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

Thanks thumbwitch - your answer to 1) has helped me understand for the first time why, scientifically, there is a greater risk to subsequent pregnancies. That was never clear to me before.

I think the slight uncertainties you raise about the possibility of being sensitised but not showing antibodies - which I'd read before - actually reinforce my decision not to have the anti-D, as I understand that prophylactic anti-D can actually interfere with the interpretation of future antibody test results.

As you say, tests will be done after the delivery and I'll certainly have anti-D then if needed.

10 years in blood transfusion has its uses, certainly!
Glad to help.

It's obviously quite complicated, as I've been told by various different consultants, (living in 3 different areas during 2 different pregnancies) that I am 'sensitised' with anti-bodies due to being RH-
(and either having blood cross during pregnancy, or having a blood transfusion that is neither recorded nor that I remember).

And I'm still told to have Anti-D.

I'm confused about this.

mumtotwoboys - do you actually have anti-D antibodies that you make yourself? Is it on your notes, do you know? Because tbh, non-haematologist consultants/GPs are generally not too accurate when it comes to haematology/transfusion terminology. I know this, I had an interesting discussion with an obstetrician about my own haematological condition (Factor V Leiden) where it became apparent that I know more about it than he (or any other non-haematology person I've met) did.

So - have you had antibodies detected in your booking bloods? You should have had a letter to say so, if this is the case. And you would have needed to have further blood tests to monitor the levels of anti-D during pg. If none of the above applies, then chances are you don't have your own anti-D which is why you still need the anti-D prophylaxis. Happy to continue to discuss if you want.

TSC, I don't think your MW was right about the blood coming from America - the major supplier to the NHS is BPL, the Blood Products Laboratory, a UK company who get most of their blood supplies from UK transfusion centres. There were disruptions to their supply during the vCJD debacle but they still account for ~50% of the anti-D used in the NHS, according to NICE guidelines and an easily googleable letter from Baxter Healthcare.

Tbh, I'd trust BPL over American blood any day of the week - it wasn't UK factor VIII that gave haemophiliacs HIV, it was the stuff from the USA that did that.

oh and for anyone who was wondering why you shouldn't have the prophylactic anti-D if you are already sensitised (i.e. producing your own anti-D antibodies) it's because they should be monitoring your anti-D levels throughout pg to make sure that they don't suddenly shoot up, which could have serious consequences for the baby; having injected anti-D floating around would confuse the test results, so not a good idea.

....and the injections do confuse the test results - I moved hospital at 35 weeks as I was unhappy with the care I was getting at the original hospital so had booking bloods done again at 35 weeks and got call from midwife re: anti-bodies in my blood.

it was all a lot calmer when it became apparent that the anti-D injection I'd had a week earlier was in all likelihood the reason for the anti-bodies (I hadn't had any anti-bodies a week earlier in the blood test i'd had just before the injection)

Hey thumbwitch, yeah they detected the antibodies in my last pregnancy and said they'd have to kep an eye on them and possibly do scans on baby's brain to check if he becomes anemic from my blood attacking his..
My son was okay as the antibodies did'treach a dangerous level and they kept giving me anti D throughtout.
Same with this pregnancy I have a card saying I have anti-M anti bodies and another saying I'm Igm deficiant if I remember rightly and they keep checking anti-body levels..
I'm still getting anti-d shots.

It would seem that anti-M is one of a few or many antibodies a type O negative mother can produce that are a risk to RH+ baby.
It's all very confusing though.

I was told by all doctors that I have become 'sensitised' probably due to being a RH- mother carrying a RH+ child (or having a blood transfusion, but I haven't)
I did have 'anti-D' in my blood at the last check but that wasn't a concern because it was from the anti-D injection Ihave recently had.
Anti-M is the one my body has naturally formed

OK mumtotwoboys - first up, anti-M is not related to anti-D in any way, it's not even part of the Rh group of antigens, of which there are at least 42 antigens.

Anti-M is not commonly associated with any foetal problems, although there is always the minor risk that it might cause issues (as with any antibody) - however, because you have made one antibody, the docs are being more cautious because it means you could be more likely to make another one, such as anti-D. This is why you are having more anti-D than normal.

Anti-M is nothing to do with you being ORh- - it is because you are M-. You could be ARh+ and still be M- and still be able to make anti-M.

I would be verrrry surprised if you are IgM deficient - it's more likely to be IgA, which is something that the blood transfusion centres used to note about their donors. If you were IgM deficient you would be at considerable risk of any infection doing you some serious damage.

I hope that clears it up for you - what you have said certainly cleared up your situation for me!

Roary: Anti d injections have been used routinely for 30 years after the baby has been born and confirmed to be rh +ve. It has only been given during pregnancy for the last approx 5 years. Initially its use was contraindicated during pregnancy. Its unclear to me why this changed as there don't appear to be any long term follow ups on the safety of anti d to the unborn baby.

Thanks thumbwitch.

When they first found the anti-M antibodies I was in the USA and the first thing they did was test my then husband's (whom I was pregnant to) blood to see what type he was, they said if he was also RH negative it wouldn't matter, but as he was RH possitive they would have to keep a close eye out. So it certainly sounded like it was RH factor related, and my antibodies would specifically cause risk to an RH positive baby.
They said I must have gotten the anti bodies from some blood crossing when carrying a previous fetus whom would have been RH positive, either that or I've had a blood transfusion, which I haven't.

So after ALLL of that drama, it's confusing to hear you say it's not RH related??

might be confusing but trust me on this - it's not related to Rh at all. They would have tested your DH to see if he was M+ to see what the chances of you having an M+ baby were. Why this was linked to Rh is beyond me, except for my previous point regarding your higher potential for making another antibody now you've made one already.

Someone has given you duff info somewhere - what I have told you is based on the info you have given here and is accurate to the point of what you have said.

And actually, anti-M is an odd antibody because it can be acquired without exposure to M+ blood - some bacteria have proteins on their surface that resemble the M antigen, which can provoke an antibody response that will react to the M antigen at a later date.

Really, doctors who are not dedicated haematologist/transfusion experts are floundering with this stuff a lot of the time. They don't have the time to know it all properly.

OK - I'm guessing completely here - that whoever you saw read a page a bit like this one that discusses the various antibodies that have the potential to cause HDN (haemolytic disease of the newborn), the whole point behind the anti-D prophylaxis. The only antibody discussed in any detail on the page is anti-D because it is the most common - so they are using it as the example case - this could cause confusion quite quickly to someone not very familiar with blood serology.

ahhh for god's sakes
I believe you.
They've been giving me some bad information.
They tend not to know what they're talking about even when they look at my notes.
They've said 'you're sensitised, but the risk to baby is low right now'.

Honestly doctor's are just as capab;e as the next person to come out with some crap.
I took my 16 month old into hospital and mentioned him breastfeeding and he asked me like he was astonished 'is he not eating food yet'??
Of course he's eating bloody food, like doing both is just unheard of.

I have not at any point had this thing about anti-bodies explained to me properly at all, so thanks for making it a bit clearer.
Idiots they are

Yeah I remember it beingcalled 'Rhogam' when I was over there.
The way the doctor was going on it sounded really serious. He said I'd have to have brain scans on baby to check for severe anemia on him and possibly have to deliver early if my blood attacks him too much.
I think my notes now say 'low risk of HDN to baby' or something......
I've been under the impression forover 3 years now that the only way I could avoid risk would be to have a baby with another RH Negative person.

I am finding this discussion really interesting. When DD1 was born, 40 years ago, she was jaundiced and I was given the anti-D injection. I was ORh- and she was ARh+. I subsequently had a miscarriage but was not given anti-D after it which apparently I should have been. DD2, also ARh+ was born severely jaundiced and was in SCBU in an artificial sunlight machine for 5 days. Consultants from other hospitals came to see her and me and took blood samples from us both. They were puzzled as to why the baby was so ill when I had no rhesus antibodies in my blood. We were told that the jaundice was caused by an unusual factor in DH's blood which had only been identified that year i.e. was unknown when I had DD1. I think they called it factor M! A student midwife was dragged away when she tried to interview me as a case study, because I was 'too complicated' and would only confuse.

My own GP was asked to call on us at home and collect more blood samples for testing. He was very interested and told me we were the first example of this detected within our health board area. He thanked me profusely for our blood samples, saying they would really help on-going research. He also warned me that I must NEVER donate blood as mine was now 'polluted'!.

Reading this thread has made me feel proud that DD2 and I may have helped make pregnancies safer for babies yet to be conceived.

Jayzus, granny23 - quite fecking unbelievable the crap they came out with! Mind you, my Mum was given similar and despite me working in a blood transfusion centre, having to do courses on this stuff, working with it on a daily basis, she still clung to the bollox that they told her even when I explained it properly!

We actively used to seek out people with some antibodies as they were used before the invention of monoclonal antibodies to test the type of other people's blood, so you would have been quite useful!

If you read the page I linked to above (if you haven't already) there is a table on it that gives all the different antigens identified so far (and I think we've pretty much got them all by now) that have the potential to cause HDN. Sounds like you were a case of Anti-M as well - I did find an American paper that discussed 3 cases of maternal anti-M and the outcome on their babies - only one had any problems.

HDN is serious - can be fatal - which is why they need to monitor any woman with antibodies - just in your case, mummytotwoboys, someone somewhere has got confused as to which antigen/antibody they're actually dealing with! But HDN with anti-M is a rarety - much less rare with anti-D (or the other main Rh antigens for that matter).

Anyway - if you have any other questions I'll try and answer them to clarify.

Musthaveshortmemory - not right about anti-d in pregnancy only in last 5 years - i had it with dd 7 years ago it and my sister had it with DN 11 years ago.

ok - routinely since 2005 and during pregnancy - only after a sensitising event -for 30 years. Certainly not to all rh-ve women for 30 years.

No, it was done routinely at 28 and 34 weeks 7 years ago (2003) when I had my DD, and my sister had the same 11 years ago. Perhaps not for 30 years though.

here is another interesting link containing the cost benefit analysis for the injections during pregnancy.

It was area-dependent, as apparently it still is in terms of how post-natal anti-D is administered, which is beyond me tbh - our "National" Health Service really needs to be made just that, it's still a conglomeration of Regional HSs at the mo, all of whom can make their own decisions, hence the postcode lottery crap with some treatments.

Anyway - have finally discovered that the recommendations for 3rd trimester anti-D prophylaxis to be given at 28 and 34 weeks were put forward in 1998 - so technically, it should have been routinely given from 1998 onwards and would have been routinely given by any RHS that was following the guidelines. The recommendations were made by a joint working group from the Royal College of Gynaecologists and the Blood Transfusion Service.
There is an alternative option to have one larger dose at 30w instead - there appears to be no reliable data suggesting this is more or less effective than the 2 dose regime.