RH ISO IMMUNISATION.pptx 2.pptx

RH ISO IMMUNISATION
BY DR CHITRA GUPTA
MS
CHITRA HOSPITAL
JALANDHAR CANTT.
1

ISO IMMUNISATION
• A PROCESS BY WHICH ANTIBODIES ARE PRODUCED IN RESPONSE TO
ANTIGEN OF ANOTHER INDIVIDUAL OF SAME SPECIES,THE FORMER
LACKING THE ANTIGEN.
• RH ISOIMMUNISATI MAJOR CAUSE OF HAEMOLYTIC DISEASE OF
FOETUS AND NEWBORN.
2

Rh isoimmunization- Explained
 Rh isoimmunization occurs in two stages:
o Sensitization
o Immunization
Sensitization occurs due to antibodies production in women with
Rh negative blood having Rh positive fetus in utero.
Immunization occurs when Rh positive fetus blood leaks across
the placental barrier and enters the next blood stream; can also occur
as a result of a mismatched blood transfusion.
Fetal cells enter maternal circulation through “break” in placental barrier, e.g. at placental separation
Maternal production of Rh antibodies following introduction of Rh positive blood.
Source: American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 181: Prevention of Rh D alloimmunization. Clinical management guidelines for
obstetrician-gynecologists. Obstetrics & Gynecology. 2017;130(2):e57-70.
3

Pathophysiology
 Rh positive man and Rh-
negative women conceive a
child
 Rh negative mother carrying her
first Rh positive fetus. Rh
antigens from developing fetus
can enter the mother's blood
during pregnancy.
 In response to the fetal Rh
antigens, the mother will
produce anti-Rh antibodies
 If pregnant women becomes
pregnant with another Rh-
positive fetus, her anti-Rh
antibodies cross the placenta and
damage fetal red blood cells.
Rh Incompatibility
4

Pathophysiology
 First newborn (RhD+) Safe
Note: If mother is sensitized to RhD antigen prior to first pregnancy, then first fetus will be affected
 But mother (RhD-) is now sensitized
to RhD antigen
Rh Incompatibility
First pregnancy
Father (RhD+)
Mother (RhD-)
Fetus (RhD+)
Fetal- maternal blood transfer during labor
5

Pathophysiology
Note: If mother is sensitized to RhD antigen prior to first pregnancy, then first fetus will be affected
Rh Incompatibility
Second pregnancy
Father (RhD+)
Mother (RhD-)
Fetus (RhD+)
Repeat encounter with fetal RhD
antigen
Rapid production of IgG anti-D
by mother
Maternal IgG anti-D crosses
planceta.
IgG anti-D attaches to fetal
blood cells and marks them for
destruction
Mild case
Mild anemia, jaundice
Severe increased bilirubin.
CNS damage (kernicterus)
Fetal or newborn Hemolytic
Anemia
6

Causes and risk factors of Rh incompatibility
 Exposure to fetal Rh-positive blood
Source: Costumbrado J, Mansour T, Ghassemzadeh S. Rh incompatibility. StatPearls. 2020
 Nonfetal exposure to Rh-positive blood
7
o Delivery (i.e., vaginal, Cesarean section)
o Threatened miscarriage, miscarriage
o Trauma
o External cephalic version
o Invasive procedures (e.g., chorionic villus sampling, amniocentesis)
o Ectopic Pregnancy
o Molar pregnancy
o Antepartum hemorrhage (e.g., placenta previa, abruption, vasa previa,
uterine rupture)
o Transfusion
o Bone marrow transplantation
o Needle-stick injury

Fetomaternal Hemorrahage
Fetomaternal Hemorrahage
(FMH): Entry of fetal blood
into the maternal
circulation before or
during delivery
Source: Maier etal., Fetomaternal hemorrhage (FMH), an update: review of literature and an illustrative case. Arch Gynecol Obstet. 2015
Bhargava et al.,Silent Feto-Maternal Bleed as a Cause of Severe Neonatal Anemia. Journal of Pediatrics & Child Care. 2016
8
Normal FMH
The average volume of fetal blood in the
maternal circulation following delivery is less
than 1 mL in 96% of women
Abnormal FMH
• Fetal blood loss of >30 ml (up to 1% of
pregnancies)
• During pregnancy (10%) or delivery (90%)
• 99.3% of women have a FMH <4ml
• First trimester (3% of FMH)
• Second trimester (12.1% of FMH)
• Final semester (45.5% of FMH)
• After delivery (63.6% of FMH)
Silent FMH
• Large volume of feto-maternal bleeds lead to
severe neonatal anemia in the absence of
obvious maternal symptoms
• Normal appearing placenta
• Occurs at any gestation and can be fatal
Moderate to severe FMH occurs in
around 0.3 % of all life births

HAEMOLYTIC DISEASE OF FETUS & NEWBORN
• MILD- HAEMOLYSIS TOLERATED
• MILD ANAEMIA & JAUNDICE AT BIRTH
• RESOLVES WITHOUT TREATMENT
• MODERATE-----BILIRUBIN RAISED--CLEARED BY PLACENTA
• NOT CLEARED ----HYPERBILIRUBINEMIA---
KERNICTERUS AND ANAEMIA REQUIRING TREATMENT
• SEVERE--------FETAL
ANEMIA,HEPATOSPLENOMEGALY,ERYTHROBLASTOSIS,LIVER
DYSFUNCTION CARDIAC FAILURE,HYDROPS,STILL BIRTH AND IUD
9

MATERNAL EFFECTS OF ISO IMMUNISATION
• HYPERPLACENTOSIS-----PRE ECCLAMPSIA
• CORDOCENTOSIS AND AMNIOCENTESIS COMPLICATIONS
10

Incidence and volume of Feto-maternal Hemorrhage during pregnancy
11
Stages of pregnancy Feto-maternal Hemorrhage Volume (ml)
First trimester 6.7% 0.07
Second trimester 13.9% 0.08
Third trimester 29% 0.13
Delivery 76% 0.19
 The risk of sensitizing also depends on the quantum of the leak
Volume of FMH Risk of Sensitizing
0.1 ml 1%
0.5-1 ml 25%
>5 ml 65%

• RH NEGATIVE MOTHER-----HUSBAND BLOOD GP.
• RH -VE HUSBAND----NO PROBLEM
• RH POSITVE ----INDIRECT COOMBS TEST
12

SCREENING IN PREGNANCY
• IN 1ST PREGNANCY
• 1.AT 1ST BOOKING
• 20 WEEKS
• 28 WEEKS
• IN SUBSEQUENT PREGNANCY WITH NO HAEMOLYTIC DIS
• 1.AT FIRST BOOKING
• 2.EVERY 4-6 WKS SUBSEQUENT
13

• PREVIOUS PREG. WITH SEVERE HAEMOLYTIC DIS
• TITRE NOT REQUIRED
• TESTING FOR FETAL ANAEMIA BEGINING FROM 16-18 WK
14

• ICT NEGATIVE-----NO ISOIMMUNISATION PRESENT
• MANAGEMENT OF NONISO IMMUNISED MOTHER
• AIM IS---MINIMISING CHANCES OF FMH
• PREVENTING ISOIMMUNISATION--ANTI D
• ANTI D IN ICT NGATIVE MOTHER---
• AT 28 WKS
• WITH IN 72 HRS OF DELIVERY IF RH POSITIVE FETUS,IF MISSED
WITHIN 13 DAYS
15

ANTENATAL ANTI D
• At 28 wks 300 mcg in non immunised
• or at 28 wks 100 mcg, repeat dose of 100mcg again at 32 wks.
16

POST NATAL---
• After delivery in RH-ve mother ith rh+ve baby 300 mcg i/m in deltoid
muscle with in 72 hrs of delivery.
• i/v can be given.
• if missed in 72 hrs then in 13 days.
17

• DOSE OF ANTI D = AMOUNT OF FMH
• KLEIHAUER BETKE TEST/ ACID ELUTION TEST
• SAMPLE MATERNAL BLOOD
• HbF MORE RESISTANT TO ACID ELUTION THAN HBA
• 100 mcg OF ANTI D NEUTRALISE 4ML OF FETOMATERNAL BLOOD
18

• ICT POSITIVE----------RH ISOIMMUNISED PREGNANCY----
• ASSESS ANTIBODY TITRE
• CRITICAL TITRE =1:16
• LESS THAN 1:16 ICT EVERY 4WKS--DELIVER AT 37 WKS
MORE THAN 1:16 MIDDLE CEREBRAL ARTERY PEAK SYSTOLIC VELOCITY
MONITOR FETAL ANEMIA
19

• MIDDLE CERBRAL ART. PSV LESS THAN 1.5 MOM DELIVER AT 37 WKS
• MORE THAN 1.5.... MORE THAN 34 WKS--DELIVER
• OR LESS THAN 34 WKS FETAL BLOOD SAMPLING
• WATCH ON HAEMATO CRITS----INTRA UTERINE TRANSFUSION IF
HAEMATOCRIT LESS THAN 30
20

Investigation
21
Rosette test
To rule out significant Fetomaternal Haemorrhage
Detect greater than 2 mL of fetal whole blood in the maternal circulation
Incubation of a maternal blood sample with Rh immunoglobulin
Bind fetal Rh D-positive red blood cells
Addition of enzyme-treated reagent indicator red blood cells
Aggregates (rosettes)
Visualized by light microscopy
If results are positive
Kleihauer-Betke (acid elution) test or flow cytometry
Measure the amount of fetal blood in the maternal circulation
Negative
Rosette
Positive
Rosette

Investigation
 Measure the amount of haemoglobin transferred from fetus to mothers
blood stream
 Maternal blood is fixed on a slide with ethanol 80%, treated with citrate
phosphate buffer.
 After staining with hematoxylin and eosin the fetal cells will be stained while
the adult cells appear like ghost cells.
 No. of fetal cells/ No. of adult cells is equal to fetal blood volume/ maternal
blood volume.
Source: Prevention of Rh D Alloimmunization. Obstetrics & gynecology. 2017, 130 (2) 22
Kleihauer-Betke test

INDICATIONS FOR LSCS
• 1. Severe form of haemolytic dis in the term
• 2, or 34-35 weeks after antenatal prevention of fetal hyaline
membrane syndrome.
23

MEASURES DURING C SEC.
• 1.prevent spillage of blood from placenta in peritoneal cavity
• 2. spontaneous delivery of placenta,squeezing of uterus shud be
avoided
• 3.avoid avulsion of cord.
24

vaginal delivery in Rh isoimunisation’
• no fundal pushing in 1st or 2 nd stage of labour
• withold inj methergin after ant. shoulder delivery
• early cord clamping and no milking.
• no uterine massage or squeeze in 3rd stage
• lt placenta deliver spontaneously
• protect vaginal and perineal lacerations from being exposed to fetal
blood spill
25

26
Postpartum Prophylaxis
If No Postpartum Prophylaxis
Incidence of sensitization : 12% to 16%
First Rh +ve fetus Second pregnancy With Rh +ve child
HDN

27
Postpartum Prophylaxis
Postpartum Prophylaxis: All Rh D negative patients who deliver a Rh-D positive baby either by a normal delivery or a caesarean section receive 300 mcg of
Anti D within 72 hours of delivery.
Second
Pregnancy
Safe
Pregnancy
↓ risk of isoimmunization to 1.5%

*
Anti-D Prophylaxis in sensitizing events
 Anti-D immunoglobin (Ig) is given to a woman to prevent her producing antibodies
against RhD positive blood cells, thus preventing development of HDN in an unborn
baby.
 Extracted from the plasma of donors having high circulating levels of anti-D.
 Given usually intramuscularly or sometimes intravenously; prevents sensitization
during pregnancy and after childbirth
 Development of anti-D antibodies usually occurs as a result of FMH in a RhD-
negative woman with an RhD- positive fetus.
Should be administered
 As soon as possible after the potentially sensitizing event but always within 72 h.
 Within 10 days may provide some protection.
 Intramuscularly anti-D is best given in deltoid muscle.
 Women already sensitized should not be given anti-D Ig.
This is called Hemolytic disease of the fetus and newborn.

30
Potentially Sensitizing Events
 First trimester events (< 12 weeks gestation):
A dose of 50 – 100 mcg should be given, as soon as possible after the
sensitizing event.
o Significant bleeding during threatened abortion
o Spontaneous miscarriage
o Medical termination of pregnancy
o Surgical termination of pregnancy
o Ectopic pregnancy
o Vesicular mole; particularly of it is a partial mole
o Chorion biopsy
o Embryo reduction
 First trimester events (< 12 weeks gestation):
 In all these events Anti-D injection of 300 mcg atleast.
 A test for the size of FMH should be done.
 10 mcg additional dose for every additional 0.5 ml fetal RBC’s in
maternal circulation.
o Amniocentesis
o Abruption placentae
o Blunt trauma
o Intrauterine fetal death
o External cephalic version
o Placental pravia with bleeding
Source: ICOG FOGSI Recommendations for Good Clinical Practice: Use of Anti-D Immunoglobulin for Rh Prophylaxis

Anti-D prophylaxis
31
Anti-D prophylaxis
50 mcg recommended when
surgical procedure is used to
manage an ectopic pregnancy
(SOGG, Canada)
50 mcg recommended
in women who have a
surgical procedure to
manage an ectopic
pregnancy (ACOG,
America).
50 mcg
recommended in up
to 19+6 weeks of
gestation and in a
dose of 100 mcg
thereafter (RCOG,
U.K.)
 Alloimmunization has been reported after ectopic pregnancy.
 25% women with a ruptured tubal pregnancy have a significant number of fetal RBC’s in their circulation, suggesting that
anti-D is indicated.
Source: American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 181: Prevention of Rh D alloimmunization. Clinical management guidelines for obstetrician-gynecologists.
Obstetrics & Gynecology. 2017;130(2):e57-70.
50 mcg recommended for ectopic
pregnancy (RANCOZ,
Australian and NZ)
Ectopic pregnancy:

Anti-D prophylaxis
32
Anti-D prophylaxis
120 mcg of anti-D : protective
during the first 12 weeks of
gestation. After 12 weeks’
gestation: 300 mcg indicated
(SOGG, Canada)
For Abortion or
miscarriage- Before 12
weeks of gestation: 50
mcg or 120 mcg up to
beyond 12 weeks: 300
mcg (ACOG,
America).
Anti-D Ig is
administered in a
dose of 50 mcg up to
19+6 weeks of
gestation and at a
dose of 100 mcg
thereafter (RCOG,
U.K.)
 Between 3% and 11% of women with threatened abortion in the first trimester have a FMH.
 The total fetoplacental blood volume at 12-week pregnancy is 3 mL i.e, 1.5 mL fetal red cells.
Source: 1. American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 181: Prevention of Rh D alloimmunization. Clinical management guidelines for obstetrician-
gynecologists. Obstetrics & Gynecology. 2017;130(2):e57-70.
2. De Crespigny L, Davison G. Anti-D administration in early pregnancy: time for a new protocol. Aust N Z J Obstet Gynaecol 1995;35:385–7.
Abortion, either medical or surgical:
50 mcg is recommended
(RANCOZ, Australian and NZ)
Prophylaxis following abortion:

Anti-D prophylaxis
33
Anti-D prophylaxis
Anti-D Ig may be omitted when complete
mole is diagnosed in non-sensitized Rh-
negative mothers and for partial mole or
uncertain diagnosis (SOGG,
Canada)
Anti-D immune globulin to Rh D-
negative women who are suspected of
molar pregnancy and who undergo
uterine evacuation (ACOG, America)
 The risk of Rh alloimmunization in molar pregnancy is minimal due to:
o absent or incomplete vascularization of villi in complete hydatidiform mole
o absence of D antigen on the villous trophoblast
 The diagnosis of partial v/s complete molar pregnancy depends on pathologic and cytogenetic evaluations; reasonable to administer anti-D to Rh D-
negative women suspected of molar pregnancy and who undergo uterine evacuation.
Source: American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 181: Prevention of Rh D alloimmunization. Clinical management guidelines for obstetrician-gynecologists.
Obstetrics & Gynecology. 2017;130(2):e57-70.
A minimum dose of 50 mcg Anti-D
should be administered to all cases
of molar pregnancy (BCSH, London)
Molar pregnancy:

Anti-D prophylaxis
34
Anti-D prophylaxis
A 120 mcg dose of anti-D is recommended during the
first 12 weeks of gestation. After 12 weeks’ gestation,
300 mcg is indicated (SOGG, Canada)
 Anti-D is not necessary in women with threatened miscarriage before 12 weeks gestation.
 Should be given to all non-sensitized RhD-negative women with a threatened miscarriage after 12+0 weeks of gestation.
 Should be given at 6-weekly intervals in women where bleeding continues intermittently after 12+0 weeks of gestation (RCOG).
 50 mcg anti-D should be administered where bleeding is heavy or repeated or if abdominal pain occurs at around 12 weeks’ gestation.
gynecologists. Obstetrics & Gynecology. 2017;130(2):e57-70. 2. The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis. Royal College of Obstetricians and Gynaecologists 3.
Bowman J. Thirty-five years of Rh prophylaxis. Transfusion 2003;43:1661–6. (Level III)
No anti-D for spontaneous complete miscarriage before 12 weeks of
gestation. 50 or 120 mcg after a complete miscarriage during the first
12 weeks and 300 mcg after 12 weeks of gestation is recommended
(ACOG, America)
Threatened miscarriage :
 Significant FMH only occurs after curettage to remove products of conception; but not after complete spontaneous miscarriages.
 Risk of alloimmunization is 1.5–2% in susceptible women after spontaneous miscarriage.
Spontaneous miscarriage:

Anti-D prophylaxis
35
Anti-D prophylaxis
Immunoprophylaxis with anti-D 300 mcg
is recommended (SOCG, Canada)
50 to 120 mcg before 12 weeks of
gestational age and 125 to 300 after 12
weeks of gestation is recommended
(ACOG, America)
 If the placenta is implanted on the anterior uterine wall there is a risk that it will be traumatized at amniocentesis, with subsequent fetal transplacental
hemorrhage.
 Amniocentesis led to a 2–6% rate of fetal–maternal hemorrhage, even if the placenta was not traversed.
 Anti-D IgG given after amniocentesis does not harm the conceptus.
Source: 1. American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 181: Prevention of Rh D alloimmunization. Clinical management guidelines for obstetrician-gynecologists. Obstetrics & Gynecology.
2017;130(2):e57-70.
2. Lele AS, Carmody PJ, Hurd ME, O’Leary JA. Fetomaternal bleeding following diagnostic amniocentesis. Obstet Gynecol 1982;60:60–4. (Level III)
3. Bowman JM, Pollock JM. Transplacental fetal hemorrhage after amniocentesis. Obstet Gynecol 1985;66: 749–54. (Level II–3)
A dose of 125 mcg is recommended for
amniocentesis (RANCOZ, Australia
and NZ).
Amniocentesis:

Anti-D prophylaxis
36
Anti-D prophylaxis
Immunoprophylaxis with anti-D 300 mcg
is recommended. (SOCG, Canada)
50 to 120 mcg before 12 weeks of
gestational age and 125 to 300 after
12 weeks of gestation is
recommended (ACOG,
America).
 Chorionic villus sampling has been estimated to carry a 14% risk of FMH of 0.6 mL or more,.
Source: 1. American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 181: Prevention of Rh D alloimmunization. Clinical management guidelines for obstetrician-gynecologists. Obstetrics & Gynecology.
2017;130(2):e57-70.
2. Fung KF, Eason E. No. 133-prevention of Rh alloimmunization. Journal of Obstetrics and Gynaecology Canada. 2018 ;40(1):e1-0.
A dose of 125 mcg is
recommended for amniocentesis
(RANCOZ, Australia and NZ).
Chorionic villous sampling:
 Cordocentesis also can cause FMH and warrant anti-D immune globulin prophylaxis (ACOG, America).
 FMH following cordocentesis occurs particularly if a transplacental route is chosen.
 Following cordocentesis, anti-D Ig 300 mcg should be given to non-sensitized D-negative women (SCOG, Canada).
Cordocentesis:

Anti-D prophylaxis
37
Anti-D prophylaxis
Anti-D 120 mcg or 300 mcg is recommended. If FMH
is in excess (6 or 15 mL fetal RBC), 10 mcg additional
anti-D should be given for every additional 0.5 mL fetal
RBC’s – SOGC, CANNADA
 Conditions associated with potential placental trauma or disruption of the fetomaternal interface such as placental abruption, external cephalic
version, blunt trauma to the abdomen, placenta previa with bleeding can lead to sensitizing FMH.
 FMH has been identified in 2% to 6% of attempted or successful external cephalic version attempts.
 Blunt abdominal trauma in pregnancy has also been documented to cause large FMH.
 Measurement of FMH volume is prudent as these conditions may cause FMH in excess of 30 ml.
gynecologists. Obstetrics & Gynecology. 2017;130(2):e57-70.
2. Fung KF, Eason E. No. 133-prevention of Rh alloimmunization. Journal of Obstetrics and Gynaecology Canada. 2018 ;40(1):e1-0.
A dose of 125 mcg is recommended
following these events – RANCOZ,
AUSTRALIA and NEW ZEALAND
Antepartum Hemorrhage, Abdominal Trauma, External Cephalic Version and Placenta previa

38
GUIDELINES AND RECOMMENDATIONS

39
The American College of Obstetricians and Gynecologists (ACOG)
 The following recommendations are based on good and consistent scientific evidence (Level A)
Unsensitized Rh D-negative women should be offered Prophylactic anti-D immune:
 Within 72 hours of delivery, if the infant is confirmed to be Rh D +ve
 The following recommendations are based on good and consistent scientific evidence (Level B)
RhD immune globulin recommended- All invasive diagnostic procedures (chorionic villus sampling or amniocentesis) in Rh D-ve women and Rh D +ve fetus
 The following recommendations are based on good and consistent scientific evidence
Anti D immunoglobulin prophylaxis should be considered if Rh D –ve women experienced:
 Threatened abortion Pregnancy termination, either medical or surgical
 Uterine evacuation Ectopic pregnancy
 Second or third trimester antenatal bleeding Antenatal hemorrhage after 20 weeks of gestation
 External cephalic version Suspected molar pregnancy
 Abdominal trauma
ACOG PRACTICE BULLET IN. Clinical Management Guidelines for Obstetrician–Gynecologists. OBSTETRICS & GYNECOLOGY. 2017 ;130
(2)

40
The American College of Obstetricians and Gynecologists (ACOG)
 Recommendations
Indication Dose Time
Complete miscarriage 50 mcg or 120 mcg First 12 weeks’ gestation
Spontaneous complete miscarriage No anti-D Before 12 weeks’ gestation
Pregnancy termination
(medical or surgical)
50 mcg or 120 mcg
300 mcg
Up to 12 weeks’ gestation
After 12 weeks’ gestation
Ruptured tubal pregnancy 50 mcg or 120 mcg
300 mcg
Up to 12 weeks’ gestation
After 12 weeks’ gestation
Chorionic villus sampling 50 to 120 mcg
125 mcg or 300 mcg
Before 12 weeks’ gestational age
After 12 weeks’ gestational age
Amniocentesis 50 to 120 mcg
125 mcg or 300 mcg
Before 12 weeks
After weeks’ gestational age
Ectopic pregnancy 50 mcg -
Threatened miscarriage (Heavy bleeding or repeated
or if abdominal pain)
50 mcg Around 12 weeks’ gestation

41
ICOG FOGSI Recommendations for Good Clinical Practice
Aimed to prevent sensitization during and after pregnancy
All patients (MTP, medical or surgical) should have knowledge of documentation of blood group and Rh
After all sensitizing events in first trimester:
 50 - 100 mcg anti -D injection
Mid and late pregnancy sensitizing events and post partum:
 300 mcg anti D to Rh-ve women
Due to the lack of availability of FMH volume testing, administer higher doses to protect a majority of patients in high risk situations

42
Polyclonal anti D vs Monoclonal anti D vs Recombinant anti D
Conventionally, anti-D is produced via fractionation of IgG from the pooled plasma of RhD negative men immunized with RhD-positive
RBC’s.
The resultant IgG is polyclonal in nature and referred to as Polyclonal anti-D (Poly anti-D).
 Polyclonal anti-D (Poly anti-D)
 Polyclonal-derived from sera of immunized humans, made up of mixture of antibodies with affinity for a wide range of antigenic epitopes.
 Limitations
o requirement for human donors,
o limited capacity of production,
o theoretical risk of transmission of viral/prion diseases, and
o periodic shortages
Most of these limitations were addressed by the introduction of monoclonal anti-D (Mono anti-D), manufactured using the hybridoma technique.
Source: Mayekar RV, Paradkar GV, Bhosale AA, Sachan R, Beeram S, Anand AR, Mundle SR, Trivedi Y, Patole KP, Sambarey PW, Daftary GV. Recombinant anti-D for prevention of maternal-foetal Rh (D) alloimmunization: a randomized multi-centre clinical trial. Obstetrics &
Gynecology Science. 2020 Apr 21;63(3):315-22.

43
 Recombinant anti-D (R-anti-D).
The natural successors to hybridoma-derived antibodies are recombinant DNA-derived antibodies considering the
advancements made in technologies used for antibody manufacture
Developed anti-D IgG antibodies using recombinant DNA technology and genes for anti-D derived from the hybridoma to
manufacture monoclonal anti D immunoglobulin
The antibody genes from this hybridoma were isolated and introduced in Chinese hamster ovarian cells (CHO), thus enabling
the cells to express recombinant anti-D (R-anti-D).
Source: Mayekar RV, Paradkar GV, Bhosale AA, Sachan R, Beeram S, Anand AR, Mundle SR, Trivedi Y, Patole KP, Sambarey PW, Daftary GV. Recombinant anti-D for prevention of maternal-foetal Rh (D) alloimmunization:
a randomized multi-centre clinical trial. Obstetrics & Gynecology Science. 2020 Apr 21;63(3):315-22.

Rec o m binant anti - D fo r prev entio n o f maternal - fo etal Rh(D) allo immunizatio n:
a rando mized multi - c entre c linic al trial
44
 Safety data: Adverse events
<1% of participants in each group reported AEs, and none of the reported AEs were deemed to be related to the study drug. This indicates that R-anti-D was well
tolerated by the subjects and that its safety profile is in line with that of Poly anti-D.
Source: Mayekar RV, Paradkar GV, Bhosale AA, Sachan R, Beeram S, Anand AR, Mundle SR, Trivedi Y, Patole KP, Sambarey PW, Daftary GV. Recombinant anti-D for prevention of maternal-foetal Rh (D) alloimmunization: a randomized multi-centre
clinical trial. Obstetrics & Gynecology Science. 2020 Apr 21;63(3):315-22.
Adverse events R-anti D group Polu anti-D group
Pyrexia 1 2
Abdominal Pain 2 0
Itching 0 1
Hypertension 0 1
Hypotension 0 2
Deranged leucocyte count 1 0
 Incidence of immunogenicity (development of anti-drug antibodies)
The immunogenicity test showed that none of the samples were positive for anti-R-anti-D antibodies confirming that R-anti D is safe and non-immunogenic.

45
 Recombinant anti-D (R-anti-D)
Obviate the need for fetal bovine serum
Advantages of Recombinant DNA technology
Obtained from serum-free medium, which quells the concerns of
transmission of infectious diseases
Avoids problem of cell line changes and mutations as observed in
hybridoma production and storage
Provide better yield
 R-anti-D may be a suitable alternative to existing anti-D preparations in the market for the prevention of maternal
alloimmunization, especially as the supply of human-sourced Poly anti-D is expected to diminish.
Source: Mayekar RV, Paradkar GV, Bhosale AA, Sachan R, Beeram S, Anand AR, Mundle SR, Trivedi Y, Patole KP, Sambarey PW, Daftary GV. Recombinant anti-D for prevention of maternal-foetal Rh (D) alloimmunization: a randomized multi-centre clinical trial.
Obstetrics & Gynecology Science. 2020 Apr 21;63(3):315-22.

CONCLUSION
• RH -VE MOTHER & HUSBAND RH+VE shud be screened for
antibodies.
• if -ve antenatally should be given anti D AT 28 WKS IN
NONSENSITIZED.
• And after delivery within 72 hours.
• If sensitized then no use oF anti D.
• ALL PROCEDURES IN rH -VE MOTHR SHOULD BE COVERED WITH ANTI
D PROPHYLAXIS
• IN SENSITISED WOMEN MANAGEMENT ACCORDING TO GUIDELINES.
46

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