Anti-D prophylaxis involves administering Anti-D immunoglobulin to Rh-negative women to prevent the production of antibodies against Rh-positive blood cells. This prevents hemolytic disease of the newborn. Anti-D immunoglobulin suppresses the immune response and prevents sensitization. Routine antenatal anti-D prophylaxis reduces the rate of sensitization during pregnancy to 0.2% by providing anti-D at 28 weeks even if fetal blood type is unknown. First trimester events like bleeding or termination procedures also require anti-D administration to prevent sensitization. The document discusses the history, mechanisms, testing and management of Rh sensitization and anti-D prophylaxis.

1. 1
By Dr.Shashikala
APOLLO BGS HOSPITALS

2.  Anti-D prophylaxis means giving Anti-D immunoglobin to a woman to
prevent her producing antibodies against Rhesus (RhD) positive blood cells.
This will help prevent the development of HDN (Hemolytic disease of
newborn) in an unborn baby.
 Anti-D immune globulin G is a blood product containing a high titre of
antibody to Rh antigens of red blood cells
 Anti-D immunoglobulin has been routinely administered to 10% of women
after parturition for over 30 years .
 It has reduced the rate of maternal RhD alloimmunisation to fetal D+ red
cells by 90%.
 Anti-D prophylaxis has made erythroblastosis fetalis a preventable disease,
and perinatal deaths from alloimmunization have fallen 100-fold
2
Introduction

3.  RhD sensitization may occur after fetal-maternal hemorrhage through out
pregnancy and delivery.
 In embryonic development, the primitive heart begins to contract on day 21 or
22, and primitive blood begins to form during the third week. At this point fetal
blood and maternal blood exchange nutrients, oxygen, and waste across a
primitive placenta (chorion) .
 Fetal red blood cells have been shown to express the RhD antigen at 38 days
after conception, or about 7 weeks’ 3 days gestation .
• Sensitization 1 – 2 % -during pregnancy
17% after 1st
delivery
 A review of pre- and post abortion blood smears demonstrated that fetal-
maternal hemorrhage can occur with early termination
 Third-trimester antenatal alloimmunization posed a significant problem
7
Introduction

4. Extent of problem in India
• Prevalence of Rh negative blood group - 5-10% - In India
- 15% in the West
• Incidence of Rh alloimmunization is 6/1000 births.
• In India – PND due to Rh alloimmunization is 1-2.5%.
• 0.1 ml minimum is the sensitizing dose.
 Deka D etal observed that failure to administer post natal anti D prophylaxis
was responsible for RhD alloimmunization in more than 50% of cases, followed
by failure to administer Anti D after MTP (10%).
 With postpartum prophylaxis the risk of isoimmunization will reduce to
1.5%.Similarly antenatal prophylaxis can reduce the risk to 0.18% (Deka etal)
4

5. 5
History of Rhesus prophylaxis
Anti D acts by suppressing the immune response in Rh negative individuals who
are exposed to Rh D positive red cells, thus preventing the development of
antibodies to Rh D.
1940- Landsteiner and Weiner discovered the Rhesus factor .
1941- Levine and Stetson confirmed that erythroblastosis was due to maternal
isoimmunization against paternally inherited fetal factors.
1959- Dr Bruce Chown, showed that the cause of Rh immunization was the
passage of foetal Rh (D)-positive red cellsinto the maternal circulation.
1961- Finn and associates (1961), Freda (United States) discovered
the subsequent development of effective maternal prophylaxis .
1969 - Immunoprophylaxis using anti –D Immunoglobulin (anti -D Ig) began
1970’s-Antepartum prophylaxis -JM Bowman

6. 6
Sensitizing Events in Pregnancy

7. Incidence and volume of Fetal-maternal hemorrhage during pregnancy
Stages of
pregnancy
Fetal 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
7
The risk of sensitizing also depends on the quantum of the leak
Volume of FMH Risk of Sensitizing
0.1ml 1%
0.5-1ml 25%
>5ml 65%

8.  First trimester bleeding or miscarriage.
 Medical or surgical termination of first trimester pregnancy
 Ectopic pregnancy
 Vesicular mole(especially partial mole )
 Second trimester MTP.
 Antepartum haemorrhage
 External cephalic version
 Closed abdominal injury
 Intra uterine death
 Normal or caesarean delivery
 Manual removal of placenta
 Twin deliveries
 Mismatched platelet or blood transfusion.
( highlighted conditions: associated with high risk of fetomaternal
haemorrhage)
Sensitizing events

9. Incidence of significant antenatal fetal-maternal hemorrhage
Event Incidence of significant feto-maternal hemorrhage (%)
CVS 14 – 18
Amniocentesis 6 – 15
Cordocentesis 40
External cephalic version 1.8 – 6
Molar pregnancy Sensitization has been reported
Spontaneous abortion 1.5 – 2a
Elective termination 4 – 5%a
Threatened abortion 11%b
Third-trimester bleeding 4 – 8%
Abdominal trauma Unknown
Uneventful pregnancy 2.6 – 8%
9
a- Percentages refer to risk of sensitization rather
than risk of fetal-maternal hemorrhage.
b - Compared with 4% in pregnant control group.
Included women up to 20 weeks gestation

10. Test for the size of fetomaternal haemorrhage
 Studies have shown that 99.3% of women have a fetomaternal haemorrhage
less than 4ml at delivery.
 Up to 50% of larger fetomaternal haemorrhages occur after normal deliveries.
 Tests to estimate the size of the fetomaternal haemorrhages are recommended
in many countries including the UK, the USA, Canada, France and Ireland,
although not in India and most European countries.
 While the Kleihauer acid elution test which detects foetal haemoglobin (HbF) is
the test usually undertaken in the UK and Canada, tests which specifically
identify Rh positive red cells are used in the USA.
 The amount of fetal haemorrhage can be calculated from the results of a
kleihauer- Betke Stain using the formula.
fetal blood volume = maternal blood volume maternal hematocrit fetal red blood cells
Newborn hematocrit
10

11. 11 11th
November 2008
Flow cytometry
 An alternative technique for quantifying the size of FMH.
 Advantages
- results are more accurate and more reproducible than those
from the Kleihauer test and that
- It detects RhD positive cells, making it particularly helpful in
patients with high HbF levels.
 Flow cytometry is probably most effectively employed in those
cases where a Kleihauer screening test indicates a large FMH
which requires accurate quantitation and follow-up
 Not all hospitals will have ready access to a flow cytometer
though several Blood Centres offer to estimate FMH.
Rosetting technique is a relatively simple serological method which
offers another alternative for quantifying FMH of RhD positive
red cells greater than 4ml.
Test for the size of fetomaternal haemorrhage

12. 12

13. Prevention of Rh Incompatibility
Premarital counseling
Proper matching of blood particularly in women before
childbearing.
Blood grouping is a must for every woman, before 1st
pregnancy.
Rh+veBlood transfusion-300mcg Immunoglobulin
(minimum).
Proper management of unsensitised Rh negative
pregnancies.

14. Anti D prophylaxis
14
 Routine antenatal anti-D prophylaxis (RAADP)
 Prophylactic antenatal anti-D prophylaxis given because of likely
sensitization.

15. Routine antenatal anti-D prophylaxis (RAADP)
 Routine antenatal prophylaxis reduces the rate of sensitization during pregnancy to
0.2%, (shown by at least 9 clinical studies)
 Without antenatal anti-D prophylaxis, 1.6% to 1.9% of Rh-negative women at risk become
sensitized.
 All pregnant women (D-negative or D-positive) should be typed and screened for
alloantibodies, with an indirect antiglobulin test at the first prenatal visit and again at 28
weeks. (III-C)
 Where paternity is certain, Rh testing of the baby’s father may be offered to all Rh-
negative pregnant women to eliminate unnecessary blood product administration. (III-C)
 Anti-D Ig 300 μg should be given routinely to all Rh-negative nonsensitized women at 28
weeks’ gestation when fetal blood type is unknown or known to be Rh-positive
(recommended by the American College of Obstetricians and Gynecologists, and the US
Preventive Services Task Force).
 Alternatively, 2 doses of 100–120 μg may be given (120 μg being the lowest currently
available dose in Canada): one at 28 weeks and one at 34 weeks. (I-A)
 A repeat antepartum dose of Rh immune globulin is generally not required at 40 weeks,
provided that the antepartum injection was given no earlier than 28 weeks’ gestation. (III-
C)
15

16.  A test for weak D phenotype (e.g., Du) (approx. 1% of those RhD positive), must
be performed in women who initially test Rh-negative. These women are
genetically Rh-positive and are at low risk of producing anti-D antibodies and at
very low risk of having an affected fetus.
 In cases of weak RhD phenotype "weak D" there is quantitative weakening of D
antigen expression. All D epitopes are weakly expressed, but individuals do not
form anti-D antibodies during contact with erythrocytes with normal D
expression.
 Prevention of RhD alloimmunization is generally not indicated.
16
Management of “Weak D”

17. Repeat dosing at 40 weeks
 Twelve weeks after injection of anti-D IV or IM, the mean residual
circulating anti-D is 0.6 ng/mL to 1.0 ng/mL (representing 5 μg to 8 μg
of anti-D), and some women have no residual anti-D.
This is not enough to protect against a volume of FMH of greater than
1 Ml
 Manitoba guidelines (1999) mandate a 39 to 40 week dose; ASCP
practice parameters say it may be done.
 There is insufficient evidence at this time to make a recommendation
for or against administering another dose of anti-D to an unsensitized
D-negative woman who remains undelivered at 40 weeks

18. 18
First trimester events:
■ Significant bleeding during threatened abortion
■ Spontaneous miscarriage
■ Medical termination of pregnancy (Anti D to be
given soon after misoprostol administration)
■ Surgical termination of pregnancy
■ Ectopic pregnancy
■ Vesicular mole; particularly of it is a partial
mole
■ Chorion biopsy
■ Embryo reduction
In all these events a
dose of 50 – 100 mcg
anti d Ig given, as soon
as possible after the
sensitizing event
Evidence that women are
sensitized after uterine
bleeding in the first 12
weeks of pregnancy where
the fetus is viable and the
pregnancy continues is scant.
(threatened abortion)
However it is safer to give 50
mcg of anti D injection in this
case.
Antenatal anti-D prophylaxis (AADP)

19.  The D antigen is detectable on embryonic red blood cells by 38 days from
conception, or 7-3/7 weeks’ gestational age.
 Fetal erythrocytes can be found in maternal circulation after spontaneous
abortion in up to one-third of women at risk, and fetal red cells >0.05 mL can
be detected in 26% of women.
 The risk of alloimmunization following spontaneous abortion – 1.5%-2%
Induced abortion – 4-5 %
 Even 0.1 mL of D-positive red blood cells can sensitize 3% of D-negative
women, so anti-D is indicated.
 The total fetoplacental blood volume at 12-week pregnancy is 3 mL ( 1.5 mL
fetal red cells). A 120 μg dose of anti-D would be protective.
 For miscarriage or induced abortion beyond 12 weeks’ gestation, anti-D 300 μg
is indicated.
 If an Rh-negative woman has had a negative anti-D antibody screen during this
pregnancy, antibody screening need not be repeated before giving anti-D at
abortion.
 If a blood type and antibody screen have not been done in this pregnancy, it
should be done at the time of abortion.
19
Prophylaxis following Abortion

20. 20
spontaneous miscarriage:
 Significant FMH only occurs after curettage to remove products of conception but does
not occur after complete spontaneous miscarriages.
 Anti-D Ig should therefore be given when there has been an intervention to evacuate the
uterus.
 Risk of immunisation by spontaneous miscarriage before 12 weeks" gestation is
negligible when there has been no instrumentation to evacuate the products of
conception and anti-D Ig is not required in these circumstances (Grade C
recommendation)
Threatened miscarriage:
 Anti-D Ig should be given to all non-sensitised RhD negative women with a threatened
miscarriage after 12 weeks of pregnancy.
 Where bleeding continues intermittently after 12 weeks" gestation, anti-D Ig should be
given at 6-weekly intervals (Grade C recommendation).
 Evidence that women are sensitized after uterine bleeding in the first 12 weeks of
pregnancy where the fetus is viable and the pregnancy continues is scant ..
 It may be prudent to administer anti-D Ig where bleeding is heavy or repeated or where
there is associated abdominal pain particularly if these events occur as gestation
approaches 12 weeks (Grade C recommendation). The period of gestation should be
confirmed by ultrasound.
Prophylaxis following Abortion

21. Ectopic pregnancy and Molar pregnancy
ECTOPIC PREGNANCY
 Alloimmunization has been reported after ectopic pregnancy.
 25% of women with a ruptured tubal pregnancy have a significant
number of fetal red blood cells in their circulation, suggesting that
anti-D is indicated.
MOLAR PREGNANCY
 Due to absent or incomplete vascularization of villi in complete
hydatidiform mole, and the probable absence of D antigen on the
villous trophoblast, the risk of Rh alloimmunization in molar
pregnancy is minimal.
 Anti-D Ig may be omitted when complete mole is diagnosed in
nonsensitized Rh-negative mothers. Anti-D may not be omitted for
partial mole or uncertain diagnosis
21

22. 22
Invasive fetal diagnostic procedure
Amniocentesis :
If the placenta is implanted on the anterior uterine wall there is a risk that it will be
traumatized at amniocentesis, with subsequent fetal TPH.
Even with sonographic placental localization, a potentially immunizing volume of FMH
(>0.1 mL) occurs in at least 2% of pregnancies undergoing amniocentesis, and
immunoprophylaxis with anti-D 300 μg is recommended.
A second dose should be given 12 weeks after the first if the woman is undelivered.
 anti-D IgG given after amniocentesis does not harm the conceptus, has been shown by
the thousands of normal infants born after antenatal Rh prophylaxis
Chorionic villus sampling:
As 14% of first-trimester sampling of chorionic villi results in FMH,immunoprophylaxis
is recommended, although estimates of the risk of subsequent alloimmunization are
imprecise.
Since the total fetoplacental blood volume is 3 mL at 12 weeks,anti-D 50 μg is sufficient
at 12 weeks’ gestation or less.
 For procedures carried out later in gestation, 300 μg of anti-D should be used. The
minimum dose available commercially is 120 mg.
Cordocentesis :
Fetomaternal hemorrhage can occur following cordocentesis, particularly if a
transplacental route is chosen. The prevalence of FMH following cordocentesis exceeds
that following amniocentesis.

23. Second Trimester events
Anti-D Ig 300 μg should be given routinely to all Rh-negative nonsensitized
women at 28 weeks’ gestation when fetal blood type is unknown or known to
be Rh-positive. Alternatively, 2 doses of 100–120 μg may be given (120 μg
being the lowest currently available dose in USA and Canada): one at 28 weeks
and one at 34 weeks. (I-A)
Routine antenatal prophylaxis
 All patients should be tested for Rh sensitization at the time of registration and
again at 28 weeks.
 All non sensitized women should be given 100 mcg Anti D at 28 weeks and
again at 34 weeks or a single dose of 300 mcg at 28 weeks.
 Reduces sensitization to 0.1%.
 No fetal risk.
 Half-life 24 days.
 It is desirable to offer antenatal prophylaxis to all Rh negative women who are
nonsensitised, and have a Rh positive partner
23

24.  Amniocentesis
 Abruptio placentae
 Blunt trauma
 Intrauterine fetal death
 External cephalic version
 Placental pravia with
bleeding
Sensitizing events during second or third trimester
• All these events should be covered by an
Anti-D injection of 300 mcg atleast. (This
covers 15ml of fetal RBC’s or 30 ml of fetal
blood.)
• Ideally, a test for the size of fetomaternal
haemorrhage should be done.
• 10 mcg additional anti D should be given for
every additional 0.5 ml fetal RBC’s in maternal
circulation.

25.  Conditions associated with potential placental trauma or disruption of the
fetomaternal interface (e.g., placental abruption, external cephalic version, blunt
trauma to the abdomen,placenta previa with bleeding) can lead to sensitizing FMH.
 Fetomaternal hemorrhage has been identified in 1% to 6% of attempted or
successful external cephalic version attempts.
 Blunt abdominal trauma in pregnancy has also been documented to cause large
FMH(>25ml)
 Since these conditions may be more likely to cause fetomaternal hemorrhage in
excess of 30 mL, measurement of FMH volume is prudent
 Anti-D 120 μg or 300 μg is recommended in association with testing to quantitate
FMH following conditions potentially associated with placental trauma and disruption
of the fetomaternal interface (e.g., placental abruption, external cephalic version,
blunt trauma to the abdomen, placenta previa with bleeding).
 If FMH is in excess of the amount covered by the dose given (6 or 15 mL fetal RBC),
10 μg additional anti-D should be given for every additional 0.5 mL fetal red blood
cells. There is a risk of excess FMH, especially when there has been blunt trauma to
the abdomen.
25
Ante partum hemorrhage ,Abdominal Trauma ,External cephalic version
fetomaternal hemorrhage

26. 26

27. 27
Prophylaxis with postpartum anti-D immunoglobulin (Cochrane) effective in reducing the
risk of sensitisation after pregnancy and in a subsequent pregnancy irrespective of the ABO
status of mother and baby.
If Rh-negative mothers do not receive postpartum anti-D IgG prophylaxis after an Rh-
positive baby, the incidence of sensitization during the next pregnancy is 12% to 16%,
compared to 1.6% to 1.9% in mothers receiving postpartum prophylaxis
 Anti-D Ig 300 μg IM or IV should be given within 72 hours of delivery to a postpartum
nonsensitized Rh-negative woman delivering an Rh-positive infant.
Additional anti-D Ig may be required for fetomaternal hemorrhage (FMH) greater than 15 mL
of fetal red blood cells (about 30 mL of fetal blood).
Alternatively, anti-D Ig 120 μg IM or IV may be given within 72 hours of delivery, with testing
and additional anti-D Ig given for FMH over 6 mL of fetal red blood cells (12 mL fetal blood).
(I-A)Maximum benefits up to 14 days after exposure.
 If anti-D is not given within 72 hours of delivery or other potentially sensitizing event, anti-D
should be given as soon as the need is recognized, for up to 28 days after delivery or other
potentially sensitizing event. (III-B)
Postpartum ProphylaxisProphylaxis

28. 28
Postpartum ProphylaxisProphylaxis
UK 100mcg(500IU)(RCOG)
Australia 125mcg(625IU)NHMRC1999
USA and Europe 200-300mcg(1000-1500IU)
25mcg(125IU) 1ml of fetal cells(2ml of fetal blood)
100mcg(500IU) 4ml of fetal cells/8ml of fetal blood
300mcg(1500IU) 15ml of fetal cells/30ml of fetal blood
• Recommendations in different countries will depend on the relative availability
and costs of anti-D, and the costs of laboratory assessments of the volume of
feto-maternal haemorrhage.
The evidence on the optimal amount of anti-D to recommend for prophylaxis is
limited
A feto-maternal haemorrhage of 30 ml or more is uncommon but does occur in
up to 0.6% of births (Zipursky 1977).
1% will have FMH more than4mL
0.3% will have FMH more than10mL

29. 29
Sensitising event Minimum dose anti-D Ig
ERPC and
miscarriage 250 units up to
20 weeks
500 units after 20
weeks
CVS
Amniocentesis,
cordocentesis
APH 500 units initially
FMH test
Abdo trauma, fall
ECV
500 units initially
FMH test
Post delivery
RAADP 500 units at 28
and 34 weeks
Sensitizing Events in Pregnancy
125 units(10 mcg) anti-D Ig im
covers 1mL fetal red cells
1% will have FMH more than4mL
0.3% will have FMH more than10mL
250IU-50 microgm
500IU-100 microgm
1500IU- 300 microgm
2500IU-500 microgm
5000IU-1000microgm

30. Choice of Preparations of Anti DChoice of Preparations of Anti D
PolyclonalPolyclonal MonoclonalMonoclonal
•Produced by Epstein-Barr virus (EBV)
transformed B-lymphoblastoid cell lines
•But regulatory authorities were reluctant to
sanction the use of these antibodies as there
is a rare chance of infectious EBV in the
purified product.
•Another approach had been to fuse B cells or
B-lymphoblastoid cell lines with murine
myeloma cells to produce heterohybridoma
cell lines.
• Derived from serum of hyper immunized
Rh-negative individuals .
•The human plasma derived polyclonal anti
D is composed of IgG1 and IgG3 subclasses
•There are possibilities of transmitting west
Nile virus, Creutzfeldt-Jakob disease, etc.
•The chance of contamination with a known
virus is in the order of 1 in 10,000 billion
doses.

31. Polyclonal anti D antibody
 Four polyclonal products are currently available
 Two of the products (RhoGAM, Ortho-Clinical Diagnostics, Inc., Raritan, NJ, and
HyperRho S/D, Talecris Biothorgenetics, Raleigh, NC) are derived from human plasma
through Cohn cold ethanol fractionation—a process that results in contamination with IgA
and other plasma proteins.
 The remaining two products (WinRho-SDF, Cangene Corporation, Winnipeg, Manitoba,
and Rhophlac, ZLB Behring, King of Prussia, Penn.) are prepared through sepharose
column and ion-exchange chromatography, respectively.
 All products are subject to ,
- solvent detergent treatment to inactivate enveloped viruses;
- micropore filtration step to further reduce the chance for viral contamination.
- Thimerosal, a mercury preservative used to prevent bacterial and fungal contamination.
31

32. Monoclonal Anti D antibodiesMonoclonal Anti D antibodies
 Hundreds of human anti-D monoclonal antibodies have been produced since
1980, using different technologies for MAbs generation: heterohybridoma by
cell fusion, EBV transformation of B cells, phage display technology,
recombinant Ab engineering
 Several monoclonal anti-D are not as effective as polyclonal anti-D and is due
to unusual oligosaccharides on monoclonal anti-D affecting binding Fc
receptors.
 Recent research shows that the binding to FccRIII and subsequent activation
of effector cells (natural killer cells or macrophages) is an important criterion to
select efficient monoclonal antibodies.
 Recombinant anti-D has been manufactured by phage display and antibody
engineering.
 Two human monoclonal antibodies (MoAbs), BRAD-3 (lgG3) and BRAD-5
(IgG1), produced from stable Epstein-Barr virus-transformed B-lymphoblastoid
cell lines.
 Both monoclonal anti-Ds caused accelerated clearance of D+ RBCs from the
circulation of D- subjects.
32

33. Comparison between Monoclonal and polyclonal anti D antibodiesComparison between Monoclonal and polyclonal anti D antibodies
Features Monoclonal Polyclonal
Efficacy Greater & consistent Lower and inconsistent
Specificity High Mixed
Half life 18 days 15.6 days
Purity Highly purified Contains other antibodies
and plasma proteins.
Lot to lot variation Nil Present
Risk of transmission of
viral diseases
No risk of transmission of
any viral diseases.
Some risk associated with
emerging viral diseases.
Supply Unlimited supply Possible periodic
shortages due to
unavailability of healthy
donors.

34. 34
Successful prophylaxis of RhD immunization by anti-D immunoglobulin is associated with a
rapid elimination of Rh(D) positive red blood cells (RBC) from the circulation of Rh(D)
negative individuals.
This clearance is mainly due to interactions of the anti-D coated RBCs with Fc gamma
receptor bearing mononuclear cells .
The mode of action of prophylactic anti-D may be merely to clear the D-positive cells from
the circulation to the spleen , by interaction of the IgG-coated red cells with macrophages
bearing IgG Fc receptors (Fc3~R), resulting in phagocytosis or lysis of the red cells
Currently available products consist of immunoglobulins G with a predominance of the
subclass IgGl and a variable content of IgG3
Assessment of the pharmacodynamic properties of anti-D immunoglobulin has shown that
elimination of 1 mL of packed Rh(D) positive RBCs or 2 mL of whole blood required
approximately 20 pg anti-D .
Mechanism of action of anti D

35.  Routes of administration include intravenous (IV) or intramuscular (IM). The duration of
action of either route is the same.
 After IV administration, the initial serum levels of anti-D are higher in the first week but
similar thereafter until 3 months.
 Highly circulating levels of anti-D might be of benefit when the timing of FMH is known
(e.g., postpartum, third trimester bleed), but are not relevant to antenatal prophylaxis at
28 weeks.
 Following administration of anti-D, a positive antibody screen will be found in the
woman.
 This response is typically of low titre and weakly reactive. Anti-D crosses the placenta
and binds to fetal red blood cells, without causing hemolysis, anemia, or jaundice.
 In one study, 20% of the Rh-positive babies, born to mothers receiving 2 ante partum
doses of anti-D immune globulin, had a positive direct antiglobulin test, but their
hemoglobin and bilirubin levels were no different from those of Rh-negative babies.
35
Administration and preparations

36. 36
Administration and preparations
Intramuscular anti-D Ig should preferably be given into the deltoid muscle.
Injections into the gluteal region often only reach the subcutaneous tissues and
absorption may be delayed.
For successful immunoprophylaxis, anti-D Ig must be offered as early as possible
and preferably within 72 hours after the sensitising event.
In case the injection is missed in the first 72 hours, it should be administered as
early as possible as this may still provide some protection.
If a woman for some reason, refuses to take the injection her refusal should be
documented.
Women who are already sensitised should not be given anti-D Ig.
Women who have a weak expression of the Rh blood group (Du positive) do not
form anti-D and do not therefore require prophylaxis. It should be noted that anti-
D Ig does not protect against the development of other antibodies which can
cause haemolytic disease of the newborn.

37. Half life and interactions
Half Life
 The half life of Rh D immunoglobulin is approximately 3-4 weeks. It can be
detected in a patient’s serum up to six weeks after administration. This time
span would be shortened with ongoing bleeds
RhD-Ig and Vaccinations
Administration of RhD-Ig and MMR/Rubella vaccine (or any other live
attenuated vaccine) may be compromised if;
 RhD-Ig is given within 2 weeks after MMR/Rubella vaccine.
 RhD-Ig and MMR/Rubella vaccine are given at same time (in different sites).
 MMR/Rubella vaccine is given within 3 months of RhD-Ig administration.
37

38. Side effects
Maternal
Reports of adverse drug reactions from administration of prophylactic anti-D to Rh-
negative women are rare and usually mild,
 Local tenderness, erythema, or stiffness at site of injection, should resolve in a
few hours.
 local swelling, headache, or chills ,Occasional temperature, malaise,
drowsiness, urticaria or hives (rare).
 The rare hypersensitivity reaction manifesting as urticaria, itching, or
maculopapular rash may be treated with antiurticarial agents
 A rare but possible risk of transmission of blood borne disease.
 Remote chance of idiosyncratic or anaphylactoid reaction , but warrants the
availability of epinephrine when administering anti-D IgG.
 The Royal College of Obstetricians and Gynecologists concluded that no
serious adverse reactions have been reported in women receiving anti-D IgG
Foetal/Neonatal
 No evidence of any harm to baby.
 It is considered safe to breastfeed following administration of RhD-Ig.
38

39. Guide lines for antenatal prophylaxis of Rh negative pregnancy
The National institute for clinical excellence ,SOGC,and ACOG provides guide lines on
use of routine Anti-D prophylaxis for Rh negative women.
1.All pregnant women (D negative or D positive)should be typed and screened for
alloantibody with an indirect antiglobulin test at the first prenatal visit and again @ 28
weeks .
2.Rh testing of baby’s father may be offered to all Rh negative pregnant women to
eliminate unnecessary blood product administration.
3.Anti d 300 mcg should be routinely given to all Rh negative nonsensitized women @28
weeks gestation when fetal blood type is unknown or known to be Rh positive.
4.It is recommended that routine antenatal anti D prophylaxis is offered to all non
sensitized pregnant women who are Rh negative
5.The clinician responsible for the prenatal care of the nonsensitized Rh negative women
should discuss with her RAADP and the opinion available so theat the women can
make informed cholce about treatment .this includes circumstances where RAADP
would be neither necessary nor cost effective .such circumstance include those where
the women :
- has opted to be sterilized after the birth of the baby
- father is known to be Rh negative
- is certain that she will not have another child after her current pregnancy.
39

40. 6.Routine antenatal anti D prophylaxis @ 28 weeks should not be affected by whether she
has already has antenatal anti D prophylaxis for a potentially sensitizing event early in
pregnancy. Women’s use of postpartum anti D prophylaxis should similarly not be
affected by whether she has had RAADP or AADP as a result of sensitizing event.
7.Anti D Ig 300mcg given within 72 hrs of delivery to a postpartum nonsensitized Rh negative
women delivering a Rh positive infant. Additional Anti D Ig may be required for
fetomaternal hemorrhage greater than 15 ml of fetal red blood cells (about 30 ml of fetal
blood)
8.If Anti D is not given within 72 hrs of delivery or other potentially sensitizing event anti D
should be given as soon as the need is recognized ,for up to 28 days after the delivery or
other potentially sensitizing event.
9.A women with weak D (Du positive )should not receive anti D .A test for weak phenotype
must be performed in women who initially test Rh negative .
These women are genetically Rh positive and are at low risk of producing anti D antibodies
and are at very low risk of having an affected fetus.
40
Guide lines for antenatal prophylaxis of Rh negative pregnancy

41. 10.A repeat ante partum dose of Rh immune globulin is generally not required @40 weeks
provided that ante partum injection was no earlier than 28 weeks gestation. There is
insufficient evidence at this time to make a recommendation for or against
administration of another dose of anti D at 40 weeks in an undelivered women .Manitoba
guideline(1999)mandated a 39-40 weeks dose .ASCP practice parameters say it may be
done.
11.After miscarriage or threatened abortion or induced abortion during the first 12 weeks of
gestation non sensitized D negative women should be givne a minimum anti D of 50
mcg.after 12 weeks 300 mcg should b e given.the risk of alloimmunization following
spontaneous abortion is 1.5%-2%.the risk of alloimmunization following induced abortion
is 4-5-%.even 0.1ml od D positive red bllod cells can sensitize 3 %of D negatve women so
anti D is induced.
12.@abortion blood type and antibody screen should be done unless results of blood type
and antibody screen during the pregnancy is avilable in which case antibody screenign
need not be repeated.
13.Anti D should be given to nonsensitized women following ectopic pregnancy.A minimum
of 50 mcg should be given before 12 weeks gestation and 300 mcg after 12 weeks
gestation.
41
Guide lines for antenatal prophylaxis of Rh negative pregnancy

42. 14. Anti D should be given following molar pregnancy because of possibility of partial mole.
Anti D may be withheld if the diagnosis of complete mole is certain .
15. At amniocentesis , anti D 300mcg should be given to nonsensitized women .Even with the
sonographic placental localization potentially immunizing volume of FMH (0.1ml)occurs
atleast in 2%of pregnancies undergoing amniocentesis .Study shown that 5.2%of women
not treated with anti D @amniocentesis become alloimmunized where as none of the
treated women become sensitized following invasive procedure.
16. Following chorionic villus sampling minimum of 50 mcg of anti D given during the first 12
weeks of gestation and at a dose of 300mcg after 12 weeks gestation, as 14 %of first
trimester sampling of chorionic villi results in FMH,immunoprphylaxis is recommended.
17. Anti d 300 mcg should be given following the cordocentesis .FMH following the
cordocentesis can occur particularly if the transplacental route is chosen .the prevalence
following the cordocentesis exceeds that following the amniocentesis.
42
Guide lines for antenatal prophylaxis of Rh negative pregnancy

43. 18. Quantitative testing of FMH may be considered following events potentially associated
with the placental trauma and disruption of the fetomaternla interface (placental
abruption, blunt trauma to the abdomen ,cordocentesis, placental previa with the
bleeding ).there is substantial risk of FMH over 30 ml with the such events especially
with the blunt trauma to the abdomen.
19. 300mcg of anti D recommended in association with the testing to quantitate FMH
following conditions potentially associated with the placental trauma and disruption of
the fetomaternal interface (placental abruption, blunt trauma to the abdomen
,cordocentesis, placenta previa with the bleeding ). If FMH is in excess of the amount
covered by the dose given (6ml or 15ml fetal RBS),10mcg additional antiD should be
given for every additional 0.5ml fetal red blood cells.
FMH has been identified in 1-6% of attempted or successful external cephalic version
attempts. There is a risk of excess FMH ,especially when there has been blunt trauma to
the abdomen. since these condition may be more likely to cause FMH in excess of 30 ml
,measurement of FMH volume is prudent.
20.Verbal or written informed consent must be obtained prior to administration of the blood
product Rh immune globulin.
43
Guide lines for antenatal prophylaxis of Rh negative pregnancy

44. ACOG RecommendationsACOG Recommendations
Based on good and consistent scientific evidence (level A) Rh negative woman
who is not Rh D-alloimmunized should receive anti – D immune globulin,
 At 28 weeks of gestation, unless father of the baby is known to be Rh D
negative.
 Within 72 hours after delivery of Rh D positive infant.
 After a first trimester pregnancy loss.
 After invasive procedures, (CVS, amniocentesis, FBS).
Based on consensus and expert opinion (level C) anti D immunoglobulin
prophylaxis should be considered if pt experienced
 Threatened abortion.
 Second or third trimester antenatal bleeding.
 External cephalic version.
 Abdominal trauma..

45. Despite the dramatic success of anti D immunoglobulin prophylaxis
protocols , 27% of susceptible women still become Rh D
alloimmunized .The reasons are :
• Failure to follow recommended protocols.
• 0.1-0.2% rate of spontaneous immunization occurs despite
prophylaxis ,observed in pregnancies in which no prior sensitizing
events have occurred.
• Alloimmunization involving atypical blood grops (Kell and C blood
groups ) is not preventable.
ACOG RecommendationsACOG Recommendations

46. Management of Non Sensitized PregnancyManagement of Non Sensitized Pregnancy
NEGATIVE
Father Rh FactorFather Rh Factor
POSITIVE
No further testing
POSITIVE NEGATIVENEGATIVE
Manage as sensitized
pregnancy
Anti- D at 28 weeks and
also after delivery if the
baby is positive
Ab screen at booking,Ab screen at booking,
28 wks (ICT) & every 4 weeks28 wks (ICT) & every 4 weeks

47. 47
rand Name Composition Company Packing MRP
MATERGAM-P inj Human anti-d immunoglobulin 300 iu ZYDUS 1.5ml vial 2495.00
MACRHOGAM inj Immunoglobulin G anti-Rho (D) 50 mcg,
sodium chloride 2.9mg, polysorbate 80
0.01%, thimerosal 0.003%, glycine 15mg per
ml
JOHNSON &
JOHNSON
1 prefilled
syringe
1200.00
PARTOBULLIN inj Human anti-d immunoglobulin 1250 iu FOREVA 1ml 2200.00
RHESUMAN inj Human anti-d immunoglobulin 300 iu CADILA-H Vial 1988.00
RHOCLONE inj Human anti-d immunoglobulin 150 iu BHARAT
SERUM
Vial 1575.00
RHOCLONE inj Human anti-d immunoglobulin 300 iu BHARAT
SERUM
Vial 2598.00
ROHOGAM inj Human anti-d immunoglobulin 300 iu, sod chl
2.9mg, polysorbate 80 0.01%, thimerosal
0.003%, glycine 15mg per ml
JOHNSON &
JOHNSON
Vial 2500.00
VINOBULIN inj Human anti-d immunoglobulin 100 iu BHARAT
SERUM
Vial 978.00
VINOBULIN inj Human anti-d immunoglobulin 300 iu BHARAT
SERUM
Vial 2299.00
WIN RHO SD inj Human anti-d immunoglobulin 300 iu PANACEA Vial 2390.00

48.  Reviews in the Cochrane Library , indicate that antenatal administration of
Anti-D can result in a reduction in alloimmunisation of 78% .
 Overall a policy of Anti-D administration at 28 and 34 weeks during pregnancy
to all Rh (D) negative women (who have not actively formed their own Anti-D)
will result in a reduction of alloimmunisation from about 1% to 0.3%.
 Postnatal treatment with rhesus immunoglobulin to prevent RhD sensitisation
is successful in approximately 90% of all RhD-negative women at risk,
resulting in a decrease of immunised women to approximately 1% .
 Deka D etal observed that failure to administer post natal anti D prophylaxis
was responsible for RhD alloimmunization in more than 50% of cases,
followed by failure to administer Anti D after MTP (10%).
Evidence of benefit

49. RhD immunisation continues to occur. This results from failure to adhere to
previously published guidelines on RhD prophylaxis.
The key recommendations of the current guidelines are as follows:
 Following delivery, irrespective of the dose of anti-D Ig routinely administered,
postnatal prophylaxis must include a screening test to identify women with a
large FMH who need additional immunoglobulin (Grade B recommendation).
 Anti-D Ig should be given after sensitising events before delivery and after
abortion (Grade B recommendation).
 Anti-D Ig is no longer necessary in women with threatened miscarriage with a
viable fetus and cessation of bleeding before 12 weeks" gestation (Grade C
recommendation).
 At least 500iu of anti-D Ig should be given to non-sensitised RhD negative
women at 28 weeks and 34 weeks of pregnancy according to NICE guidance
(Grade A recommendation).
Women should have all necessary information to enable them to make an
informed choice about Rh prophylaxis.
Conclusion and summary of recommendation