Anti-D Ig 500IU should be given after the following:
1) Vaginal bleeding with associated severe pain
2) Evacuation of retained products of conception/molar pregnancy
3) Invasive prenatal diagnostic procedures e.g. amniocentesis, CVS
4) Other invasive procedures eg. embryo reduction, insertion of shunts, intrauterine transfusion, laser therapy for TTTS, transabdominal cerclage
5) Antepartum haemorrhage
6) Abdominal trauma – sharp/blunt, open/closed
7) External cephalic version
8) Therapeutic termination of pregnancy
- Anti-D Ig 500 IU is required for women having a medical or surgical TOP after 10+0 weeks’ gestation.
- Anti-D Ig 500 IU is required for women having a surgical TOP up to and including 10+0 weeks’ gestation.
- Do not give anti-D Ig to women having a medical TOP up to and including 10+0 weeks’ gestation.
9) Spontaneous miscarriage, threatened miscarriage ≥12+0weeks (if the gestational age is different to the size of the fetal pole on ultrasound, the ultrasound measurements should be used)
- Complete spontaneous miscarriage
- Prior to 12+0 weeks – anti-D Ig not required.
- ≥ 12+0 weeks - anti-D Ig 500 IU is required.
- Medical management of miscarriage
- Anti-D Ig is not required for solely medical management of miscarriage prior to 12+0 weeks.
- Anti-D Ig 500 IU should be given to all women receiving medical management of miscarriage ≥12+0 weeks.
- Surgical management of miscarriage/Manual Vacuum Aspiration (MVA)
- Anti-D Ig 500 IU should be given to women undergoing a surgical procedure for management of miscarriage or MVA. This is also the case for women undergoing evacuation of uterus for molar pregnancy.
- Threatened miscarriage
- Anti-D Ig 500 IU should only be considered in women with threatened miscarriage and a viable fetus prior to 12+0 weeks if PV bleeding is recurrent, heavy and/or associated with significant abdominal pain.
- Anti-D Ig 500 IU should be given to women with a threatened miscarriage after 12+0 weeks gestation.
10) Ectopic pregnancy
- Anti-D Ig 500 IU should be given to women who have surgical management of an ectopic pregnancy.
- Anti-D Ig is not required for women who have solely medical management of ectopic pregnancy or a pregnancy of unknown location (PUL).
11) Intrauterine death (IUD)
- Diagnosis and delivery of an IUD at ≥20+0 weeks should be considered as 2 separate PSEs.
- Therefore, anti-D Ig 500 IU should be given to women at the time of diagnosis of IUD, unless the patient presents in advanced labour.
- At diagnosis of IUD ≥20+0 weeks, maternal bloods for Group & Save and Kleihauer should be taken.
- At the point of diagnosis of IUD ≥20+0 weeks, Blood Bank would aim to process the request for anti-D in an urgent manner following a telephone call. There should be minimal delay for the patient. Ensure relevant details on the request form.
- Please ensure Group & Save is repeated every 72hours until delivery.
- Following delivery, maternal Group & Save and Kleihauer samples should be obtained and sent to Blood Bank. Bloods should be obtained 30-45 minutes following delivery.
- Administration of anti-D Ig 500IU should be repeated within 72 hours of delivery.
12) Delivery of RhD positive baby or baby of unknown Blood Group
- Following delivery, maternal Group & Save and Kleihauer samples should be obtained and sent to Blood Bank. The Kleihauer sample should be taken when sufficient time has elapsed to allow fetal cells to be distributed within the maternal circulation following delivery, or manual removal of placenta. A period of 30-45 minutes is considered adequate.
- Cord bloods should also be obtained from baby to determine baby’s ABO and RhD type.
- If cord samples cannot be obtained, document on maternal request form and the neonatologist must be contacted to obtain a newborn group sample from the baby. Every effort should be made to obtain cord blood to avoid unnecessary invasive sampling of baby. If the baby requires blood samples for any other reason eg sepsis or blood sugars, please obtain newborn group sample at the same time to avoid unnecessary sampling of the newborn.
- If baby confirmed to be RhD positive, give anti-D Ig 500 IU within 72 hours of delivery.
- If for any reason a sample from baby cannot be obtained, the baby should be assumed to be RhD positive for the purposes of anti-D Ig administration.
- If the Kleihauer test indicates a FMH >4ml then further anti-D Ig will be required. The dose advised will be dependent on the estimated volume of FMH. A further repeat Kleihauer should then be taken 72 hours after administration of the additional anti-D Ig if given IM and 48hours if given IV to ensure clearance of fetal cells.
- Any postnatal RhD negative patients leaving the hospital without receiving anti-D Ig should be discussed with an obstetric consultant.
13) Intra-operative cell salvage (full guideline here)
- When intra-operative cell salvage is used during Caesarean section, reinfused blood may contain fetal red cells.
- The volume of fetal red cells in reinfused blood can vary from 1-20ml.
- It is therefore recommended that a minimum dose of 1500 IU anti-D Ig is administered after reinfusion of salvaged cells if baby group is confirmed as RhD positive (or blood group unknown).
- Maternal samples for estimation of FMH should be taken 30 – 45 mins after reinfusion of salvaged red cells. Depending on the Kleihauer result, an additional dose of anti-D should be administered if necessary and additional follow up Kleihauer sent as appropriate.
- It is important that clinicians inform Blood Bank if intra-operative cell salvage is being used to ensure that the correct dose of anti-D Ig is issued. This information should be added to the pre-operative maternal request for Group & Save/Crossmatch.