eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Rh Incompatibility: Treatment & Medication

Author: Leon Salem, MD, MS, Associate Attending Physician, Kaiser Permanente, Southern California
Coauthor(s): Karen R Singer, PA-C, Department of Pediatrics, Fountain Valley Medical Center, South Counties Pediatric Critical Care Medical Group, Fountain Valley and Long Beach, California
Contributor Information and Disclosures

Updated: Nov 4, 2009

Treatment

Prehospital Care

When possible, prehospital care personnel should direct their efforts on stabilization of the mother and infant, followed by immediate transport to a facility specializing in high-risk obstetric and neonatal care.

Emergency Department Care

  • ED care of the pregnant woman with Rh-negative blood and a suspected fetomaternal hemorrhage varies depending on the presentation of the patient and the gestational age of the fetus.
  • If the mother has Rh-negative blood and has not been sensitized previously, administer human anti-D immune globulin (Rh IgG or RhoGAM) and refer the woman for further evaluation.
  • If the mother has been sensitized previously, as determined by elevated level of maternal Rh antibodies, administration of Rh IgG is of no value. In this situation, prompt referral to a center that specializes in high-risk obstetrics is warranted.
  • When an infant with Rh incompatibility is delivered in the ED, a more aggressive approach is required, centering on respiratory and hemodynamic stabilization of the infant and determining the need for an emergent exchange transfusion and phototherapy.

Consultations

Refer every pregnant female with Rh incompatibility to a medical center specializing in high-risk obstetric care.

Medication

Rh IgG, first released for general use in 1968, has been remarkably successful in the prevention of Rh incompatibility. In the Rh-negative mother, the preparation is administered after a suspected fetomaternal hemorrhage. The exact mechanism by which passive administration of Rh IgG prevents Rh immunization is unknown. The most likely hypothesis is that the Rh immune globulin coats the surface of fetal RBCs containing Rh antigens. These exogenous antibody-antigen complexes cross the placenta before they can stimulate the maternal endogenous immune system B cells to produce IgG antibodies.

Since Rh IgG became the standard of care in the United States, the risk of Rh incompatibility has been reduced from 10-20% to less than 1%. Because of its short half-life, Rh IgG routinely is administered once at 28-32 weeks' gestation and again within 72 hours after birth to all Rh-negative pregnant females as a part of routine prenatal care.

The current recommendation is that every Rh-negative nonimmunized woman who presents to the ED with antepartum bleeding or potential fetomaternal hemorrhage should receive 300 mcg of Rh IgG IM. For every 30 mL of fetal whole blood exposed to maternal circulation, 300 mcg of Rh IgG should be administered. A lower 50-mcg dose preparation of Rh IgG is available and recommended for Rh-negative females who have termination of pregnancy in the first trimester when fetomaternal hemorrhage is believed to be minimal.

Blood derived product

This agent is effective in preventing Rh isoimmunization.


Human anti-D immune globulin (RhoGAM, BayRho-D, Rhophylac, HyperRho)

Suppresses immune response of nonsensitized Rh O (D) negative mothers exposed to Rh O (D) positive blood from the fetus as a result of a fetomaternal hemorrhage, abdominal trauma, amniocentesis, abortion, full-term delivery, or transfusion accident. Should be administered if the patient is Rh negative, unless the father also is Rh negative.

Adult

RhoGAM, BayRho-D, HyperRho:
<13 wk gestation: 50 mcg IM
>13 wk gestation: 300 mcg IM

Rhophylac: 20 mcg/2 mL transfused blood or 20 mcg/mL erythrocyte concentrate administered IV/IM

Pediatric

Administer as in adults

Documented hypersensitivity; patients who have received Rho(D)-positive blood within the last 3 mo

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in thrombocytopenia, bleeding disorders, or IGA deficiency; when administered close to delivery, may interfere with Rh typing of the newborn

More on Rh Incompatibility

Overview: Rh Incompatibility
Differential Diagnoses & Workup: Rh Incompatibility
Treatment & Medication: Rh Incompatibility
Follow-up: Rh Incompatibility
References
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References

  1. Thorp JM. Utilization of anti-RhD in the emergency department after blunt trauma. Obstet Gynecol Surv. Feb 2008;63(2):112-5. [Medline].

  2. [Guideline] US Preventive Services Task Force. Screening for Rh(D) incompatibility: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ). 2004;[Full Text].

  3. Herold TJ, Whittaker DS, Glynn T. Determining the accuracy of a rapid point-of-care test for determining Rh(D) phenotype. Acad Emerg Med. May 2005;12(5):474-6. [Medline].

  4. McMahan MJ, Donovan EF. The delivery room resuscitation of the hydropic neonate. Semin Perinatol. Dec 1995;19(6):474-82. [Medline].

  5. Agre P, Smith BL, Hartel-Schenk S. Biochemistry of the erythrocyte Rh polypeptides: a review. Yale J Biol Med. Sep-Oct 1990;63(5):461-7. [Medline].

  6. American College of Obstetricians and Gynecologists. Management of isoimmunization in pregnancy. ACOG Technical Bulletin 148; 1990.

  7. American College of Obstetricians and Gynecologists. Prevention of D isoimmunization. ACOG Technical Bulletin 147; 1990.

  8. Bowman JM. Hemolytic disease (erythroblastosis fetalis). In: Maternal-Fetal Medicine: Principles and Practice. 2nd ed. Philadelphia, Pa: WB Saunders; 1989:613-655.

  9. Copel JA, Gollin YG, Grannum PA. Alloimmune disorders and pregnancy. Semin Perinatol. Jun 1991;15(3):251-6. [Medline].

  10. Daffos F, Capella-Pavlovsky M, Forestier F. Fetal blood sampling via the umbilical cord using a needle guided by ultrasound. Report of 66 cases. Prenat Diagn. Oct 1983;3(4):271-7. [Medline].

  11. Grant J, Hyslop M. Underutilization of Rh prophylaxis in the emergency department: a retrospective survey. Ann Emerg Med. Feb 1992;21(2):181-3. [Medline].

  12. Issitt PD. Race-related red cell alloantibody problems. Br J Biomed Sci. Jun 1994;51(2):158-67. [Medline].

  13. Kleihauer E, Braun H, Betke K. Demonstation von fetalem Haemoglobin in den Erythrozyten eines Blutausstrichs. Klin Wochenschr. 1957;35:637-8.

  14. Mourant AE, Kopec AC, Domaniewska-Sobczak K. The Distribution of the Human Blood Groups and Other Biochemical Polymorphisms. 2nd ed. London, England: Oxford University Press; 1976.

  15. Peterec SM. Management of neonatal Rh disease. Clin Perinatol. Sep 1995;22(3):561-92. [Medline].

  16. Reece EA, Copel JA, Scioscia AL, Grannum PA, DeGennaro N, Hobbins JC. Diagnostic fetal umbilical blood sampling in the management of isoimmunization. Am J Obstet Gynecol. Nov 1988;159(5):1057-62. [Medline].

  17. Selinger M. Immunoprophylaxis for rhesus disease--expensive but worth it?. Br J Obstet Gynaecol. Jun 1991;98(6):509-12. [Medline].

  18. Walker RH. American Association of Blood Banks Technical Manual. 11th ed. Bethesda, Md: AABB; 1993.

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Further Reading

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Keywords

Rh incompatibility, rhesus factor, Rh disease, Rh factor, Rh-negative blood type, Rh-positive blood type, Rh antibodies, maternal Rh antibodies, Rh antigens, Rh sensitization, Rh blood group, Rh immunoglobulin G, Rh IgG, type O blood, O negative blood, Rh-positive fetal blood

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Contributor Information and Disclosures

Author

Leon Salem, MD, MS, Associate Attending Physician, Kaiser Permanente, Southern California
Leon Salem, MD, MS is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Karen R Singer, PA-C, Department of Pediatrics, Fountain Valley Medical Center, South Counties Pediatric Critical Care Medical Group, Fountain Valley and Long Beach, California
Karen R Singer, PA-C is a member of the following medical societies: American Academy of Physician Assistants
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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