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#1 of 49 Old 11-24-2013, 09:59 AM - Thread Starter
 
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Rhogam is a blood product which is pooled. It is actually a blood product from RH - mothers along with sensitizing their blood. Hence, Rhogam.  I understand the "This is how we treat mothers who are Rh-." but I am looking for more in depth info in relation to my questions specifically. 

 

I have researched the Rhogam / Anti-D shot. I am currently pregnant and am O- Neg blood type. I had the RHD genotype test done (via my blood) to test the fetal blood type. The fetus blood type tested as positive. I understand the Rhogam is "routinely" given to all RH - mothers at 28 weeks. If you have a healthy pregnancy, but all of a sudden an accident happens or trauma that caused bleeding before 28 weeks which would require you to go into the hospital immediately and get and the Rhogram shot, I'm wondering what does the Rhogram shot actually do to help the current baby.

This is my first pregnancy. I am still a little uncertain if bleeding occurs and you go into the hospital to get the Anti D shot, what and how does it help the current child (who is positive) in relation to the blood mixing? I have read in literature it only works by protecting your next pregnancy and has nothing to do with the current pregnancy. So I'm a little confused if trauma happens and I were to get the shot, what does it actually do for the current child, and will and how does help the current child the mothers blood (RH- and babies blood RH+) were to mix? 

 

While I have done research and understand the general how Rhogam works. My question is more specific with this scenario. It is sort of confusing to me how it actually works in a trauma situation where the mothers blood (negative) has mixed with the babies blood (positive). Within 72 hours the shot is given. If trauma has happened within those 72 hours and the blood has already mixed, how will the Rhogam shot help prevent what has already started? I do understand it works similar to a "flu shot" injecting just enough so your body fights it off. But if the blood has already mixed within 72 hours or even after 5 hours if trauma has happened where the blood is confirmed to have mixed and my blood is already "attacking" the fetus, I'm not understanding how the Rhogam shot would help the current baby exactly?

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#2 of 49 Old 11-24-2013, 10:09 AM
 
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You could definitely develop antibodies & wind up with an isoimmunized current pregnancy in that scenario. There is *always* blood mixing (that is why they are even able to do the fetal test from maternal blood), just usually not sufficient enough to cause isoimmunization.

In a trauma scenario, the fetus could begin to be affected right away. Best case scenario this just requires monitoring, worst it ends in StillBirth.

The Rhogam works by providing antibodies so your body does not manufacture them. It always works the same way. In some Trauma scenarios, isoimmunization happens anyway, typically that is because of delays (no need to wait 72 hours!) or insufficient quantity of Rhogam (there are formulas but medical professionals are mostly woefully undereducated about proper admin, beyond the basics).
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#3 of 49 Old 11-24-2013, 10:14 AM
 
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ETA: The only reason it mostly does not affect the current pregnancy is that in a normal, trauma free pregnancy, *sufficient* blood mixing does not occur until delivery, if then.
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#4 of 49 Old 11-24-2013, 10:20 AM
 
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When blood mixing happens, it takes a few days for antibodies to develop. The hope is that prompt administration of rhogam can prevent antibodies from developing and attacking the fetus.
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#5 of 49 Old 11-24-2013, 10:50 AM - Thread Starter
 
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Thank you for your responses.  I have had the test done for anitbodies, and I have none. I have not been sensitized.  I have a normal healthy pregnancy. I am RH - and Baby is tested RH+

 

Quote:
The shot does work after pregnancy when it can not possibly harm the baby.
It is said by some that it offers no additional benefit during pregnancy.
The safety concern duringpregnancy is real.  It doesn't make sense to inject antibodies into the
mother's blood stream that are designed for the sole purpose to eliminate
cells of the baby? There are numerous case reports of babies born anoxic
and asphyxiated because the RHoGam antibodies crossed the placenta during
the gestation period. This is not the only safety concern with the
injection, just the most obvious.

 

The problem is that injecting Rhogam during gestation you are getting
protection for your second pregnancy at the expense of your first. If you
put Rhogam antibodies into your body during your first pregnancy you are
putting antibodies against your baby into your blood stream where, if blood
mixing does occur, those antibodies will attack your baby. This is exactly
what you are trying to avoid for the second pregnancy. So, in reality you
are protecting your second pregnancy from the antibodies by injecting them
into yourself during the first pregnancy. I can't state it any better than
this: if you inject Rhogam during your first pregnancy you will prevent a
potentially harmful situation for your next pregnancy by causing that exact
same harmful situation in your first pregnancy.
 

REF: http://www.nccn.net/~wwithin/rhogam.htm

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#6 of 49 Old 11-24-2013, 10:54 AM - Thread Starter
 
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Quote:
Originally Posted by dinahx View Post



In a trauma scenario, the fetus could begin to be affected right away. Best case scenario this just requires monitoring, worst it ends in StillBirth.
 

 

So getting the rhogam shot due to trauma wouldn't help being the fetus is affected right away, (blood already mixed).  If you got the  test to detect transplacental hemorrhage right there and then in the emergency room, and it detected transplaental hemmorrage, what would be the point of rhogam helping if the blood has already mixed?

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#7 of 49 Old 11-24-2013, 11:53 AM
 
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The shot acts to PREVENT isoimmunization, which cannot be reversed once initiated by the body. If the antibodies take care of the exposure, there is no need for your body to isoimmunize.

The greatest Rhogam benefit is postnatal, that is because the greatest blood mixing is during delivery. However even with postnatal Rhogam, 1% of women will still be isoimmunized in normal pregnancies. The 28 week shot reduces that to 0.1%.

Rhogam that is Thimerisol free in no way adversely affects the fetus, the affect is on the *mother*. It is not harming the existing baby for the benefit of the next baby @ all.

Isoimmunized pregnancies involve more ultrasound, more driving to MFM doctors, more anxiety. IMO not worth it . . .
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#8 of 49 Old 11-24-2013, 11:58 AM
 
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What you don't seem to understand is the levels of antibodies required to adversely affect a fetus. Even in an isoimmunized pregnancy, the body has to produce a certain level of antibodies to cause harm. Those levels are simply not present in Rhogam. They have to build up over time, which they will, if the body is allowed to isoimmunize.

I personally want as many low risk pregnancies as I can have. A transplacental hemorrhage would threaten a current Rh+ fetus *unless* sufficient Rhogam was given in a timely manner. The danger to the baby is not from the blood mixing itself (which again, always occurs to some degree) but from the mother's body learning to manufacture copius quantities of those antibodies, unchecked.
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#9 of 49 Old 11-24-2013, 11:59 AM
 
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And I am not a huge Rhogam lover, I also had my fetus tested this pregnancy in hopes of avoiding it (which I was able to do as my current fetus is Rh-) but beliefs about it that are not grounded in fact simply help no one.
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#10 of 49 Old 11-24-2013, 12:29 PM
 
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I'd challenge you to find even one case of a baby born Hypoxic because of Rhogam 12 weeks prior to delivery. Feel free to search VAERS, the cases are not there. It is just not possible.
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#11 of 49 Old 11-24-2013, 12:41 PM - Thread Starter
 
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Quote:
Originally Posted by Catmom2 View Post
 

Thank you for your responses.  I have had the test done for anitbodies, and I have none. I have not been sensitized.  I have a normal healthy pregnancy. I am RH - and Baby is tested RH+

 

 
The shot does work after pregnancy when it can not possibly harm the baby.
It is said by some that it offers no additional benefit during pregnancy.
The safety concern duringpregnancy is real.  It doesn't make sense to inject antibodies into the
mother's blood stream that are designed for the sole purpose to eliminate
cells of the baby? There are numerous case reports of babies born anoxic
and asphyxiated because the RHoGam antibodies crossed the placenta during
the gestation period. This is not the only safety concern with the
injection, just the most obvious.

 

The problem is that injecting Rhogam during gestation you are getting
protection for your second pregnancy at the expense of your first. If you
put Rhogam antibodies into your body during your first pregnancy you are
putting antibodies against your baby into your blood stream where, if blood
mixing does occur, those antibodies will attack your baby. This is exactly
what you are trying to avoid for the second pregnancy. So, in reality you
are protecting your second pregnancy from the antibodies by injecting them
into yourself during the first pregnancy. I can't state it any better than
this: if you inject Rhogam during your first pregnancy you will prevent a
potentially harmful situation for your next pregnancy by causing that exact
same harmful situation in your first pregnancy.
 

Forgot to add the REF:  for the above cut/paste  : http://www.nccn.net/~wwithin/rhogam.htm  

 

While I cannot say I agree 100% with statements, I can only go by fact. Fact is Rhogam has helped babies, I will never argue that.  But is it necessary for every RH- woman that has a healthy pregnancy?   I am referring to prenatal rhogam of course at 28 weeks.  My doctor actually advised me I do not need it at 28 weeks, because I have a healthy pregnancy.  It is only recommended if trauma where to occur of course.  Which is why I am asking for any literature/links in relation to my specific questions etc.

 

I do appreciate your feedback from others who are willing to present valid fact behind their statements and glad you are trying to help in any case.  Not looking for drama.  Peace.

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#12 of 49 Old 11-24-2013, 05:57 PM
 
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Quote:
Originally Posted by Catmom2 View Post

Thank you for your responses.  I have had the test done for anitbodies, and I have none. I have not been sensitized.  I have a normal healthy pregnancy. I am RH - and Baby is tested RH+

Quote:

The shot does work after pregnancy when it can not possibly harm the baby.
It is said by some that it offers no additional benefit during pregnancy.
The safety concern duringpregnancy is real.  It doesn't make sense to inject antibodies into the
mother's blood stream that are designed for the sole purpose to eliminate
cells of the baby? There are numerous case reports of babies born anoxic
and asphyxiated because the RHoGam antibodies crossed the placenta during
the gestation period. This is not the only safety concern with the
injection, just the most obvious.


The problem is that injecting Rhogam during gestation you are getting
protection for your second pregnancy at the expense of your first. If you
put Rhogam antibodies into your body during your first pregnancy you are
putting antibodies against your baby into your blood stream where, if blood
mixing does occur, those antibodies will attack your baby. This is exactly
what you are trying to avoid for the second pregnancy. So, in reality you
are protecting your second pregnancy from the antibodies by injecting them
into yourself during the first pregnancy. I can't state it any better than
this: if you inject Rhogam during your first pregnancy you will prevent a
potentially harmful situation for your next pregnancy by causing that exact
same harmful situation in your first pregnancy.
 
REF: http://www.nccn.net/~wwithin/rhogam.htm

I don't know who is running nccn.net, but they don't seem to have all that great an understanding of rhogam.

I'm rh-. My first baby was also rh-. I received prenatal rhogam as a precaution (it was winter, I'd taken some falls on ice), but after the baby's blood type w as determined, we skipped the postnatal shot. I was not sensitized to rh factors when I got pregnant with my daughter, but I had placenta previa, and she was rh+. I bled at various points during pregnancy, and was given rhogam to prevent sensitization. Rhogam is a small dose of anti rh antibodies, which prevent a full scale immune response from occurring.

I had three rhogam shots during my last pregnancy, and my dd was not affected by rh incompatibility problems.

A lot of people - me included -feel really strongly about rhogam. It's saved thousands of children, mine included.
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#13 of 49 Old 11-24-2013, 06:09 PM - Thread Starter
 
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Every woman is different.  And I do believe Rhogam has helped a lot of babies.  

 

Here is an interesting article I just got finished reading.  

 

http://sarawickham.files.wordpress.com/2011/10/a1e-routine-antenatal-anti-d-an-overview-of-the-evidence.pdf

 

Has anyone read Anti-D in Midwifery: Panacea or Paradox?, By Sara Wickham ?  I do find it interesting and wondering if anyone can relate?

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I haven't read the book in question. The article you link describes standard practice concerning rhogam in the UK, twelve years ago. It does not remotely describe my experiences in the US 4-5 years ago. The article argues that the apparant need for routine prenatal rhogam is an artifact of poor application of procedures for identifying and administering rhogam in response to trauma. The hospitals I dealt with had iron clad procedures to address these problems. Has there been additional research since 2001, and have the procedures in question been changed?
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#15 of 49 Old 11-24-2013, 09:06 PM
 
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The shot is to keep your body from becoming sensitized if your body is exposed to babies bloody type. I had 3 shots in one pregnancy once.

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#16 of 49 Old 11-24-2013, 10:20 PM
 
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I suppose I have a strong emotional feeling about Rhogam but that is because I feel really strongly that it is poorly understood by many facets of the medical community, and that includes the NCB community.

The largest benefit is definitely postnatal. Sensitization rates with zero Rhogam would be about 13% for Rh- women carrying Rh+ fetuses. Postnatal Rhogam drops that to only 1%. So you are only going from a 1% to a 0.1% risk with the 28 week shot in a low risk pregnancy.

Based on those numbers, probably as this is maybe my final pregnancy, I could have taken a calculated risk to skip the 28 week shot with zero consequences, even w/o the Fetal blood typing. IMO it depends on if you think you could deal with a future isoimmunized pregnancy & how likely you think you are to try to have one or two or more . . .

I am a huge advocate for reducing Rhogam use with Prenatal blood typing or @ least with Paternal blood type ID (as some providers give it to all Rh- women on the theory that the father could be anyone). But IMHO that is only because of a theoretical risk to the mother (specifically BSE, MadCow & then it just being a blood product), rather than any risk to the baby.
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#17 of 49 Old 11-25-2013, 06:41 AM - Thread Starter
 
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Quote:
Originally Posted by MeepyCat View Post

I haven't read the book in question. The article you link describes standard practice concerning rhogam in the UK, twelve years ago. It does not remotely describe my experiences in the US 4-5 years ago. The article argues that the apparant need for routine prenatal rhogam is an artifact of poor application of procedures for identifying and administering rhogam in response to trauma. The hospitals I dealt with had iron clad procedures to address these problems. Has there been additional research since 2001, and have the procedures in question been changed?

Hi MeepyCat :)  Fellow Cat cat.gifhamster.jpg

 

"The article argues that the apparant need for routine prenatal rhogam is an artifact of poor application of procedures for identifying and administering rhogam in response to trauma."

Did you have any thoughts on the above? Are these points in the article valid in your opinion?   If they are not valid , what research/literature can you share, maybe statistics, clinical trials etc.. can back that up?

 

"The hospitals I dealt with had iron clad procedures to address these problems"

Can you please share the Iron clad procures in detail how to address these problems you are referring to?

 

"Has there been addtional research since 2001, and have the procedures in question been changed?

To my knowledge, Rhogam from what I have researched has not changed in relation to what the article is saying.  The one obvious change was removing thimerosal starting back in 2001 that most are aware of that have researched Rhogam.  Other than that, Rhogam is still Rhogam.  A blood product.

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#18 of 49 Old 11-25-2013, 06:51 AM - Thread Starter
 
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Also, I was told by a midwife it doesn't affect your first.  Since this is my first pregnancy, getting the routine Rhogam at 28 weeks is not necessary.  She did say Rhogam is misunderstood by many, and not all woman should get/need the routine shot.   Also, in different countries of the world, it is not standard to get Rhogam at 28 weeks.  Also it may be a risk being exposed to blood products when the need is not there. The impacts on the mothers/babies immune systems still remain unknown.

 

I also have had hypersensitive reactions to flu shots in the past, so not sure if this if this blood product is necessary, if I have a healthy pregnancy, and its my first pregnancy 

 

Also, does anyone have any literature on WHY it doesn't affect your first? and more info behind that statement.  I hear it all over the place, but it is not explained why, or how valid statistically that statement is.

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#19 of 49 Old 11-25-2013, 07:03 AM - Thread Starter
 
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I suppose I have a strong emotional feeling about Rhogam but that is because I feel really strongly that it is poorly understood by many facets of the medical community, and that includes the NCB community.

The largest benefit is definitely postnatal. Sensitization rates with zero Rhogam would be about 13% for Rh- women carrying Rh+ fetuses. Postnatal Rhogam drops that to only 1%. So you are only going from a 1% to a 0.1% risk with the 28 week shot in a low risk pregnancy.

Based on those numbers, probably as this is maybe my final pregnancy, I could have taken a calculated risk to skip the 28 week shot with zero consequences, even w/o the Fetal blood typing. IMO it depends on if you think you could deal with a future isoimmunized pregnancy & how likely you think you are to try to have one or two or more . . .

I am a huge advocate for reducing Rhogam use with Prenatal blood typing or @ least with Paternal blood type ID (as some providers give it to all Rh- women on the theory that the father could be anyone). But IMHO that is only because of a theoretical risk to the mother (specifically BSE, MadCow & then it just being a blood product), rather than any risk to the baby.

 

Hi Dinahx

 

Thank you for the stats.  Much appreciated.

 

So if I get the post natal Rhogam, and opted out from the prenatal Rhogam, I'm only deciding on a 1% to a 0.1% risk with the 28 week shot in a low risk pregnancy.  If I didn't get the routine Rhogam my risk would be 1% instead, of 0.1%?

 

Now taking the risk difference of 1%  VS the Risk of  being exposed to blood products when the need is not there. The impacts on the mothers/babies immune systems still remain unknown. Rhogams saftey Information:

RhoGAM® and MICRhoGAM® Ultra-Filtered PLUS Rho(D) Immune Globulin (Human) are made from human plasma. Since all plasma-derived products are made from human blood, they may carry a risk of transmitting infectious agents, e.g., viruses, and theoretically the Creutzfeldt-Jakob disease (CJD) agent. RhoGAM® and MICRhoGAM® are intended for maternal administration. Do not inject the newborn infant. Local adverse reactions may include redness, swelling, and mild pain at the site of injection and a small number of patients have noted a slight elevation in temperature. Patients should be observed for at least 20 minutes after administration. Hypersensitivity reactions include hives, generalized urticaria, tightness of the chest, wheezing, hypotension and anaphylaxis. RhoGAM® and MICRhoGAM® contain a small quantity of IgA and physicians must weigh the benefit against the potential risks of hypersensitivity reactions. Patients who receive RhoGAM® and MICRhoGAM® for Rh-incompatible transfusion should be monitored by clinical and laboratory means due to the risk of a hemolytic reaction.

 

The patient label of both RhoGam and WinRho clearly states that neither drug has ever been scientifically tested for safety on pregnant women or fetuses. With any drug made of human blood plasma, there is a slight risk of transmitting disease. So adverse reactions in both mother and fetus are certainly possible.

 

Rhogam was known to contain mercury and we all know the effects it can cause especially in the body of a fetus not even born yet, but then came the announcement that Rhogam was allegedly mercury free. But here is the catch:

If you are an Rh-negative mother, remember that, although Thimerosal-free Rho-GAM became available in 2002, the supply of mercury-containing Rho-GAM is still on the market. Remember the word “thimerosal” means it contains 49.6% mercury. This is especially important because fifty-three percent of mothers of autistic children are Rh negative, while only three percent of mothers of normal children are Rh-negative. REF: http://healthfreedoms.org/2012/02/16/why-do-53-of-autistic-children-have-rh-negative-mothers/

It is stated "Thermersol has been removed since 2001-02.  BUT Johnson and Johnson uses thimerosal in the manufacturing process, then adds a post-manufacturing process to remove the preservative...but "trace amounts" of mercury remain in the medicine. J & J admitted this in Congressional testimony a few years back.  J&J is the only brand my hosptials/doctor uses.  

 

If thermersol was in Rhogam and given to mothers by the medical industry that most trusted, why did they all of a sudden "remove it" back in 2001?.  Shouldn't really be a shock to some who wonder why we question the medical industry.

 

Although many have had the shot and all is fine, nobody can predict how one can react after the shot is given.  Nobody can prove the mother or  their baby has had some sort of reaction, or death due to the shot itself.  

 

Seems to me getting the shot over such a minimal difference compared to the possible risks of the shot isn't worth it for the baby.  Is it necessary really for MY situation? Something I have to really research.   How are the risks really outweighing the benefits having said the above?

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#20 of 49 Old 11-25-2013, 07:50 AM
 
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That is an analysis you have to make on a personal tip.

It is 2013 tho, almost 2014. There may have been residual Rhogam with 25 mcg Thimerisol on the market in say, 2003, but I read my package inserts in 2006 & it was gone. I honestly haven't dug too far into the trace residual amount issue.

Your MW was *not* correct that it *never* affects your first pregnancy. You have already identified situations ( trauma, trans placental hemorrhage) where a first pregnancy could be affected (tho the body *might* not have time to build isoimmunization to a sufficient level). Also if there have been ABO or m/c without Rhogam but with Rh+ fetuses before a first FT pregnancy . . .

It is definitely reasonable to skip the 28 week shot as the largest risk reduction is from the postnatal dose. However there are actually 'silent' cases of isoimmunization that occur between 28-40 weeks. They give the shot @ 28 weeks to cover the time of the highest amount of blood mixing. For me, the knowledge that there *will always be* some amount of blood mixing & my desire for a longer childbearing career, coupled with the actual risk of driving 1 hour @ least to MFM apts (in a future isoimmunized pregnancy) was enough for me to opt for the 28 week shot 2x & after each loss. I just didn't want to take any risk whatsoever on that tip, even tho it was only 1%.

I do however regret getting the 28 week shot in my 2010 pregnancy, only b/c I should have been able to access fetal blood typing by then & my fetus was in fact negative.
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#21 of 49 Old 11-25-2013, 08:12 AM
 
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Catmom, my concern is that the article you linked is out of date.  Rhogam hasn't changed (aside from the removal of thimerosal), but procedures for administering it and for making sure it's appropriately offered continue to evolve. 

 

So if Wickham's opposition to routine prenatal Rhogam is that we could avoid the theoretical risk of blood-borne disease (there's never been a Rhogam-related case of blood borne illness) if we just tightened up procedures for better practices for non-routine administration - is it possible that those steps have already been taken?  A quick Google search reveals that the NHS updated their recommendations for Anti-D administration in 2008 (www.nice.org.uk/nicemedia/pdf/ta156guidance.pdf).  Did these updates adequately address Wickham's concerns?  (Wickham's concerns seem a touch vague to me, so I can't really answer this.)  There has not been research comparing routine Anti-D administration to Rh- pregnant to Anti-D offered to those women only in cases where maternal-feto hemorrhage is known or suspected to have occurred - it strikes me as probably impossible to get ethics board approval for such a study. 

 

Hospitals can and do update standard operating procedures, and professional best practices undergo frequent review and revision - but these things are not research and are not published in the same way.  In 2007, when I had a baby at a teaching hospital of a major university, I was tested for Rh factors at my pregnancy intake appointment, and those records were referred to every time my blood type came up throughout the pregnancy.  In 2009, a different teaching hospital of the same university insisted on retesting my blood on each admission, to assure that lab errors weren't left mouldering in my file, and "I know it seems dumb, but the system helps us make sure we're giving Rhogam to everyone who needs it."  The ED kicked all pregnant women upstairs to L&D as a matter of course, and the newer procedures required the L&D department to test all admitted patients for Rh factors, and document consideration of Rhogam for each case.  The options were "patient is Rh+," "patient is Rh-, administered Rhogam," or the incredibly time-consuming "patient declined", which required extensive discussion of risks and benefits, and documentation of patient's understanding of all key points. 

 

IMO, Wickham's concerns about the failure of NHS personnel to appropriately offer bloodtyping and Rhogam in cases of abdominal trauma, etc., are solid arguments for making those things routine parts of pregnancy care, rather then arguments for demanding that emergency room personnel step up their games (or however Wickham would like to address it).  It's a lot easier to say that OB should routinely give Rh- pregnant women Rhogam then it is to say that when a pregnant woman presents at the ED, part of her evaluation and treatment should include an additional blood test and results-dependent administration of Rhogam - that means a pregnant woman is going to occupy space in the ED for additional hours (however long it takes to get the blood test back, keeping in mind that not all hospitals have 24/7 on-site lab facilities for this testing).  Rhogam is cheap compared to the costs of a sensitized pregnancy, and Rhogam is extremely safe in absolute terms, and even more so when compared with the risks of treatment for sensitized infants (which can involve transfusions in utero, which have a 2% risk of pregnancy loss, and involve far less rigorously screened blood products).  Rhogam is also cheap compared to the costs of having a patient taking up space (that might be needed by another patient) so that you can hold her until the labs come back.

 

Because Rhogam is in somewhat short supply, worldwide, there has been some research on the benefits of targeting administration using non-invasive testing for fetal blood types.  In this way, we can limit Rhogam administration to Rh- pregnant women carrying Rh+ babies.  The initial results of this appear quite promising.  (http://www.plosone.org/article/info:doi/10.1371/journal.pone.0070984)

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#22 of 49 Old 11-25-2013, 08:31 AM - Thread Starter
 
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That is an analysis you have to make on a personal tip.

It is 2013 tho, almost 2014. There may have been residual Rhogam with 25 mcg Thimerisol on the market in say, 2003, but I read my package inserts in 2006 & it was gone. I honestly haven't dug too far into the trace residual amount issue.

Your MW was *not* correct that it *never* affects your first pregnancy. You have already identified situations ( trauma, trans placental hemorrhage) where a first pregnancy could be affected (tho the body *might* not have time to build isoimmunization to a sufficient level). Also if there have been ABO or m/c without Rhogam but with Rh+ fetuses before a first FT pregnancy . . .

It is definitely reasonable to skip the 28 week shot as the largest risk reduction is from the postnatal dose. However there are actually 'silent' cases of isoimmunization that occur between 28-40 weeks. They give the shot @ 28 weeks to cover the time of the highest amount of blood mixing. For me, the knowledge that there *will always be* some amount of blood mixing & my desire for a longer childbearing career, coupled with the actual risk of driving 1 hour @ least to MFM apts (in a future isoimmunized pregnancy) was enough for me to opt for the 28 week shot 2x & after each loss. I just didn't want to take any risk whatsoever on that tip, even tho it was only 1%.

I do however regret getting the 28 week shot in my 2010 pregnancy, only b/c I should have been able to access fetal blood typing by then & my fetus was in fact negative.

 

I still wonder why its out there that it doesn't affect your first, and what is the point even mentioning that to patients if situations like trauma, trans placental hemmorrhage happens.  Which makes sense that it would still affect your first pregnancy.  

 

If the routine 28 week Rhogam wasn't given, you still have the option of going into the hospital right away if trauma where to happen, or experiencing any symptoms which feels necessary to go into the hospital.  Since Rhogam works within 72 hours, if trauma where to happen their is still time to help the issue, but I still do not have facts that it helps the current baby once the blood is already mixed in a trauma situation trans placental hemorrhage (my original question)  Do we have statistics/literature on percentages of a placental hemorrhage or medical condition that "may" happen, certain risk factors etc?  If it is a normal healthy pregnancy is this chance less than 1%?  I understand you had commented the info was made on a personal tip, so if you have any documentation or links in regards to the above please do share.

 

 

I opted out for the Amnio and CVS.  But did get the RHd Genotype (tests mothers blood for fetal blood type) and the maternit21/Panorama tests done instead of the Amnio and CVS. I personally didn't get it because I had a non invasive alternative that did not risk miscarriage or require me to get Rhogam after both.  There are a lot of mothers that get the Amnio and CVS done which risks a miscarriage rate by 1%, but being the risk is small 85% choose to get an amnio or CVS.

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I had placenta previa, and was advised that blood mixing was likely (blood mixing with my Rh+ daughter definitely happened - they were able to ID early stages of immune response in the lab), and that it was happening early enough to potentially affect my daughter before the end of the pregnancy.  So I don't have research, just the anecdote that, in my case, there was definitely potential for it to happen.

 

Lots of obsolete medical info lingers on.  Just because the field moves on doesn't mean that every practitioner or every conversation keeps up.

 

Quote:
 If the routine 28 week Rhogam wasn't given, you still have the option of going into the hospital right away if trauma where to happen, or experiencing any symptoms which feels necessary to go into the hospital.

 

Ideally, this would be true, but in practice it's not as clear cut.  Not every pregnant woman lives conveniently close to a hospital, they don't all have reliable transportation, it can be hard to arrange childcare or take time off work, particularly in the absence of a specific, symptomatic concern.  If you're well off and living in a major metropolitan area, you probably get to the hospital right away any time you feel like it.  If either of these things is not true, you won't make it.  I've heard stories of rural Medicaid patients having to drive three hours for prenatal visits.  Those women are not heading into the ER because they feel a little funny or had some brown discharge.

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Also you are still not understanding how Rhogam works: blood mixing is *always* happening, otherwise you would never be able to have tests like MaterniT21 & the fetal blood type test. Where would they get it? The issue is quantity.

When Rhogam is given, the antibodies attack the mixed blood, instead of the mother's body learning to make them (and then being unable to stop making them). 72 hours is an *upper limit*. In a trans placental hemorrhage, you are trying to attack the mixed blood with sufficient Rho before the immune response occurs, as it is not immediate, but it would be really unwise to push the 72 hour limit, ideally you would deal with it right away.

The idea that it doesn't affect the first baby is out there because it is *mostly true*. The absolute risk of isoimmunization is only 13% in any one pregnancy, even with no Rhogam. Then even if a mother's body becomes isoimmunized in a first pregnancy, typically it happens late (28-40 weeks) & her body doesn't produce enough antibodies to have a really harmful affect by the time of delivery. With each subsequent Rh+, isoimmunized pregnancy, she would produce more & more.

So before Rhogam, Rh- women affected by isoimmunization with Rh+ partners would typically have a first pregnancy w/o incident, but in some cases, lose every baby after that. I have an aunt that it happened to, my Nana had a neighbor, etc.

To complicate matters a tiny bit more, because I have had Rh+ & Rh- fetuses, it means my husband is actually Rh+/- & I have a 50% chance of any fetus I conceive being negative (and all will @ least be Rh+/-). However as Rh+ is dominant, I believe the only way to know if your partner is Rh+/+ or Rh+/- is if you wind up with an Rh- fetus @ some point . . .

Both my DH's parents are Rh+, but one of them must be Rh+/-
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So it just really comes down to ideas like how many children do I want? How upset would I be by a high risk pregnancy? Am I comfortable with a risk of pregnancy loss in my future? Do I live close to a hospital & a MFM doctor?

However I will say that the very existence of tests like MaterniT21 & Fetal blood typing from maternal blood proves definitively that the NCB idea that blood mixing ONLY occurs during trauma is patently false.
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Catmom, my concern is that the article you linked is out of date.  Rhogam hasn't changed (aside from the removal of thimerosal), but procedures for administering it and for making sure it's appropriately offered continue to evolve. 

 

So if Wickham's opposition to routine prenatal Rhogam is that we could avoid the theoretical risk of blood-borne disease (there's never been a Rhogam-related case of blood borne illness) if we just tightened up procedures for better practices for non-routine administration - is it possible that those steps have already been taken?  A quick Google search reveals that the NHS updated their recommendations for Anti-D administration in 2008 (www.nice.org.uk/nicemedia/pdf/ta156guidance.pdf).  Did these updates adequately address Wickham's concerns?  (Wickham's concerns seem a touch vague to me, so I can't really answer this.)  There has not been research comparing routine Anti-D administration to Rh- pregnant to Anti-D offered to those women only in cases where maternal-feto hemorrhage is known or suspected to have occurred - it strikes me as probably impossible to get ethics board approval for such a study. 

 

Hospitals can and do update standard operating procedures, and professional best practices undergo frequent review and revision - but these things are not research and are not published in the same way.  In 2007, when I had a baby at a teaching hospital of a major university, I was tested for Rh factors at my pregnancy intake appointment, and those records were referred to every time my blood type came up throughout the pregnancy.  In 2009, a different teaching hospital of the same university insisted on retesting my blood on each admission, to assure that lab errors weren't left mouldering in my file, and "I know it seems dumb, but the system helps us make sure we're giving Rhogam to everyone who needs it."  The ED kicked all pregnant women upstairs to L&D as a matter of course, and the newer procedures required the L&D department to test all admitted patients for Rh factors, and document consideration of Rhogam for each case.  The options were "patient is Rh+," "patient is Rh-, administered Rhogam," or the incredibly time-consuming "patient declined", which required extensive discussion of risks and benefits, and documentation of patient's understanding of all key points. 

 

IMO, Wickham's concerns about the failure of NHS personnel to appropriately offer bloodtyping and Rhogam in cases of abdominal trauma, etc., are solid arguments for making those things routine parts of pregnancy care, rather then arguments for demanding that emergency room personnel step up their games (or however Wickham would like to address it).  It's a lot easier to say that OB should routinely give Rh- pregnant women Rhogam then it is to say that when a pregnant woman presents at the ED, part of her evaluation and treatment should include an additional blood test and results-dependent administration of Rhogam - that means a pregnant woman is going to occupy space in the ED for additional hours (however long it takes to get the blood test back, keeping in mind that not all hospitals have 24/7 on-site lab facilities for this testing).  Rhogam is cheap compared to the costs of a sensitized pregnancy, and Rhogam is extremely safe in absolute terms, and even more so when compared with the risks of treatment for sensitized infants (which can involve transfusions in utero, which have a 2% risk of pregnancy loss, and involve far less rigorously screened blood products).  Rhogam is also cheap compared to the costs of having a patient taking up space (that might be needed by another patient) so that you can hold her until the labs come back.

 

Because Rhogam is in somewhat short supply, worldwide, there has been some research on the benefits of targeting administration using non-invasive testing for fetal blood types.  In this way, we can limit Rhogam administration to Rh- pregnant women carrying Rh+ babies.  The initial results of this appear quite promising.  (http://www.plosone.org/article/info:doi/10.1371/journal.pone.0070984)

"Rhogam hasn't changed (aside from the removal of thimerosal), but procedures for administering it and for making sure it's appropriately offered continue to evolve. "

The procedures for administering it, for my situation isn't what I am concerned about.  What hasn't changed is the fact of the risks of Rhogam which are clearly written up to date on Rhogam.com which are: RhoGAM® and MICRhoGAM® Ultra-Filtered PLUS Rho(D) Immune Globulin (Human) are made from human plasma. Since all plasma-derived products are made from human blood, they may carry a risk of transmitting infectious agents, e.g., viruses, and theoretically the Creutzfeldt-Jakob disease (CJD) agent. RhoGAM® and MICRhoGAM® are intended for maternal administration. Do not inject the newborn infant. Local adverse reactions may include redness, swelling, and mild pain at the site of injection and a small number of patients have noted a slight elevation in temperature. Patients should be observed for at least 20 minutes after administration. Hypersensitivity reactions include hives, generalized urticaria, tightness of the chest, wheezing, hypotension and anaphylaxis. RhoGAM® and MICRhoGAM® contain a small quantity of IgA and physicians must weigh the benefit against the potential risks of hypersensitivity reactions. Patients who receive RhoGAM® and MICRhoGAM® for Rh-incompatible transfusion should be monitored by clinical and laboratory means due to the risk of a hemolytic reaction.

REF: http://www.rhogam.com/

 

Giving Rhogam while you are pregnant does affect the fetus by 10%. If something where to happen to the mother or baby after administering Rhogam, it couldn't be "proven" off 1 case as a result of the Rhogam.  Could you prove a still born was a result of Rhogam? probably not.  Could you prove your child with neurological problems/birth defects/immune deficiencies was a result of Rhogam, probably not.  But yet the risks are clearly given that it may carry a risk of transmitting infections agents along with a lot of other risks.   That to me doesn't make me feel confident in the product itself, either though the risk is "small". Its enough they issued a warning on the label about it.

 

"So if Wickham's opposition to routine prenatal Rhogam is that we could avoid the theoretical risk of blood-borne disease (there's never been a Rhogam-related case of blood borne illness) if we just tightened up procedures for better practices for non-routine administration "

 

In Wickham's book there have been cases of viruses being passed through

Quote:

During the 1970's the anti-D projected faced other problems, not least of which was the issues of virus transmission to women receiving anti-D.  During 1978 and 1979, a single-source outbreak of hepatitis C occurred in 2,533 Irish women who had received contaminate anti-D.  This episode was followed by a handful of studies that followed up groups of women to assess whether hepatitis C and other viruses were being contracted from batches of the product.  Unfortunately, there is no central source of data on virus transmissions, and it is impossible to determine the rate of viral transmission from anti-D because of the difficulty in  tracing these data.  Women are reassured by various sources that their risk of receiving virally-contaminated anti-D is low, but, although this may well be the case, the same women are not offered specific data so they can judge the risk for themselves, and decide whether it is one they are willing to take.  

 

In 1994 a national screening program was set up in Ireland in response to another cluster of hepatitis C cases and reported the identification of a number of "suspect batches' of anti-D.  clearly the 1978 outbreak was not an isolated episode, even for one country.  The problem of virus transmission is not unique to anti-D; The Irish Blood Transfusion Board conducted a tribunal of inquiry into the cases, and found 'many other transmission episodes of hepatitis C virus by immunoglobulin preparations (Yap, 1997)  Anti-D is, however, the only immunogloblulin preparation routinely administered to healthy women of childbearing age.

 

Other forms of hepatitis of also been transmitted via anti-D in the former East Germany there were cases of hepatitis B and non-A non-B hepatitis contracted through contaminated anti-D (Kircheber et al., 1994)  This group of researchers along with a number of others, sought to assess the extent of the problem by testing the blood of a group of randomly chosen women who had received anti-D since its introduction.  They compared the presences of viruses in this group with those found in a group of rhesus-[positive women, concluding that the fact that they found no statistically significant differences between the groups confirmed the viral safety of the products.  However, this may be considered is less convincing upon funding that the conclusion was mad e on the basis of blood tests on just 520 rhesus-negative women.  Thus far, nobody has suggestion that virus contaminated anti-D is the norm; merely that batches of contaminated anti-D have been identified and that there is an occasional or potential risk of infection.  With thousands of women receiving anti-D every year in any given country, the real surprise would be if a random sample of 520 women showed an incidence of viral transmission from any blood product.  We need much better ways of measuring the incidence of viral transmission through anti-D or other, products, and of storing these data in a way that is easily accessible to women and their caregivers.  In this way, women could be given more accurate information regarding the risks of anti-D or similar products, and those responsible for monitoring such outbreaks toud be able to identify contaminated product more quickly and remove it from use. (makes sense to me)

 

The HIV antibody has also been transmitted through anti-D in some countries.   (Dumasia et al., 1989 Malvivya et al., 1989).  Since it became understood that the HIV virus can be transmitted in plasma, routine screening of blood products has been undertaken in most countries.  In the case o the UK, this was implemented in 1985.  However, other countries were not so fast to react to developments in this area.  Dumasia et al. 1989 confirmed that "batches produced in India in late 1988 would have been administered to several RhD negative women before the product was banned.  In fact, four contaminated batches found to be HIV antibody positive, and two batches were described as "indeterminate".  Where transmission of HIV in Anti-D has occurred, it is quite possible that this contamination form one blood donor; several batches may be contaminated because blood donations are pooled in order to make anti-D.  This raises the question of whether pooling blood to make anti-D is truly essential to the manufacturing process, if this increases the chance of more Women being infected.

 

Other risks of anti-D

Other aspects of the safety of anti-D have also been questions; Inamay Gaskin, an American midwife, was one of the first to raise concerns about the effects of anti-D.  she noticed the correlation between the issues in this area and the work of Durandy et al. 1981, who studied the effects of the administration of gamma globulin to children between the ages of 4 and 10 years.  While the children did not show negative effects of this immediately, the researchers found that their immune systems where compromised for up to 5 months after receiving the gamma globulin.  

 

Penni Harmon, another American midwife, looked at the risks and benefits of anti-D around the them that the American College of Obstetricians and Gynecologists were promoting the use of this in the antenental period.  While stressing the importance of maternal choice, she noted that "the long-term risks of anti=d are not known, and there is controversy as to the safety of this application (Harmon, 1987) 

 
Whether or not issues happened years ago, or its outdated information, doesn't change what has happened.  Even if it isn't in the USA, even if it was back in 1979. Again we relied on the medical industry and were given Rhogam which contained Thermosal before 2001.  Why did the US and other countries decide to remove the Thermosol from Rhogam if it wasn't a concern? The concerns were mercury linking to autism and neurological problems.  What about the mothers/children that had gotten the shot and their doctors told them it was Okay back before 2001? Its not a shock why I am questioning the risks of Rhogam.   The truth is we don't know.  The only thing we can do is research to decide if something is best for our particular situation or not.   
 

Having reading this, doesn't matter when or what year it happened, doesn't matter what country.  It has happened and could happen.  The fact the country I am in the USA to this present date Rhogam states the warning on the label "Since all plasma-derived products are made from human blood, they may carry a risk of transmitting infectious agents, e.g., viruses, and theoretically the Creutzfeldt-Jakob disease (CJD) agent."

What it comes down to is that it carries risks, and you can't ever prove it came from Rhogam as the research seems to be not there to prove it.  Proving it really wouldn't matter at that point when you are clearly warned about  the risks.

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I still wonder why its out there that it doesn't affect your first, and what is the point even mentioning that to patients if situations like trauma, trans placental hemmorrhage happens.  Which makes sense that it would still affect your first pregnancy.  

 

If the routine 28 week Rhogam wasn't given, you still have the option of going into the hospital right away if trauma where to happen, or experiencing any symptoms which feels necessary to go into the hospital.  Since Rhogam works within 72 hours, if trauma where to happen their is still time to help the issue, but I still do not have facts that it helps the current baby once the blood is already mixed in a trauma situation trans placental hemorrhage (my original question)  Do we have statistics/literature on percentages of a placental hemorrhage or medical condition that "may" happen, certain risk factors etc?  If it is a normal healthy pregnancy is this chance less than 1%?  I understand you had commented the info was made on a personal tip, so if you have any documentation or links in regards to the above please do share.

 

 

I opted out for the Amnio and CVS.  But did get the RHd Genotype (tests mothers blood for fetal blood type) and the maternit21/Panorama tests done instead of the Amnio and CVS. I personally didn't get it because I had a non invasive alternative that did not risk miscarriage or require me to get Rhogam after both.  There are a lot of mothers that get the Amnio and CVS done which risks a miscarriage rate by 1%, but being the risk is small 85% choose to get an amnio or CVS.

 

It doesn't effect your first because like all allergies it needs first exposure to create antibodies.

 

A 1 in a hundred risk is huge.  We do so much other testing for things that are 1 in thousands.

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However I will say that the very existence of tests like MaterniT21 & Fetal blood typing from maternal blood proves definitively that the NCB idea that blood mixing ONLY occurs during trauma is patently false.

 

Not sure what you mean by that statement.  MaterniT21 is to test chromosomal abnormalities and Fetal blood typing is to test for the fetal blood type which is a separate issue.   These tests are done non invasive through the mothers blood.  So not sure what you mean by "Those tests have nothing to do with proving that the NCB  idea that blood mixing only occurs during trauma is patently false."  What is NCB?

 

I'm not sure what you mean by that, please clarify.  

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It doesn't effect your first because like all allergies it needs first exposure to create antibodies.

 

.

 

So if trauma or  a trans placental hemorrhage happened and this is my first pregnancy, how do they tell if the blood has mixed enough where I need the Rhogam shot?  Would the Rhogam shot help the current baby (in the above particular situation), or is it just administered to help future pregnancies?  How will it help the current pregnancy if blood has already mixed?   

 

If you have a suggestion of links/literature where this is better explained, please post.

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#30 of 49 Old 11-27-2013, 08:33 AM
 
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You not producing antibodies would likely help the current baby, depending on the week you are @ & it would help each subsequent Rh+ baby more and more, because unchecked, allowed to isoimmunize, your body would produce more & more antibodies each time, until finally each pregnancy would be attacked so early that MFM doctors could not help. It is progressive. Basically in any real trauma situation, blood mixing would occur to the extent where your choices are: isoimmunize or get Rhogam to attempt prevention. Certainly in any type of hemorrhage.

My point earlier was: where do you think they are *getting* the blood from the fetus that allows them to test chromosomes & blood type?!? They are drawing only the mother's blood! So of there wasn't always *some* small level of blood mixing (typically insufficient to isoimmunize) they wouldn't be able to do that . . . They would have to go into the Amniotic sac or the placenta.
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