This CPG guides the administration of Rh D Immunoglobulin (Anti-D) to Rh D negative pregnant women including post partum administration, antenatal administration for sensitising events and antenatal prophylaxis. It is based on recommendations contained in Guidelines on the Prophylactic Use of RhD Immunoglobulin (anti D) in Obstetrics. NH&MRC. June 2003.
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For successful immunoprophylaxis, Rh D Immunoglobulin should always be administered as soon as possible after the sensitising event, but always within 72 hours. If Rh D Immunoglobulin has not been offered, a dose offered within 9-10 days may provide protection.
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All women should be offered routine antenatal blood group testing according to the Red Cell Antibody Testing In Pregnancy CPG Red Cell Antibody Testing In Pregnancy CPG
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When to give Rh D Immunoglobulin
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Refer to the following table: Rh D Immunoglobulin for Rh D Negative women with no preformed Anti-D.
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Rh D Immunoglobulin for Rh D Negative women with no preformed Anti-D
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| First Trimester Sensitising Events |
| Rh D Ig 250 IU* (ARCBS/CSL brand product)
| - Threatened / spontaneous abortion without curettage (conflicting evidence)
- Surgical or medical abortion (Level II / III evidence)
- Ectopic pregnancy
- Chorionic villus sampling (CVS)
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| *If gestation unclear / possibly > 12 weeks / multiple pregnancy: default to 625IU dose
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| Second / Third Trimester Sensitising Events
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| Initial dose* Rh D Ig 625 IU (ARCBS/CSL brand product)
| - Chorionic villous sampling or amniocentesis beyond 12 weeks
- Abdominal trauma
- Ante-partum haemorrhage
- External cephalic version (level III evidence)
- Fetal loss beyond 12 weeks
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| *An assessment of Feto-Maternal Haemorrhage (FMH test) should be performed to see whether additional doses of anti-D are required.
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| | Rh D Ig 625 IU (ARCBS/CSL brand product)
| 28 week visit (extra antenatal visit at RWH)
34 week visit (At RWH & instead of 33 week visit)
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| | Rh D Ig 625 IU (ARCBS/CSL brand product)
| - All Rh D negative women delivering an Rh D positive infant within 72 hours of birth.
- All Rh D negative women with an Rh D positive infant should have an estimate of feto-maternal haemorrhage (FMH test) to determine the need for additional doses of anti-D.
- Advice regarding administration of additional doses for women with a greater than 6 ml FMH can be obtained from the Haematologist on-call.
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Postpartum Use: Rh D Ig 625 IU (ARCBS/CSL brand product)
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Post birth or fetal loss from 20 weeks gestation
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Indication
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All Rh D negative woman with no preformed anti-D¹, post delivery or post fetal loss > 20 weeks gestation, who give birth to an Rh D positive (or unknown group) infant.
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| | | | | | Cord Blood
(Infant's details)
- Infant's UR No.
- Maternal surname &
- Christian name
Infant gender
Date & time of birth
Date & time of blood collection
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| Blood Group and
DAT (Coombs test)
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| Maternal Blood (Post Birth)
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| Cord Blood Rh D Positive / weak D
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| | - Administer Rh D Ig 625IU to mother
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Discussion guidelines
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A guide for discussing Rh status with pregnant women: Rh D Immunoglobulin in Obstetrics - Discussion Guidelines
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Administration and Documentation Checklist
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Rh D Immunoglubulin (Anti-D) is a blood product and its administration should be strictly documented in accordance with the Blood Products: Transfusion policy (Intranet access only)
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This ensures full traceability of the product issued to any individual in the event of any recall from the Australian Red Cross Blood Service or adverse reactions. Any clinician administering Rh D Immunoglobulin is responsible for the following:
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1. Ensuring that Anti-D and has been fully discussed with women prior to administration
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2. Complete and sign the Blood Bank Release Order Form and collect Anti D from the Blood Bank, Core Laboratory, Level 1. Link to Royal Women's Hospital Transfusion site (Intranet access only)
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3. Document the administration of Anti D on Page 6 - Record of Pregnancy Care MR 90097 (antenatal) or the maternal drug chart (postnatal), including:
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- dose (625 IU or other dose)
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- date and time administered
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4. Complete and return the Batch Product Issue Form which is issued with Anti D from Blood Bank::
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- place a patient identification label (or handwrite: full name, DOB and UR)
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5. If a woman has declined Anti-D antenatally, this should be documented by:
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- circling 'Declined' on Page 6 - Record of Pregnancy Care MR 90097
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- having the woman sign in the space provided
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- name and staff signature in space provided
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6. If a woman has declined Anti-D postnatally, this should be documented by:
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- indicating a variance on her care plan
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- entering Anti-D was declined after full discussion on the variance sheet
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Note: Blood Bank staff no longer inform clinicians that Anti-D is ready for collection for any Rh D Negative mother whose newborn tested Rh D Positive. It is the responsibility of ward staff to check and ensure that any Rh D Negative woman who requires Anti-D according to these guidelines, is given this prior to discharge home (and within 72 hours of infant's birth).
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Notes
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1. Sometimes passive anti-D will be detectable at delivery due to administration of prophylactic Anti-D injections. Where there is any doubt as to whether detectable anti-D is due to passive administration or represents active alloimmunisation, Anti -D should be given.
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2. Pathology specimens must be labelled with the patient Surname, First Name and DOB and/or UR number. The date and time of collection must be indicated on the sample tube. If a patient identification label is used, the label must be signed and dated. Verification of patient details must be performed at the time of sample collection by inspection of the patient wristband or by direct inquiry. Samples must be labelled immediately after collection and before leaving the patient bedside. Refer Specimen Labelling and Signing Policy (Intranet access only)
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3. The FMH test result will indicate whether additional doses of Anti D are required. It is not necessary to wait for the FMH test result before administering the first dose of Anti D. Additional doses should be given within 72 hours of delivery. In rare instances where massive FMH has occurred and > 4 vials of Anti D are required, administration advice should be sought from the Haematologist on-call.
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References
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- Rh D Immunoglobulin in Australia: Past Present & Future. CSL & Australian Red Cross Blood Service. 2002
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- Guidelines on the prophylactic use of Rh D Immunoglobulin (Anti D) in obstetrics. NHMRC Report. 22 March 1999
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- Guidelines on the prophylactic use of RhD immunoglobulin in obstetrics. NH&MRC Report. June 2003.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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