We are discussing changes to our RhIG workup protocol, I'm curious about what the consensus is regarding including an antibody screen in routine testing. Please see the poll above. Thanks.

Edited July 30, 20196 yr by AMcCord

There is no requirement for a current absc for RhIg administration.   With the advent of the hypersensitive technologies, most of my abids are antenatal RhIg (when the docs order a T&S perinatally).

36 minutes ago, David Saikin said:

There is no requirement for a current absc for RhIg administration.   With the advent of the hypersensitive technologies, most of my abids are antenatal RhIg (when the docs order a T&S perinatally).

Same here. If the patient has a T&S upon admission, I will not perform the ABSC again for the RhIg workup. A couple of years back we tried to get the OB docs to all send their prenatal workups to us so that we could at least get baselines on their patients because every OB in town delivers at our hospital. Unfortunately, we have 2 groups in town--1 that is affiliated with the hospital system , and 1 that is not. Its really a struggle with these patients that you can guess had antenatal rhogam but their ABSC is all over the place. The blood banker in us wants to work it all up, but its so aggravating--esp if we have no history to compare to.

When I started here a few years back, we were repeating the ABSC along with performing the Fetal Screen. I have since with the blessing of our Medical Director done away with the second ABSC.

4 hours ago, MAGNUM said:

When I started here a few years back, we were repeating the ABSC along with performing the Fetal Screen. I have since with the blessing of our Medical Director done away with the second ABSC.

9/10 times we don't perform the 1st ABSC. So, we spend a lot of time working up that ABID that is just remnants of antenatal RhIg.

On 7/30/2019 at 5:36 AM, AMcCord said:

We are discussing changes to our RhIG workup protocol, I'm curious about what the consensus is regarding including an antibody screen in routine testing. Please see the poll above. Thanks.

Over the decades since Rh Immune Globulin became available and a standard for care in 1968, the guiding principle changed from 'looking for reasons not to give', i.e. withholding the injection versus currently 'looking for reasons to give'.  Initially, the injection vial was packaged with a crossmatch vial that required a test tube crossmatch with the patient's rbcs.  This was a safety step to address the concern of giving such a large volume (at that time I think it was 5ml in the US) of anti-D to an Rh positive individual.

Much later, it was determined that a second injection was required around 28 wks to prevent sensitization of women who might be hyper-responders. 

Those safety concerns have been addressed with low volume (0.7ml), low protein formulations.  Crossmatching is no longer required.

Performing an antibody screen with a workup is consistent with the original philosophy of 'looking for reasons to withhold the injection'.

We don't.  It doesn't change the patient's treatment so why expend the resources?  If the screen is positive with anti-D we give RhIG.  If the screen is negative, we give anti-D.  If the baby has HDFN then we would be looking at the strength of the mom's anti-D.  That would be our evidence of sensitization that I think a standard still refers to.

We perform a type and screen on all of our labor patients at admission, so we do not repeat an antibody screen after delivery; but if the patient is in our facility and they want to give her antenatal RhIG, we do one before we issue it.  We have identified a few patients who had already developed an immune anti-D so the treating physician had been able to monitor their pregnancy more closely.

Postpartum: Type and Screen (Pretransfusion specimen) upon admission to the Delivery/Labor Room.  We do not repeat the Rh Type or Antibody Screen if an RhIG injection is needed but a KB is done (post-partum specimen) to determine the dose.

Antenatal (28 week gestation dose):  Rh Type + Antibody Screen

Miscarriage/Abortion: Rh Type

Emergency or Other Indications (Pregnancy): Rh Type + Antibody Screen, but we will issue RhIG if needed asap with only the Rh Type done.  AS can wait.

We still do the Antibody Screen because it is good documentation that will likely answer questions later, like 'Is this patient producing Anti-D or is this the RHIG injection she got a month ago?'  As far as the MD is concerned, they rarely care about the AS result, e.g. we've reported an Active (as opposed to Passive) Anti-D and they still want to give the RHIG, so it's good documentation for that, too.

We get a specimen for all L&D patients. All get a blood type. Some have orders for a Type and Screen. If we've done the antibody screen with a T&S, we don't repeat it w/ the RhIG workup.

To refine my question, how many of you issue RhIG with NO antibody screen done during the admission?

22 hours ago, Dansket said:

 "Initially, the injection vial was packaged with a crossmatch vial that required a test tube crossmatch..."

Performing an antibody screen with a workup is consistent with the original philosophy of 'looking for reasons to withhold the injection'.

I remember doing RhoGAM 'crossmatches'. Guess that makes me old 😏.

The statement regarding 'looking for reasons to withhold' is exactly the issue. If the screen is negative, we give RhIG. If the screen is positive and we ID anti-D, unless we have evidence to the contrary we assume it's from previous RhIG administered and we give more RhIG. Either way, we don't withhold the RhIG. Why then require a test that doesn't affect outcome...what value is added? If there is another pregnancy, the patient will have another screen done at her first Prenatal visit. That test then drives her treatment, not a test performed at her last delivery.

I have hopes of streamlining the process to save the patient $$$ if possible, shorten the TAT time for issuing RhIG, and save us working up all those RhIGs that the Echo helpfully detects.

 

 

 

The only time we perform an antibody screen on a postpartum specimen for RhIG is if, for some reason, we do not have record of one from prenatal testing.

On ‎07‎/‎31‎/‎2019 at 9:14 AM, MAGNUM said:

When I started here a few years back, we were repeating the ABSC along with performing the Fetal Screen. I have since with the blessing of our Medical Director done away with the second ABSC.

the majority of our OB pts do not have T&S ordered, though we do receive a JIC tube.  After delivery, if they are an RhIg candidate, we only perform the rosette test.  There is no standard which demands a current antibody screen for the post-delivery RhIg.  We did away with that many years ago.

In the last few days, we have been talking about doing away with the AB Screen during the Rhig Workup. I've reached out to sister facilities who keep citing to me Standard 5.30.2 # 2 "The woman is not known to be actively immunized to the D antigen." My goal is to eliminate the unnecessary antibody panels and the anguish passive D can cause. But my justification will be this, and correct me if this is wrong:

We can determine whether the patient has had Rhogam with one phone call to the floor. If so, then more than likely, she would have the passive D. It's not an active immunization. If she hasn't had any prenatal treatment, then, at that point, we'll do an antibody screen.

We have docs that will give rhogam no matter what.

Are you inspected by the AABB?