Womens & Childrens Services

SDMS ID: P2010/0305-001 Clinical Guidelines

3.2/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Rh D Immunoglobulin (Anti-D) Rh D Immunoglobulin (Anti-D) WACSClinProc3.2 Dec2007 The use of prophylactic Anti D in obstetrics Midwives and medical officers, QVMU Rh negative, Rh D Immunoglobulin, Anti-D Statewide Policy for Transfusion of Blood & Blood Components

Purpose: The administration of Rh D immunoglobulin (Anti-D) has been shown to result in a significant reduction in the incidence of Rh isoimmunisation. Summary of dosing recommendations for Rh D Immunoglobulin Obstetric conditions Sensitising events in the first trimester (singleton pregnancy) Sensitising events in the first trimester (multiple pregnancy) Sensitising events beyond the first trimester Pregnancy Antenatal prophylaxis (28 and 34 weeks gestation) Postpartum

250 IU (50g) 625 IU (125g) 625 IU (125g) 625 IU (125g) 625 IU (125g)

General For successful immunoprophylaxis, Rh D immunoglobulin should be administered as 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 within 9 10 days may provide protection. Blood for Kleihauer and antibody screening should be taken from the mother before administration of the Rh D immunoglobulin to assess the magnitude of fetomaternal haemorrhage (FMH). A single dose of Rh D immunoglobulin should not be withheld based upon or pending these results. Where FMH quantitation (Kleihauer) shows that FMH greater than that covered by the dose already administered has occurred, administration of an additional dose/s sufficient to provide immunoprophylaxis must be administered and preferable within 72 hours. Sensitising Events in the First Trimester A dose of 250 IU (50g) Rh D immunoglobulin should be offered to every Rh D negative woman with no preformed anti-D to ensure adequate protection against immunisation for the following indications up to and including 12 weeks gestation: o miscarriage o termination of pregnancy o ectopic pregnancy o chorionic villus sampling. A dose of 250 IU (50g) Rh D is sufficient to prevent immunisation by a fetomaternal haemorrhage of 2.5ml of fetal red blood cells (5ml of whole blood).
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There is insufficient evidence to support the use of Rh D immunoglobulin in bleeding prior to 12 weeks gestation in an ongoing pregnancy, although if the pregnancy requires curettage Rh D immunoglobulin should be given. If miscarriage or termination occurs after 12 weeks gestation, 625 IU (125g) Rh D immunoglobulin 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 against immunisation for the following indications after 12 weeks: o genetic studies (chorionic villus sampling, amniocentesis and cordocentesis) o abdominal trauma considered sufficient to cause fetomaternal haemorrhage o each occasion of revealed or concealed antepartum haemorrhage (where the woman suffers unexplained uterine pain the possibility of concealed antepartum haemorrhage should be considered, with a view to immunoprophylaxis o external cephalic version (performed or attempted) o miscarriage or termination of pregnancy. Antenatal Prophylaxis All women should have ABO and Rh D typing at their first antenatal visit to identify women who may require the administration of prophylactic anti-D during pregnancy and after birth. All Rh D negative women should have an antibody screen at 26 to 28 weeks gestation. Universal prophylaxis with Rh D immunoglobulin 625 IU (125g) to Rh D negative women 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 Coombs test. The sample must be labelled with the newborns UR, maternal surname and B/O maternal Christian name, infants gender, date and time of birth and date and time 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 following delivery of an Rh D positive baby. Rh D immunoglobulin should not be given to women with preformed anti-D antibodies, except where the preformed anti-D is due to the antenatal administration of Rh D immunoglobulin. Kleihauer Test The Kleihauer test is used to identify women with large FMH who may need additional anti-D immunoglobulin to ensure clearance of all fetal red blood cells. A negative Kleihauer 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 a medical officer to obtain the Rh D immunoglobulin from pathology. The Human Anti-D Antibody Product Administration Form 17H should be commenced antenatally and used to document all administrations of Anti-D. Rh D immunoglobulin should be checked by two midwives prior to administration as per 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 a large 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 divided doses at different sites.

Attachments
Attachment 1 References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. January 2012. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 References Australian & New Zealand Society of Blood Transfusion Ltd 2007 Guidelines for blood grouping 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 2007 College Statement Guidelines for the use of Rh (D) Immunoglobulin (Anti-D) in Obstetrics in Australia, online: http://ranzcog.edu.au/publications/collegestatements.shtml#CObs

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