Some of our doctors would like us to give the Rhogam shot to their patients without a repeat ABO&RH or antibody screen after miscarriages.

What is your practice?

We always repeat the ABO/Rh and antibody screen just for the simple fact that there is always a remote chance that the patient was incorrectly typed or the patient's specimen was mislabeled prior to delivery.

The other possibility we have seen is the patient is sharing their medical card with friends and family. You may never know who is the real patient this time.

Good thought.

Our practice is to repeat the testing before giving the shot- we have had some doctors that wanted to just give it with no testing also. But once we explained that the testing needed to be repeated they didn't argue.

We haven't stocked the RhIG shots for at least 10 years. The doctor's offices have their own. I am sure they give it sometimes without any testing. It isn't like it would harm anything but the pocketbook of an Rh Pos person if it was given by mistake. What value--except economic--is the antibody screen after a miscarriage?

Mabel, there is always the possibility of physical harm anytime you inject anything into anyone. The Docs can do anything they want in their offices but when they come to my house they must play by my rules. Actually they are not "MY" rules but that's a subject for another discussion.

The only time we don't repeat the antibody screen is at delivery and we have a record of a negative screen during that pregnancy. Since they started shipping all of our prenatals out we seldom have any record of the preganacy and even before that a lot of the miscarriages we saw occurred prior to any prenatal care so we didn't have a record of any previous testing. The only miscarriages we know about come through our ER and more often than not it's the first time we've seen them.

We had a patient in our ER who had a miscarriage. She was drawn for a blood type and she was B NEG. This did not match with our previous history of A Pos. She knew she would need rhogam and when she was confronted with the past history it came to light that she was using her friend's insurance card not realizing we had a history on her friend. She left AMA before giving her real identity and hopefully received rhogam elsewhere.

Lesson: Never take a historical blood type for a rhogam work up.

Must be a Florida thing. We have had the same situation occur several times in our ER and occasionally in L&D. Therefore we never go by a historical type and always request the patient be re-drawn for a blood type prior to giving out RhIG.

Nope, not just Florida - we see it here in Boston, too. One of the major reasons we insist on a spec prior to RhIG.

I thinks it is pretty global. Utah has a big problem with this. People don't realize how dangerous it could be for them.

Nope, it is a problem in Arizona as well. We retest with every order. We will give the rhogam prior to the antibody screen being complete but the type is confirmed first.

Actually I'd never thought of this as being a significant problem in the past but nowdays it obviously is. My wife is a nurse in Maternity at the local health department. It is not uncommon at all to have women come in off the street with what are later found out to be aliases and/or bogus social security numbers. The nurses have been advised that they have no responsibility to question any of the information that they are given and should just treat the patient as a routine prenatal. It seems therefore that the practice of repeating previous ABO/Rh and antibody screening results may indeed carry some validity.

I think it is a big problem...same in New york and New Jersey...Patient's type keep switching every year or two???

Insurance fraud is fairly common. We had a patient submit to the ER with a bleeding problem. The name on the insurance card had an historical A+ blood type, and the patient was O+. I told the ER doc what I suspected. He went to the patient and said that apparently the patient's blood type had changed from A+ to O+, and that was indicative of a rare form of rapidly fatal cancer that could only be cured by removing the long bones of the legs. He said he would return in a few minutes after he scheduled the emergency surgery. When he returned, the patient was gone with the wind.

BC

what is your policy on giving RhOGAM for the patient(Rh neg) @ 7-8 week and admitted to ER for vaginal bleed or spotting??

We do not address this in a policy. If the doctor wants to give RHIG, then they need to order a K-B stain. I have not seen RHIG issued for spotting only.

BC

I thought the fetal blood volume supposedly won't exceed 30 ml till about 20 weeks gestation. Is there some reason I haven't thought of that would make you do a KB at 7-8 weeks?

Happens in Europe too. At least I know of cases in France and Switzerland. This is one of the consequences of having an insurance-based healthcare system

Anna

The physician would need to order the RhIG. If the patient is <13 weeks gestation we would not do a K-B. The testing we would do is an Rh and if there was no record of a negative antibody screen during this pregnancy we would do an antibody screen as well.

In a hospital I used to work in if the ER wanted Rhogam on a women that had miscarried

they could request it from us without a blood type. The reasoning behind this was many of these kids would not want to wait and take off. So rather being safe then sorry they would err on the side of caution and give them the injection.

Someone should be tracking this health care ID fraud. I would expect it to get worse as more people can't afford insurance. It seems to me to be a part of the national health care crisis.

Do the hospitals where this has happened require photo ID or are they even faking that?

Our facility does require a photo ID - BUT - if they don't have one they just put a note in the patient's file in the computer, stating that there was no photo ID available at time of service.

Thanks for your response, Dr. M. I wasn't criticizing the use of Rhogam during pregnancy. I'm always amazed at how protocols change. When I was having babies (1979 and 1981) this was not done routinely, but I think they were starting to talk about it but then not too many years before me Rhogam wasn't even an option! I realize that you are depending on a patient being honest with you, but there are situations-denial etc. where the patient might not even realize she is lying. Or where the risk of being honest too great (of course the patient may not realize by not being honest that the risk to the baby could be even greater.) Rather than take this risk, or risk offending the patient by auggesting that her husband might not be the father, I wondered if it would be acceptable to go ahead and give Rhogam to all RH negative women unless proven (as in baby' blood type) that it is not necessary. I guess the same would apply to an RH negative woman having a miscarriage and has an RH negative husband. I'm not expecting an answer on this, just wondering.

I am one of those Rh Negative mom's who knows that my husband is the father of my babies and that he is also Rh negative. I want to keep my right, as a medically informed patient, to refuse the Rhogam shot. I understand completely what you are saying about lying or being misinformed and taking the chance of not receiving Rhogam when they really need it. It is just not always best to make blanket policies.