Rhogam

[SaraFR]

Forgive my ignorance,

Being that I'm not pg. (far as I'm aware-that nursing throws off your body), this isn't relevant currently. I'm more looking for food for thought. I did end up having the vax with both boys. This was before I was aware of most of the vax issues.

My question is, how can one have the Rh incompatability and not vax? What can you do instead to prevent the body from reacting to an Rh pos. baby?

[maxmama]

In a nutshell, you can't.

It's unlikely to cause problems in a first pregnancy, or the first after having been prophylaxed in previous pregnancies. But I chose to prophylax, no sweat, because I'm already isoimmunized against another blood group factor (Kell) and I didn't need Rh isoimmunization on top of that.

Isoimmunization to Rh is not a minor problem. The prenatal treatments of an affected fetus are amniocentesis and in utero transfusion; after birth, some babies require a full exchange transfusion. Yes, isoimmunization is more likely after an abdominal trauma, but small utero-placental bleeds are quite common and can be enough to sensitize.

My experience with Kell has, quite frankly, scared the s*** out of me. It reminded me how common an experience isoimmunization was before RhoGAM, and how dismal the outcomes can be.

[trini]

Can I jump on this thread and ask a related question?

Is it necessary to do it during the pg AND at delivery? Would it be effective to just do it at delivery, therefore preventing it from affecting the baby in any way?

[Momtezuma Tuatara]

I don't understand why pregnant women have the jab when they are pregnant.

They have the jab because they are told if they have antibodies in the blood from a previous pregnancy that will damage the baby?

Well, keep in mind a very important point about RhoGam and that is that the antibodies attack ALL RH positive cells. The entire premise is that if the mother's blood mixes with the baby's blood, the antibodies will neutralize the baby's blood cells before the mother can create her own antibodies against the baby. The dilemna is that if the mother's and baby's blood does actually mix it is equally likely that the RhoGam antibodies will cross over and attack the baby itself. This happens frequently but isn't discussed by most doctors. It is a big reason to only get the shot after pregancy if the baby really is RH+

The RhoGam antibodies will attach to your baby's blood cells and render them incapable of delivering oxygen. This has long term consequences on brain development. Most doctors are completely ignorant of this issue.

The RhoGam antibodies do not cross the placenta. But neither do blood cells from the baby which is exactly why the RhoGam is injected. In very rare circumstances, such as the mother becoming injured, the blood of the mother and baby can mix. It's a paradox, only when the antibodies are needed can they harm the baby.

The RhoGam antibodies are put there to attack any baby's blood that comes across. But if there is mixing then the antibodies can go across the other way and they do exactly that. Antibodies diffuse much more readily through the bloodstream than whole cells.

Immunology textbooks still correctly point out that RhoGam should be given after childbirth only if the baby is RH+. These are the mothers that are at high risk. However the company that manufactures RhoGam lobbied to have it's use expanded to all RH- mothers during and after pregnancy to 'guarantee' that all high risk mothers were protected. Doctors try to rationalize this by saying that even during the first pregnancy blood can mix and antibodies can be produced that will attack the baby. This almost never happens because the blood would have to mix twice, once to stimulate the production of Abs in the mother and the second time for those antibodies to diffuse to the baby. And regardless, the paradox comes into play because if the mother's Abs can diffuse to harm the baby, then so can the injected RhoGam Abs. They are the same exact antibodies.

Each RhoGam injected contains blood serum pooled from several different persons with the antibodies. The manufacturer can not possibly screen or remove all viruses from it. But that's a separate issue.

The Rhogam antibodies in the injection are identical to the antibodies that the Rh- mother makes against her child. The Rhogam antibodies were collected from RH- mothers who did have an immune response to their RH+ babies. The Rhogam antibodies will attack and destroy the baby's red blood cells (if they do come across the placenta) before the mother's immune response kicks in and makes her own antibodies. You give rhogam to a mother after delivery because that is when the blood mixes. The rhogam antibodies destroy the baby's cells so that the mother's immune system never sees them and therefore never becomes sensitized to make those exact same antibodies.

If you give the Rhogam antibodies during pregnancy you have just created the situation you were trying to avoid. The whole point is for the pregnant mother to NOT have antibodies against her own child circulating in her system while she is pregnant.

Any blood mixing would allow those antibodies to attack the baby.

It does not matter if the mother's immune system made those antibodies or another mother's immune system (rhogam) made those antibodies. They are identical down to their molecular structure and you do not want them to contact the baby.

[maxmama]

Originally Posted by trini

Can I jump on this thread and ask a related question?

Is it necessary to do it during the pg AND at delivery? Would it be effective to just do it at delivery, therefore preventing it from affecting the baby in any way?

It's debatable. Yes, the largest blood exposure will come at birth. But it is possible to have a small utero-placental bleed with no symptoms, and that blood exposure could be enough to sensitize.

I freely admit my isoimmunization paranoia, because I never saw my Kell isoimmunization coming and it occurs the same way Rh sensitization does. Would the postpartum dose of RhoGAM be enough? Probably, for the vast majority of pregnancies. But I personally prefer to prophylax.

[Momtezuma Tuatara]

Hmmm maybe I should rewrite that?

[maxmama]

Originally Posted by Momtezuma Tuatara

Hmmm maybe I should rewrite that?

I think we posted simultaneously. But I am a huge example of how possible it is to be sensitized during pregnancy. At the start of my pregnancy with my son, my Kell titer was negative. At my 28 week antibody screen, my titer was positive. At some point in that pregnancy, when I had not had any abdominal trauma or other known placental disruption, enough fetal blood entered my circulation to create an antibody response.

So yes, I do believe in "silent" isoimmunization, and if there was an equivalent to RhoGAM for Kell, I would have gotten it in a heartbeat. I'm spending this pregnancy in various perinatologists' offices discussing at what point in my titers I need a cordocentesis and transfusions, and when I become a hostile enough uterine environment that it's better for my child to be a micropreemie than continue being attacked by my antibodies. Right now, my titers are not rising and I'm hopeful. But I also know that utero-placental bleeds are most likely to occur in the third trimester, and I'm only 19 weeks.

[Momtezuma Tuatara]

But your baby will not be damaged unless there is an event which will cause a second bleed. You are essentially in the same position as a person who has just had the shot.

You have antibodies which if you bleed again, could affect your babies, so you are actually in the identical position as a woman who has received rhogam. A woman who is given rhogam during pregnancy also has antibodies which, if she has a bleed and blood mixes will likewise damage her baby.

I don't understand why people don't see that.

It's basic, clear medicine.

The very argument you give here, shows WHY a woman shouldn't have rhogam during pregnancy.

[caedmyn]

OK I'm not sure if I am understanding this right. Does it work the way a sensitivity to a bee sting does, in that the first exposure sensitizes but there won't be a reaction until the second exposure?

And if that is the case, in subsequent pregnancies is the person in the first exposure position, where a reaction will occur with one exposure in that pregnancy, or is that only if there was an exposure in the first pregnancy?

Hopefully that makes sense...

[rozzie'sma]

I would suggest reading Anti-D in Midwifery panacea or Paradox by Sara Wickham. There are things that you can do to prevent the mixing of blood but it is not a guarantee that sensitization will not occur, It is a hard subject to think about. As an rh- woman myself who is only able to have rh+ babies dur to my dh being homozygous positive, I am going to refuse the 28 week injection but get the after birth injection. THe 28 week injection came about because docs were being lazy about informing women after a sensitizing event (blow to the abdomen, bleeding etc) that they need the shot and a small percentage of women were becoming sensitized. The 28 week shot is not even recommended in most european countries. Also they have been no studies done on what effects it may have on the offpring of a positive daughter whose mother recieved rhogam prenatally. It is not a black and white issue by any means. Please read her book, search your soul, and the answer will hopefully come to you. THis has been one of the toughest decissions of my life.

[japonica]

This is all very interesting and I'm enjoying the food for thought...just thought I'd share my experience...

I am isoimmunized for anti-D. I was given Win-RHO (Canadian version of RhoGAM) during my first pg at 13 weeks (bleeding), 30 weeks, and at delivery. I was testing negative for antibodies up until delivery. We lost my daughter when I was 40 weeks pg and the follow up pathology on the placenta indicated that there was a "feto-maternal hemorrhage" (even though I had no signs of bleed) at the end of the pg (that and massive inflammation of the placenta--so some type of reaction was going on--no infections were found in my b/w results). With my second pg, the initial b/w indicated that I had become sensitized. I find your info very thought-provoking MT...maybe more was going on that we realized with the WinRHO. Like many people's experiences with vaxes, we were told that with me being Rh neg, it was just something we HAD to do...and also that it was almost 100% effective (so imagine my surprise when I found out I had been sensitized anyway after all those shots).

My second pg went fairly well...my DH is homozygous positive for D, so any additional pgs will be affected as well. My titers stayed fairly low (highest was 1:8), my DD did not become overly anemic and only needed the lights for a week, but no transfusions, after she was born.

We are considering trying for a third child and are meeting with the perinatalogist to get an idea of what to expect this time around.

As an rh- woman myself who is only able to have rh+ babies dur to my dh being heterozygous positive

If your DH was heterzygous, would you have a chance that your baby could be neg for D? That was why we had my DH tested because of that possibility he could be +/- and we could end up with an unaffected baby...My DH turned out to be homozygous for D, so we're stuck with every pg being affected. Well, that's how it was explained to us anyway.

J

[maxmama]

Originally Posted by Momtezuma Tuatara

But your baby will not be damaged unless there is an event which will cause a second bleed. You are essentially in the same position as a person who has just had the shot.

You have antibodies which if you bleed again, could affect your babies, so you are actually in the identical position as a woman who has received rhogam. A woman who is given rhogam during pregnancy also has antibodies which, if she has a bleed and blood mixes will likewise damage her baby.

I don't understand why people don't see that.

It's basic, clear medicine.

The very argument you give here, shows WHY a woman shouldn't have rhogam during pregnancy.

If you look at the outcomes for babies whose moms received RhoGAM v. those whose moms were sensitized, you are going to be looking at two very different groups of babies. The RhoGAM babies have received, if any, extremely small doses of antibody, and there have not been negative efffects associated with it in reputable studies. These are essentially healthy babies.

The babies born to sensitized moms are at high risk for HDNB, hydrops fetalis (which, by the way, carries a mortality rate of approximately 50%; I really doubt you can come up with data that shows a congruent risk for receiving RhoGAM) and severe neurologic sequelae. Do I choose to avoid these known risks at the cost of a theoretical risk? You bet your ass I do, and my midwife, my perinatologist, my OB and the neonatologist I consulted with (all of whom have actually seen affected babies, as I suspect you have not) agree.

It's a risk-benefit analysis; for me, this is what I chose. At no point did I say that all women should get antenatal RhoGAM. What my point remains is that one does not know whether she will have a silent utero-placental bleed, and that needs to be factored into whether one chooses to have antenatal RhoGAM, which has documented efficacy and some theoretical risk.

[SaraFR]

Both of my boys were neg. so the shot during the pregnancy ended up not being needed (not that we nkew the blood type till after birth).

Is it just as effective to get no shot during the pg. but get one postpartum IF the baby ends up being pos.?

[rozzie'sma]

The US didn't used to do a prenatal Rhogam AT ALL. That didn't start till the 80's

[SaraFR]

Was it added prenatally for money-making reasons or for effectiveness?

Athough, after being on the vax forum for a bit I'm willing to wager that the answer will be it was added for financial health.

[Momtezuma Tuatara]

The information I posted here was put up some time ago, by someone else on the board, who is at the moment somewhat busy, but gave me permission to post it if it was needed.

I have asked them to come and explain, if they can find the time.

I understand the principles in the information I posted, that the poster was trying to get across.

There was another post posted by the person I've asked to come and explain, regarding rhogam to try to explain it further. This is what that post said:

The rh+ cells of the baby stimulate rhogam production by the rh-mother's immune system. We want to prevent rhogam from circulating in the mother while she is pregnant because those antibodies will harm the baby. To do this we give rhogam immediately after birth so that any rh+ cells that are still in the mother will be destroyed. This keeps the mother's immune system from seeing those cells and producing her own rhogam which would stay in her circulation where they could attack any subsequent rh+ babies. Doctors would like us to inject rhogam antibodies during pregnancy to prevent the formation of rhogam antibodies. The rhogam will destroy all the rh+ cells thus preventing the mother from making her own rhogam antibodies. But what's the point, you prevented the mother's antibodies from being there by putting someone else's antibodies in the exact same spot. This is the point which I am not getting across: rhogam is the immune response to the baby. It is the pooled serum from rh- mother's who have had an immune response to their rh+ babies. You do not want those antibodies to come into contact with your rh+ baby.

Rhogam works. It works well. It should be administered after pregnancy like it is in Europe. During pregnancy is a decision that was made by the manufacturer to make money.

If a woman has a miscarriage she should have the shot immediately. If there is an amniocentesis performed it may be worth while to have the injection but there is some risk to that. It makes no sense to give the injection at 28 weeks during a healthy pregnancy. The blood does not mix in a sufficient manner to cause an immune response in the mother. If there were that much mixing then the injected antibodies (rhogam) would have access to the baby and kill the baby's red blood cells. It's a no win situation with rhogam at 28 weeks. The reason the manufacturer can get away with it is exactly because there is usually no blood mixing. The rhogam works it's way out of the mother's system without ever doing anything.

Another way to look at rhogam. Rhogam kills the baby's red blood cells no matter where those cells are. If the baby's blood cells are in the mother, those cells will be destroyed. If the baby's red blood cells are circulating through the baby delivering oxygen to the baby's brain, the rhogam will still kill those cells and deprive the baby of oxygen. It is not a good idea to take any chance that would allow the rhogam access to the baby. The doctors are concerned only about baby's cells circulating in the mother but antibodies diffuse much more easily than whole cells so the rhogam will readily find the baby's cells where the baby is than for the whole cells of the baby to find their way to the rhogam.

The makers of rhogam have funded some lame studies to show that getting the injection DURING pregnancy is more effective. I have found that most doctors are not intelligent enough to see the paradox becasue they blindly accept FDA and CDC recommendations. But there is a wonderful study that compared the efficacy of the post-natal vs. the ante-natal shot. The study examined the corporate studies and explained how they are flawed. It turns out there is absolutely no evidence to show that ante-natal is more effective than post-natal. So mothers should only get the shot post-natal IF the baby is rh+ (and the mother is rh-).


Here is a link to that study http://www.upstate.edu/fmed/cebp/Pre...ompilation.pdf You have to go to page 226

Page 234 summary on Th issues states

6. We found no direct evidence of benefit of antnatal anti-D prophylaxis in terms of maternal or neonatal morbidity or mortality

Pg 236 makes the point that

One Cochrane review of randomised trials of antenatal anti-D prophylaxis for Rh-negative women (Crowther 2000) See table 1. The reviewers searched for RCT's of the effect of antenatal anti-D prophylaxis for Rh-negative women after 27 weeks... only two trials were found. Both were of marginal quality (one with poor randomization scheme and the other with high dropout rates) ....The articles were appraised with the level of evidence shceme and described narratively and the results as qualitative comparison of the individual studies results....the overallquality of this evidence is fair to poor due to the lack of good quality RCTs and relinace on open label studies often with historical controls. There is no direct evidence that antenatal propphylaxis reduces maternal or neonatal morbidity or mortality or improves patient satisfaction....

the studies were weakly positive, but so weakly as to be meaningless in my opinion. Manufacturers are usually very good at constructing studies to prove their point, and if in those two studeis, they haven't been able to show conclusive benefit, then I'd wager there is none at all....

Fact. Rhogam antibodies cross the placenta and attack the baby's red blood cells (if the baby is rh+)? Well again it's just obvious but take a look at the package insert. Here's a quote from rhogam: ""Some babies born of women given Rho(D) immune globulin (human) antepartum have weakly positive direct antiglobulin (Coombs) tests at birth."" There's your admission by the company. Weak or not the test proves the presence of the antibodies in baby's whose mother received the shot while pregnant. One antibody molecule can wipe out one red blood cell - that's all it takes. Any amount of antibodies is dangerous because it decreases the baby's red blood cells and hence the oxygen that the baby's brain receives.

Hopefully the person concerned will drop by. If that doesn't happen, you'll just have to put your thinking and decision making caps on.

[SaraFR]

MT-That gave me some good reading. Are there any other links that anyone can provide?

[monocyte]

Great thread.

I never thought about rhogam during pg (although I took it without thinking much...) and needed some extra as we had a bleed during delivery.

Having just had a miscarriage, I am wondering about my status now. Any thoughts on when a shot is necessary post mc?

[japonica]

I recall being told to get a shot within within 72 hours of bleeding, trauma, amnio etc....not sure if that's correct though...

J

[Momtezuma Tuatara]

Japonica is correct.