The transfusion of Rh-positive blood into Rh-negative women LOUIS GARY
KEITH, S.
BERGER,
WILLIAM Chicago,
M.D. M.D.
POLLACK. Illinois.
PH.D.
Chapel Hill,
North
Curolina,
und Raritan,
.‘v’eul Jersey
Of
The incidence of occurrence tran.sJusion of Rh-positive blood into Rh-negative individuals is unknown at the present time. A survey was designed to ascertain this information for the 12 month period ending March 31, 1974. Replies were obtained from 2,286 transfusion facilities in the United States. .4 total of 203 patients were reported to have received Rh-incompatible transfusions during the interval studied. Of these, 44 were women 49 years of age or under. Slightly more than half the women who received Rh-positive blood were treated with Rho (4, immune globulin. Those ulho received an adequate dose did not develop antibodies when appropriatel? tested. Twentyjive prr rent those who received an inadequate dose of Rh-immune globulin developed antibodies. Forty-two per cent of those receiving no Rh-immune globulin prophylaxis were noted to have antibodie.,.
qf
reports and reviews have appeared.13-‘j The present study is the first report of data obtained from a survey designed to enumerate the occurrence of Rhincompatible transfusions in the United States. It deals with those transfusions having been given to Rhnegative women under 50 years of age. Further data regarding women over the age of 50 years and all men will be reported in a subsequent communication.
of Rh-immune globulin to unsensitized Rh-negative women virtually assures that maternal isoimmunization will not occur after delivery of Rh-positive infants. *i-j This method of prophylaxis has been extended to include other obstetric events, such as abortion6-R and ectopic pregnancyqg, lo both of which may cause exposure to the Rh antigen. Larger than usual doses of Rh-immune globulin have been advocated after multiple gestation” and for Rhnegative men and women who have had transfusions ot Rh-positive blood.‘* The frequency of Rh-incompatible transfusions in the United States is unknown. although several case THE
ADMINISTRATION
Materials and methods A questionnaire was designed to ascertain the frequency- of Rh-incompatible transfusions in the United States for the 12 month period ending March 3 1, 1974. Questions were also directed toward the frequency of attempts to utilize anti-Rh immunoglobulin prophylaxis after Rh-incompatible transfusions and the consequent immunologic status of such patients. The questionnaire was mailed along with a selfaddressed return envelope to all transfusion facilities listed in the A. M. A. 1973 Directory of Blood Banks. Hospital and nonhospital facilities were included. Respondents were asked not to identify themselves, although about 5 per cent did so bv using their addresses on return envelopes. Of the original 5,437 mailed surveys, 89 were returned with indications that the facility was not functioning as a blood bank during the time of this
From the Departments $Obstetrics and Gynecology, University oj‘ Health Sciences-The Chicago &fed&l School, and Cook County Hospital, Chicago, and The University of North Carolina at Chapel Hill; and The Ortho Research Foundation, Raritan. Read before the Chicago January 17, 1975.
Gynecological
Received for publication
March
Rev&d
Society, Chicago,
5, 1975.
June IO, 1975
Accepted June Ijr,
1975
Reprint requests: Dr. Louis Keith, Prentice Women’s Hospital and Materni$ Center, 333 E. Superior St., Chicago, Illinois 60611. *Rh, as med here, refers to the main antigen system, commonly noted as Rho or D.
of the rhesus
502
Volume Number
Rh-positive blood transfusion in Rh-negative women
125 4
Table I. Distribution of Rh-negative women years of age administered Rh-positive blood Characteristic
1
No.
1
under
50
Pew?ntage
11 13 11 7
20-29 30-39
40-49 Blood group: A B 0 Not stated
Rh-IC: Administered Not administered Follow-up: Attempted Not attempted Total
26.2 16.7
20 1 17 4
47.6 2.4 40.5
21 17 4
50.0 40.5
9.5
9.5
22 20
52.4 47.6
30 12
28.6
s
given:
26.2
(ml.):
501
globulin
30.9
Volume RBC trun.$~sion
Table II. Volume of Rh-incompatible transfusion, dose of Rh-immune globulin, and anti-Rh antibody status among women with adequate follow-up A. R&immune
Age (yr.) : 20 &ml. .: Two
disease
years’
reporting,
Calif.
If all facilities had responded the projected total number of cases would be approximately 500. I expect that this number is still low but the prevention of some 500 transfusion and/or obstetric cripples is a worthwhile challenge. Dr. Keith’s finding that 42 per cent of recipients having (I~IZ’ follow--up developed Rh antibody is quite compatible with Pollack’s 80 per cent in his conrrolled prospective study. Follow-up of all patients for an adequate period with ideal serologic testing could only increase the number of immunized recipients identified.
Moreover,
in limiting
his
report
to women
less
than 50 years of age, Dr. Keith deleted 150 cases from consideration. This was probably unnecessary since sex is not a factor in primary immunization to the Rh factor via blood transf’usion. Certainly Rh-negative male volunteers undersrandng
have
contributed
much
to
our
present
of Rh isosensitization. Only 52 per cent of these women recipients received Rh immune globulin. There is a great over-all awareness of the importance of the Rh factor in women during the childbearing period and this undoubtedly favored prophylaxis in this group. I would expect the incidence of prophylaxis to be less for the over-all case series. This means that a formidable educational challenge lies ahead. Our goal should be the prevention of isosensitization in ~7~3 susceptible recipient. Rh sensitization can be a matter of life or death in even a male or a postmenopausal female receiving an emergency transfusion under circumstances not allowing adequate time for antibody screening or crossmatching. Finally, Dr. Keith’s data clearly support both thr efficacy of prophylaxis and the dosage level of 20 a per tmlliliter of red cells transfused as advocated bl Pollack.
KEITH, S.
BERGER,
WILLIAM Chicago,
M.D. M.D.
POLLACK. Illinois.
PH.D.
Chapel Hill,
North
Curolina,
und Raritan,
.‘v’eul Jersey
Of
The incidence of occurrence tran.sJusion of Rh-positive blood into Rh-negative individuals is unknown at the present time. A survey was designed to ascertain this information for the 12 month period ending March 31, 1974. Replies were obtained from 2,286 transfusion facilities in the United States. .4 total of 203 patients were reported to have received Rh-incompatible transfusions during the interval studied. Of these, 44 were women 49 years of age or under. Slightly more than half the women who received Rh-positive blood were treated with Rho (4, immune globulin. Those ulho received an adequate dose did not develop antibodies when appropriatel? tested. Twentyjive prr rent those who received an inadequate dose of Rh-immune globulin developed antibodies. Forty-two per cent of those receiving no Rh-immune globulin prophylaxis were noted to have antibodie.,.
qf
reports and reviews have appeared.13-‘j The present study is the first report of data obtained from a survey designed to enumerate the occurrence of Rhincompatible transfusions in the United States. It deals with those transfusions having been given to Rhnegative women under 50 years of age. Further data regarding women over the age of 50 years and all men will be reported in a subsequent communication.
of Rh-immune globulin to unsensitized Rh-negative women virtually assures that maternal isoimmunization will not occur after delivery of Rh-positive infants. *i-j This method of prophylaxis has been extended to include other obstetric events, such as abortion6-R and ectopic pregnancyqg, lo both of which may cause exposure to the Rh antigen. Larger than usual doses of Rh-immune globulin have been advocated after multiple gestation” and for Rhnegative men and women who have had transfusions ot Rh-positive blood.‘* The frequency of Rh-incompatible transfusions in the United States is unknown. although several case THE
ADMINISTRATION
Materials and methods A questionnaire was designed to ascertain the frequency- of Rh-incompatible transfusions in the United States for the 12 month period ending March 3 1, 1974. Questions were also directed toward the frequency of attempts to utilize anti-Rh immunoglobulin prophylaxis after Rh-incompatible transfusions and the consequent immunologic status of such patients. The questionnaire was mailed along with a selfaddressed return envelope to all transfusion facilities listed in the A. M. A. 1973 Directory of Blood Banks. Hospital and nonhospital facilities were included. Respondents were asked not to identify themselves, although about 5 per cent did so bv using their addresses on return envelopes. Of the original 5,437 mailed surveys, 89 were returned with indications that the facility was not functioning as a blood bank during the time of this
From the Departments $Obstetrics and Gynecology, University oj‘ Health Sciences-The Chicago &fed&l School, and Cook County Hospital, Chicago, and The University of North Carolina at Chapel Hill; and The Ortho Research Foundation, Raritan. Read before the Chicago January 17, 1975.
Gynecological
Received for publication
March
Rev&d
Society, Chicago,
5, 1975.
June IO, 1975
Accepted June Ijr,
1975
Reprint requests: Dr. Louis Keith, Prentice Women’s Hospital and Materni$ Center, 333 E. Superior St., Chicago, Illinois 60611. *Rh, as med here, refers to the main antigen system, commonly noted as Rho or D.
of the rhesus
502
Volume Number
Rh-positive blood transfusion in Rh-negative women
125 4
Table I. Distribution of Rh-negative women years of age administered Rh-positive blood Characteristic
1
No.
1
under
50
Pew?ntage
11 13 11 7
20-29 30-39
40-49 Blood group: A B 0 Not stated
Rh-IC: Administered Not administered Follow-up: Attempted Not attempted Total
26.2 16.7
20 1 17 4
47.6 2.4 40.5
21 17 4
50.0 40.5
9.5
9.5
22 20
52.4 47.6
30 12
28.6
s
given:
26.2
(ml.):
501
globulin
30.9
Volume RBC trun.$~sion
Table II. Volume of Rh-incompatible transfusion, dose of Rh-immune globulin, and anti-Rh antibody status among women with adequate follow-up A. R&immune
Age (yr.) : 20 &ml. .: Two
disease
years’
reporting,
Calif.
If all facilities had responded the projected total number of cases would be approximately 500. I expect that this number is still low but the prevention of some 500 transfusion and/or obstetric cripples is a worthwhile challenge. Dr. Keith’s finding that 42 per cent of recipients having (I~IZ’ follow--up developed Rh antibody is quite compatible with Pollack’s 80 per cent in his conrrolled prospective study. Follow-up of all patients for an adequate period with ideal serologic testing could only increase the number of immunized recipients identified.
Moreover,
in limiting
his
report
to women
less
than 50 years of age, Dr. Keith deleted 150 cases from consideration. This was probably unnecessary since sex is not a factor in primary immunization to the Rh factor via blood transf’usion. Certainly Rh-negative male volunteers undersrandng
have
contributed
much
to
our
present
of Rh isosensitization. Only 52 per cent of these women recipients received Rh immune globulin. There is a great over-all awareness of the importance of the Rh factor in women during the childbearing period and this undoubtedly favored prophylaxis in this group. I would expect the incidence of prophylaxis to be less for the over-all case series. This means that a formidable educational challenge lies ahead. Our goal should be the prevention of isosensitization in ~7~3 susceptible recipient. Rh sensitization can be a matter of life or death in even a male or a postmenopausal female receiving an emergency transfusion under circumstances not allowing adequate time for antibody screening or crossmatching. Finally, Dr. Keith’s data clearly support both thr efficacy of prophylaxis and the dosage level of 20 a per tmlliliter of red cells transfused as advocated bl Pollack.
