RhIG policies

[chicagotech]

What are practices/policies at other large institutions to ensure that all obstetric patients that are RhIG candidates receive their RhIG? Do you require a type and screen on all obstetric patients, or are prenatal records acceptable? How do you ensure that all Rh negative obstetric women at your institution have a rhogam evaluation - nursing or blood bank oversight? Also, how soon after delivery are your rhogam evaluation samples drawn, and what are your practices surrounding this?

[kmoremedtech]

We TS all OB patients. All babies of Rh neg patients have type and DAT performed. If baby is Rh positive, then a STAT Fetal Screen test is ordered. If it is neg...patient receives 1 vial of RhiG. If pos..then a KB stain is performed STAT and patient recieves appropriate vials of RhiG. When RhiG is ready for pick up, we call the floor and document in computer. The floor usually comes right away to get it.

[John C. Staley]

It is the physicians first and the nurses second to make sure their patients receive RhIG if they need it. We can not be responsible for every woman that walks through the doors. They order the testing, we do it. We can not be the RhIG Police. I helped the nursing staff along with risk mgt come up with a system they follow to assure their patients needing RhIG are identified and tested and provided with the injection. It's their patients let them be responsible.

These are not just deliveries, they come through the ED and perinatology as well. It is impossible for the transfusion service to be responsible and at my facility I have refused to be responsible. It's time for the docs and nurses to be accountable for caring for their patients.

[Mary]

Why do you do it STAT?

[kmoremedtech]

To be honest...I don't know. I did not set the policy merely walked into its pre-existance. I believe it comes down to ... giving the floor as much time as possible to administer the product. As for ED and Surg patients..I agree with John. The physicians do order the RhiG evaluation...and if it is missed...it is their problem. If we set up a product and it is not picked up...it is out of our hands. We have done our part, which is filling the request.

[Eagle Eye]

We go one step beyond after we prepare RHIG. Once we receive request for RHIG workup and it is postpartum RHIG or RHIG due to ABdominal trauma, we prepare RHIG and follow up to make sure RHIG is given within 72 hrs. FOr some reason patient gets discharged(eg. AMA) we document is our system and notify physician.

[galvania]

We TS all OB patients. All babies of Rh neg patients have type and DAT performed. If baby is Rh positive, then a STAT Fetal Screen test is ordered. If it is neg...patient receives 1 vial of RhiG. If pos..then a KB stain is performed STAT and patient recieves appropriate vials of RhiG. When RhiG is ready for pick up, we call the floor and document in computer. The floor usually comes right away to get it.

Could you explain to someone in Europe exactly what you mean by a 'Fetal Screen test'. Thanks

Anna

[AMcCord]

The fetalscreen or rosette test is a qualitative test for detection of fetal cells in maternal circulation. If the fetal screen is positive, a Kleihauer-Betke or flow cytometry is done to quantitate the fetal cells for calculation of the RhoGAM dose. If the screen is negative, 1 vial of RhoGAM is administered.

[galvania]

The fetalscreen or rosette test is a qualitative test for detection of fetal cells in maternal circulation. If the fetal screen is positive, a Kleihauer-Betke or flow cytometry is done to quantitate the fetal cells for calculation of the RhoGAM dose. If the screen is negative, 1 vial of RhoGAM is administered.

Thanks. How do you do the rosette test exactly? and why not just do the K-B?

Anna

[bbbirder]

The Fetal Screen kit we use is actually based on detecting Rh positive cells. It will detect small quantities of Rh positive cells in a suspension of Rh negative cells. (But it will also be positive if the mother is a D-variant.)

The reagents are a chemically modified anti-D, pos and neg controls, and indicator cells. The patient's cells are incubated with anti-D reagent, washed (like for a Coombs/AHG test), then the indicator cells are added. The indicator cells are ficin (?) treated D-positive cells. They will bind to any anti-D coating D-positive cells in the suspension, forming rosettes. The rosetting technique is much more sensitive than a typical AHG test.

Reason to perform... MUCH FASTER and easier than the KB stain. If the screen is positive, we run the KB stain, to determine the actual dose of RhIG. We do many Fetal Screens each year and very few KB stains.

You can't do this test if you are trying to detect a FMH and the fetus Rh is unknown.

Linda Frederick

[chicagotech]

We are currently working on a system for our nurses as well, so they don't miss the Rh neg patients. What kind of system did you put in place at your facility on the nursing side?

[jhoannac]

We go one step beyond after we prepare RHIG. Once we receive request for RHIG workup and it is postpartum RHIG or RHIG due to ABdominal trauma, we prepare RHIG and follow up to make sure RHIG is given within 72 hrs. FOr some reason patient gets discharged(eg. AMA) we document is our system and notify physician.

why do we have to draw an EDTA blood at least 1-2 hours after delivery? Can we make it within 24 hrs after delivery?

[jhoannac]

What are practices/policies at other large institutions to ensure that all obstetric patients that are RhIG candidates receive their RhIG? Do you require a type and screen on all obstetric patients, or are prenatal records acceptable? How do you ensure that all Rh negative obstetric women at your institution have a rhogam evaluation - nursing or blood bank oversight? Also, how soon after delivery are your rhogam evaluation samples drawn, and what are your practices surrounding this?

the doctors order the antepartum rhig based on the patients blood type that comes with our regular prenatal work-up.

for post partum, OB calls the lab with information on every new birth they have, which includes baby's name, time of birth, mom's name, mom's DOB and blood type. All Rh negative moms gets a blood draw w/in 2 hrs post-delivery for possible rhogam work-up after we get cord blood samples to be tested for ABO/Rh and DAT.

It's the labs responsibility to order a post-partum rhogam work-up if the baby's blood type is positive.

[Mabel Adams]

why do we have to draw an EDTA blood at least 1-2 hours after delivery? Can we make it within 24 hrs after delivery?

Because the package insert says you should. However, I recall a lengthy debate on the AABB forums several years ago which revealed that many of us can't achieve a time-frame much better than 24 hours. Considering the rarity of RhIG failure, I doubt if we are causing much of a problem for our patients if it takes a few extra hours.

Here's my logic for why it doesn't really matter so much: The claim is that ABO incompatible fetal cells will be removed from the mother's circulation fairly quickly so we need to collect a sample before those fetal cells are removed or we won't get an accurate count of the amount of fetal bleed. In the days before RhIG, it was observed that Rh neg moms whose babies were ABO incompatible with them were less likely to become sensitized to D. The theory I heard was that the ABO incompatible cells were removed by intravascular hemolysis so were never presented to the immune system like ABO compatible fetal cells would be when they are removed by the spleen. Seems to me the fetal cells the rosette testing package inserts are so worried about us detecting are not likely to cause sensitization anyway. Someone feel free to correct me if I am wrong.

[Mary]

I agree with you. We would see more RhIg failures if this was true. We do the post partum work up the next morning with the hemoglobin draw. Been doing this for 30 years and haven't seen a failure.

[Ardele]

So, does anyone out there have any "rules" on when to do the Fetal Screen? I know about after delivery of an Rh-positive baby to an Rh-negative mom; but what about other cases? Say an emergency room patient who mis-carries at 20 weeks? Do you do a fetal screen on her? When do you do it and when not? Are there specific recommendations any one knows of? Thanks.

[bbbirder]

Here are our 'rules' (cobbled together over time and with the agreement of the OB/GYN department)

DO the Fetal Screen: post delivery; after abdominal trauma if greater than 20 weeks gestation

Do NOT do the FS: routine 28 week antenatal; abdominal trauma less than 20 weeks; amniocentesis at any gestational age (this last one, only do FS if requested by the OB doc)

Linda Frederick

[John C. Staley]

Our rules/guidelines are similar to Linda's except our corporate transfusion medical director set the gestational age at 13 weeks instead of the 20 weeks Linda indicated for the need for fetal bleed screens.

[Mabel Adams]

I remember being told that the entire fetal blood volume would not exceed the 30 mls covered by one dose of RHIG until after 20 weeks gestation. However, since then I have heard of cases with chronic fetal-maternal bleeds where maybe more than that could (rarely) accumulate over time as the baby makes more red cells. That would probably mean a FMH could conceivably be that big earlier than 20 weeks. Of course twin pregnancies would change the value too.