestation to eligible women booked for confinement in one county; the intervention not offered in the other county.

MAIN OUTCOME MEASURES

1. Rhesus D sensitised second pregnancy rate; 2. success in providing prophylaxis to eligible women; 3. serology laboratory activity changes; 4. potential savings from the prophylaxis programme.

RESULTS

Prophylaxis significantly reduced iso-immunisation in the next pregnancy when compared with historical (OR 0.28, CI 0.14-0.53; P < 0.0001) and contemporary controls (OR 0.43, CI 0.22-0.86; P = 0.02). However, success at achieving comprehensive prophylaxis was disappointing, with only 89% of eligible women receiving the first injection, 74% both injections, and for only 29% were both at the correct gestation. Fifty-two percent of women delivered after 40 weeks of gestation, beyond the period of adequate prophylaxis protection. The savings in antenatal interventions, neonatal care and possible long term ill-health that result from very preterm birth should be considerable.

CONCLUSION

Routine prophylaxis for nulliparae significantly reduces the incidence of sensitised next pregnancies with consequent savings, and its adoption nationwide should be encouraged. A programme offering antenatal prophylaxis for all Rhesus D negative women is unlikely to be economic. Improvement in uptake of prophylaxis is needed; alternative administration strategies should be explored.

Implementation of the rhesus prevention programme: a prospective study

All rhesus-negative women who completed a pregnancy between January and August 1992 in two Scottish regions were studied to assess whether the administration of the rhesus prevention programme was complete: 671 rhesus positive (or rhesus type unknown) pregnancies were completed in 1120 Rh D negative women. For eight pregnancies no record of Rh D administration at birth was available. For recorded antenatal events that should have resulted in its administration anti-D was given in 195/280 (69.6%). Kleihauer testing was carried out in 9 of 98 instances of antepartum haemorrhage occurring after 20 weeks gestation. No cases of antenatal immunisation were identified. The study identified a need to increase awareness of the necessity for anti-D administration after potentially immunising events during pregnancy, and for increasing compliance with administration of postnatal anti-D in one of the study regions. Re-evaluation is also required of the recommendation that Kleihauer testing should be done when antenatal anti-D is given following an obstetric event after 20 weeks.

Causes and clinical consequences of Rhesus (D) haemolytic disease of the newborn: a study of a Scottish population, 1985-1990

OBJECTIVE

To identify the reasons behind failures to prevent the development of Rhesus (D) haemolytic disease of the newborn.

DESIGN

Retrospective analysis of the case records of all pregnancies that resulted in the birth of an infant with a positive direct antiglobulin test on the cord red cells born to Rh(D) negative women between 1 April 1985 and 31 March 1990.

SETTING

Obstetric units in the South East Scotland region and the South East Scotland Regional Blood Transfusion Service Antenatal Laboratory.

MAIN OUTCOME MEASURES

The causes and clinical consequences of maternal immunisation to the Rhesus (D) antigen.

RESULTS

Between 1985 and 1990, 80 pregnancies resulted in the birth of an infant sensitised with anti-D on the cord red cells. There were no deaths due to haemolytic disease, but considerable resources were deployed in obstetric and neonatal care for these pregnancies. Sufficient data were available to categorise the cause of maternal immunisation in 70 pregnancies. Seven cases were due to immunisation by pregnancy before 1970. Sixty-three cases could be attributed to failure of the Rhesus programme: 10 cases (16%) were due to failure to implement the programme adequately, the other 53 cases (84%) were due to failure of the current guidelines to provide adequate protection. Late immunisation in an uncomplicated pregnancy was the single commonest identifiable cause.

CONCLUSIONS

It is likely that substantial further reductions in Rhesus (D) immunisation and haemolytic disease of the newborn will require changes in the Rhesus prevention programme. In particular the role of antenatal prophylaxis requires detailed consideration.

Decline in deaths from rhesus haemolytic disease of the newborn

Giving anti-D immunoglobulin postnatally to Rh negative women to prevent Rhesus haemolytic disease of the newborn in future pregnancies has reduced the incidence of this disease in the UK to such low levels that younger doctors are no longer familiar with it.

Use of anti-D in an accident and emergency department

A retrospective study was made of the use of anti-D in an accident and emergency (A&E) department in 1 month. Patients who are discharged home with a diagnosis of threatened miscarriage should have their blood group determined and anti-D should be given to those who are rhesus negative. We found that only 8/29 patients discharged from the department had their blood group determined and none of the rhesus negative patients was given anti-D. We have introduced a practical method of reminding medical staff to give anti-D to patients who require it.