A Critical Look at Rhogam and Rhesus Disease


There are a lot concerns that surface when a woman finds out she is expecting. If you happen to be a RhD-Negative mother then you have one more to add to the list.

When I was pregnant with both of my daughters I sought out information, and frankly, I was always left feeling like there must be more.

I gathered this information in the desire to help other mothers out there understand what it means to be RhD-Negative, what the Rhogam shot is and what it isn’t, and lend my personal experience.



Blood Type

To be able to understand what the RhIg (Rhogam) shot does and to determine if it is necessary in your circumstance, we must begin with this brief lesson.

A blood type is a classification used to express if someone has either the presence or absence of a specific antigenic substance on the surface of their red blood cells. These red blood cells are the most common type of blood cells in our system and is the principle means of delivering oxygen to the body.

There are a total of 30 human blood group systems according to the International Society of Blood Transfusion (ISBT). [1]

If you are a RhD-Negative mother then your blood cells lack a specific protein found on the surface of red blood cells called a Rhesus D (RhD) antigen. This is never a concern during a woman’s lifetime, until she becomes pregnant.

When a woman is pregnant it is probable that the baby will have a different blood type from her own and there is no concern with this unless the mother is RhD-Negative and the father is RhD-Positive. (if the father is RhD-Negative the concern is alleviated)

You can determine the likelihood of having a RhD-Positive child by reviewing the father’s parents blood type.

Your partner carries two copies of the gene that generates the D antigen (one from his mother and one from his father). If your partner has two copies of the D antigen (homozygote DD) which would happen if both his mother and father are RhD-Positive, then the child will definitely inherit one copy of the D antigen and will be RhD-Positive.[2]  (see chart to illustrate)




If, however, your partner only carries one copy (heterozygote Dd) there is a  50 percent chance your baby will be RhD-Negative like the mother. If this is the case, the baby will lack the RhD antigen and there is no apprehension on hazard to the process of sensitization.[2]

Two interesting points to note. There is a rather new technique developed in England where is it possible to determine the baby’s blood type by performing a genetic test on the mother’s plasma. Apparently, there is free-floating DNA from the baby in the mother’s blood.[3]

Another tidbit, an individual will most likely have the same blood type for life, but in rare occasions such as particular infections, malignancy or autoimmune disease the blood type will change due to the addition or suppression of an antigen (pretty interesting stuff ehh?).
 

Red Cell Alloimmunization (aka Sensitization)

**Now listen up - enough of the refresher, time to take notes!**

Let us assume, for the sake of 100% safety, that the baby is RhD-Postive.

When a woman is pregnant her blood is contained separate from the baby. The mother’s blood will run alongside of the placenta and the nutrients are absorbed and transfer to the baby through a membrane separating the blood (as known as the “placental barrier”). There is, however, a very valuable antibody (IgG) which is able to pass through this placental barrier which provides humoral immune protection to the baby (colostrum contains a high percentage of IgG). If the mother’s blood has never encountered the baby’s blood, then this antibody trucks along doing its job like normal – protecting the baby. However, it does carry potential concern for RhD-Negative moms.

Mother's blood does not mix with baby's - however,
benefical IgG antibodies freely move past the placental
barrier provided humoral immune protection.

**Initially, if in the event when the blood of a RhD-Negative mother and RhD-Positive infant mix, the mother’s body produces the IgM (not IgG which passes through the placenta) antibody in response to the red blood cells that appear foreign to her body (because they lack the RhD antigen). It is crucial to note that the IgM protein can not cross the placenta. It is in subsequent pregnancies, a repeat encounter with the Rh D antigen which stimulates the rapid production of the IgG anti-D. This antibody is then transported across the placenta and enters the baby’s circulation marking the red blood cells to be destroyed. [2][4][5][6]


When sensitization occurs, mother will produce IgM antibodies.
Remember, IgM will NOT cross the placenta - so the CURRENT
pregnancy is NOT AT RISK

Let me pause here and reiterate that sensitization occurs in the first pregnancy but the risk is only to the subsequent pregnancies. [2][4][5][6][7]
It is in subsequent pregnancies, a repeat encounter with the Rh D
antigen which stimulates the mother to rapidly produce IgG anti-D
which passes through the placenta.

How Sensitization Can Occur

Nearly 90% of sensitized cases occur during child birth (for example: when the placenta is forcibly detached from the uterine wall).[8]

Medical interventions during pregnancy that breach the uterine wall increase the risk of sensitization such as amniocentesis and chorionic villus sampling (CVS).  



Obviously, injury trama may result in the mixing of blood between the mother and baby. This is seen occurring in approximately 10% of cases.[8]

Other risk factors include miscarriage, abortion, ectopic pregnancy, external version (adjusting a breech baby), or a blood transfusion.

There is a vary rare sensitization model that can occur in blood type O Rh-Negative mothers (this is what I actually have). An immune response against A and B antigens has the potential to occur since they are widespread in our environment which could lead to the production of IgM antibodies early in life. Very rarely, IgG antibodies are produced.

You can have a doctor test your blood to determine if you have been sensitized at anytime in your life or throughout your pregnancy. A simple blood test is performed.


Rhesus Disease (or hemolytic disease of newborn, HDN)

The Disease

HDN is an alloimmune condition (alloimmune conidtions are seen in such instances when a person gets a skin graph or possibly after a blood transfusion). When the mothers IgG anitbodies pass through the placental wall, the antibodies break down the infants red blood cells and the baby may become anemic (anemia is when an individual has a low red cell blood count).

This disease can range from mild to severe.

Elavated bilirubin may develop as well after the birth since the mother is no longer aiding the baby in eliminating this waste product. Bilirubin is the yellow by-product of the breakdown of red blood cells – this is seen when you get a bruise and the yellow coloring develops, also is responsible for the yellow color of urine and for the coloring of jaundice.

Because of this, infants that suffer from HDN may show symptoms of jaundice which increases within 24 hours after birth.

If the case is severe enough, the liver, spleen and other organs increase in size because they are producing an over load of red blood cells to compensate the ones being destroyed. Disfunction of the liver may result.


Treatment

After the birth, treatment is dependent upon the severity of the condition. Ten percent of babies that suffer from Rh disease will have a severe case. In some cases Rh disease is so mild that it doesn't require treatment.


 
photo-therapy for jaundice
Postnatal Treatment- Phototherapy may be performed on infants showing jaundice in mild cases. A blood transfusion may occur for moderate to severe disease. Sodium bicarbonate may be given to correct acidosis.

Antenatal Treatment– Ultrasound will be performed during the pregnancy to monitor increasing blood flow. Early delivery may be recommended (usually around 36 weeks gestation). Blood transfusions in utero may also be performed.


Prevalence

According to the March of Dimes, Rh disease affects 4,000 infants each year and a mother with a RhD-Negative blood type has approximately 0.7 percent chance of giving birth to a baby that suffers from the disease. (This is without the anti-D injection aka Rhogam).[7][9][10]

If you receive the injection your chances decrease by 0.02 percent.) [7][9][10]



Rho(D) Immune Globulin

This medicine is recommended by the American College
of Obstetricians and Gynecologists (ACOG) to mothers with RhD-Negative blood and is routinely administered at 28 weeks gestation and within 72 hours after childbirth. It is also given in following a traumatic event such as a car accident or a fall.[11]

Anti-D Injection



Interesting to note that the half life of this injection is 23 to 26 days; if you receive the injection at 28 weeks then you would be susceptible again to become sensitized at 31 weeks pregnant. [11] [12]

  

The solution consists of IgG antibodies (from mothers that have been sensitized) that bind to and destroy the fetal RhD-Positive red blood cells.


Yes, you read that correct. The solution contains the very antibodies that we are attempting to avoid-the IgG antibodies that pass through the placental wall and enter the blood system of the fetus.


You see, according to the March of Dimes, it is not known exactly how RhIg works. In theory, the smaller does of IgG will elude the full force of the mother’s immune response to mount an attack on her child’s red blood cells. This will in turn avoid a mother becoming sensitized. Some of the IgG antibodies from the medicine will be transferred to the fetus and destroy a few red blood cells but it is believed to be not as many as if the mother was sensitized herself. [7] [10]

woman getting Rhogam shot


This medication has been given a Category C drug rating from the FDA. This means that animal reproduction studies have demonstrated an adverse effect on the fetus (or safety research is lacking) and that there are no adequate, well controlled studies in humans, but doctors believe the potential benefits may warrant use of the drug in pregnant women despite potential risks. There is a chance of fetal harm if the drug is administered during pregnancy.[13]


The RhIg is a derived from several human plasma pools. By using a method developed in the 1950’s, the plasma is filtered to eliminate bacterial and viral contaminates.

RhIg does have the potential to trigger an allergic reaction and carries the possibility to infect the mother with Creutzfeldt-Jakob disease (a degenerative neurological disorder that is incurable and fatal).
Live vaccines (such as the influenza vaccine) may interact with this injection according an article in Gold Standard (this may be within a 3 months time frame).[14]


Another vaccine currently recommended to pregnant mothers is the Tdap booster. I have not found any completed research regarding the effects of the combination use of Rhogam and this vaccine.

The medicine is not approved for use in children.

My Story

happy, confident and pregnant!


At 28 weeks pregnant with my first child I was written a prescription for the anti-D injection (Rhogam) by a real jackass of an OBGYN (lets just say he instructed me to get the shot while doubting me if I was sure if my husband was indeed the father of my baby…in front on my husband no less).


At that time, I was just beginning to learn more about vaccines and such. Most of what I was attempting to learn about at that point in time was how bad the epidural was going to hurt (since who actually gives birth naturally these days if they don’t have to, right?...ahhhh, to be young and na├»ve again).


From what I read, it didn’t make sense to get the shot until after the birth. I decided to decline the prenatal shot and decided to administer the injection after the birth only in the case if my daughter was born Rh positive. My daughter was born at 2 am  with type O negative blood, just like her mama and no shot was given.


With my second daughter, I declined both the prenatal and postnatal shot since me and my husband both decided that we did not want anymore children. She was born au natural in the living room.


If we did decide to have more children, I would have my blood tested to make sure I was not sensitized. If I was, then I would consider any risks (0.07 risk of Rhesus disease if the mother is sensitized). [7][9]


In hindsight, I am glad that I declined this medicine in my particular situation and circumstance. I also feel lucky to have the blood type that I do because it has provided my the opportunity to learn this information and spread it to those women in my similar situation.


This subject is close to my heart and I anticipate that it will help spread information regarding what educated options we have as RhD-Negative mothers.


Thank you for reading and sharing!!

Reference
[1] Table of blood groups. HUGO Gene Nomenclature Committee. Retrieved 2008-09-12.http://ibgrl.blood.co.uk/isbt%20pages/isbt%20terminology%20pages/table%20of%20blood%20group%20systems.htm.

[2] Causes of Rhesus Disease. NHS Choices. Nov 2011

[3] Hill, M. Blood test could save babies. BBC News. Oct 2002

[4] Bethesda

, D. Blood Groups and Red Cell Antigens (Chapter 4 Hemolytic disease of the newborn). National
Center for Biotechnology Information (US). 2005

[5] Beischer, N., Colditz, P., Mackay, E. Obstetrics and the Newborn (Third Edition). W.B. Saunders Company, Ltd., Philadelphia
, PA 1997. p226

[6] Letsky E.; Leck
I., Bowman J.Rhesus and other haemolytic diseases (Chapter 12-Antenatal & neonatal screening). Oxford University Press. 2000

[7] March of Dimes Website. Printable Articles about Birth Defects – Rh disease


[8]Bowman J et al . Rh-immunization during pregnancy: antenatal prophylaxis. Canadian Med Ass Journal . Vol 118: 623–627. 1978

[9] Lubusky M., Prochazka M., Krejcova L., Vetr M., Santavy J. and Kudela M. Prevention of Rh (D) alloimmunization in Rh (D) negative women in pregnancy and after birth of Rg (D) positive infant, Mendeley. Vol 71 Issue 3 Pgs 173-179. 2006


[10] Moise K. Management of Rhesus Alloimmunization in Pregnancy. Obstetrics & Gynecology (ACOG)
. Vol 112 No 1. Jul 2008

[11] The Official RhoGAM Website. Page Title: “Aligned with ACOG/AABB Standards

[12]Mintz PD. Rh Immune Globulin. Transfusion Therapy: Clinical Principles and Practice (2nd Edition). AABB Press. 2005.

[13] American Pregnancy Association Website. Page Title: “FDA Drug Category Ratings”

[14] Brigham and Women’s Hospital (Affiliate of Harvard Medical School) Website. Encyclopedia Section – Page Title: “Rho
(D) Immune Globulin Solution for Injection


Blood type picture from: Precious Passage Website (Rh Incompatibility) http://www.preciouspassage.com/d/rhIncompatability

Photo-therapy picture from: http://www.norwanie.blogspot.com  

Rhogam injection picture from : http://www.theanellos.com  
IgM is produced when mother becomes
sensitized.

10 comments:

  1. Hi, I have just started researching this information and was told at 10 weeks that I should go ahead and receive the rhogam shot b/c I was spotting a little bit and b/c I was O- according to a very old red cross card in my wallet. Come to find out I am O+ and not O-. They say the shot won't "hurt anything" but I cannot find any research on this. I should of gone with my gut at the time and told the midwife, I wanted to wait until they were 100% sure of what my blood type was. I am not the type to get shots, go to the dr, take prescriptions, etc, and the thought of being injected with something that was not needed and at 10 weeks, not 28 as what I am reading is the "norm" is making feel a bit weary and worried. Would love to know your thoughts or if you ran into any research of women that were given rhogam who did not need it.

    ReplyDelete
  2. Thanks for commenting on this - I think this is my favorate post I've compiled and written so far because I know how challenging it was for me to find information that made sense regarding the Rhogam injection.

    I would focus on ways to improve the health and wellbeing of your baby and yourself in the current moment. If you are worrying about what happened in the past, you are taking precious energy away from more productive measures.

    I have heard of this happening from many other mothers - women who where administered the shot even though they were not at risk. It's amazing what happens and no one is held accountable.

    ReplyDelete
  3. Rhogam....and us mommas..way to go I heartpeonies....YES..IT IS THATGUT FEELING...and now Learning to Speak Up!!

    I got to speak up....contacted the nurses jffice 3x....i asked SPECIFIXALLY if dr. could do a bloodtiter BEFORE rhogam to just even see if it was even necessary...Dr. declined.....REALLY??? that simply is just poor labratory skills!! Never would you willy nilly just give a shot (let alone a $300 shot) WITHOUT checking the body first..Aaarrggh.

    ReplyDelete
  4. Very good information, thankyou. I also declined the 28 week rhogam shot, 3 times now.

    ReplyDelete
  5. Thanks for this post. I found out I'm A- a few weeks ago (32 weeks pregnant), and am struggling. My grandmother lost three babies (stillborn, full-term) due to this response. I am very natural, and question all vaccinations. I loved everything you said, but was unable to find the quote from the March of Dimes that mentioned the prevalence. (According to the March of Dimes, Rh disease affects 4,000 infants each year and a mother with a RhD-Negative blood type has approximately 0.7 percent chance of giving birth to a baby that suffers from the disease. (This is without the anti-D injection aka Rhogam).[7][9][10]) I'm probably looking in the wrong place. Could you please specify where this information is? Thanks!!!!

    ReplyDelete
    Replies
    1. The March Dimes source is referring to the 4,00 infants each year that are born with Rh disease.... The 0.7 percent refers to a source from a 2006 publication which you can review here: http://www.ncbi.nlm.nih.gov/pubmed/16768042

      I apologize for the confusion, this is source #9.

      I hope this post has helped you.

      The time at which your grandmother would have given birth, from what I have read, was a terrible time - women were not treated very well at all during labor and there were some really crazy 'routine' procedures in practice

      Check out the section 'The Modern Period' : http://www.faqs.org/childhood/Me-Pa/Obstetrics-and-Midwifery.html

      Also - check out 'Twilight Sleep' which was used and encouraged from 1902 to the 1960s: http://blog.ctnews.com/elwood/2009/09/29/going-back-in-time-twilight-sleep

      Delete
  6. Hi, I have been given possibly six injections of Rhogam and it has always been presented as not optional. I was treated like a lunatic when I balked at receiving this type of material through and injection. I was bullied by so many medical professionals into taking this injection. This is the first time I have ever read that there is another path. I wonder if you have any more information about the risks of Rhogam. I developed an autoimmune disease two months after my first child was born. I was given Rhogam and MMR booster at the same time upon discharge from maternity hospital and I never felt right after that. I assumed many symptoms were merely due to postpartum but then I got slammed with Ulcerative Colitis two months almost to the day after my injections. Do you think possibly these were the reasons? No doctor will entertain the idea.

    ReplyDelete
    Replies
    1. Rhogam should not be administered with a live vaccine, I’m surprised to hear they administered this injection with the MMR vaccine!

      According to the package insert (pg 6): Immune globulin preparations including Rho(D) Immune Globulin (Human) may impair the efficacy of live vaccines such as measles, mumps and varicella. Administration of live
      vaccines should generally be delayed until 12 weeks after the final dose of immune
      globulin.

      As for your UC, It is believed that one has to be genetically predisposed to UC… you simply need an initial trigger to ‘turn on’ your genetic marker for UC. One could assume that it is possible that this shot triggered your UC. Although I have seen others indicat a bout with food borne illness, the use of antibiotics, even the cessation of smoking as a trigger.

      All of these could be triggers but they would not technically cause your UC unless you were already had the genetic mapping for it….

      Delete
  7. So basically it's safer to decline the Rhogam shot during pregnancy bc it can hurt the fetus? I'm currently 27 weeks pregnant and just got the shot yesterday :( I seriously thought that it was safer to take the shot since my doctor told me it was very important to get the shot.

    ReplyDelete

Please be respectful. If you are about to say something that you would not let your child hear, then please refrain from saying it.