Pre-delivery Type and Screen

[Sko681]

Hi all! I was just curious to see what everyone was doing. Today we had a meeting where the pathologists and some of the OB docs want to start doing type and screens for all women who come to the hospital in labor. They want to do this because they are concerned about the risk for maternal hemorrhage and a mother who may have an antibody that was previously undetected or found at another hospital. The counter argument of course was cost. So again is anyone out there currently doing this?

Thanks!

Shaunna:)

[Malcolm Needs ☆]

No, this was not done when I was working in a hospital, but I most certainly can see from where they are coming.

That having been said, in a real obstetric haemorrhagic emergency, you are going to go through blood like there is no tomorrow. If the lady has made an antibody late in pregnancy, the chances are that you are going to go through any phenotyped blood well before the bleed is stopped. In many cases, it is worthwhile giving random blood during the emergency, and giving the phenotyped blood as the bleeding comes under control (on the grounds that the transfusion reaction will take place on the Labour Ward floor, rather than in the mum).

Having some phenotyped blood available is a really good idea though (even if we are only talking about approximately 2 to 5% of mums).

[John C. Staley]

In my previous life we had an acceptable sample collected on "all" OB patients but no testing unless the OB doc specifically ordered something. This was drawn in conjunction with a CBC so they were getting stuck anyway. The biggest problem was that L&D nurses drew the blood and I don't think I will go into all the problems associated with that!!

The theory was that if everything went baddly we at least had a sample in hand to start working with. The occasions the sample was actually used were very rare but when we needed it we were very glad it was available.

Shaunna I don't know how big the OB practice is at your facility but at my old place a type and screen on every OB patient would have been a horrendous waste of time and money. If you are only looking at one or two per day or fewer it's probably not too big of a deal. I guess it's all a matter of where the greatest concern lies. Have you had a recent incident where having a T&S already done would have made a difference?

[Malcolm Needs ☆]

In my previous life we had an acceptable sample collected on "all" OB patients but no testing unless the OB doc specifically ordered something. This was drawn in conjunction with a CBC so they were getting stuck anyway. The biggest problem was that L&D nurses drew the blood and I don't think I will go into all the problems associated with that!!

The theory was that if everything went baddly we at least had a sample in hand to start working with. The occasions the sample was actually used were very rare but when we needed it we were very glad it was available.

Shaunna I don't know how big the OB practice is at your facility but at my old place a type and screen on every OB patient would have been a horrendous waste of time and money. If you are only looking at one or two per day or fewer it's probably not too big of a deal. I guess it's all a matter of where the greatest concern lies. Have you had a recent incident where having a T&S already done would have made a difference?

Good points John. Perhaps having a sample in the laboratory, rather than actually testing the sample in the laboratory is a far better idea than that I put forward.

[Sko681]

Well what happened is that we recently merged 3 hospitals and the two smaller hospitals had OB. Combined there are about 2,000 births per year. The pathologist who suggested this said that they have approximately 4 severe bleeds per year and in 10 years she experienced one with an antibody that did not have previous work. I do not know the fate of that particular patient or what the antibody was. A hold specimen is always drawn, but the concern then, is that "what if" there was an antibody. Also one of the major hospitals in the area is doing this ( I personally believe that this is because they have alot of high risk OB patients). If they decide that this is what they want to do we certainly will have to do a cost analysis on it.

Thanks you both for your input it is greatly appreciated!

[adiescast]

What is the percentage of patients who come in with no prenatal work? Usually you can detect the antibody in the prenatal work (assuming no further developments during late pregnancy, which may not always be a valid assumption...). It is definitely worth at least having a sample on hand at delivery. If no prenatal work was performed, it may be worth doing a type and screen (and often the doctor will order it, if only to determine if the patient is a candidate for RhIg). We are working on having type and screens done routinely at admission for delivery because we have had problems with Labor and Delivery waiting until they were in deep trouble before yelling at us and not producing a sample. Malcolm's point about using any blood during the emergency and switching to antigen typed after things slow down is well taken, but I would like to at least know what ABO type I am dealing with!

[Packer Banker]

Most of our OB MDs like to do Type & Screen on their C-sections when they come in. They all have Type & Screen as well with their general pre-natal work-up (with hepatitis, glucose, etc.).

[Malcolm Needs ☆]

Most of our OB MDs like to do Type & Screen on their C-sections when they come in. They all have Type & Screen as well with their general pre-natal work-up (with hepatitis, glucose, etc.).

Most of your OB MDs wouldn't have a clue how to do a Type and Screen. Surely what you mean is that they like to order a Type and Screen?

When I was working in a hospital environment, we often had Clinicians telephone us and say that they would like to cross-match 2 units of blood for a patient. The standard answer was to invite them up to Pathology and tell them that we were quite willing to let them cross-match the 2 units, or would they prefer it if we did the cross-match for them.

In the end, it usually worked, and they treated the people in the laboratory who could actually perform the cross-match with an awful lot more respect.

I know that I am being pedantic here, but I do think it is important that we are respected for our skills by our colleagues, and should not run ourselves down by allowing disrespect, even if it is only unintentional (on both sides).

[Sko681]

Adiecast- The instance of moms with no prenatal work up (or record of it even if there was) was approximately 40%. Again this is before the merger and before all of the computer systems were standardized. The computer systems were just standardized at the beginning of July.

Thanks!

[sgrovenger]

SKO681-

We do a Type and Screen on all patients that come in to deliver where I work- that is about 90% of our total type and screen work each month. We usually have one or two of those convert to a crossmatch, but usually they just need 1-2 units. However, in the past month, we have had 3 patients who had an antibody upon delivery, but the antibody screen was negative for the initial prenatal workup. So, it can be a good thing, but it can be expensive- especially when you are using gel!

[richardsonj]

Thank you for this discussion...it is something we have been dealing with at our hospital now for a couple of months. Our old policy was to draw an "extra" tube on all patients admitted in labor. We would then check the history of the patient in the blood bank. If the patient had had thier prenatal work done at our hospital and we had history, the tube was just kept "just in case." If the patient had no history at our hospital, we did a type only to have on file. All patients going for a C-section were order a Type and Screen. Recently, our techs began to notice that they were getting more type and screens on the OB patients so I inquired about the increase. Turns out, the OB docs had decided at their last perinatology meeting that they would begin doing type and screens on EVERY patient admitted in labor WITHOUT TELLING ANYONE IN THE LAB AT ALL!!! Later, our pathologist had a meeting with the OB docs to discuss the necessity of doing the test on everyone (lab didn't think it necessary, OB docs did). We lost and are still doing it on everyone. It has really put a lot of pressure on the BB techs in an already busy to the limit blood bank. Especially because most rH negative moms have anti-D!

[L106]

Your last sentence mentioned that "most" Rh Neg mothers have Anti-D. That's interesting. I assume you are attributing that to antenatal Rh-ImmuneGlobulin? We find Anti-D in these patients far less frequently (maybe 25%???) Hmmm....

If you are finding Positive Antibody Screens that frequently, I can certainly see how that would be !#$&! annoying!

[richardsonj]

Yes, I am referring to the antenatal Rh-immune globulin. We use the gel system and we pick up the anti-D in most of the Rh negative patients so yes, it is a real pain in the ****!!! We also have a policy to set up double units on any patient with an antibody so that means that any Rh-negative mother that comes in to deliver who shows an anti-D has to have 2 units of blood set up. We do immediate spin XM on anyone without an antibody and since we have to do a full crossmatch on anyone with an antibody, we autimatically set up the units. If we did not, this would defeat the purpose of doing the type and screen on admission. The OB docs do not want to wait for blood if needed.

[John C. Staley]

I'm curious, was this a knee jerk response by the OB docs due to some catastrophic accurrance or did some new doc on staff bring the practice with them from a previous facility or are they just suffering from a collective paranoia based on "WHAT IF..........."?

You could always look at it as fairly easy job security. Are you automated or still all manual testing? This might be just what you need to convince the facility it's time to automate the blood bank testing. You'll find it's just "what the doctor ordered!"

[Sko681]

Hi John if your question was to me... I think this came from my director who convinced the OB hospital pathologist who has now brought it to all the OB docs. There has been no issues to my knowlege recently. I really think that she is doing this becasue at the hospital that she came from they did (but they have the majority high risk patients in the area). My blood bank is automated, but the hospital with the OB is not and really doesn't have much staff so it will be an issue I am sure. I think that this is a big case of the "what ifs" but like you said job security. The argument was that "even though there was only one case in 10 years where it was an issue...( or one out of approx. 20,000) what if it was your family memeber". My hospital does all the "reference" testing for them now which makes them better off than before the merger since we have more resources and inventory...but we will see. I guess I am not for or against it. :-)

[richardsonj]

As for my facility...there was no disaster, just a "they do it in the city" and a bunch of "what ifs". It's a comfort level for them. We are still manual gel, but are hoping desperatly for the Immucor Echo. So far, not even this has helped push administration over the edge to sign the papers. They counter with "what if the OB's change their practice?" As if!!! And anyways, what about all of the other work that is almost pushing us over the edge also? Patient safety!

[Malcolm Needs ☆]

As for my facility...there was no disaster, just a "they do it in the city" and a bunch of "what ifs". It's a comfort level for them. We are still manual gel, but are hoping desperatly for the Immucor Echo. So far, not even this has helped push administration over the edge to sign the papers. They counter with "what if the OB's change their practice?" As if!!! And anyways, what about all of the other work that is almost pushing us over the edge also? Patient safety!

I would suggest a formal risk assessment.

I would, but it would probably be ignored!

:rolleyes:

[BSIPHERD]

We stopped allowing hold tubes a few years ago for the following reasons.

1. At the AABB meeting several years ago, it was pointed out that having Hold Tubes for Blood Bank could lead to legal problems. If a hold tube was collected and not tested, then the patient had an emergent need for blood, it the patient had a serologic problem (or the tube was deficient - i.e. mislabelled, hemolyzed, wrong tube type, etc.), it could be claimed that we had the tube for long enough to resolve the problem and we did not. We stood a chance of being legally liable.

2. We had several instances where a patient went to surgery and patient care personnel assumed there was blood bank testing/components because there was a BB No. on the patient's armband. We did not, the BB No. was from a hold tube.

3. The amount of resources consumed was significant. We collected more Hold tubes than Type and Screens and/or Crossmatches.

We also see a significant number of patients with Probably passive anti-D. If the patient has rec'd RhIG recently, we do a 1:8 dilution. If it's negative, we do a Modified Antibody Screen to rule out additional antibodies. We do not require a Type and Screen to be converted for probably Passive Anti-D and we allow I.S. crossmatches.

[RR1]

We also see a significant number of patients with Probably passive anti-D. If the patient has rec'd RhIG recently, we do a 1:8 dilution. If it's negative, we do a Modified Antibody Screen to rule out additional antibodies. We do not require a Type and Screen to be converted for probably Passive Anti-D and we allow I.S. crossmatches.

Just for interest, please could you explain the rationale behind performing the 1:8 dilution if patient has received Anti-D Ig.

Thanks!

[Malcolm Needs ☆]

Just for interest, please could you explain the rationale behind performing the 1:8 dilution if patient has received Anti-D Ig.

Thanks!

I presume that this is the titration equivalent of our cut-off point of 0.5 IU/mL for passive anti-D (that amount is brand new, by the way. It used to be 1.0 IU/mL). If the anti-D titre is above 8, or the quant is above 0.5 IU/mL, the anti-D is presumed to be immune.

[LaraT23]

OH, Malcom you crack me up, seriously. Our OB docs do order T&S on each delivering mom. This is only if delivery is emminent and not when someone is here just for observation or if they aren't sure "this is it". We have had 3 moms bleed profusely in the past six years and one who was told not to become pregnant again after 3 C-Sections and her uterus ruptured. So, 40 units of blood, 4 platelets ( pheresed), 10 FFP and 4 cryo pools later ( yes just one person, the aforementioned rupture), we do T&S on every mommy just in case!

[LaraT23]

We just include a canned comment on our antibody ID that reads something like, patient received RhIg on X date please consider that the identified antibody could be due to passive Anti-D resulting from that injection.

[landsnark72]

We have high risk patients and also a large OB service. We do T&S on everyone, and feel like it is warranted. It is more important than doing cords and bilis on every baby, which is also something we do.

[RR1]

I presume that this is the titration equivalent of our cut-off point of 0.5 IU/mL for passive anti-D (that amount is brand new, by the way. It used to be 1.0 IU/mL). If the anti-D titre is above 8, or the quant is above 0.5 IU/mL, the anti-D is presumed to be immune.

When anti-D prophylaxis is administered the titre will vary in each patient- depending on weight. How can you assume that a titre of 8 or quantitation of 0.5IU/mL is due to prophylaxis? (this is from the lab point of view- not ref centre).

Patient history of receiving Ig is more important, together with knowing the antibody screen was negative immediately prior to administration.

[Malcolm Needs ☆]

When anti-D prophylaxis is administered the titre will vary in each patient- depending on weight. How can you assume that a titre of 8 or quantitation of 0.5IU/mL is due to prophylaxis? (this is from the lab point of view- not ref centre).

Patient history of receiving Ig is more important, together with knowing the antibody screen was negative immediately prior to administration.

Whilst I hate to admit this, particularly on a worldwide site, I have to agree with you about the knowledge of an antibody screen prior to prophylaxis.

This is why, unless we have been told by a hospital that prophylaxis has been given, and we detect an anti-D with a level of 0.5 IU/mL or below, we state that an unspecified anti-D is present. If, however, the level is above 0.5 IU/mL, we are confident that it is an immune anti-D, as extensive tests have shown that, even with a prophylaxis dose of 1, 500 IU (and a BSW {British Standard Woman!]) the level never exceeds 0.5 IU/mL.

Of course, if the lady is very petite, or they give the world's supply of anti-D immunoglobulin to a single lady (or, a married lady, come to that, ha!, ha!), then we may be caught out by stating the anti-D to be immune, but then, if we are not told of these circumstances by the hospital, what can we do?