The targeted RAAPD program was implemented effectively in the national maternity care program in Finland. An accurate fetal RHD screening test allows discontinuation of newborn testing without risking the postnatal prophylaxis program. In the future, the main area to investigate will be the clinical effect of RAADP on subsequent pregnancies.

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Introduction: Targeted routine antenatal anti-D prophylaxis was introduced to the national prophylaxis program in Finland in late 2013. The aim of this study was to assess the incidence, time-points, and risk factors for Rhesus D immunization after the implementation of routine antenatal anti-D prophylaxis, in all women in Finland with antenatal anti-D antibodies detected in 2014-2017. Material and methods:In a nationwide population-based retrospective cohort study, the incidence, time-points, and risk factors of anti-D immunizations were analyzed.Information on antenatal screening was obtained from the Finnish Red Cross Blood Service database, and obstetric data from hospital records and the Finnish Medical Birth Register. Results:The study included a total of 228 women (197 with complete data for all pregnancies). After the implementation of routine antenatal anti-D prophylaxis, the prevalence of pregnancies with anti-D antibodies decreased from 1.52% in 2014 to 0.88% in 2017, and the corresponding incidence of new immunizations decreased from 0.33% to 0.10%. Time-points for detection of new anti-D antibodies before and after 2014 were the first screening sample at 8-12 weeks of gestation in 52% vs 19%, the second sample at 24-26 weeks in 20% vs 50%, and the third screening at 36 weeks in 28% vs 32%. Conclusions:The incidence of new anti-D immunizations decreased as expected after the implementation of routine antenatal anti-D prophylaxis. True failures are rare and they mainly occur when the prophylaxis is not given appropriately, suggesting a need for constant education of healthcare professionals on the subject.

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Background: Ula, part of the Kell blood group system, is a low-frequency antigen found predominantly in the Finnish population. Anti-Ula is a rare antibody to cause hemolytic disease of the fetus and newborn (HDFN). Methods and Findings:We report one woman with two pregnancies in which anti-Ula caused severe HDFN requiring intrauterine (IU) transfusions. In the first affected pregnancy, two IU transfusions were performed, but the cause of fetal anemia was unknown at the time and an immune-based mechanism was not suspected. In the following pregnancy, anti-Ula with a titer of 1-2 was identified, and as the fetus was anemic, six IU transfusions were performed. The detection of anti-Ula is difficult, because it is not usually included in the antibody screening cells. Conclusions:The possibility of a rare antibody as the cause of severe HDFN should be kept in mind in cases in which the antibody screening has been negative, and further antibody detection studies should be performed as part of fetal anemia investigations. If anti-Ula is identified in a pregnant woman, close ultrasound monitoring of the fetus is important because HDFN may develop even when the antibody titers are low.

Anti-G is commonly present with anti-D and/or anti-C and can confuse serological investigations. In general, anti-G is not considered a likely cause of severe hemolytic disease of the fetus and newborn (HDFN), but it is important to differentiate it from anti-D in women who should be administered anti-D immunoglobulin prophylaxis. We report one woman with three pregnancies severely affected by anti-C+G requiring intrauterine treatment and a review of the literature. In our case, the identification of the correct antibody was delayed because the differentiation of anti-C+G and anti-D+C was not considered important during pregnancy since the father was D-. In addition, anti-C+G and anti-G titer levels were not found to be as reliable as is generally considered in Rh immunization.Severe HDFN occurred at a maternal anti-C+G antibody titer of 8 and anti-G titer of 1 in comparison with the critical titer level of 16 or more in our laboratory. Close collaboration between the immunohematology laboratory and the obstetric unit is essential. In previously affected families, early assessment for fetal anemia is required even when titers are low. Immunohematology 2015;31:123-127.