Alloantibodies and pregnancy Lab Matters 26th June 2019
Alloantibodies and pregnancy Lab Matters 26th June 2019 Tim Wreford-Bush Transfusion Laboratory Manager North Bristol NHS Trust Alloantibodies and pregnancy Alloantibodies and pregnancy BCSH guidelines 2016
ABO and D typing Red cell antibody screening/identification Screening cells C,c,D,E,e,K,k,Fya,Fyb,Jka,Jkb,M,N,S,s,Lea Homozygous expression of Rh, Fy, Jk, S antigens Follow up tests Alloantibodies and pregnancy
MAIN RECOMMENDATIONS Sample labelling ABO and D grouping Antibody screens Timing of tests (early in pregnancy and again at 28/40)
Labs to keep records of anti-D administration Alloantibodies and pregnancy MAIN RECOMMENDATIONS FMU referrals Antibody Card Post delivery testing of babies
Regular audit of practice Alloantibodies and pregnancy
Clinically significant antibodies (IgG) Anti-D Anti-c Anti-K Anti-C Anti-E Anti-Fya Anti-Jka Other antibodies Alloantibodies and pregnancy
Anti-D+C specificity Possible anti-G Demonstrated by disproportionately high titres of anti-C ALWAYS refer to a reference lab as patients with anti-G are still eligible for RAADP and post delivery anti-D Ig Alloantibodies and pregnancy Techniques CAT Capture Tube
Paternal testing Fetal genotyping Referral to reference laboratory Alloantibodies and pregnancy Anti-D quantification (NIBSC 2003)
Differentiation between immune and prophylactic anti-D Test every 4 weeks to 28/40 then Test every 2 weeks to delivery <4iu/ml HDN Unlikely 4-15iu/ml Moderate risk of HDN >15iu/ml High risk of hydrops fetalis Alloantibodies and pregnancy Anti-c quantification (NIBSC 2003) Test every 4 weeks to 28/40 then Test every 2 weeks to delivery <7.5iu/ml Continue to monitor
7.5-20iu/ml Risk of moderate HDN >20iu/ml Risk of severe HDN Alloantibodies and pregnancy Anti-K titration
Anti-K often present as a result of previous transfusion Severity not correlated with antibody titre Affected pregnancies usually titre of 32+ Paternal sample K negative Alloantibodies and pregnancy
Other antibodies Many other specificities Repeat testing at 28/40 No further testing recommended Medical decision regarding women with hx of HDN Alloantibodies and pregnancy Routine ante-natal anti-D prophylaxis (RAADP) 1500iu at 28/40 gestation OR 500iu at 28/40 and again at 34/40
Alloantibodies and pregnancy BCSH guidelines 2013 Administration of anti-D immunoglobulin for the prevention of HDFN NICE guideline 2008 Routine antenatal anti-D prophylaxis for women who are rhesus D negative RCOG guidelines 2011 (Archived) The use of Anti-D for Rhesus (D) prophylaxis Alloantibodies and pregnancy
ffDNA testing 16/40 Results dictate issue of RAADP Alloantibodies and pregnancy Potentially sensitising events Amniocentesis, chorionic villus biopsy and cordocentesis Ante-partum haemorrhage/vaginal bleeding in pregnancy External cephalic version Fall or abdominal trauma Ectopic pregnancy Evacuation of molar pregnancy
Intrauterine death and stillbirth In utero therapeutic interventions (transfusion, surgery, insertion of shunts, laser) Miscarriage, threatened miscarriage Therapeutic termination of pregnancy Delivery normal, instrumental or Caesarean section Intraoperative cell salvage Alloantibodies and pregnancy Miscarriage or painless PV bleeding at <12 weeks, no anti-D required unless surgical intervention T.O.P./Ectopic pregnancy/Molar pregnancy need PAD
Any sensitising event after 12/40 gestation regardless of whether RAADP has been given or is due to be given Guidelines say at least 250iu Between 12 20 weeks give 500iu >20 weeks perform Kleihauer (or flow) and give at least 500iu Alloantibodies and pregnancy A CAUTIONARY TALE
Result at booking PAD issued for use at 28/40 Result at 28/40 rr test Delivery
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