Rh Program of Nova Scotia...Rh Program of Nova Scotia The presenter does not have any involvement with industry that may be perceived as potentially influencing the presentation of

Rh Program of Nova ScotiaRh Program of Nova Scotia

The presenter does not have any involvement with industry that mThe presenter does not have any involvement with industry that may be ay be perceived as potentially influencing the presentation of the eduperceived as potentially influencing the presentation of the educational cational material contained withinmaterial contained within

Blood MattersBlood MattersOct 29, 1010Oct 29, 1010

M.C. Van den HofM.C. Van den Hof


Provide overview of Nova ScotiaProvide overview of Nova Scotia’’s Rh s Rh programprogramReview guidelines for perinatal antibody Review guidelines for perinatal antibody screeningscreeningReview guidelines for Rh immunoglobulin Review guidelines for Rh immunoglobulin administrationadministration


History:

Early 1960’s: !% of all births were Rh(D) alloimmunized in Nova Scotia

NS infant mortality among highest in Canada

1964: Rh Committee established, modelled on Winnipeg Rh Program

2nd Fetal Transfusion in Canada --Halifax, 1964

Program GoalsProgram Goals

Reduce Rh(D) alloimmunization to lowest Reduce Rh(D) alloimmunization to lowest possible (0.4 per 1000 total pregnancies)possible (0.4 per 1000 total pregnancies)

Achieve 0% mortality & morbidity due to Achieve 0% mortality & morbidity due to red cell and platelet antibodiesred cell and platelet antibodies


Effectiveness

•New Rh(D) alloimmunized women in NS: reduced from 1 per 100 in 1964 to 1.5 per 1000 in 1982 to <0.4 (.27)per 1000 total births in 2009

•Excellent Provincial compliance with guidelines

•Early detection and management of women with antibodies


Program Structure:

Provincial program: NS Department of HealthIWK Health Centre-----Dept Obs & Paeds

Medical DirectorNurse coordinatorNurse part time

Rh CommitteeRCP – administrative support/ database


Links

IWK Health Centre: FATC; transfusion services; nursing units; Perinatal CentreProvincial hospital transfusion services; obstetrics departmentsObstetrics clinics, physicians officesLaboratories and clinicians throughout the Maritime provincesFetal antigen testing: Wisconsin

Rh Program of Nova ScotiaRh Program of Nova ScotiaNursing Role

Promote guidelines for antibody screening & WinRho SDF administration

Review/record data: antibody screens; RhIG (WinRho SDF) administration; cord typing; Kleihauer-Betke for FMH; procedures/events; pregnancy outcomes

Maintaining/updating:- Guidelines for Perinatal Antibody Screening and RhIG administration- Patient pamphlet -Consent for WinRho SDF

Resource for:women who are Rh negative or have antibodies; family care providers; obstetricians;

nursing staff

Education: medical students, nursing staff; nursing students:; Telehealth

Database and Research

Website: www.rcp.nshealth.ca/rh

Rh Program of Nova ScotiaRh Program of Nova ScotiaManaging red blood cell & platelet antibodies

Contacting physician: letters, calls, faxes

Maternal antibody testingPaternal antigen testing

Arranging/assisting with special procedures:ultrasoundsamniocentesisfetal transfusionsdelivery alerts & followup

Rh PoliceRh Police

StimulusStimulus

Fetal red blood cells (fetoFetal red blood cells (feto--maternal maternal hemorrhage)hemorrhage)Blood transfusionBlood transfusionDrug abuse Drug abuse -- sharing needlessharing needlesNaturally occurring Naturally occurring

Primary response (IgM); may take 2wks Primary response (IgM); may take 2wks to 6 months to become IgG antibodyto 6 months to become IgG antibody

What antibodies doWhat antibodies dopermanent IgG permanent IgG antibodiesantibodies fit through fit through

placental barrierplacental barrier

attach to attach to antigenantigen on fetal red blood cellson fetal red blood cells

hemolysis causes fetal anemia antenatallyhemolysis causes fetal anemia antenatally

hemolysis causes neonatal anemia and hemolysis causes neonatal anemia and hyperbilirubinemiahyperbilirubinemia

Antibody typesAntibody typesRh antibodies: (D*, C, c, E, e) Rh antibodies: (D*, C, c, E, e)

**preventable (17% of pop. Rh neg, preventable (17% of pop. Rh neg, missing Rh antigen on RBCmissing Rh antigen on RBC’’s)s)

Other examples (nonOther examples (non--preventable): preventable): KellKellDuffy (Fya, Fyb)Duffy (Fya, Fyb)Kidd (Jka, Jkb)Kidd (Jka, Jkb)

From: Ortho Diagnostics Inc. (1968). Blood group antigens and antibodies as applied to hemolytic disease of the newborn. Raritan, NJ: Author






In-utero bilirubin metabolism

From: Ortho Diagnostics Inc. (1968). Blood group antigens and antibodies as applied to hemolytic disease of the newborn.Raritan, NJ: Author

Kernicterus risk


GenotypingGenotypingMOM is Rh neg = missing D antigenMOM is Rh neg = missing D antigen

DAD is Rh neg = also missing D antigenDAD is Rh neg = also missing D antigen

BABY will be Rh (D) neg (cannot inherit D)BABY will be Rh (D) neg (cannot inherit D)

Genotyping (continued)Genotyping (continued)MOM is Rh neg (d/d = missing D antigen)MOM is Rh neg (d/d = missing D antigen)DAD is Rh pos (carries D antigen)DAD is Rh pos (carries D antigen)

Dad can be D / d Dad can be D / d 50% chance baby will be D50% chance baby will be D--pospos

OR Dad can be D / DOR Dad can be D / D100% chance baby will be D100% chance baby will be D--pospos

Laboratory TestingLaboratory Testing

Initial Initial ------ ABO; Rh; screenABO; Rh; screen

Positive antibody for HDNPositive antibody for HDN

Repeat titres q monthly or as directed by Rh ProgramRepeat titres q monthly or as directed by Rh ProgramMay require further investigations depending on titreMay require further investigations depending on titreMay require antenatal Rx depending on investigationsMay require antenatal Rx depending on investigations

Neonatal bloodsNeonatal bloods ------ ABO; Rh; DAT; Hgb; BiliABO; Rh; DAT; Hgb; Bili

Laboratory TestingLaboratory Testing

Initial Initial ------ ABO; Rh; screenABO; Rh; screen

No antibody associated with HDNNo antibody associated with HDNRh neg (check father)Rh neg (check father)------ repeat screen at 28 weeks; repeat screen at 28 weeks;

repeat at deliveryrepeat at delivery

Rh pos Rh pos ------ repeat screen at 24repeat screen at 24--28 weeks28 weeks

Neonatal bloodsNeonatal bloods ------ ABO; Rh; DATABO; Rh; DAT

Antibody screeningAntibody screening““group & screengroup & screen””

1st prenatal visit (all women)1st prenatal visit (all women)28 weeks (all women)28 weeks (all women)delivery (Rhdelivery (Rh-- or or HDN antibodies)HDN antibodies)prepre-- Rho(D) immune globulin (RhRho(D) immune globulin (Rh--))

MONTHLY or q 2 wks (if antibodies MONTHLY or q 2 wks (if antibodies causing HDN are detected)causing HDN are detected)

Risk of Rh (D) immunizationRisk of Rh (D) immunization

<28 weeks:<28 weeks: 0.1%0.1%28 weeks to delivery:28 weeks to delivery: 1.7%1.7%Postpartum: Postpartum: 2 to 8 %2 to 8 %Spontaneous abortion:Spontaneous abortion: 22--3%3%Therapeutic abortion:Therapeutic abortion: 44--5%5%Antenatal bleeding:Antenatal bleeding: ??

Prevention: Prevention: Rh Immune Globulin (WinRho SDFRh Immune Globulin (WinRho SDF™™))

28 weeks (Rh28 weeks (Rh-- Dad?)Dad?)postpartum postpartum (Rh+baby)(Rh+baby)abortion/ectopicabortion/ectopicantepartum bleedingantepartum bleedingspecial procedures special procedures (amniocentesis, (amniocentesis, cordocentesis, CVS)cordocentesis, CVS)

external versionexternal versionplatelet transfusionplatelet transfusionabdominal traumaabdominal traumapartial molar partial molar pregnancypregnancyblighted ovumblighted ovuminadvertent inadvertent transfusion Rh+ bloodtransfusion Rh+ blood


Rho(D) Immune GlobulinRho(D) Immune Globulin““WinRho SDFWinRho SDF™”™” ““RhoGAMRhoGAM™”™”

WinRho SDFWinRho SDF™™ used in Canadaused in Canadablood product blood product deep I.M. deep I.M. OrOr I.V. routeI.V. routeALWAYS draw antibody screen ALWAYS draw antibody screen firstfirst120 120 µµg g or or 300 300 µµg doseg doseKleihauer when indicatedKleihauer when indicatedobtain informed consent (may refuse)obtain informed consent (may refuse)

Informed ConsentInformed Consent

blood product (from plasma)blood product (from plasma)donors screened for Hep B, C, HIVdonors screened for Hep B, C, HIVviral inactivation stepviral inactivation stepno reports of disease transmissionno reports of disease transmissionrisk of Rh disease from 1:10 to 1:1000risk of Rh disease from 1:10 to 1:1000mandated by Krever Inquirymandated by Krever Inquiry

KleihauerKleihauer--Betke TestBetke Test% fetal red blood cells in maternal circulation% fetal red blood cells in maternal circulation

AmniocentesisAmniocentesisantenatal bleeding (2nd & 3rd trimester)antenatal bleeding (2nd & 3rd trimester)postpartum (Rhpostpartum (Rh-- mom/Rh+ baby)mom/Rh+ baby)Formula for Kleihauer > 0.2% Formula for Kleihauer > 0.2% Massive fetoMassive feto--maternal hemorrhage maternal hemorrhage (abruptio, stillbirth) Rh (abruptio, stillbirth) Rh -- or Rh+or Rh+

Kleihauer slideKleihauer slide

Fetus at RiskFetus at Risk

Fetal anemia diagnosed by: Fetal anemia diagnosed by: amniocentesisamniocentesiscordocentesiscordocentesisultrasoundultrasound

hydropshydropsmiddle cerebral artery Dopplermiddle cerebral artery Doppler

Treatment:Treatment:intravascular fetal transfusionintravascular fetal transfusionpreterm birthpreterm birth

Infant at RiskInfant at RiskDiagnosis:Diagnosis:

history of HDN antibodies?history of HDN antibodies?early jaundice < 24 hoursearly jaundice < 24 hourscord DAT (cord DAT (““CoombCoomb’’ss””) ) positive positive (due to HDN (due to HDN or ABO antibodies)or ABO antibodies)

Treatment:Treatment:PhototherapyPhototherapyExchange or Direct blood transfusionExchange or Direct blood transfusion

CORD blood testingCORD blood testingDirect Antiglobulin Test (DAT) Direct Antiglobulin Test (DAT)

oror““Direct CoombDirect Coomb’’ss””

POSITIVE test = antibodies on babyPOSITIVE test = antibodies on baby’’s s red blood cellsred blood cells

Cord DAT testCord DAT testMost COMMON reason for POSITIVE DAT:Most COMMON reason for POSITIVE DAT:1. ABO incompatibility1. ABO incompatibility

eg. Mom group O, baby group A or Beg. Mom group O, baby group A or B

2. Winrho (anti2. Winrho (anti--D) from MomD) from Mom’’s recent s recent injection coats some of babyinjection coats some of baby’’s red blood s red blood cellscells

Cord DAT positiveCord DAT positiveOther reasons, less common:Other reasons, less common:

Hemolytic disease causing antibodies Hemolytic disease causing antibodies crossed over from mother crossed over from mother (anti(anti--D, c, Kell, Duffy, etc)D, c, Kell, Duffy, etc)

Case StudyCase Study

27 y o G1 P0 is Rh neg; partner is Rh pos27 y o G1 P0 is Rh neg; partner is Rh pos

Has antibody screen and WinRho at 28 weeksHas antibody screen and WinRho at 28 weeksAntibody screen is positive Antibody screen is positive

What has happened?What has happened?


27 y o G1 P0 is Rh neg; partner is Rh pos27 y o G1 P0 is Rh neg; partner is Rh pos

Has antibody screen and WinRho at 28 weeksHas antibody screen and WinRho at 28 weeksAntibody screen is positive Antibody screen is positive

What has happened?What has happened?

1) Isoimmunization or1) Isoimmunization or2) Antibody screen taken after injection instead of before2) Antibody screen taken after injection instead of before


29 y o G3 P1 A1 at 28 weeks 29 y o G3 P1 A1 at 28 weeks A neg ; Positive screen for Fya 1/64A neg ; Positive screen for Fya 1/64What are the next two steps?What are the next two steps?


29 y o G3 P1 A1 at 28 weeks 29 y o G3 P1 A1 at 28 weeks A neg ; Positive screen for Fya 1/64A neg ; Positive screen for Fya 1/64What are the next two steps?What are the next two steps?

Assess for fetal anemia; paternal genotypeAssess for fetal anemia; paternal genotypeWinRhoWinRho


29 y o G2 P1 presents @ 29 weeks with 29 y o G2 P1 presents @ 29 weeks with antenatal bleeding, U/S shows small antenatal bleeding, U/S shows small marginal abruption, fetus well, uterus nonmarginal abruption, fetus well, uterus non--tendertenderOther important Mx issues?Other important Mx issues?


29 y o G2 P1 presents @ 29 weeks with 29 y o G2 P1 presents @ 29 weeks with antenatal bleeding, U/S shows small antenatal bleeding, U/S shows small marginal abruption, fetus well, uterus nonmarginal abruption, fetus well, uterus non--tendertenderOther important Mx issues?Other important Mx issues?

Check Rh; pt is neg and had just received Check Rh; pt is neg and had just received her WinRho 300ug 5 days earlier; Is this her WinRho 300ug 5 days earlier; Is this adequate?adequate?


29 y o G2 P1 presents @ 29 weeks with 29 y o G2 P1 presents @ 29 weeks with antenatal bleeding, U/S shows small marginal antenatal bleeding, U/S shows small marginal abruption, fetus well, uterus nonabruption, fetus well, uterus non--tendertenderOther important Mx issues?Other important Mx issues?

Check Rh; pt is neg and had just received her Check Rh; pt is neg and had just received her WinRho 300ug 5 days earlier; Is this adequate?WinRho 300ug 5 days earlier; Is this adequate?NoNo------needs Kleihauerneeds Kleihauer

[With permission]

A healthy baby after A healthy baby after six insix in--utero utero transfusionstransfusions

BILIRUBIN BILIRUBIN In UTERO = unconjugated changed to In UTERO = unconjugated changed to

conjugated; excreted by mother conjugated; excreted by mother

After Birth = baby cannot do this wellAfter Birth = baby cannot do this wellUnconjugated bilirubin causes JAUNDICE Unconjugated bilirubin causes JAUNDICE

and risk of KERNICTERUS (staining of and risk of KERNICTERUS (staining of brain cells) if not treatedbrain cells) if not treated

FetoFeto--maternal hemorrhagematernal hemorrhageBabyBaby’’s and mothers and mother’’s blood systems are s blood systems are

separate in placentaseparate in placenta

Break in barrier can let come babyBreak in barrier can let come baby’’s red s red blood cells enter motherblood cells enter mother’’s circulations circulation

WinRho DosingWinRho Dosing300 ug 28 weeks300 ug 28 weeks

antenatal bleed*antenatal bleed*amniocentesis, etc*amniocentesis, etc*abd trauma*abd trauma*>12 wk preg loss>12 wk preg loss

120 ug postpartum*120 ug postpartum*<12 wk preg loss<12 wk preg lossexternal versionexternal versionplatelet transfusionplatelet transfusion

* Kleihauer* Kleihauer------ 120 ug for <0.2%; 300ug for <0.5%120 ug for <0.2%; 300ug for <0.5%

Antibody typesAntibody typesRh antibodies: (D*, C, c, E, e) Rh antibodies: (D*, C, c, E, e)

**preventable (17% of pop. Rh neg, preventable (17% of pop. Rh neg, missing Rh antigen on RBCmissing Rh antigen on RBC’’s)s)

Other examples (nonOther examples (non--preventable): preventable): KellKellDuffy (Fya, Fyb)Duffy (Fya, Fyb)Kidd (Jka, Jkb)Kidd (Jka, Jkb)

Cause of antiCause of anti--D sensitization [NS residents]D sensitization [NS residents]

Presumed Cause 1988-2000 2001-2009Failed 28 week injection 10 7Failed postpartum injection 14 9Sensitized before 28 weeks 27 1228 week not given 5Postpartum not given 2Antenatal bleeding – not given 2Spontaneous abortion – not given 6Mismatched blood – not given (plasma) 1Therapeutic abortion – not given 1Patient refusal 2Unknown sensitization time 4 16Not given before protocol establishedTOTALS (% based on # Rh-/yr reported to Rh Program)

73 (0.32%) 45 (0.27%)

Documents

Rh Program of Nova Scotia...Rh Program of Nova Scotia The presenter does not have any involvement with industry that may be perceived as potentially influencing the presentation of