Rh D Immunoglobulin (Anti-D)

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Rh D Immunoglobulin (Anti-D) 1 WACSClinproc3.2/09Oct-10

3.2/09WACS

Title: Rh D Immunoglobulin (Anti-D)

Replaces: Rh D Immunoglobulin (Anti-D) WACSClinProc3.2 Dec2007Description: The use of prophylactic Anti D in obstetricsTarget Audience: Midwives and medical officers, QVMUKey Words: Rh negative, Rh D Immunoglobulin, Anti-D

Policy Supported: Statewide Policy for Transfusion of Blood & Blood Components

Purpose:The administration of Rh D immunoglobulin (Anti-D) has been shown to result in asignificant reduction in the incidence of Rh isoimmunisation.

Summary of dosing recommendations for Rh D ImmunoglobulinObstetric conditions

Sensitising events in the first trimester (singleton pregnancy) 250 IU (50g)Sensitising events in the first trimester (multiple pregnancy) 625 IU (125g)Sensitising events beyond the first trimester 625 IU (125g)

PregnancyAntenatal prophylaxis (28 and 34 weeks gestation) 625 IU (125g)

Postpartum 625 IU (125g)

General

For successful immunoprophylaxis, Rh D immunoglobulin should be administeredas soon as possible after the sensitising event, but always within 72 hours.

If Rh D immunoglobulin has not been offered within 72 hours, a dose offered within9 10 days may provide protection.

Blood for Kleihauer and antibody screening should be taken from the mother beforeadministration of the Rh D immunoglobulin to assess the magnitude of fetomaternalhaemorrhage (FMH). A single dose of Rh D immunoglobulin should not bewithheld based upon or pending these results.

Where FMH quantitation (Kleihauer) shows that FMH greater than that covered bythe dose already administered has occurred, administration of an additional dose/s

sufficient to provide immunoprophylaxis must be administered and preferable within72 hours.

Sensitising Events in the First Trimester

A dose of 250 IU (50g) Rh D immunoglobulin should be offered to every Rh Dnegative woman with no preformed anti-D to ensure adequate protection againstimmunisation for the following indications up to and including 12 weeks gestation:

o miscarriageo termination of pregnancyo ectopic pregnancyo chorionic villus sampling.

A dose of 250 IU (50g) Rh D is sufficient to prevent immunisation by afetomaternal haemorrhage of 2.5ml of fetal red blood cells (5ml of whole blood).

Womens & Childrens Services

Clinical GuidelinesSDMS ID: P2010/0305-001


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There is insufficient evidence to support the use of Rh D immunoglobulin inbleeding prior to 12 weeks gestation in an ongoing pregnancy, although if thepregnancy requires curettage Rh D immunoglobulin should be given. If miscarriageor termination occurs after 12 weeks gestation, 625 IU (125g) Rh Dimmunoglobulin should be offered.

Sensitising Events Beyond the First Trimester

A dose of 625 IU (125g) Rh D immunoglobulin should be offered to every Rh D

negative woman with no preformed anti-D to ensure adequate protection againstimmunisation for the following indications after 12 weeks:

o genetic studies (chorionic villus sampling, amniocentesis and cordocentesis)o abdominal trauma considered sufficient to cause fetomaternal haemorrhageo each occasion of revealed or concealed antepartum haemorrhage (where

the woman suffers unexplained uterine pain the possibility of concealedantepartum haemorrhage should be considered, with a view toimmunoprophylaxis

o external cephalic version (performed or attempted)o miscarriage or termination of pregnancy.

Antenatal ProphylaxisAll women should have ABO and Rh D typing at their first antenatal visit to identifywomen who may require the administration of prophylactic anti-D during pregnancyand after birth.

All Rh D negative women should have an antibody screen at 26 to 28 weeksgestation.

Universal prophylaxis with Rh D immunoglobulin 625 IU (125g) to Rh D negativewomen at 28 and 34 weeks gestation is generally regarded as best practice.

Postpartum

Cord blood should be collected and sent to pathology for blood group and Coombstest. The sample must be labelled with the newborns UR, maternal surname andB/O maternal Christian name, infants gender, date and time of birth and date andtime of collection.

Maternal blood should be collected within 24 hours of birth to assess FMH(Kleihauer Test) and the dose of Rh D immunoglobulin required.

Rh D immunoglobulin should be offered to every Rh D negative woman followingdelivery of an Rh D positive baby.

Rh D immunoglobulin should not be given to women with preformed anti-Dantibodies, except where the preformed anti-D is due to the antenatal administrationof Rh D immunoglobulin.

Kleihauer TestThe Kleihauer test is used to identify women with large FMH who may need additionalanti-D immunoglobulin to ensure clearance of all fetal red blood cells. A negativeKleihauer test indicates that one dose of anti-D immunoglobulin is sufficient.

Administration and Documentation

The LGH Transfusion Medicine Request Form A/2500 is to be completed by amedical officer to obtain the Rh D immunoglobulin from pathology.

The Human Anti-D Antibody Product Administration Form 17H should becommenced antenatally and used to document all administrations of Anti-D.

Rh D immunoglobulin should be checked by two midwives prior to administration asper the Statewide Policy for Transfusion of Blood & Blood Components.


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Rh D immunoglobulin should be given as a deep intramuscular injection using alarge bore needle into the deltoid muscle or the anterolateral thigh.

If a dose of more than 5ml is required it is recommended to administer it in divideddoses at different sites.

AttachmentsAttachment 1 References

Performance Indicators: Evaluation of compliance with guideline to be achieved throughmedical record audit annually by clinical Quality improvementMidwife WACS

Review Date: Annually verified for currency or as changes occur, andreviewed every 3 years via Policy and Procedure workinggroup coordinated by the Clinical and Quality improvement

midwife. January 2012.

Stakeholders: Midwives and medical staff WACS

Developed by: Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director(Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)

Womens & Childrens Services Womens & Childrens Services

Date: _________________________


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ATTACHMENT 1References

Australian & New Zealand Society of Blood Transfusion Ltd 2007 Guidelines for bloodgrouping and antibody screening in the antenatal and perinatal setting, online:http://www.anzsbt.org.au/publications/index.cfm

National Health & Medical Research Council 2003 Guidelines on the prophylactic use of

Rh immunoglobulin (anti-D) in obstetrics, online:http://www,nhmrc.gov.au/publications/synopses/wh33syn.htm

Royal Australian and New Zealand College of Obstetricians and Gynaecologist 2007College Statement Guidelines for the use of Rh (D) Immunoglobulin (Anti-D) in Obstetricsin Australia, online:http://ranzcog.edu.au/publications/collegestatements.shtml#CObs
http://www.anzsbt.org.au/publications/index.cfmhttp://www.anzsbt.org.au/publications/index.cfmhttp://www%2Cnhmrc.gov.au/publications/synopses/wh33syn.htmhttp://www%2Cnhmrc.gov.au/publications/synopses/wh33syn.htmhttp://ranzcog.edu.au/publications/collegestatements.shtml#CObshttp://ranzcog.edu.au/publications/collegestatements.shtml#CObshttp://ranzcog.edu.au/publications/collegestatements.shtml#CObshttp://www%2Cnhmrc.gov.au/publications/synopses/wh33syn.htmhttp://www.anzsbt.org.au/publications/index.cfm

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Rh D Immunoglobulin (Anti-D)