These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.
My Mother and father are both Rh+, which is dominant, right? So how did I become Rh-???? Is it because they BOTH had a recessive neg gene that they passed on to me to make me a full neg?
Yes, totally correct!
My husband is Rh positive, as are all the children; will I be forevever doomed to anti-D injections, or is there a possibility I may get an Rh negative baby?
Andrea
You can only have an Rh -ve baby if your hubby is carrying a Rh negative gene... basically if you have an Rh -ve kid then either he is carrying one, or you've been playing away ;-) (But see Rhesus Variations below.)
Angela
I thought I would share a joke with you.
'Have you heard they have produced a new morning after pill for men? It changes their blood group!'
Debs
I recently accompanied a consultant ward round. ... There was a woman who had given birth in the night and was awaiting baby's group before having Anti D. The teaching session that followed in the corridor about Rhesus Isoimmunisation focussed on Why does it still happen, why do some women not have Anti D? And discussion about prophylaxis ante-natally...The Consultant did go on to say that he wondered if there was a place for Blood Grouping of the baby's father antenatally, before giving routine antenatal doses. Does anyone know whether this is ever done?
Andrea.
I have heard of practitioners who do this, but it is an art. The question about testing the "father" must be done in a very trusting environment, without the partner(or anyone else!)present. This is to allow the woman a safe environment to choose gamma globulin regardless of her partner's status,in case he is not the father of the baby. Full information must be provided (ie-NOT to husband/male partner "Do you know your blood type, negative, oh good than (to woman)you don't need this stuff")
Just a note.. I don't know if it is done all over Ontario, but protocol in at least three major hospitals in the Toronto area ia a routine 28 week antenatal prophalaxis, followed by baby blood typing, and second dose for moms of Rh+ babes.
One more thought..
"Single" women may know the blood type of their partners, if they have been inseminated or have had donor sperm. This is a common occurance in the lesbian community.
Sky
Just adding my experience as a midwife and Rh negative mother of two. I was tested (as is the norm) for antibodies at 28 weeks (none present) and then the babies' blood group was tested from cord blood after delivery. As it happened, both my boys were Rh positive, so I had anti-D. If they had been Rh neg, I wouldn't have had it, it wouldn't have even been offered. The only situation where I would be given anti-D "blindly" ie without knowing the blood group of the baby would be with a spontaneous or induced abortion where the blood group of the baby could not be established, or in the case of a antepartum haemorrhage.
Kirsten Blacker
I have been talking to a pregnant woman recently who is Rh negative. She has been told that her obstetrician would expect her to have anti-D post delivery. She has pointed out that her partner is also Rh negative, so the baby wil be too. At which point she was told that the medical staff had no guarantee that her partner was the baby's father and they still recommended anti-D. She was horrified at this, especially as it was said in front of her partner. She is going to refuse the anti-D anyway. Anyone else had anything like this happen or any comments?
Jill. Student midwife.
Yes, this too happened to me when I was a student, and I too was horrified. The woman and her partner were both very angry.
However, taken in the context of hospital, with a couple arriving on the labour ward not already known to anybody working there, there is an element of common sense in the policy. It is a fact that many women have babies whose father is not their partner, without telling the partner. It is also quite likely in such a situation that the woman will not tell the midwife at booking or during antenatal visits either - would you?
Since there is no way for the hospital staff to know whether the father of the baby is actually the woman's partner - and she is most unlikely to say any different in that context, especially in the partner's presence - the fail safe approach is indeed to give anti-D as a routine, irrespective of the partner's blood group. It is insulting for a couple who know without doubt that the baby belongs to them both, but these things do happen.
In a community or home birth context, where the woman hopefully knows her midwife well, and the whole rhesus negative issue has hopefully been carefully discussed, perhaps there is more of an opportunity for the truth to come out before labour. I don't know. As an independent midwife I trust the woman to make good decisions about this. Only she knows the truth. If she wants to have anti-D then fine, and if she doesn't I trust her to have weighed the information given in the balance and come to a responsible conclusion. Not many hospital staff feel able to do this - in their shoes I wouldn't either, probably.
Interesting issue, and not as straightforward as at first may appear.
Melanie
I think that if a Midwife explains all aspects of care antenatally in a totally non-judgemental way, then clients are likely to say if the current 'partner' is not the biological father at booking or subsequent visits. I feel very uneasy reading that a failsafe approach would be to routinely give Anti -D..... Education, explanation and excellent communication skills are a failsafe approach for care surely ?
Ella Jackson
At which point she was told that the medical staff had no guarantee that her partner was the baby's father and they still recommended anti-D.
I think this is appalling - surely to suggest something like this to a couple is defamation of character? I think the couple should be outraged and insulted and should write a very strong letter of complaint to the person who made the comment and copy it to as many different people in the hospital that they can, right up to the most senior administrators and heads of department.
Katherine Davies
A funny story re Anti D happened. The mum was Rh-ve and the dad was also, but regular cord bloods showed the baby was Rh+ve. After much much discussion, tears, anger etc, the registrar finally suggested the ultimate solution: that the baby having a different Rh group from both its -ve parents, was that it was an act of God! Everyone was "relieved" and the parents were happy.
Judy
Reading Judy's posting about the baby who was Rhesus positive but had Rhesus Negative parents (act of God) I thought it might be useful to let you know about a lady I saw in the Early Pregnancy Clinic last week.
She had an ultrasound which showed that she had had a miscarriage. She was concerned that it was because she hadn't had anti D in the last pregnancy. This left me confused as the computer showed a Rhesus positive result for her booking bloods. Thinking that I had called up the wrong patient's details, I printed out all the results of previous pregnancies in this lady's name and date of birth.
They showed that in her first pregnancy she had been classified as Rhesus Negative, in her second pregnancy she had been reclassified as Rhesus positive and this was commented on - saying that a new type of test which had been introduced was more specific and she was now considered Rhesus positive. I explained this to her and gave her the printed versions with the explanations for midwives booking any future pregnancy. She seemed quite confused (as indeed I had been initially) but because her last baby had been Rhesus Negative I was able to reassure her that whatever her blood group classification she wouldn't have received any anti-D anyway
I too came across a woman who had booked for her second pregnancy and had been found to be rh+ve whereas in her first pregnanct she was rh-ve and recieved anti-d after miscarriage. I followed this up and was told by Sheffield that on retesting her blood she was rh variant.
Louise
Here is a good, detailed and technical text on rhesus variation and genetic basis: http://www.perinatology.com/Archive/Isoimmunization.htm
I recently accompanied a consultant ward round. (Consultant, Registrar, SHO's x 3, Med students x 2, Midwife and Me [student midwife]). There was a woman who had given birth in the night and was awaiting baby's group before having Anti D. The teaching session that followed in the corridor about Rhesus Isoimmunisation focussed on Why does it still happen, why do some women not have Anti D? And discussion about prophylaxis ante-natally. The overwhelming view from the Docs seemed to be that some irresponsible women will not do as they are told, and those who question, or worse still refuse, prophylaxis are wierdos who refuse all modern medicine has to offer. I'm afraid that I was too cowardly to challenge this view in this setting, and only managed to put the point that some women are concerned because Anti D is a blood product. It seems that the view that women should do as they are told and not ask questions is still with us...
Andrea.
I am 28 weeks pregnant with my sixth (and last baby!). I have been offered anti-D as per protocol here.. In previous pregnancies (in the UK) I have only had anti D once the baby has been born and it has been established to be rhesus +. Is there any point in my having the anti-d since there will be no further pregnancies (husband had vasectomy), and as far as I understand it the reason you have anti d is to mop up any antibodies associated with the current pregnancy that may have implications for future pregnancies. Is that right? Thus is there any point in my having it at 28 weeks?
F, mother
Yes you are right, it is to prevent problems in future pregs. We do it here in the UK at 28/34 weeks, used to be blood tests at those points and anti-d if antibodies found then, or if you had a sensitising event in preg - like PV (per vaginum) bleed, fall on belly etc...It is just an offer and you can decline.
Cheryl, midwife
I'm wondering if anyone can help. In Sarah Wickham's "Anti-D in midwifery: panacea or paradox" she mentions testing for homozygosity of Rh factor -- so that an Rh-ve mother could find out, for example, if her baby's Rh+ father was homo- or heterozygous for Rh+. As the risk of possible sensitisation is reduced by 25% by a heterozygous result (father is Rh+/Rh-ve rather than Rh+/Rh+) it would be helpful for a couple desiring a large family to have this information in order to make informed decisions about the balance of risks (taking Anti-D, perhaps prophylactically *vs* the odds of sensitisation over several pregnancies).
I'm Rhesus negative (O negative) and my husband is AB positive, although we don't know whether he's homozygous- or heterozygous for Rh+. As I understand it, the ABO incompatibility works in my favour: my body is likely to react to A or B cells (and destroy them) before it reacts to the Rhesus incompatibility, making a reaction in the case of fetomaternal transfusion somewhat less likely. My first child's cord blood was lost by the hospital, so we still have no idea what his blood type is. My second child was B-positive. Obviously if we knew that my first was Rh-ve then there would be no need to test for heterozygosity, but we don't.
My midwife has requested a test for heterozygosity through the hospital but has hit a blank wall. Does anyone out there have any suggestions? It is very important to me and my husband to have a large family, but having read the NICE guidelines on Anti-D, Sarah Wickham's book, and the few bits of relevant research that I've been able to get my hands on, I'm extremely loathe to go the prophylactic route.
Does anyone have any suggestions or further information or new research that they could point me towards?
Does anyone know about blood testing for heterozygosity?
Many thanks and best wishes
Antonia, mother
Dear Antonia,
My best friend growing up lost three siblings (numbers 4-7) due to Rh isoimmunization. The first Rhogam became available the year before my first daughter was born (1968), I believe.
You will not know your baby's Rh factor until the cord blood is tested after birth, no matter what heterozygous-ity you discover! (Is that a word?) So, plan accordingly.
It is statistically safe to say that the baby will be Rh positive. If so, a simple injection will prevent you from developing antibodies and preserve the health of any future babies you have (planned or not)
I had to send a lovely Rh negative mother (who wanted her fourth baby to be born at home just like his previous two siblings) to a high risk Obstetrician for monitoring and intrauterine blood transfusions. She had refused the RhoGam injection after her third trusting instead on the low statistical risk to preserve future babies, but had become sensitized after her third birth to her third Rh positive baby.
I really think that it does not have to be complicated. If parents only ever had two babies prophylaxis would only rarely be warranted unless external version or injury to the pregnant abdomen had occurred.
If you are currently not iso-immunized to the Rh factor, then this pregnancy is like any other first pregnancy, and you start "fresh". If you are sterilized after giving birth this time, then you would not have to get an injection, because there would be no more babies. At least theoretically. But, if you plan on more babies or might want to keep that option open, an injection, after verifying Rh status of your newborn, is a simple and easy solution.
Very very few women become sensitized during pregnancy, but because it is a possibility-however remote, an injection is recommended during pregnancy as well as after any potentially disruptive procedure.
Rh isoimmunization during pregnancy: antenatal prophylaxis
J. M. Bowman, B. Chown, M. Lewis and J. M. Pollock
Canadian Medical Association Journal, Vol 118, Issue 6 623-627,
Copyright © 1978 by Canadian Medical AssociationOf 3533 Rh-negative women who began a pregnancy without detectable Rh antibodies, 62 (1.8%) demonstrated evidence of Rh isoimmunization during pregnancy or within 3 days after delivery. All denied transfusions as well as abortions or previous pregnancies not followed by the administration of Rh immune globulin. Rh isoimmunization during pregnancy or within 3 days after delivery, which will not be prevented by the administration of Rh immune globulin after delivery, is the most important cause of residual Rh isoimmunization. A clinical trial of antenatal administration of Rh immune globulin, initially at 34 weeks's and subsequently at 28 and 34 weeks' gestation, in 1357 Rh-negative pregnant women who were delivered of Rh-positive babies, was effective in preventing the development of Rh isoimmunization during pregnancy or within 3 days after delivery. Antenatal prophylaxis with Rh immune globulin will be necessary if the incidence of Rh isoimmunization is to be reduced to its lowest possible level. Antenatal prophylaxis at 28 weeks' gestation is now an insured service in Manitoba.
ABO and Rh
Overall, 16% of Rh-negative women will become sensitized after their first pregnancy if not given Rhogam. ABO incompatibility reduces this risk to 4-5%.[5] The reduced risk of Rh sensitization with ABO incompatibility may result from the rapid clearance of incompatible red cells thus reducing the overall exposure to D antigen.
http://www.obfocus.com/high-risk/Rh_disease/rh_diseasepr.htm (now moved to http://www.perinatology.com/Archive/Isoimmunization.htm)
Linda - retired midwife, USA
It is statistically safe to say that the baby will be Rh positive.
Actually if the father is heterozygous for Rh then there is a 50:50 chance that the baby will be Rh negative, while if he is homozygous for Rh positive then there is a 100% chance that the baby will be Rh positive.
It is statistically safe to say that the baby will be Rh positive. If so, a simple injection will prevent you from developing antibodies and preserve the health of any future babies you have (planned or not)
I only wish that it was as straightforward as "a simple injection" -- as I'm sure you're aware Anti-D is a blood product (non single- source) with all of the attendant risks of such a product. It also often contains thimerosal/thiomersal (spelling depends on which side of the pond you live on) which has an unknown impact on the developing foetus as well as the mother's immune system. A third worry is whether Anti-D prophylaxis in pregnancy could affect the antibody status of a Rh-ve female baby in utero -- it has not been used for long enough during pregnancy for us to assess the long term impact on the babies whose mothers accept prophylactic Anti-D at 28/40 weeks. We simply do not have enough evidence, nor is there enough research to make more than an educated guess.
What I am trying to do is assess the relative risk of prophylactic anti-D: weighing up the potential for harm to the baby in utero against the benefits for future siblings.
I have no qualms about taking Anti-D postnatally myself: I have done so twice, despite negative Kleihauer results. The Kleihauer test is at best a snapshot of the mother's reactive status *at the moment* that the blood was taken. It is also useful where fetomaternal transfusion has occurred in order to determine the dose of Anti-D required.
As with the mother you describe, I am aware of more than one case where a mother having declined Anti-D post-natally following a negative Kleihauer test has shown sensitisation for her next pregnancy. We still do not understand enough about the mechanics of foetomaternal transfusion and Rh sensitisation to know how or why this happens. For me that risk is unacceptably high, hence why I will always take Anti-D after the birth of a Rh+ baby, despite a negative Kleihauer result -- but this isn't relevant to the issue of Anti-D prophylaxis antenatally, which is the risk that I'm trying to assess. Knowing whether my husband is homozygous or hetrozygous for Rh+ is a significant factor in determining that risk.
Best wishes
Antonia, mother
Linda, thank you very much for the links and abstracts which you gave on this subject - the article you cited had lots of refs and detailed info, and links to other sources which look great.
I had a look at these, following on from your link:
http://www.obfocus.com/high-risk/Rh_disease/rh_diseasepr.htm (now moved to http://www.perinatology.com/Archive/Isoimmunization.htm)
http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=114183 - which has a section on genetic testing to determine parental and foetal Rhesus status, both in the UK and abroad
I know that Antonia has looked into this in great detail, and that Linda and Anna have had personal as well as professional experience of the topic. I've never really looked at the issue before, but scanning through the most recent abstracts on antenatal prophylaxis, it looks like the routine administration of anti-D at 28 weeks, compared to just giving it to women with risk factors like a known bleed or known blunt trauma to the abdomen, reduces the rate of sensitisation in pregnancy from about 1.5% to about 0.2%. The abstracts copied below mention a number of studies with numbers in this range. So taking routine anti-D antenatally reduces your risk of sensitisation in each pregnancy from about 1 in 67 to about 1 in 500. Does that accord with others' interpretations of this research?
If those studies are fair, then that's a very strong *known* benefit of routine antenatal anti-D - what, reducing your chances of sensitisation by about 7.46 ? It sounds like the problem is going to be weighing this benefit against the rational, but unproven, concerns that routine anti-D administration could be harmful. So is there any research on side-effects of anti-D to weigh against the benefits? Or any way of quantifying the chances of the routine anti-D causing problems in the future?
Re the concerns about female babies who are Rh negative becoming sensitised in utero - presumably this means you'd be less worried about antenatal prophylaxis if the baby was known to be a boy? And that if the father was known to be homozygous for Rh positive, since all babies would be Rh positive, again you could discount this concern regardless of the sex of the baby?
I didn't even know that babies could produce their own antibodies to anything in utero - excuse my ignorance, but I thought this was one of the reasons why, eg, catching chickenpox in the last fortnight of pregnancy was so risky. I suppose I always thought the baby's immune system just didn't kick in until it was born - perhaps that is naive of me!
Here are links to some relevant abstracts: to find them, go to PubMed (www.ncbi.nlm.nih.gov/sites/entrez) and copy the PMID into the search box.
Angela H, mother
J Gynecol Obstet Biol Reprod (Paris). 2006 Feb;35(1 Suppl):1S93-1S103.
[Comparison of the efficacy of different methods for the prevention of anti-D allo-immunization during pregnancy: targeted strategy limited to risk situations or associated with systematic prevention in the 3rd trimester]
RESULTS: Globally, immunization rate was to the order of 1.5% (1.2-1.9%) for targeted prevention limited to situations at risk and to the order of 0.2% (0-0.9%), all parities included, for systematic antenatal prevention. Comparative analyses have reported significant odds ratios of 0.20 and 0.37 in all subgroups.
CONCLUSION: Despite the heterogeneous nature of the published studies, available data are in favor of systematic prevention: either with a 300g dose at 28GW or 100g at 28GW and 34GW complementary to the postnatal prevention. Few data are available on the real perinatal benefit of systematic prevention.
Publication Types: Meta-Analysis Review
PMID: 16495834
Br J Obstet Gynaecol. 1998 Nov;105 Suppl 18:11-8.
The scientific basis of antenatal prophylaxis.
Urbaniak SJ.
Academic Transfusion Medicine Unit, Aberdeen, UK.
..A reduction in alloimmunisation is seen from 1.11% (4/360) in controls to <0.28% (0/362) in the treatment group in the French study , and from 0.95% (19/2000) in controls to 0.32% (4/1238) in the treatment group in the English study...
PMID: 9863973
I have recently changed Health Authorities - and at my new job, it is expected to give Anti-D at 28 weeks and 34 weeks to all primips and women with no live children. It is also then given postnatally as well! I feel extremely uncomfortable with this arrangement as at my last employer it was decided against as in 4 years with 2500 births a year, there had been only 2 women with antibodies detected. Imagine - 15% of these women being exposed to Anti-D for the sake of 2 women. Extreme. I suspect that my present employer sees it as a good idea as they are a referal centre for Rhesus disease. I currently spend quite a lot of time talking to the women about it, but they, mostly, have already been 'primed' by the GPs.
Lynn
I have been involved in raising issues for midwives and women around RhD/ Rhesus negative for some time and have articulated the shared concerns as explored on this email list BUT local voices have not been heard and this an example of communication and importance of womens health issues - the whole concept of choice is a farce at times!
The references below indicate this - plus I have networked widely with user groups etc to profile the issues. I was an active committee memeber of the British Blood Transfusion Society (BBTS) Committee of Special Interest Group on Alloimmune Diseases on the Fetus / Newborn London (1996-1998)
Published :-
Wray J Jackson-Baker A (2000) Anti-D immunolglobulin and antenatal prophylaxis. RCM Midwives Journal, February 2000, 3:2; 59-61 Wray J Benbow A (1999) In the spotlight: Current debate and issues surrounding anti-D immunoglobulin. MIDIRS Midwifery Digest 9:4; 517-519
Wray J, Vause S, Maresh M (1999) Maternity Care Audit: Management of women who are RhD negative in Northern Ireland. Project report for DoH Belfast Northern Ireland. RCOG, Clinical Audit Unit, Manchester, January 1999.
Everett C, Wray J (1998) Preventing RhD haemolytic disease of the newborn: New recommendations must be explained to GP’s and midwives (letter) British Medical Journal 3;16, 1164-65.
I am happy to debate further but we really should look at how we communicate ....
Julie Wray
Research Fellow
The University of Salford Salford M5 4QA
This has been an interesting thread. In my pratice (independent home and hospital as primary provider) I have had some exposure to women declining prenatal and postnatal Anti D.
I provide informed choice to all RhNeg women re the risks and benefits of AntiD prophylaxis. Most take it up. It is important to remember that the rate of isoimunnisation is 15%. So 85% of women do not become isoimmunised. If it was a significant risk to the population, there would be no RHneg individuals left as the numbers would have dwindled over thousands of years of reproduction!
My first experience was with a woman having her 5th child. She refused it prenatally and when the cord blood showed the newborn to be Rh+ she still declined (for religious reasons). I respected her choice, and documented it clearly.
The sticky question is when a woman and her "partner" are both Rh-, then I explain that my practice is to do cord bloods on the newborn. So far I have not had an issue with the 'father' not being the true father.
If the baby was Rh pos, I would approach the woman privately, and offer her Anti D.
But it is possible, in more than the usual way (wink, wink) A recent client's husband's sperm was treated before artificial insemination. I pointed out that there might be a small risk of error at the lab.
Freda, Ontario
In Australia over the last couple of years, the obs were routinely giving Anti D at 28/40, after every APH regardless of size of bleed and Kleihour results, they even tried to routinely give after all Rh-ve mums delivered. As a consequence Australia was very short of Anti D and loads of Rhogam was imported from the USA and of course had to be accompanied by a formal information session by the registrar and a formal consent form to be signed.
Judy
I have always told mums that Anti-D is a blood product, regardless of their religion. I just think it is an important piece of information as unless you have been told about it, you would never think of Anti-D being a blood product, it sounds like some artificially made product. I certainly did not know about it until I started my midwifery training. Until now I have not come across any women who had refused it because of it being a blood product once they know the reason why it is reccomended, but of course, there are probably some women who might refuse it, and unless we give them the information they will not have that choice.
Jo
I would suggest that you look at the following work of Sara Wickham with reference to an alternative view of RHesus incompatibility and anti-D. Sara is the only person I know challenging the belief that every Rh neg woman requires anti-D.
Wickham, S (1999) Anti-D: Exploring Midwifery Evidence MIDIRS Midwifery Digest, Vol 9, No 4, December 1999, pp 452-458.
Wickham, S (1999) Anti-D; A woman’s choice (2) Practising Midwife, Vol 2, No 6, pp 38-39.
Wickham, S (1999) Anti-D; A woman’s choice (1) Practising Midwife, Vol 2, No 5, May 1999, pp18-19.
Lorna Davies
Is it now routine everywhere to give anti - D to all neg. women? I am neg -but have not had anti -D. Both my babies were neg I presume as I was told I didnt need it. My husband is positive. Seems a shame to have something that may not be needed. Do they not test for antibodies and blood group anymore, and give only if needed?
Jane (antenatal teacher)
Here in sunny Perth, we only give Anti-D to Rh neg women if the baby is Rh pos. Perhaps this is done because we have problems with our Anti-D supply, and sometimes have to 'resort' to Rhogam from the US. Maybe in the UK with more plentiful supplies of Anti-D, it is more cost effective to give Anti-D than test the babies. Perhaps at least a blood group for the babies could be offered to women with reservations or objections to Anti D, so they don't get it unless they need it.
Kirsten Blacker
Here in rainy Wales, it's given in our area to all Rh -ve women prior to receiving cord blood results! There also appears to be moves a foot to give to all at 28/40 and at another point in Preg. New RGOG guidelines, call me cynical but all the glossy guidelines that appeared from RCOG were paid for by the drug company who produces anti-D.
Cate
In Australia over the last couple of years, the obs were routinely giving Anti D at 28/40, after every APH regardless of size of bleed and Kleihour results, they even tried to routinely give after all Rh-ve mums delivered. As a consequence Australia was very short of Anti D and loads of Rhogam was imported from the USA and of course had to be accompanied by a formal information session by the registrar and a formal consent form to be signed.
I came across a lady whose religion is Jehovah's Witness. Fortunately the babe was Rh- too, but until I came across this situation I never considered that such a group should recieve information that anti D is a blood product and that due to their beliefs they may refuse the medication. Any thoughts.......
Robyn
Robyn, you are quite right. I knew a grand multip who was Rh- and whose religion was JW. As the last baby was born over 2 years ago, I can't recall whether we took blood for antibody screening, or for kleihauer at delivery. I recall discussing the issues with her, and she certainly never had any Anti-D treatment. The babies I knew were all breast fed, and none had any more than the usual physiological jaundice. I really can't remember if we knew the blood groups of these babies or not. I feel that it is important to inform all Rh-ve mums about Anti-D being a blood product.
Janet
See Sara Wickham's book about Anti D.
You can probably buy it in the shop part of her website. Here are
links to the two articles about it by her:
http://www.withwoman.co.uk/contents/info/antid.html
http://www.withwoman.co.uk/contents/info/anantid.html
Kirsten
A little while ago I cared for a British woman who had the first part of her care in the UK. She was needle phobic and had declined blood tests, and had it written on her chart (her blood group was known to be O Positive due to previous testing). So she came to me... We discussed blood tests and she declined, I documented.
Then in late pregnancy she developed an increased BP. Eventually she made a decision to be induced (actually against my advice if I remember correctly as BP meds could have been used to stabilise her and BP wasn't that raised)...as part of the induction we had to hold her down and insert a cannula and bloods were taken (very traumatic I can assure you, but she consented to restraint prior to cannula insertion)...just as I was about to rupture her membranes and start the Syntocinon drip a call came from the lab... "That blood you sent this morning has a strange antibody, it is being sent to Wellington and we won't be able have cross-matched blood for her until the morning"
As it turns out the antibody was harmless for the woman and baby and they were able to cross-match some blood (although we didn't need it!) for her by the end of the day...but my lesson was learnt that regardless of rhesus status you can still get an odd antibody that shows.
We've just had another one come through, with Anti-Kell and Anti-e antibodies, a very high titre and climbing, she's O-positive too. Unfortunately she's been warned that her baby is at risk for hydrops fetalis and may need an intrauterine blood transfusion in order to survive.
My partner also had a woman who had previously screened negative for antibodies (again Opos) become positive for antibodies.
Now we don't have a large caseload, about 50 women per year, so that's three in four years, three out of approx 200 women...
I'm reluctant not to screen for antibodies now, although obviously it's a choice thing.
..It is of course up to you whether you have the test or not, but be aware that you can develop dangerous antibodies even if you are a postive blood group. You can develop an antibody in pregnancy too, that perhaps wasn't present on your initial screening... It is rare but it happens, as the woman on my caseload who is facing an intrauterine blood transfusion for Anti Kell and anti e antibodies will tell you.
Annemarie - midwife, New Zealand
We had a lady last year with Anti-K antibodies, diagnosed at 32 weeks that baby had hydrops fetalis, was born at 33/34 weeks and died at 3 days old. She was O +ve as well.
Claire - Student midwife
I work on a pregnancy and birth helpline, but sometimes get medical calls which are beyond my knowledge as an antenatal teacher. I had a woman phone today who is 12 weeks pg, B+, and has been told her blood test showed she had antibodies and that they needed to keep a close eye on her. Nothing else was explained to her and she was panicking. I told her to go back to her mw, or ring the hospital mws for further info as I hadn't come across this before. Obviously it's a danger in rhesus neg women, but can someone explain how common this is in a pos woman and what the implications might be.
Sam - antenatal teacher (ANT)
Women can have other irregular antibodies, not just anti D. I don't have figures about how common they are. If a mum makes any antibodies during her pregnancy they can cross the placenta and harm the baby. What will probably happen with this mum is that she will be asked for a repeat blood test every month to check if the level of antibody is rising. Depending on how high it rises affects how seriously the baby may be affected. I'm caring for a mum at the moment with anti Jka antibodies, she had them on a previous pregnancy and they never rose above 2 (which means the baby has a very low risk), but we're still checking them monthly on this one. Coincidently, she previously also had anti-e antibodies, but they're not there at the moment!!!!
Janet - midwife
Yes, we've had a couple of midwives on the list write this year about caring for women with anti-M, anti-Kell and anti-e antibodies.
In addition, it seems that for women who are Rhesus negative and who have an injection of anti-D, the jab can cause anomalous blood test results as it can provide you with a range of antibodies, not just anti-D. You also have to be careful about giving anti-D around the same time as immunisations as they can interact.
If anyone's interested in this, have a look at the section on antibodies in this anti-D information leaflet, from the drug manufacturer:
http://www.bpl.co.uk/shared/downloads/frameset/frameset.asp?PDF=Anti-d
I think this is also mentioned in the NICE technology appraisal report for Anti-D (different from their guidance on Rhesus neg issues) which is here: http://www.nice.org.uk/page.aspx?o=31696
Angela,mother
I have recently been attending women who choose physiological 3rd stages from time to time, but as I do not routinely clamp or cut the cord I have a dilemma - when to obtain cord blood for a Kliehauer?
Although the Trust that I work for recommend all (rhesus negative) women to have anti-D, I prefer to test cord and maternal blood. Most of the time, the cord is 'drained' after the 3rd stage with physiological management - I worry about affecting the progress of the 3rd stage by taking blood from the cord prior to completion of the 3rd stage. Any ideas?
Lynn
The way we manage blood sampling for the direct Coombes test following birth of baby to Rhesus neg woman is to allow the cord to finish pulsating (keeping quite a close eye) and AS SOON as it has, to double-clamp the cord. As soon as the blood sample has been taken the maternal end can be released again, to allow the maximum reduction of the placenta before third stage completes. We usually seem to have enough blood left in the cord to do this, but if not, we have in the past got enough from the blood vessels in the placenta following the end of 3rd stage.
Melanie
This is an interesting issue, physiological third stage and rhesus neg mothers. Except in very rare situations I leave the 3rd stage to progress on its own. Normally if a woman is rhesus neg I just take blood from the placental vessels and cord following the birth of the placenta. I have not come across problems with this and have picked up equally both positive and rh neg babies this way.
What do other midwives do? Is there any actual evidence out there that taking blood this way for a coombs test is not reliable? I agree that flapping around as soon as the baby has joined us is distruptive and I believe unnecessary.
Susan
Independent midwife (London)
Anti-D: Exploring Midwifery Knowledge, by UK midwife Sara Wickham, on the With Woman website.
(www.withwoman.co.uk/contents/info/antid.html), and by the same author:
Routine antenatal anti-D - a review of the evidence
(www.withwoman.co.uk/contents/info/anantid.html)
From NICE - the UK's National Institute for Clinical Excellence:
NICE press release on guidance for rhesus negative women during pregnancy - 10 May 2002 (NICE 2002/ 024).
(www.nice.org.uk/article.asp?a=31717)
Full guidance on the use of routine antenatal anti-D prophylaxis for RhD-negative women (PDF)
(www.nice.org.uk/Docref.asp?d=31686)
Assessment report of the clinical effectiveness and cost effectiveness of routine anti-D prophylaxis for pregnant women who are rhesus (RHD) negative
This document is the health technology assessment report prepared by the School of Health and Related Research at the University of Sheffield (ScHARR).
(www.nice.org.uk/pdf/prophylaxisHTAreport.pdf)
US Midwife Archives section on rhesus negative mothers
(www.gentlebirth.org/archives/genpcare.html#RhoGAM)
Detailed overview , from 'Drugbase' in the USA.
(www.drugbase.co.za/data/med_info/rhesus.htm)
An 'alternative' perspective from 'Mango Mama', focusses on worries about administration of Anti-D during pregnancy.
(www.geocities.com/Heartland/Woods/2924/rh.html)
AH updated 1 September 2009