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Blood bank testing for OB admit patients

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We do a type and screen on only on patients having a C-section. An "extra" pink top

tube is drawn on every OB patient admitted.

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Even if they do have a weak "real" anti-D, give them the RhIg anyway. There is no easy way to prove if it is primary or secondary sensitization until well after delivery. I wish I could get my ob docs to stop ordering absc for the RhIg workup . . . isn't needed. Just give the stuff to the ladies who require it. I have never had a f/u on any perinatal anti-D's. As Denny puts it - we have screened them at 16 and 28 weeks . . . they don't need another one. Itf they have something else clinically significant it will get dealt with if it impacts the child. You don't still do minor crossmatches . . . do you?

The whole point of antinatal screening is to pick it up *before* it impacts the child. A term G&S is covering the mother for the next pregancy - allowing problems to be identified before they happen - allowing the mother to be counselled before she gets preganant, rather than upon having a hydrops foetus and miscarrying before the 16 week screen. With modern advances a mother carrying immune D can have a foetus screened at 10-12 weeks and decide whether to advance with the pregnancy or not.

Antenatal screening cannot be compared to crossmatching - if blood is needed they can have it in 10 minutes if need-be. If an immune D is missed it can impact a whole family for life. If you have presumed passives that aren't being followed up your clinicians need educating to the potential impact. It isn't difficult to recall a woman with presumed passive at 3 or 6 months post delivery - she'll be vising for follow-ups anyway. In the grand scheme of things sticking an extra tube on the analyser isn't much when we're talking about preventing suffering from HDFN. If proper follow-up was done the 0.3% that are still happening might be reduced further.

There is a lot of talk of comparing BTS now with pharmacology terms in deaths/or serious morbidity per million. 0.3% is still 3,000 affected babies per million Rh Neg mothers and 450 per million of all groups. If this was in pharmacology, where off the top of my head I think the cutoff is 5 per million, it wouldn't be accepted.

Edited by Auntie-D

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We also do a type and screen on all OB patients when admitted. That way we are ready for any emergency. We do not repeat the screen when doing a RHIG work-up. We also find positive screens due to RHIG at 28 weeks. We simply verify the date they got the injection and do a simple rule out panel, using the cells marked on the commercial panels.

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We also do a type and screen on all OB patients when admitted. That way we are ready for any emergency. We do not repeat the screen when doing a RHIG work-up. We also find positive screens due to RHIG at 28 weeks. We simply verify the date they got the injection and do a simple rule out panel, using the cells marked on the commercial panels.

This is precisely our process as well.

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This is precisely our process as well.

Us too. If something is going to go wrong during delivery it is ususally going to go seriously wrong. My biggest blood issues during my career have been for a AAA and ruptured placenta - 43 units was the most during labour... Having the group and screen already done meant that the blood could just go out EI - if we'd had a fresh sample it would have delayed things unecessarily.

As the midwives keep remining us - it's two lives that are at stake...

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The whole point of antinatal screening is to pick it up *before* it impacts the child. A term G&S is covering the mother for the next pregancy - allowing problems to be identified before they happen - allowing the mother to be counselled before she gets preganant, rather than upon having a hydrops foetus and miscarrying before the 16 week screen. With modern advances a mother carrying immune D can have a foetus screened at 10-12 weeks and decide whether to advance with the pregnancy or not.

Antenatal screening cannot be compared to crossmatching - if blood is needed they can have it in 10 minutes if need-be. If an immune D is missed it can impact a whole family for life. If you have presumed passives that aren't being followed up your clinicians need educating to the potential impact. It isn't difficult to recall a woman with presumed passive at 3 or 6 months post delivery - she'll be vising for follow-ups anyway. In the grand scheme of things sticking an extra tube on the analyser isn't much when we're talking about preventing suffering from HDFN. If proper follow-up was done the 0.3% that are still happening might be reduced further.

There is a lot of talk of comparing BTS now with pharmacology terms in deaths/or serious morbidity per million. 0.3% is still 3,000 affected babies per million Rh Neg mothers and 450 per million of all groups. If this was in pharmacology, where off the top of my head I think the cutoff is 5 per million, it wouldn't be accepted.

All of this is true Auntie-D, and put together with the best motives I am sure, but do you follow up after six months all women and girls of child-bearing potential who have had a transfusion? One has to perform a risk/benefit analysis on doing what you are suggesting and, with Foetal Medicine Units able to "salvage" (horrible word, but that is the word used these days) pregnancies with anti-D levels well into the hundreds of International Units (very high titres for those of you that don't quantify anti-D and anti-c during pregnancy) these days, and with the fact that the foetus is unlikely to be hydropic prior to the first antenatal visit in the following pregnancy, I doubt whether knowing that the lady has produced an alloanti-D would actually make that much difference, because you would still have to monitor the pregnancy throughout, and still, possibly, have to intervene with IUT's, etc, so you actually wouldn't be saving any money, whilst still saving the unborn child.

Just a thought.

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Quick question to add to this discussion:

Mom has presumptive RhoGam/Anti-D in gel upon admission. You have performed the Type and Screen and antibody ID and documented that she had a dose of RhoGam at 28 weeks or later. Computer Software (SoftBank) has now made her inelligible for electronic crossmatch. How many of you automatically crossmatch 2 units because now she needs the full AHG crossmatch? Would it be appropriate to wait until there is a transfuse order to crossmatch her? If an emergency occurs the computer software will allow an override to issue uncrossmatched blood.

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Hi Saralm88, Thank you. Yes, we do the type and screen (gel) on all of our OB patients as well. I am just wondering if you crossmatch the patients who are positive for presumptive residual RhoGam upon admission for delivery. In our facility it would be very rare for a mom to actually need to be transfused during delivery (or after for that matter), but it seems to be safer to crossmatch since the patient is now inelligible for an electronic crossmatch.

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Quick question to add to this discussion:

Mom has presumptive RhoGam/Anti-D in gel upon admission. You have performed the Type and Screen and antibody ID and documented that she had a dose of RhoGam at 28 weeks or later. Computer Software (SoftBank) has now made her inelligible for electronic crossmatch. How many of you automatically crossmatch 2 units because now she needs the full AHG crossmatch? Would it be appropriate to wait until there is a transfuse order to crossmatch her? If an emergency occurs the computer software will allow an override to issue uncrossmatched blood.

We have Anti-D due to RhoGam set as a clinically insignificant antibody, so that it does not require AHG crossmatches in SoftBank. Correct that it won't let you do electronic because of the positive screen, but it will then allow you to do only immediate spin crossmatches.

If you don't already have two Anti-D antibodies built in Setup, you should think about it. One clinically significant (the real one) and one not (the RhoGam) one.

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We were only doing a type and Type/Screen as ordered. THEN a patient busted loose during delivery. The doctor didn't want uncrossmatched & had to wait for a screen. "How will this never happen again?" was the topic...only answer is doing a Type & Screen on every patient, so that's what we do now. We are a low risk hospital that delivers @ 120 infants/ month. Over 3/4 of our patient mix is uninsured so they're all on house $$. We get about 15 Passive Anti D workups/ month. Run Extend II on the Echo and done in 30 minutes. Try calling to confirm Rhig but since most have sketchy history not much help.

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We currently only do a Type and Screen as ordered, but one of our OB physicians wants to start a Massive Bleed protocol that will call for a Type and Screen specimen drawn on every pt (we use a BB ID label band), but the actual Type and Screen will only be run on some of them, based on where they stand on the Risk Protocol. We will have some trouble figuring out how to know we have a specimen "on hold" since we do not allow any "extras" to be drawn and banded at this time. Have to work that one out in the computer records.

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This is similar to our protocol. All L&D admits are drawn and banded for blood bank "Just In Case" (called JIC in the LIS). This allows us to be prepared for the bleeds and emergency c-sections and does not force OB to "wait on lab to draw the patient" as they prep them for surgery. Has been about a year now for this process and it seems to work well.

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We do Type and Screen on all OB patients admitted for delivery, but they have to be ordered by the consultant. Very rarely has an OB patient been missed. If screen is positive we cross-match 2 units just in case.

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We currently only do a Type and Screen as ordered, but one of our OB physicians wants to start a Massive Bleed protocol that will call for a Type and Screen specimen drawn on every pt (we use a BB ID label band), but the actual Type and Screen will only be run on some of them, based on where they stand on the Risk Protocol. We will have some trouble figuring out how to know we have a specimen "on hold" since we do not allow any "extras" to be drawn and banded at this time. Have to work that one out in the computer records.

Deny's idea sounds like a good solution to your problem, cswickard.

Invent a test (called "BB Hold Sample" or whatever you want.) Then you could do a Patient Inquiry in your Lab Information System to look up whether you have a BB specimen from the patient. (You wouldn't even need to link the test code to your BB Computer System, if you have a BB computer system.)

Donna

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This is similar to our protocol. All L&D admits are drawn and banded for blood bank "Just In Case" (called JIC in the LIS). This allows us to be prepared for the bleeds and emergency c-sections and does not force OB to "wait on lab to draw the patient" as they prep them for surgery. Has been about a year now for this process and it seems to work well.

We require a second specimen to verify ABO/Rh on all transfusions when there is no history. In that case we would still need a specimen when they prep them for surgery. We currently do a Type and Rh on all L&D admits. If they need a screen added for surgery we use that specimen and request a second specimen for Blood Type confirmation. Unfortunately they almost never send them because the patient is already in the OR.

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This is similar to our protocol. All L&D admits are drawn and banded for blood bank "Just In Case" (called JIC in the LIS). This allows us to be prepared for the bleeds and emergency c-sections and does not force OB to "wait on lab to draw the patient" as they prep them for surgery. Has been about a year now for this process and it seems to work well.

This is what we have done for several years as well.

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Hi blbnkr !

We do a crossmatch on anyone going to the OR who has an antibody - Rhogam or real. For normal delivery - we do not.

Hope this helps!

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We have been doing a Type and Rh on all admissions since CAP said that the Blood Bank is responsible to make sure all women get RhoGam if needed. We don't get all the prenatal work so we don't have history on about half of the women who deliver.

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Quick question to add to this discussion:

Mom has presumptive RhoGam/Anti-D in gel upon admission. You have performed the Type and Screen and antibody ID and documented that she had a dose of RhoGam at 28 weeks or later. Computer Software (SoftBank) has now made her inelligible for electronic crossmatch. How many of you automatically crossmatch 2 units because now she needs the full AHG crossmatch? Would it be appropriate to wait until there is a transfuse order to crossmatch her? If an emergency occurs the computer software will allow an override to issue uncrossmatched blood.

 

I am currently dealing with the same issue.  Technically whenever a patient presents with an antibody, we order two units on the patient to have available.  We have decided not to do this for Anti-D due to rhogam.  The problem is, when/if the patient does need units, our system requires the complete crossmatch.  Does everyone just do immediate spin for Anti-D due to rhogam?

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Yes, we have SoftBank and we would have to do immediate spin crossmatches because the positive antibody screen would make it ineligible for electronic crossmatch.

You should not have to do AHG crossmatches though if you have Anti-D due to RhIg built as not clinically significant.

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We draw a specimen and hold on all OB patients. If the patient has a C-section, we get an order for the type and screen. So, the majority of our patients are not tested pre-delivery.

ditto

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I see this topic was resurrected.  We deliver @150 a month at a "low risk" facility.  We used to only to front types on the OB patients but they were BB armbanded just in case.  Well a patient almost bled out  and needed UNXM cells.  The OB docs wanted to know how that scenario would Never happen again.  We said an antibody screen on everyone so now we do.  We transfuse maybe 8 units to L&D a month, rarely during delivery.  We do see about 1-2 non passive Anti D antibodies a month.  Even if its PAD, we AHG XM for consistency.  Now that we have Epic & I can easily access the scans of the prenatal records to confirm Rhig being issued prior to delivery, I'm amazed at how many "reference" labs get the blood type wrong and don't titer antibodies.  We have over half of our deliveries on some type of Medicaid or charity reimbursement.

 

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