Kimster

We do not wait to test after delivery, so testing after an amnio makes sense. If the FMH from the amnio is larger than 15ml of RBC's, then the patient would require more than one syringe of Rh Immune Globulin. This is the same for post delivery, or even continual spotting during the pregnancy. This would be a rare occurrance but this is a disease of prevention.

I posed the question to JCAHO online and this is their response: No, this is not a mandatory practice. Rho Immune Globulin is a "blood derivative". Our practice is to survey blood derivatives (albumin, Rhogam, factor concentrates, etc.) under either the Immunohematology or Medication Management standards, depending on which of the two hospital departments is overseeing it. Specifically, if managed by the blood bank, we would survey it under our Immunohematology standards in the laboratory manual. If managed by pharmacy, we would survey it under the Medication Management standards in the hospital manual . The former has stringent tracking requirements (see QSA.05.01.01 and AABB standards 5.1.6.1 & 6.2.3) ; the latter requires sufficient tracking to determine who may be impacted in the event of a recall (MM.05.01.17). Note that full compliance with the intent of the standards can only be assessed during an onsite survey. Please feel free to contact me directly with any further questions or discussion for clarification purposes.Megan SawchukJoint Commission

Liz most RhIg costs between $78-roughly $90 in most hospitals. Alot cheaper than treating a woman who becomes sensitized.

Remember that <0.1 ml of RBC's can cause sensitization to a Rh negative person.

I have had the Ortho rep also bring up half life and the Ob doc ordering scenario. The issue with half-life is Ortho did their study on Rh-negative males. CSL Behring did the Rhophylac study with Rh negative pregnant females. It's apples and oranges, can't be compared. I asked the Ortho rep to explain what half life is, didn't have a clue. As far as the docs orders just substitute the pre-written orders that I know most hospitals use to Rh Immune Globulin doesn't matter what is on the shelf then. We probably shouldn't have been using "Rhogam" all these years anyway.

As a dog lover welcome and the best to you as you set this up.

There is a great article by Dr Werch out of Ben Taub in Clinical Apheresis this month on this subject. I actually looked at the PI's for all the RhIg and none have information on how to give large doses. We have to remember that when we give large doses of RhIg we are treating these patients like they have ITP. Those patients are not post-partum with a new baby and know they will have some side effects from the treatment, they are usually pre-medicated with Benadryl and Tylenol to ward off some of these side effects from large doses of RhIg. The red blood cell hemolysis causes the side effects you mentioned from slight to severe. I believe in Dr Werch's paper they pre-medicated both patients, and used Rhophylac on both. It seems it depends on the situation how she would treat the patient.

This is where the differences between AABB and ACOG guidelines do not mesh. AABB guidelines have a prenatal antibodies screen to be performed prior to the 28 wk administration of Rh Immune Globulin. ACOG leaves this to the discretion of the the physician. With blunt trauma, (falls, car accidents, domestic abuse) being the number one reason a Rh negative pregnant women becomes sensitized and the state of defensive medicine, the wise choice would be to draw the type and cross, perform the antibody screen after the administration of the Rh Immune globulin if the mother is Rh negative. This will prevent the mom from waiting but will still be covered and no one is worried whether or not she will come back. Many blood banks do it this way. If she has become sensitized prior to the 28 week administration, one does of Rh Immune Gobulin will not hurt her or the fetus.

I have always found it interesting how they can rationalize a 100% increase in prices in one year. The FTC should be more interested in this type of issue within medicine. What changed to warrant that type of price increase, how can they justify this. Reagents are not the only product within hospitals that this has happened to and if they want to cut medical costs then the government needs to look at price increases on products used within medicine for at least the past 5-7 years.

On day 38 the fetus has developed RBC's. FMH is one of the largest reasons for fetal demise. That is why a KB should be done on all Rh negative moms with a Rh positive fetal death to determine how much RhIG should be given. I recently asked a maternal fetal specialist regarding multiple births and he does not treat any different than a single fetus when it comes to covering with RhIg.

Microdose is 50mcg per syringe.

Fetal blood volume is about 150 mL/kg. The average fetal hematocrit is 50% so 30 mL of circulating RBCs would correspond to 60 mL of whole fetal blood. Using the 150 mL/kg rule, 60 mL would roughly be the circulating volume for a 400 gram fetus. 400 grams is approximately the 50th centile for fetal weight at 20 weeks.

The number one reason an Rh negative pregnant woman becomes sensitized is blunt trauma, be it a fall, car accident , domestic abuse, etc. The standard of care is to perform a KB to determine if there is a bleed greater than 15ml. One syringe of RhIg may not be enough to cover the bleed.

This idea of adding one syringe came about because until recently most Rh Immune Globulins dose on their PI read as approximately 300mcg.. This idea was reinforced when several products had a recall for insufficient dosing. In some cases the amount of Anti-D in a syringe could be as low as 234mcg.

Linda, I agree. Unless the patient is female and of child bearing age should this be an issue. And then I would space the dose of Anti-D over several days.

Just an FYI, there is another IV Anti D- Rhophylac. It is about 1/3rd of the price of WinRho, also usually cheaper than Rhogam too. That is what Dr. Werch used in her cases in her abstract.

He could always become a Rh plasma donor if he becomes sensitized. Depending on where he lives and if there is a plasma center with such a program nearby.

During AABB this year, Dr. Werch out of Ben Taub in Houston had a abstract poster on this subject. Although this was based on females of child bearing years, it gave two scenarios on the treatment. Also Dr. Jay Herman out of Philadelphia had a paper in Transfusion this past year on mismatched blood transfusions. Most people do not worry about males being treated for this but some do treat. In Dr. Werch's paper she discussed a patient who received 2 units of PRBC's, but the calculations will vary by the amount of PRBC's in each unit. Most are around 200-250cc, which works out to around 16-17 syringes of Rh Immune Globulin per unit. Rhogam use to have a maximum dosage of 3000mcgs. not sure if they still do but that would be only 10 syringes. In both if Dr. Werch's cases she gave the product IV. There are two IV formulas on the market, WinRho and Rhophylac. She used the latter.

Has anyone been told that Rhogam is on allocation due to a sterility issue? I was told I could only have half of my order until maybe around Thanksgiving for the rest? Here we go again, it is always something with Ortho, they will probably raise my price.

She may have ITP and is being treated with Rho(D) Immune Globulin. It is used only in Rh positive patients for ITP.

Good morning, according to the way it is administered the information needed on the insurance claim form is as follows (using a uniform claim form) Field 19- enter name of drug and NDC number 44206-300-1 : 1 prefilled 2ml syringe 1500 IU (300mcg) Field 21- enter all ICD-9-CM diagnosis codes For suppresion of Rh isoimmunization in pregnancy and obstetric conditions: 656.0- Fetal maternal hemorrhage- leakage(microscopic) of fetal blood into maternal circulation 656.1- Rhesus isoimmunization-anti-D antibodies Rh incompatibility -5th digit required 0-unspecified as to the episode of care or not applicable 1-Delivered with or without mention of antepartum condition 3- Antepartum condition or complication Field 24D-Enter the HCPCS codes that correctly describe the procedure performed or enter the the appropriate CPT codes J2791- Injection Rho(D) immune globulin (Human), (Rhophylac), Intramuscular or Intravenous, 100IU Field 24E-Enter the corresponding ICD-9-CM diagnosis code (see field 21 above) Field 24F- Medication charges/Procedural charges -$ Field 24G- Enter total billable units of Rhophylac administered I hope this helps ask your sales rep for their coding sheet like I did. Kim

Our contract has changed recently and we can now look at changing from rhogam to this new product Rhophylac. I would appreciate hearing other hospitals experience with this for our moms and if you have used for ITP yet, we go to the transfusion committee next month. It seems like a good product plus we can replace our winrho for alot less. Thanks