Vaginal Bleeding and anti – D

Last Updated on by FRCEM Intermediate

Causes for bleeding in pregnancy

First trimester 0-12

  • Spontaneous miscarriage
  • Ectopic pregnancy
  • Molar pregnancy

Second trimester 13-28

  • Spontaneous miscarriage
  • Molar pregnancy
  • Placental abruption
  • Placenta praevia

Third trimester 29-40

  • Placental abruption
  • Placenta praevia
  • Vasa praevia
  • Uterine rupture

General Management 

  • Call obstetric team immediately
  • Give high flow oxygen
  • Insert 2 large (14G) IV cannulae, send FBC, U&E, clotting, cross-match for 6 units
  • Start IV fluids, transfuse blood if necessary
  • check Rhesus status-Give anti-D immunoglobulin to Rhesus negative women
  • Check Urine beta hCG test
  • Analgesia as required
  • ultrasound (transvaginal in early pregnancy) to identify extrauterine pregnancy
  • Fetal monitoring – CTG

Rhesus status and anti-D immunoglobulin

Rhesus-negative mothers can become sensitized to, and produce antibodies against foetal rhesus positive red blood cells causing the destruction of these cells
Administration of anti-D immunoglobulin to women at risk of Feto-maternal hemorrhage (FMH) reduces the risk of sensitization.
Feto-maternal hemorrhage (FMH): Is most common in the third trimester, during childbirth and following events associated with FMH. include

  • medical interventions – chorionic villus sampling, amniocentesis, external cephalic version, terminations,
    late miscarriages,
  • APH
  • abdominal trauma
  • Ectopic pregnancy
  • Intrauterine death
  • Spontaneous miscarriage (all pregnancies >12/40, and <12/40 if surgical management used to evacuate uterus) Threatened miscarriage (pregnancies >12/40 and <12/40 if heavy/repeated bleeding or associated with abdominal pain)
  • Termination of pregnancy

It Causes

  • fetal anaemia which in utero leads to heart failure,
  • hydrops foetalis
  • intrauterine death.
  • Neonatally haemolytic disease of the newborn ensues causing kernicterus

Use of Anti-D

  • Current guidelines state that Anti-D immunoglobulin should be administered as soon as possible and always within 72 hours of a sensitizing event
  • In pregnancies <12 weeks gestation, Anti-D is only indicated following ectopic or molar pregnancies, therapeutic termination of pregnancy and in cases of heavy or repeated uterine bleeding, or bleeding associated with abdominal pain. The minimum dose is 250IU, and a Kleihauer test is not required.
  • For potentially sensitizing events between 12 and 20 weeks, again the minimum dose is 250IU, and a Kleihauer test is not required.
  • After 20 weeks, a minimum dose of 500IU of Anti-D immunoglobulin and a Kleihauer test are both required
  • Anti-D rhesus prophylaxis (250 ICJ) should be offered to all rhesus-negative women who have a surgical procedure to manage a miscarriage.

Refer: https://patient.info/doctor/anti-d-rho-immunoglobulin

Refer: https://www.rcemlearning.co.uk/modules/bleeding-in-pregnancy/use-of-anti-d/

https://www.rcemlearning.co.uk/modules/bleeding-in-pregnancy/sensitising-events/

anti-D to rhesus-negative women: (Rcemlearning)

  • Women who have heavy or repeated bleeding or where there is associated abdominal pain in the first
    trimester,
  • Women having a spontaneous miscarriage or threatened miscarriage or who suffer intermittent
    bleeding after the first trimester,
  • Women having a therapeutic termination of pregnancy,
  • Women having an  ectopic pregnancy,
  • Women who undergo intervention to remove products of conception,
  • Women who have  potentially sensitising events at any stage of pregnancy

NICE: 😯  😯  😯  😯  😯 😡  😡  😡 😡 😡 😡 😡 😡 ❓  ❓  ❓  ❓ ❓ ❓  ❓ 

Offer anti-D rhesus prophylaxis at a dose of 250 IU (50 micrograms) to all rhesus negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.

Do not offer anti-D rhesus prophylaxis to women who:

  • receive solely medical management for an ectopic pregnancy or miscarriage or
  • have a threatened miscarriage or
  • have a complete miscarriage or
  • have a pregnancy of unknown location.

Do not use a Kleihauer test for quantifying feto–maternal haemorrhage.

refer: https://www.nice.org.uk/guidance/cg154/chapter/1-Recommendations#anti-d-rhesus-prophylaxis

😯

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