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Rhogam- I'm so confused!

post #1 of 26
Thread Starter 

I'm Rh- and my husband is Rh+, and I'm about 6 weeks pregnant with our 1st child. I do not want to get the Rhogam shot prenatally, and only want to get it after the birth if it's absolutely necessary. My mom's a GP and has been giving me lots of...facts about why I need a rhogam shot. She told me that if my mother was Rh+, then I would have been sensitised at birth and therefore need the Rhogam shot both at 14 and 28 weeks. She also said that the mother's blood and the baby's blood is always mingling, and this doesn't just happen during trauma. I was really confused about this because I thought that the Rhogam shot would be useless if the mother was already sensitised? I also thought that the baby's blood only mixed with the mother's if there was trauma or during birth? Also, I have heard that if you have a natural childbirth, it is less likely for the baby's blood to mix during birth. Is there any way of knowing if this has happened for sure after the birth other than by doing a blood test? How does the mother's blood mix with the baby's during birth usually, and why does a natural birth make a difference?

 

I'm getting so much conflicting information about this, and it's been really hard to weed out what's true and what people are simply telling me to get me to take the shot. Help!

post #2 of 26

There is only book book on the subject, Anti-D in Midwifery, I would highly suggest getting a copy of it. Yes, the chance of mixing blood is decreased with natural birth, the book details things. Pulling the the cord/placenta should be avoided, etc... The more interventions mean the higher the chance of mixing of the blood between mom and baby. There is a low risk of being sensitized during pg if there is no major trauma, other countries do not offer the Rhogam prenatally. The mom and baby's blood do not intermingle all the time. 

 

I have accept and declined rhogam after birth for various children based on my thoughts if I needed it or not. I do not take it prenatally. 

post #3 of 26

Search in the homebirth forum (and other forums) for Rhogam.  There are lots of us RH- mamas, and lots of experience, advice, and resources. 

post #4 of 26

I beleive it's only an issue if you plan to have more than one baby.  The first baby will sensitize you, and therefore put future babies at risk.  Is there a reason you are avoiding it?  I was able to but only because dh is also rh negative.

post #5 of 26

I feel strongly about Rhogam being awesome and lifesaving.  However, absent any kind of abdominal trauma or increased risk of bleeding, I don't think you absolutely have to get it before birth.  Think about your lifestyle and your concerns, and decide for yourself. 

 

This is the first I have ever heard of the suggestion that Rh- women need a 14 week shot.  Overall, your mom's info sounds off.  Maternal and fetal blood do not mix all the time.  Rh+ women can sensitize their Rh- children at birth, but it's rare.  Many doctors think the sensitivity wears off over time if the child isn't re-exposed.  There is a blood test for Rh sensitivity that you can take if your mom is making you concerned.  FWIW, I was sensitized at birth and had an immune reaction.  At my pediatrician's advice, my mom started warning me that I might not ever be able to have children around the age of 6.  She was well-intentioned, but I think that might have been overkill.  I tested negative for Rh sensitivity at age 23.  (And my kids are fine, but it turns out my dh is also Rh-, so that doesn't reveal anything about my Rh status.) 

 

I don't know the answers to all your questions about maternal-fetal blood mixing during birth and why natural childbirth decreases risk.  I think, though, that you should end this line of conversation with your mother.  This sounds like a situation that calls for bean dip. 

post #6 of 26

Rhogam after birth when the baby is confirmed Rh+ is one thing. I think that there is some merit to it and that it warrants looking into it before dismissing it. My take on it was to make the final decision based on the circumstances of the birth.

 

Prenatal rhogam, however, is not supported by evidence. The package insert (for the Canadian version at least) even specifies that it is not tested or proven safe in pregnancy and that it should only be given when the benefits outweigh the risks. I guess it might be worth doing if you are in a car accident or something similar.

 

You should also look into what happens if you do end up being sensitized. The reality is that, while it can sometimes be deadly, it generally only warrants closer monitoring in future pregnancy.

post #7 of 26
Thread Starter 

Thanks everyone. I'm still really confused about rhogam but hopefully I'll be able to clear things up a bit when I talk with my midwife and doctor. I've been looking for the Anti-D book, but I've been having a hard time trying to find a copy for under $50. I guess I'll make the investment though...

 

I'm hesitant to put anything like that in my body when I'm pregnant, and I have a pretty big phobia of needles which are the two main reasons why I'm avoiding it. I'll probably end up getting it after I give birth if the baby's Rh+ just in case, but honestly I just don't understand why it's needed during pregnancy if the only time you would need it is if trauma happened causing your blood to mix, in which case you have 72 hours to get the shot.

 

Thanks girls, I'll be heading over to the home birth forum!

post #8 of 26
Quote:
Originally Posted by RabbitMomma View Post

Thanks everyone. I'm still really confused about rhogam but hopefully I'll be able to clear things up a bit when I talk with my midwife and doctor. I've been looking for the Anti-D book, but I've been having a hard time trying to find a copy for under $50. I guess I'll make the investment though...

 

I'm hesitant to put anything like that in my body when I'm pregnant, and I have a pretty big phobia of needles which are the two main reasons why I'm avoiding it. I'll probably end up getting it after I give birth if the baby's Rh+ just in case, but honestly I just don't understand why it's needed during pregnancy if the only time you would need it is if trauma happened causing your blood to mix, in which case you have 72 hours to get the shot.

 

Thanks girls, I'll be heading over to the home birth forum!


I've read that in the past that women in Western Europe were only given the post-partum shot and did not have higher rates of sensitization.

post #9 of 26
Quote:
Originally Posted by RabbitMomma View Post

I'm Rh- and my husband is Rh+, and I'm about 6 weeks pregnant with our 1st child. I do not want to get the Rhogam shot prenatally, and only want to get it after the birth if it's absolutely necessary. My mom's a GP and has been giving me lots of...facts about why I need a rhogam shot. She told me that if my mother was Rh+, then I would have been sensitised at birth and therefore need the Rhogam shot both at 14 and 28 weeks. She also said that the mother's blood and the baby's blood is always mingling, and this doesn't just happen during trauma. I was really confused about this because I thought that the Rhogam shot would be useless if the mother was already sensitised? I also thought that the baby's blood only mixed with the mother's if there was trauma or during birth? Also, I have heard that if you have a natural childbirth, it is less likely for the baby's blood to mix during birth. Is there any way of knowing if this has happened for sure after the birth other than by doing a blood test? How does the mother's blood mix with the baby's during birth usually, and why does a natural birth make a difference?

 

I'm getting so much conflicting information about this, and it's been really hard to weed out what's true and what people are simply telling me to get me to take the shot. Help!


 
I can see that you are confused!  I'm confused by your post: you said that your mom is a GP, and that your mom said to you 'if your mother was Rh+'....um, huh???  If the GP is your mom, then why is she uncertain about the Rh type of your mom...I guess adoption, maybe?

 

Anyway--whoever it is telling you this info, she is very wrong.  The mother's and baby's blood is NOT always mingling!  The system for all women/babies is designed so that nutrients and wastes are exchanged across placental membrane.  Mother's blood stays on one side of that membrane, baby's blood stays on the other.  Only some sort of injury/trauma to you, leading to rupture of that membrane (even if only in a small area), causes baby blood to get into mom's bloodstream.

 

All of the way you understand this is completely wrong.  Maybe she just wasn't good at explaining it?  Anyway, yeah, there are many threads here on Rh factor and rhogam--that make the facts and viewpoints much more clear.

post #10 of 26

To those people saying only the US does prenatal Rhogam and that Europe does not--NHS standard practice is to give it:

 

http://www.nhs.uk/Conditions/Rhesus-disease/Pages/Prevention.aspx

post #11 of 26
Thread Starter 

Yes I was adopted so I don't know my birth mother's blood type sorry rereading my first post that was a tad bit confusing! I think my mom might have embellished about a few things to get me to take the shot. Honestly I'm not entirely sure she knows what she's talking about with Rhogam, only that she's been told/taught that it's necessary postnatally but not why.

 

Okay, one more question. Is the prenatal Rhogam recommended for mothers who have already given birth? This is my first pregnancy, but I've been hearing that the prenatal Rhogam is not needed for first time mothers. Is it needed after that, or only if you are sensitised during your first pregnancy?

post #12 of 26

RabbitMomma, if you're sensitized during your first pregnancy, you need much closer monitoring and more intensive treatment during subsequent pregnancies (unless you're lucky enough to have all Rh- babies). 

 

The time when exposure and sensitization most commonly occur is at birth.  There are situations in which exposure may occur earlier - if you experience any bleeding or abdominal trauma, or if there is any reason to believe that blood may be mixing internally, then sensitization can occur during pregnancy.  However, the current pregnancy is usually not affected.  The shots are intended to prevent sensitivity from developing in the first place.  Once you are sensitized, Rhogam won't help you.

 

Prenatal Rhogam is recommended for Rh- mothers, whether or not they have previously given birth.  (Whether you choose to take the recommendation is up to you.)

post #13 of 26

There is a new blood test that can determine your baby's blood type while you are still pregnant. You can take it starting at 9 weeks. There is only one lab that does it, though, so it has to be sent there. If your baby is Rh-, then the Rhogam shot is definitely not necessary. If your baby is Rh+, then it's possible that you could be sensitized, which could adversely affect future pregnancies. I consider the chance of being sensitized during pregnancy to be so small that I choose not to get the prenatal rhogam... even if I found out the baby was Rh+. I would get the postnatal shot if I had an rh+ baby, even if it means going to the doc's office a couple days after a homebirth.

 

Your mother's information doesn't make sense. You can get a blood test to determine if you are already sensitized... and if you are, Rhogam will not help. It only prevents sensitization, and needs to be given within a couple days of the sensitization exposure.

 

I know there are a lot of other threads with all the links, including the one about the blood test to determine blood type (the test also tells you gender of the baby, btw).

post #14 of 26
Thread Starter 

Thanks Honeybee, I'll definitely look into that test. Do you know how early in the pregnancy you can take it?

post #15 of 26

 

 

Quote:
You should also look into what happens if you do end up being sensitized. The reality is that, while it can sometimes be deadly, it generally only warrants closer monitoring in future pregnancy.

 

 

Yup...I had two successful sensitized pregnancies after a case of prenatal winrho failure. Both of my subsequent children were fine. I did need to see a peri team during both pregnancies, but no major issues arose and no major interventions were needed (IUTs, etc.)

post #16 of 26

With this pregnancy I was tested early on for RH sensitivity to verify that the last pregnancy did not result in sensitivity.    I am RH- and DD was RH+.   I can't remember if this test was done with my first pregnancy or not but you could ask about it.  That would put to rest any concerns about your being sensitized already from a possible RH + mother.

post #17 of 26

OP - your initial bloodwork will include a test for RhD sensitivity since you are RhD-.  The actual test is called an indirect Coombs test, but I think on the lab paperwork it has another name because they also test for other antibody incompatibilities.  If this tests comes back negative, then you are not sensitized, from either your own birth with a possible RhD+ mother or from a previous pregnancy where the baby was RhD+.

 

If the test shows you are sensitized, your pregnancy will be monitored more closely, as PP mentioned, unless you opt (and pay for?) the early test to determine the in utero baby's blood type.  I don't know how invasive this test is though (do they insert a needle?  eek!), or if there is any risk for the fetus.  I don't know much about the test, I would like for someone to fill us in here! 

 

If the test shows you are not sensitized, the protocol for RhD- mothers with RhD+ partners in the US (used to be?) one shot at 28 weeks, and another within 72 hours after the birth.  Additional doses are recommended in certain situations, ie abortion or threatened or actual miscarriage; invasive testing like CVS, amniocentesis, etc;  after an external version; etc.  The manufacturer of the main formulation used in the US, Rhogam, says that the shot lasts for 12 weeks, although I am not sure where this data came from.  So, by this reasoning a 28-week shot and a post-birth shot would provide continuous coverage (up to the limits of the shot) from the 28-week mark onward.  It's not quite this simple, since the Rhogam shot is "dosed" to provide protection for a certain amount of exposure to fetal RhD+ blood (up to 15 mL).  If a mother experiences blood mixing that is in excess of this upper limit for the dose (for example, trauma to the stomach, car accident, etc), then it is possible that some of baby's RhD+ cells will remain in circulation after the anti-D in the shot has been expended and will cause the mother's immune system to sensitize to the RhD antigen.  Also, I believe that some women who are exposed to a large amount of blood mixing may not become sensitized, while others who are exposed to only a small amount of blood mixing do become sensitized.  Just as with everything in nature, I believe it is a highly individual and difficult-to-predict process in an individual woman.

 

According to the University of Connecticut Health Center, ACOG recommends repeated doses of Rhogam to pregnant women every 12 weeks while they remain undelivered.  I can't find the ACOG bulletin where the recommendation was actually made, so I don't know when this protocol should start (according to ACOG).  But, this may be the source of your mom's recommendations for 14 and 28 weeks (official Rhogam dosing instructions still put 28 weeks as the time of first dose unless there are other factors mentioned above).  That would put dosing at every 14 weeks, which is a couple weeks outside the 12-week recommendation.  Dosing at (12, 24, and) 36 weeks could lead to the newborn testing positive on the direct Coombs test at birth.  The direct Coombs test is a different test from the indirect test.  In general it measures if an infant has been exposed to anti-D antibodies, presumably from the mother's blood, and needs a transfusion after the birth.  However, if a mother receives Rhogam very near the time of birth, it is possible that the test could come back positive and require transfusion for the newborn, because the Rhogam shot itself can attack (baby's) red blood cells that have RhD antigen on them.

 

The original data on anti-D (Rhogam) came from experiments that were done on inmates several decades ago.  They injected RhD- men with RhD+ blood and then measured sensitization with and without the prophylaxis.  This became the basis of the original dosing recommendations and intervals.  IIRC, the inmates were injected on a Friday, and they couldn't access them again to test until the following Monday, so that is where the 72-hour rule following childbirth came from.  AFAIK there have been no other studies to determine exactly how long a woman has to get the anti-D shot to prevent isoimmunization, and I am sure it is an individual thing.  I believe that most physicians recommend that mothers who miss the 72-hour window still receive the shot within 4 weeks of birth, but there is no data to determine how effective the shot at this point would be.  IIRC the average rate of isoimmunization for an RhD- woman with a RhD+ baby in the absence of ANY Rhogam is 13% (meaning 87% will be fine and their body will not mount an immune response).  For women who receive the post-birth shot ONLY and not the prenatal shot, the incidence drops to 1-2% (98-99% will not mount an immune response).  For women who receive the shot at 28 weeks and the post-birth shot, the incidence drops to 0.1-0.2% (99.8-99.9% will not mount an immune response).

 

Another thing to consider is that the anti-D shot is derived from human blood plasma and therefore has all the risks of a blood product.  I don't know if anyone has actually ever had a disease transmitted due to the anti-D shot, but the risk is still there, however small.  Also, some people are not comfortable with injecting another person's blood product into their body for other reasons.

 

It's a complex situation, and I don't think there is one "right" answer for every woman.  Rhogam has helped to reduce the rates of hemolytic disease of the newborn since the 60's when it was introduced.  I personally opted out of Rhogam completely with my first daughter.  I was not sensitized following that pregnancy, but we also do not know her blood type.  This time I purchased two Eldon cards to test the blood of the new baby as well as my first child.  I believe my midwife will also order a lab test to verify baby's blood type from cord blood.  If it is positive, I am not sure what I will decide.  I may still forego post-birth Rhogam. 

 

Good luck to you, however you decide.


Edited by Pirogi - 12/30/10 at 10:36am
post #18 of 26

For some reason the link didn't work.  Here it is: http://health.uchc.edu/clinicalservices/maternal/rhogam.htm

post #19 of 26



 

Quote:
Originally Posted by RabbitMomma View Post

I'm Rh- and my husband is Rh+, and I'm about 6 weeks pregnant with our 1st child. I do not want to get the Rhogam shot prenatally, and only want to get it after the birth if it's absolutely necessary. My mom's a GP and has been giving me lots of...facts about why I need a rhogam shot. She told me that if my mother was Rh+, then I would have been sensitised at birth and therefore need the Rhogam shot both at 14 and 28 weeks. She also said that the mother's blood and the baby's blood is always mingling, and this doesn't just happen during trauma. No, the mother and baby's blood is not continuously mingling, but it is possible that the mixing could occur at any time throughout the pregnancy or birth.  I was really confused about this because I thought that the Rhogam shot would be useless if the mother was already sensitised? This is correct.  I also thought that the baby's blood only mixed with the mother's if there was trauma or during birth? Those are the most probable times/reasons for blood mixing to occur.  Also, I have heard that if you have a natural childbirth, it is less likely for the baby's blood to mix during birth. I believe this is true, but I don't have any scientific research to back it up.  Is there any way of knowing if this has happened for sure after the birth other than by doing a blood test? No, the blood test is the only way to know for sure.  How does the mother's blood mix with the baby's during birth usually, and why does a natural birth make a difference?  As the placenta shears from the uterine wall, it is possible for blood mixing to occur, especially if the placenta is abnormally attached to any degree for any reason (eg, placenta accreta).  There may also be risk of blood mixing if the uterus is over-stimulated in any way, naturally or from synthetic pitocin, which could case a small degree of placental separation.  Also, I believe that medically managed birth, especially third stage, increases the likelihood of blood mixing.  Cord traction, fundal pressure or massage, pitocin, etc disrupts the physiological separation mechanism and (I believe) increases the risk.  Then again, a completely physiological third stage could still have blood mixing, to a small degree.  For women who are especially prone to become sensitized, this could be enough to push them into isoimmunization.  The 87% figure above is, I am sure, from women who have had hospital births with medically managed third stage.  I don't know what the rate is, or if it is different, for physiological third stage without any anti-D shot.

 

I'm getting so much conflicting information about this, and it's been really hard to weed out what's true and what people are simply telling me to get me to take the shot. Help!

post #20 of 26
Quote:
Originally Posted by RabbitMomma View Post

Yes I was adopted so I don't know my birth mother's blood type sorry rereading my first post that was a tad bit confusing! I think my mom might have embellished about a few things to get me to take the shot. Honestly I'm not entirely sure she knows what she's talking about with Rhogam, only that she's been told/taught that it's necessary postnatally but not why.

 

Okay, one more question. Is the prenatal Rhogam recommended for mothers who have already given birth? It is recommended for any RhD- pregnant woman who is not already sensitized, unless her partner or the baby are known to be RhD-, regardless of how many times she has been pregnant or given birth.  This is my first pregnancy, but I've been hearing that the prenatal Rhogam is not needed for first time mothers. It depends what you mean by "needed."  If a woman is sensitized during her first pregnancy with a RhD+ baby, then her lab work will reflect that for future pregnancies, and her future pregnancies will be more closely monitored for hemolytic disease of the newborn (HDN).  I think it is unlikely that a woman would become sensitized early in the pregancy with a first baby, and that baby would go on then to develop HDN before birth.  So getting Rhogam with your first pregnancy with a RhD+ baby is not intended to protect that baby, but to protect future RhD+ babies you may carry. Is it needed after that, or only if you are sensitised during your first pregnancy? If you are sensitized, Rhogam is useless for prevention of HDN, and monitoring is required.  As long as you remain not sensitized, the protocol for getting Rhogam is the same regardless of how many babies/pregnancies you have had.

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