CHHS17/216

Canberra Hospital and Health ServicesClinical ProcedureAnti-D AdministrationContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Background.............................................................................................................3

Section 2 – Administration of Anti-D.........................................................................................4

Administration of Anti-D.......................................................................................................4

Prophylactic Anti-D............................................................................................................... 4

Anti-D for potential sensitising events during pregnancy.....................................................4

Miscarriage, termination of pregnancy or genetic studies in the first trimester (weeks 1-12)..................................................................................................................................... 5

Miscarriage, termination of pregnancy or genetic studies e.g. amniocentesis in the second and third trimester (beyond week 12)..................................................................5

Trauma..............................................................................................................................5

Women whose pregnancy is >12/40 with intermittent vaginal bleeding..........................5

Postnatal Anti-D (within one hour of birth)..........................................................................6

Commence ‘Postnatal RhD Immunoglobulin (Anti-D) Pathway-for women with RhD negative blood group............................................................................................................6

Postnatal ward/Birth Suite....................................................................................................6

Intrauterine fetal death........................................................................................................ 6

Cell salvage............................................................................................................................6

Storage..................................................................................................................................6

Documentation.....................................................................................................................6

Outcome............................................................................................................................... 7

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................7

References................................................................................................................................ 8

Search Terms............................................................................................................................ 8

Attachments..............................................................................................................................8

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Attachment 1 – RhD Immunoglobulin (Anti-D) Pathway – for women with sensitising events during pregnancy.......................................................................................................9

Attachment 2 – Postnatal RhD Immunoglobulin (Anti-D) Pathway-for women with RhD negative blood group..........................................................................................................10

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Purpose

The purpose of this procedure is to identify those women who require Anti-D (RhD) immunoglobulin and the administration of the required dose.

RhD immunoglobulin is offered to all RhD negative women (with no preformed anti-D antibodies): prophylactically at 28 and 34 weeks as per NHMRC guidelines following a sensitizing event during pregnancy after birth if their baby/babies has a RhD positive blood group.

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Scope

Alerts

Rh D Immunoglobulin (RhD-Ig or Anti-D) is a blood product and the transmission of infective agents cannot be totally excluded even though there have been no documented reports of this product being responsible for the transmission of disease.

There may be some mild reactions for example mild pyrexia, malaise and urticaria after intramuscular injections.

True allergic responses are rare.

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This Standard Operating Procedure (SOP) describes for staff the process to

CHHS17/216

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Section 1 – Background

RhD immunoglobulin can be recommended for RhD negative women with no preformed anti-D antibodies (level II evidence). The Australian product recommended for use in antenatal prophylaxis contains 625 IU (125 µg), which is an appropriate dose.(NHMRC Guidelines 2003, p 9).

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Section 2 – Administration of Anti-D

Administration of Anti-D Anti-D (RhD) immunoglobulin should be administered by deep intramuscular injection. It should not be given subcutaneously. The deltoid muscle or the anterolateral thigh is the best site. The buttocks should be avoided.

For women with a body mass index (BMI) of 30 or more, particular consideration should be given to factors which may impact on the adequacy of the injection, including the site of administration and the length of the needle used (National Blood Authority, Australia).

Prophylactic Anti-D Offer antenatal RhD Immunoglobulin immunization to all RhD negative women at 28 and

34 weeks as per NHRMC Guidelines (2003). Check previous antibody titre results for any preformed Anti-D antibodies prior to

administration at 28 weeks – test should have been attended within past two weeks and results clearly documented in the clinical record.

Explain that the indication for the use of RhD immunoglobulin in RhD negative pregnant woman is to prevent RhD antibody formation.

Give written information: o The Use of Anti-D in Pregnancy Canberra Hospital Brochure or ACT Health Maternity

Shared care Guidelines Fact Sheet Anti-D in Pregnancyo You and Your baby: Important information for RhD-negative Women Australian Red

Cross Brochure. Explain to the woman the potential risks and potential side effects of RhD

immunoglobulin Check blood group and recent antibody result with 2nd midwife/midwifery student Obtain consent and document in clinical record, prescribe and administer RhD

immunoglobulin. Document administration in electronic medical record - Birthing Outcomes System (BOS),

medication chart and pathway and handheld Maternity Record booklet. Following the administration of the 28 week RhD immunoglobulin ensure the woman has

an appointment to return at 34 weeks.

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ALERTThe RhD immunoglobulin prophylactic dose of 625 IU is given at 28 and 34 weeks. It is only given after an antibody screen has been attended and results obtained at 28 weeks.When completing the pathology form for the antibody screen the woman’s gestation must be clearly documented.

Anti-D for potential sensitising events during pregnancyRhD Immunoglobulin is given to RhD negative women for the following indications: miscarriage or threatened miscarriage termination of pregnancy ectopic pregnancy antepartum haemorrhage trauma external cephalic version genetic studies where transplacental access is needed or puncture of fetal blood vessels

is performed such as chorionic-villus sampling or amniocentesis Intrauterine fetal death

Note: Document in the clinical record and notify medical officer if the woman does not consent to the administration of RhD Immunoglobulin

Alert:Test for fetal maternal haemorrhage not required before 20 weeks.

Miscarriage, termination of pregnancy or genetic studies in the first trimester (weeks 1-12) Administer one dose of RhD Immunoglobulin 250 IU for a single pregnancy. Administer one dose of RhD Immunoglobulin 625 IU for a multiple pregnancy. No further action is required.

Miscarriage, termination of pregnancy or genetic studies e.g. amniocentesis in the second and third trimester (beyond week 12) Administer one dose of RhD Immunoglobulin 625 IU Follow Attachment 1 ‘RhD Immunoglobulin (Anti-D) Pathway – for women with

sensitising events during pregnancy’

Trauma Collect the woman's blood for feto-maternal haemorrhage (FMH) testing within one

hour, or as soon as possible after the trauma. Transfusion serology / haematology will issue a report with the FMH quantification

within 72 hours and notify the woman's ward of the dose of RhD Immunoglobulin that is required.

Collect the woman's blood for an Anti D titre 36-48 hours following administration of RhD Immunoglobulin.

Follow Attachment 1 ‘RhD Immunoglobulin (Anti-D) Pathway – for women with sensitising events during pregnancy’

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Women whose pregnancy is >12/40 with intermittent vaginal bleeding Following the first episode of bleeding collect the woman's blood for feto-maternal

haemorrhage (FMH) testing within one hour of the bleed, or as soon as possible. Transfusion serology/haematology will notify the ward of the dose of RhD

Immunoglobulin that is required. Follow Attachment 1 ‘RhD Immunoglobulin (Anti-D) Pathway – for women with

sensitising events during pregnancy’ Following each subsequent episode of bleeding repeat the group and antibody screen

and Anti-D titre and consult with the Transfusion laboratory. DO NOT Administer RhD Immunoglobulin unless recommended by Transfusion Pathologist

For women with continued bleeding repeat the group and antibody screen every 48 hours.

Postnatal Anti-D (within one hour of birth)Commence ‘Postnatal RhD Immunoglobulin (Anti-D) Pathway-for women with RhD negative blood group Collect blood from the woman for feto-maternal haemorrhage (FMH) testing within one

hour of birth. Collect and send baby’s cord blood for group and Direct Coombs Test.

Postnatal ward/Birth Suite Check baby’s blood group results from pathology transfusion lab within 24 hours of birth

o If the baby’s blood group is RhD negative no further action is required.o If the baby’s blood group is RhD positive, Anti-D will be required for baby’s mother.

Administer intramuscular RhD Immunoglobulin (Anti-D) 625 IU to the woman with informed consent (within 48-72 hours of birth).

Complete medication chart and ensure the standing order is signed by medical officer within 24 hours.

If more than one dose of anti-D is required pathology transfusion lab will inform the ward staff within the next 36-48 hrs.

Intrauterine fetal deathAn appropriate dose of anti D should be given within 24 hours of diagnosis of intrauterine death, irrespective of time of subsequent delivery.

Cell salvageIf cell salvage is used the infused blood may contain up to 20mls of fetal cells; thus a large dose of anti D may be required, >1500 IU. If such a dose is required the please seek advice from transfusion laboratory pathologist re appropriate administration. A maternal sample for quantification of fetal cells should be done within 45 minutes of infusion.

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StorageAnti-D is to be stored in vaccine fridges with daily monitoring of temperature. Refrigerate between 2oC - 8oC, do not freeze. Protect from light.

Documentation Document the administration of RhD immunoglobulin on the RhD immunoglobulin

postnatal flow chart and the woman’s medication sheet. Ensure that the imprest card is returned to the pathology transfusion laboratory with the

recipient’s full name, DOB and MRN (if available) and anti-D batch number. This ensures future traceability for the anti-D product.

Outcome Women requiring RhD Immunoglobulin understand why this intervention was necessary RhD immunoglobulin has been administered to women with no preformed antibodies at

28 weeks and at 34 weeks gestation who have given their consent. RhD immunoglobulin has been administered to women with no preformed antibodies,

following sensitising events during pregnancy and after birth if the baby’s blood group is RhD positive.

Use of RhD Immunoglobulin has been safe and appropriate.

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Implementation

This guideline will be discussed at Multidisciplinary Education and Unit meetings. It will be available to access via Policy and Clinical Guidance on the ACT Health Intranet.

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Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and treatment

Procedures CHHS Healthcare Associated Infections Clinical Procedure CHHS Patient Identification and Procedure Matching Policy

Guidelines CHHS Fasting Guidelines – Elective and Emergency Surgery

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011

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References

1. ACMI National Midwifery Guidelines for consultation and referral, 20082. ACT Health, 2008, Maternity Shared Care Guidelines 3. National Blood Authority, 2005, Guidelines on the prophylactic use of RhD

immunoglobulin (anti-D) in obstetrics4. https://www.ranzcog.edu.au/RANZCOG_SITE/media/DOCMAN-ARCHIVE/Guidelines

%20for%20the%20use%20of%20Rh(D)%20Immunoglobulin%20(Anti-D)%20(C-Obs%206)%20Review%20November%202015.pdf

5. www.transfusion.com.au/disease_therapeutics/pregnancy_anti-D : RhD immunoglobulin Material Fax Request Sheet

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Search Terms

Rhesus, Anti D, RhD Immunoglobulin

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Attachments

Attachment 1 – RhD Immunoglobulin (Anti-D) Pathway – for women with sensitising events during pregnancy

Attachment 2 – Postnatal RhD Immunoglobulin (Anti-D) Pathway – f or women with RhD negative blood group.

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Attachment 1 – RhD Immunoglobulin (Anti-D) Pathway – for women with sensitising events during pregnancy

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Attachment 2 – Postnatal RhD Immunoglobulin (Anti-D) Pathway-for women with RhD negative blood group

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