Please help. Second pregnancy, Rh negative, and confused about Anti D!

[gaelicsheep]

OK, in short the story is this. I declined Anti D during my first pregnancy but had it after the birth of my DS. I'm now pregnant with my second and have to decide very soon (ie tonight, so I can ring the MW for her to order it) whether to take up the offer of antenatal Anti D at 28 weeks. I don't plan to have any more babies.

I've been trying to read up on this and my brain hurts (it's been a hard day at work!). Basically what is confusing me is the following:

1. Sensitisation events, including silent sensitisation, rarely affect the current pregnancy. What does rarely mean? Is there a risk to this baby or not basically?

2. Having had Anti D after delivery, and having had no antibodies detected during routine blood tests is this baby at any increased risk in this pregnancy as opposed to my first pregnancy?

3)Is there any chance of actually being already sensitised even though no antibodies were detected?

4. If I am already sensitised from my first delivery would having Anti D make any difference at all to this pregnancy in any case?

Answers to any or all of the above would be really helpful. I've read the NICE guidelines and several articles but I still don't feel I have a grasp on whether there are any more risks to the baby from rhesus disease this time around.

Thanks

Bump!

Sorry can't help but Rh- too so will be watching this tread.

I got round the Anti-d dilema as my Dh is also a negative blood group therefore I didn't need to get the anti-d during or after pregnancy.
You don't happen to know your dh/dp blood group do you?

Hi, can't answer all your questions, but I am one of those rare people who had antibodies in 2nd pregnancy.

I did not have any bleeds during my first pregnancy and had the anti D, but still developed antibodies when pregnant with DS2.

I had weekly scans with 2nd pregnancy to monitor antibodies and assess risk to DS2. DS2 did well and was only induced at 37 weeks. However, he was extremely jaundiced and had to have a full blood transfusion when he was 48 hours old, which was very traumatic. He did recover well and was completely fine within two weeks of his birth. It was not something I would wish anyone to go through though.

Basically, I would have the anti D rather than risk developing antibodies and all the possible complications that involves. There is just no way of knowing if you will become sensitised or not. I believe, in comparison, the risks involved in taking anti d are very low, but obviously that is something you need to consider.

1. Sensitisation events, including silent sensitisation, rarely affect the current pregnancy. What does rarely mean? Is there a risk to this baby or not basically?

Minimal risk to this baby - risk is to the next baby. There is a risk, but its small - usually sensitisation occurs at birth - see below. I guess if you had an obvious sensitisation event during the pregnancy eg a fall onto bump/ECV you'd have the anti-D to protect this baby.

2. Having had Anti D after delivery, and having had no antibodies detected during routine blood tests is this baby at any increased risk in this pregnancy as opposed to my first pregnancy?

No, no increased risk as you have no anti-bodies.

3)Is there any chance of actually being already sensitised even though no antibodies were detected?

I don't think so - I think thats why they check the anti-bodies.

4. If I am already sensitised from my first delivery would having Anti D make any difference at all to this pregnancy in any case?

No it would be too late to do anything about it. I don't think they give it under these circumstances.

BTW - I was reading about this today - if you have the post birth injection but not at 28 and 34 weeks you have I think 1.5% chance of getting anti-bodies, if you have all three injections only I think it was 0.2% chance.

Thanks people!

Linnet - sadly DH is an awkward devil and he's Rh+

Pippinlippin - when did they pick up your antibodies? Was it at the routine screening tests or did you find out later on? Was there a sensitising event?

MumNWLondon - thanks for the info. Is the relevance of those percentages what I did in the last pregnancy or what I do in this one? And is the risk talking about antibodies that will affect this pregnancy or the next one (which won't happen)? Does that make sense?! Honestly, my head's swimming with this now!

I am rh- and I had the anti d last pregnancy and from what I understand it doesn't affect your current pregnancy because as rh- your blood can be passed to any other blood group with no effect yet you can only receive rh- blood therefore if your childs blood passes into yours your body detects it as a foreign entity and learn to fight against it so therefore in subsequent pregnancies you will for already built an immunity to it and your body will fight the pregnancy. I am sure if there were a risk to the first baby that they would administer the anti d earlier than 28 weeks, and if no antibodies were detected then it is very doubtful that your bloods were mixed. Also this baby may be rh- and if you are not having anymore then it's not so important from what I know that you take it. I don't know the answer to number 3 but I am sure that if you were sensitised in the previous pregnancy the anti d would not be able to help this time as it's a preventitve measure to stop your body building a defense against a different blood group. I'm pretty sure after your first trimester is over though it is not so likely to cause a problem (i'm not a doctor obv but I am sure that they told me that it would most likely affect the next pregnancy in the early stages.) It sounds like you were not sensitised and I am positive the anti d is to protect future pregnancies and not the current. I would have the anti d to keep your mind at rest should you choose to have another child but it is interesting to me to know that my gran had 6 children and was rh- and did not once have anti d and there were no complications for her. I think myinfo is accurate but i'd double check it with a pro, having said that I had one doctor tell me the drug was man made and of course it is not it is created from human blood which I was told later on in my pregnancy. Anyway I don't think you need to worry, I hope all goes well

This is also true for me. Just out of interest, why wouldn't you get the injection? Seems to be v few cons. Had a scare with dd1 who was vv jaundiced and had to have extra tests to determine everything was ok with rhesus compatabilty. My gma had this long before the days of anti d and it caused enormous stress.

Hi Gaelicsheep, it was detected at the first routine screening and by then it was too late for the anti D to help.

I have no idea when I developed the antibodies; there was no sensitising event that I was aware of. It was assumed there must have been a very slight bleed early on.

From what I was told by my doctor, it is extremely rare for problems to occur nowadays and that is mainly down to the common administration of anti D.

Queenofthehouse is it likely that your grandad had RH- group too, hence no problems. My mum had several miscarriages and a full term stillborn baby due to being RH- and having babies before anti D was used.

• even if you don't plan to have any more children, how would you feel if you got pregnant (by accident) and the baby was really ill because you'd declined the injections in this pregnancy?

• after the birth you don't need to have for 3 days and the hospital can arrange for some cord blood to be checked to see what the babies blood group is so you only need the post birth injection if the baby really is rh+.

• you need the injections mainly to protect the next pregnancy... although rarely it could affect this one.

see:

link

The chance of making anti-D after each Rh D positive pregnancy is about 8%. This is reduced to 1.5% with the injection after birth and 0.2% with the injections at 28 and 34 weeks.

That was exactly my thoughts MumNWLondon, you may not plan another one but you really never know.

I am Rh- and cord blood was taken and I was told my son's blood type before I had the post-birth injection, so I don't think they give it to everyone just in case.

Where I am you don't get 2 during pregnancy just the one at 28 weeks which I thought was the norm these days?

I have to say I wasn't very happy about having blood products, which no-one else I knew could understand, but you have to have faith in the system and testing of blood and blood products is very rigorous now. My baby/ies was the priority and it was a risk I was not willing to take.

I hope you can come to a decision you can be happy with. I'm glad someone has been able to give you actual figures as my only understanding is about subsequent pregnancies.

OP You are very lucky your first baby didn't result in sensitisation, I'm not sure why you chose to decline the anti-D.

I could definately advise you to have the anti D this time, as you don't know what the future holds and if you do end up having another baby (unless you plan to abort any accidentals) then the next could suffer alot from you being sensitised.

I am sensitised, therfor high risk and under a consultant which is a pain.
I have to be bled reguarily to test what levels the antibodies are at (i.e high enough to attack my baby.)
I've been lucky so far.
But when I first fell pregnant I knew that the baby could be attacked by my blood and become very anemic, which can lead to brain damage, so he would need a blood transfusion in utero and possibly need to be born as early as 32 weeks if the antibodies got aggresive.
I will face this risk with furture pregnancies too because I'm sensitised.

You may well have another unplanned pregnancy so why would you risk all this happening? :-(

I appreciate how confusing this all is, even the doctors couldnt explain much to me initially.
I still have anti D despite being sensitised.
Because there are a few different anti-bodies you can get, I just have one (anti-M).
The anti-D will stop anymore forming during any blood mixtures, so i still reduces risk.

cinnamongreyhound I completely understand the not wanting blood products-that was on my mind also as I do know of cases that made me question the testing and safeness of the blood but I was reassured that anti d is actually tested twice and a time apart so the chance of anything dangerous being passed is very remote (this made me feel better.) I completely agree it is worth having it to protect your babies but I do understand why people are apprehensive about it, I think it eases your concerns for your pregnancy though and you have enough to think about as it is. My grandad was AB+ I believe but def not rh- Pippinlippin, I guess my gran was very lucky but then I don't think in her day they were offered anti d so she had no choice. I wasn't trying to suggest that everyone will get away with it nor that it is worth the risk but to be objective not everyone that does not have it will be sensitised. I am not saying that it is worth the risk at all but if you simply wont have another child and there is no possibility that will change I can see why you would think about not having the injection.

If your reasoning is that you don't want more children, I guess the question is then would you terminate an unplanned pregnancy (as any contraception could fail) - as I wouldn't I have the anti-D even though I don't intend to have another baby.

I'm nearly 38 weeks pregnant due to one incident after which I took the morning after pill, lol

Thanks for all the responses.

Just to clarify, I received anti-D after having DS and I will be getting anti-D after this birth too if the baby is Rh+. Labour is by far the most risky time for sensitisation in any case. I would also most certainly have anti-D should I have a sensitising event in this pregnancy.

It's a big single dose they give at 28 weeks and there are potential risks. For example, there are possible links between reproductive problems for female babies born to women who've had anti-D during pregnancy. Rightly or wrongly I am not keen to have any more injections of blood products than I absolutely need, especially while pregnant. I believe there are differing medical opinions regarding the routine administration of prophylactic anti-D during pregnancy.

I've spoken with the MW again today and have elected to wait for the results of the 28 week antibody check before taking a decision. The MW confirmed that there are no additional risks to this pregnancy in comparison with the last one and that I am considered low risk. The figures she quoted to me (twice now) are 0.4% of babies affected by rhesus problems where anti-D is administered and 0.7% when it is not. Plus if I was already developing antibodies at this stage (god forbid) then anti-D would be pointless anyway.

Another baby would be simply impossible for us to manage so DH will be getting the snip after this baby is born.

It's interesting that they don't bother telling you any of the risks with HAVING anti-D, or even that it's made from other people's blood??
So kudos for doing your own research.

I'm worried about why you are saying anti-d would be pointless if you already had antibodies?
Are you saying my consultant has ordered me to have anti-D on severel occasions already for no reason? Being that I already have anti-bodies.
Where have you gotten the information that Anti-D doesn't help after sensitisation?
I would like more clarity on this.
Especially as I will be having anti-D again in a few weeks at birth.
I certainly don't want to keep having unnecessary injections, but I'm trusting the health professionals that they're necessary.
Confused why you guys are saying otherwise.

Has someone in this thread had a pregnancy with anti-bodies and already been told 'you don't need anti-D it's useless now'?

I think that you can find evidence for anything on the Internet. I have a colleague who is a prof of obstetrics and asked him at lunch yesterday about the risks. He looked at me blankly and said 'what risks?'. So it may be overly cautious to get anti d if you are not planning a second pg but it is not dangerous to you or baby. It has been done routinely for 30 years. Of course. Dr Google will no doubt turn up evidence to the contrary and it is an individual choice about how to weigh that evidence. I think that if something has ltd or no risk and could prevent the death of a baby, however remote that poss, I'd take it.

link about risks of anti-d

www.nice.org.uk/nicemedia/pdf/EmmaWightmanPatientExpert.pdf

what is interesting is that when i was pregnant with DD 7 YEARS AGO i read about a new blood test in the blood donor magazine - basically they can tell the babies blood group via a blood test on the mother.

the article was saying (and remember this was 7 years ago) that in the future the test could be rolled out so you'd only have to have the injections at 28 / 34 weeks if she baby was definately rh+. of course, 7 years later and this test doesn't seem to be widely available - i guess cheaper just to give everyone the injections....

yetanothernickname - the NICE guidelines state that once sensitisation has occurred it is irreversible, and para 4.3.2 says "The Committee recognised that anti-D immunoglobulin has no clinical benefit for women who have been previously sensitised." Many many other articles, including the one that MumNWLondon linked to, state that there are no benefits to adminstering anti-D to a woman who is already sensitised. But this is in relation to the Rhesus D factor and I'm sure your consultant must be right about it preventing formation of other antibodies.

Also, you (and others I think) said previously that I was very lucky not to be sensitised during the first pregnancy. On the contrary I think I would have been very unlucky to become sensitised. Even without any anti-D treatment at all the rate of sensitisation is only 15%. Without routine prophylactic administration of anti-D, but with treatment after sensitising events, the NICE guidelines state that sensitisation would occur in 1% of cases. Since I did take up the anti-D that was offered after delivery I hardly think I was being irresponsible as your post suggested.

My confusion has been purely centred around whether or not sensitisation could affect this pregnancy. Having researched it more this time it doesn't seem quite as cut and dried as I thought previously, although it appears very very unlikely. My understanding the first time around was that it definitely could not so the decision was a very easy one to make - it was so difficult to conceive DS I was convinced there would not be another baby. Obviously I have conceived again 4 years later - but we were not using contraception that whole time so I think that proves I'm not exactly someone who gets pregnant at the drop of a hat! Incidentally, if I had become sensitised during the first pregnancy there is no way I would have risked another pregnancy at all. I'm not passing judgement on others' choices, but it would not have been an option for me.

Roary - The theoretical risk to the reproductive health of a female baby born to a woman who has received anti D antenatally is raised in the Emma Jackson article just linked to as well of several others that I (annoyingly) can't find the links to just now. Artices, note, not blogs, forums, etc. - I am pretty careful what stuff I read and take notice of on the internet. Having suffered with reproductive problems myself, and as I am likely to be carrying a girl, it is not something I am keen to risk inflicting on my child.

A long post, but basically trying to explain (not sure why or to whom) that this is not a decision that I'm taking lightly. And it's not as cut and dried as the NHS might like to make out.

Emma Wightman sorry (not sure where I got Jackson from!)

1. Sensitisation events, including silent sensitisation, rarely affect the current pregnancy. What does rarely mean? Is there a risk to this baby or not basically?

Very unlikely but not impossible - the foetus doesn't develop Rh antigens until 12w gestation but were you to have a silent sensitisation event after that point, and then had another event in the same pg, there is a slight chance. The reason being that the first sensitisation event produces igM antibodies, which are pentameric molecules (5 bits) and are too big to cross the placenta. The white blood cells that produce this antibody (IgM Anti-D) will also produce memory cells that remember the pattern, so that the next time RhD+ red cells are seen, antibodies can be produced much quicker - and these are IgG antibodies, monomeric molecules (1 bit) which are much smaller and CAN cross the placenta.

2. Having had Anti D after delivery, and having had no antibodies detected during routine blood tests is this baby at any increased risk in this pregnancy as opposed to my first pregnancy?

Very unlikely - however there are a few people whose antibody levels fall bellow detection limits when not being stimulated and suddenly appear again after a stimulation event.

3)Is there any chance of actually being already sensitised even though no antibodies were detected?

See above

4. If I am already sensitised from my first delivery would having Anti D make any difference at all to this pregnancy in any case?

Not really but being sensitised and not showing any antibodies is pretty rare.

When your baby is born, UK hospitals will routinely test the cord blood for RhD status - if the baby is RhD+ you will be offered another shot of Anti-D and a test will be done on your blood to see whether any foetal cells are showing up in your own blood. The more foetal cells that show up, the more Anti-D you might need afterwards to "mop up" these foetal cells (that's not what actually happens but it's the easiest way to explain it) You do NOT have to arrange this yourself, it will happen automatically.

If the baby is RhD- then you won't need any more anti-D. Also, just because your DH is Rh+ and your first baby was also RhD+, don't assume that the second one will be - it is possible that your DH is heterozygous for RhD, which gives you a 50:50 chance of having an RhD+ or RhD- baby.

The anti-D is pretty safe as blood products go but in the end it's your choice.