Use of anti-D immunoglobulin in the treatment of threatened miscarriage in the accident and emergency department

Abstract

Background-The UK guidelines for the use of anti-D immunoglobulin for rhesus prophylaxis have been revised. Anti-D immunoglobulin is no longer recommended for Rh D negative women after a threatened miscarriage less than 12 weeks gestation. These patients are at risk of rhesus immunisation, and there should be a policy for their treatment in the accident and emergency (A&E) department. Design-A retrospective study over a 17 month period was conducted looking at women less than 12 weeks gestation who presented to an A&E department with a threatened miscarriage. Objectives-To determine how many of these patients presented with heavy or repeated bleeding, or abdominal pain, and whether the guidelines for the use of rhesus prophylaxis were followed. Results-112 women fulfilled the criteria for inclusion. Nineteen patients were Rh D negative. Eighty three patients (74.1%) presented with either abdominal pain or heavy or recurrent bleeding. Rhesus status was recorded in the A&E notes in only 15 patients (13.3%). Ninety seven patients (86.6 %) were discharged without rhesus status being checked. Fifteen Rh D negative patients were discharged without being oVered anti-D immunoglobulin. Conclusion-Many women who present to the A&E department with a threatened miscarriage of less than 12 weeks gestation have heavy or recurrent bleeding or associated abdominal pain. These patients have an increased risk of fetomaternal haemorrhage and the consequent development of haemolytic disease of the newborn is possible. It should be mandatory for the A&E department to record rhesus status. In the context of A&E medicine, anti-D immunoglobulin should still be oVered to all non-immune Rh D negative women presenting with a threatened miscarriage less than 12 weeks gestation.

Can We Defer/Omit a Type and Screen Blood Test for Pregnant Women Who Know Their Blood Type?

“…The reduction in hemolytic disease of the fetus and newborn from 10% of overall perinatal mortality down to 0.14% is a result of Rh prophylaxis at 28 and 34 weeks of gestation and the postpartum period (3)(4)(5)(6). Expert opinion in favor of RhIG for first-trimester "threatened abortions" is based on theoretical risk of serious complications weighed against minimal risk of RhIG administration (1,4,(7)(8)(9). Given that RhIG can be given within 3 days and its utility in the first trimester (especially for "threatened abortions") is based on expert opinion only, it may be reasonable to omit a T&S for Rh status alone in first-trimester pregnant patients who know their blood type.…”

Sangrado transvaginal durante el embarazo, como factor de riesgo para isoinmunización al antígeno Rhesus-D

“…10 El sangrado transvaginal posterior a un traumatismo abdominal, se asocia con un aumento en la hemorragia feto-materna, y justifica la realización de la prueba de Kleihauer-Betke y/o la aplicación extra de gama-globulina Anti-D. 11 Se ha señalado que la principal causa relacionada con la falla de los esquemas de prevención es el no apego a las normas establecidas. Weinberg y colaboradores, 12 en un estudio realizado en Leeds, en el Reino Unido, mencionan que en mujeres embarazadas con menos de 12 semanas de gestación, admitidas en la unidad de urgencias, con presencia de STV y dolor abdominal, a sólo 13.3% de ellas se les determinó el gru-po sanguíneo. Es, por lo tanto, importante llevar a cabo adecuadamente los protocolos de manejo para poder aplicar oportunamente la profilaxis a los casos que más se beneficien.…”

Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin?

“…Most articles we examined favor RhIG administration for first trimester bleeding using the risk-versus-benefit argument. On the contrary, some experts argue the limited supply of RhIG, cost of therapy, and lack of supporting evidence as reasons to forgo RhIG administration for first trimester threatened abortions [5,6]. Most authors agree that if gestational age is in question or if traumatic etiology of vaginal bleeding is suspected, RhIG should be administered.…”