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28-week RhIg dose


scodina

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The original RhoGam studies were done in Rh negative prison volunteers at Sing Sing prison in New York. They wanted to give the volunteers IV infusions of Rh positive blood and then come back the next day and give them Rh immune globulin. The warden would not allow them to do that because of prison security considerations so they had to wait to come back in three days to see the same prisoners, thus the 72 hour wait time. I learned this in SBB school a long time ago and still remembered it because it seemed so unscientific.

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The original RhoGam studies were done in Rh negative prison volunteers at Sing Sing prison in New York. They wanted to give the volunteers IV infusions of Rh positive blood and then come back the next day and give them Rh immune globulin. The warden would not allow them to do that because of prison security considerations so they had to wait to come back in three days to see the same prisoners, thus the 72 hour wait time. I learned this in SBB school a long time ago and still remembered it because it seemed so unscientific.

This is true, but the original anti-D given was IgM (on the grounds that this would not cross the placenta) and, not only did it not work, it acted like adding fuel to the fire, because it actually promoted the production of immune anti-D. As a result, the whole anti-D prophylaxis programme was almost abandoned.

The use of IgG anti-D was only tried as the result of someone (I can't remember who now, but it may have been Ruth Sanger of Race and Sanger fame) remember ing some fairly ancient work by someone else (again, I can't remember who) doing some different, but similar work.

Sorry I can't be more specific, but the grey matter is getting old!!!!!!!!!!!!!

:D:D:D:D

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I mean no type and screen at the 28 wk visit.

We do a type and screen on all the clinic OB's for their first OB visit. Therefore, we usually have records for the patients. What is the purpose of doing the T&S at the 28 wk visit, other than to confirm whether the patient has or has not been sensitized from the previous screen? As I understand, the reason for waiting until 28 wks for the antenatal rhogam is that the fetus does not have enough blood volume to produce an antibody reaction, so the chances of the patient being sensitized before that should be very low.

If they have been sensitized, would the physician not give the rhogam? I think some of ours would still give rhogam.

What are your thoughts on this? Am I on the wrong track altogether?

Sorry, I also meant to say that, no, the foetus can have enough blood volume to sensitize the mother much earlier than 28 weeks gestation. Indeed, if there is a sensitizing event after 12 weeks gestation in a D Negative pregnant lady in the UK, anti-D immunoglobulin prophylaxis is given (but only half of the normal dose - 250IU, rather than 500IU).

:redface::redface::redface::redface::redface:

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Our practice is to draw the rhogam workup, and then give the rhogam to the patient to take to the physician office for injection. We don't make the patient wait provided:

1. We have historical evidence that she's Rh neg, and

2. No evidence of allo-anti-D.

Note, that doesn't mean she has to have a negative antibody screen on file, just no history of active anti-D.

I've been doing this for more than 35 yrs, and I count 3 ladies that had allo-anti-D when we finally tested the 28wk sample. Make it easy for everyone if possible. For those without a history, we either make them wait till we determine Rh type, or they can come back with their armband on. Actually, as long as they have the armband WITH them, we don'e redraw.

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The OB clinic gives the shot at 28 weeks. They draw the type and screen before they give it, but they do not wait for the screen results.

I don't understand the logic....If you don't wait for the screen results before Rhig is administered, then why bother even drawing the patient at 28 weeks? It sounds like an extra "stick" to me!

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There probably isn't much gained in doing the antibody screen at 28 weeks, except in the case where you might find alloanti-D, or a different previously undetected antibody. Yes, extremely rare, but they DO happen. That's why I do the antibody screen at 28 wks. I'd rather not be surprised if/when they do a TYSC at delivery. Again, rare events, but much of what we do in BB is to prevent the rare from happening.

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Our practice is to draw the rhogam workup, and then give the rhogam to the patient to take to the physician office for injection. We don't make the patient wait provided:

1. We have historical evidence that she's Rh neg, and

2. No evidence of allo-anti-D.

Note, that doesn't mean she has to have a negative antibody screen on file, just no history of active anti-D.

I've been doing this for more than 35 yrs, and I count 3 ladies that had allo-anti-D when we finally tested the 28wk sample. Make it easy for everyone if possible. For those without a history, we either make them wait till we determine Rh type, or they can come back with their armband on. Actually, as long as they have the armband WITH them, we don'e redraw.

What do you do if the patient has an Anti D? Do you refuse to release the RhIG? I think our physicians would give the RhIG anyway. I believe we would have a problem refusing their order. In fact, I had a young woman in the ER having a miscarriage who was allo anti-D and the RhIG was given. The ER doc stated, "It won't hurt her will it?"

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What do you do if the patient has an Anti D? Do you refuse to release the RhIG? I think our physicians would give the RhIG anyway. I believe we would have a problem refusing their order. In fact, I had a young woman in the ER having a miscarriage who was allo anti-D and the RhIG was given. The ER doc stated, "It won't hurt her will it?"

Of course, the other problem for everyone is when a lady has received RhIG at another venue, prior to coming to your own hospital. What do you do then, especially if she knows that she was given an injection, but does not know what it was?

:confused::confused::confused::confused::confused::confused:

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Of course, the other problem for everyone is when a lady has received RhIG at another venue, prior to coming to your own hospital. What do you do then, especially if she knows that she was given an injection, but does not know what it was?

:confused::confused::confused::confused::confused::confused:

We contact the patient's OB Doctor to ascertain this information.

It is surprising to me to hear the number of women who know they "got some sort of injection" but don't know what it was.

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We contact the patient's OB Doctor to ascertain this information.

It is surprising to me to hear the number of women who know they "got some sort of injection" but don't know what it was.

Yes, I know from where you are coming, but supposing the lady has come from another country?

We quite often get pregnant ladies who have arrived from other parts of the world (Africa, Asia, different parts of Europe, particularly eastern Europe), many of whom have poor English, and then it is not so easy.

:confused::confused:

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Yes, I know from where you are coming, but supposing the lady has come from another country?

We quite often get pregnant ladies who have arrived from other parts of the world (Africa, Asia, different parts of Europe, particularly eastern Europe), many of whom have poor English, and then it is not so easy.

:confused::confused:

Whoa, that presents a whole different problem. I wonder about the mind-set of a pregnant lady who decides to travel to a different country near her expected delivery time!! My Obstetrician told me not to travel even a mere 3 hours away from her in the last month of my pregnancies.

We still abide by the theory....If in doubt about RHIG status, do the full antibody ID. It is only when we have factual knowledge of a specific RHIG injection date that we will not ID the antibody.

We are required here in the US to have translators available 24/7 for every language. So the language barrier is not normally an issue for us. (Besides from the nurses who THINK they are speaking English!!!---UUUGGGHHHH!:D:D:D:D

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We have a slightly different request/problem from our OB/GYN doctors. Some of their patients don't get to them until after they have presented with bleeding in the ER. Our procedure has been to just follow the Er Dr's orders and do only the ABORH and give Rhig if the pt is RH Neg and the Dr requests it. It follows later that the patient is referred to an OB/GYN and then that Dr orders the antibody screen - which is, of course -positive!. They are now requesting that we do an ABSC on these pts in the ER, but they aren't working through the ER Dr's to get the orders for the ABSC. How do you handle having no Dr's orders for a test? New policy? Medical Director intervention? Do you get reimbursed for the testing if it comes from an internal policy and not Dr's orders?

And yes - we do a lot of "detective work" trying to find out "Is it Rhig or is it REAL?" I so wish Rhig had some kind of detectable tag you could look for in testing. We use Immucor's Solid Phase testing and can detect Rhig for up to 3 months!

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We have a slightly different request/problem from our OB/GYN doctors. Some of their patients don't get to them until after they have presented with bleeding in the ER. Our procedure has been to just follow the Er Dr's orders and do only the ABORH and give Rhig if the pt is RH Neg and the Dr requests it. It follows later that the patient is referred to an OB/GYN and then that Dr orders the antibody screen - which is, of course -positive!. They are now requesting that we do an ABSC on these pts in the ER, but they aren't working through the ER Dr's to get the orders for the ABSC. How do you handle having no Dr's orders for a test? New policy? Medical Director intervention? Do you get reimbursed for the testing if it comes from an internal policy and not Dr's orders?

And yes - we do a lot of "detective work" trying to find out "Is it Rhig or is it REAL?" I so wish Rhig had some kind of detectable tag you could look for in testing. We use Immucor's Solid Phase testing and can detect Rhig for up to 3 months!

I can see your problem.

In the UK we automatically do a screen on all groups sent to us, because it's paid for by National Insurance.

I cannot understand, however why, if your ER doctors are working with a pregnant lady, they would not order, not only a screen, but given that many of these ladies would either be suffering some kind of trauma, or a PV bleed, a KB. Seems daft to me. Surely they are opening themselves up to litigation if the foetus is affected by a maternal antibody, or they order too little anti-D immunoglobulin?

:confused::confused::confused::confused::confused::confused::confused::confused:

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I don't claim to know alot about reimbursement, but your pathologist is a physician and can order tests. I would think you could use an internal policy for the screen. That being said, it may be more worth your while to get a meeting up and include the ER department and the OB department to discuss the issue. Maybe the ER doctors will cooperate when they understand the problem.

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I don't claim to know alot about reimbursement, but your pathologist is a physician and can order tests. I would think you could use an internal policy for the screen. That being said, it may be more worth your while to get a meeting up and include the ER department and the OB department to discuss the issue. Maybe the ER doctors will cooperate when they understand the problem.

I agree entirely.

Good communication is everything in almost all situations.

:):):):)

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We have a slightly different request/problem from our OB/GYN doctors. Some of their patients don't get to them until after they have presented with bleeding in the ER. Our procedure has been to just follow the Er Dr's orders and do only the ABORH and give Rhig if the pt is RH Neg and the Dr requests it. It follows later that the patient is referred to an OB/GYN and then that Dr orders the antibody screen - which is, of course -positive!. They are now requesting that we do an ABSC on these pts in the ER, but they aren't working through the ER Dr's to get the orders for the ABSC. How do you handle having no Dr's orders for a test? New policy? Medical Director intervention? Do you get reimbursed for the testing if it comes from an internal policy and not Dr's orders?

And yes - we do a lot of "detective work" trying to find out "Is it Rhig or is it REAL?" I so wish Rhig had some kind of detectable tag you could look for in testing. We use Immucor's Solid Phase testing and can detect Rhig for up to 3 months!

NM location, I am assuming you are in New Mexico, US?? I am going to make this post with that assumption in mind....

I am in Tucson, AZ. I would presume we have a similar patient population base. We also get a lot of women who have had NO prenatal care whatsoever!! We see, not infrequently, a woman who only presents to any sort of physician (ER) when she is actually in labor and ready to deliver. This situation does indeed complicate things. You have to assume if she is RH neg that she has not received Rhig due to the total lack of prenatal care. We would ID the antibody in this instance.

We would not, however spend countless hours chasing down an Anti-D in a woman who we ourselves administered Rhig to earlier in the ER. Then we would have FACTUAL KNOWLEDGE of Rhig administration status. If the pattern appears to be Anti-D on the screen antigram we result it as "Passive Anti-D presumably due to Rhig dose given on_____"

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