Use of anti-D immunoglobulin in maternal trauma

• anti-D immunoglobulin
• miscarriage

We read with interest the article by Weinberg that revealed a lack of awareness among accident and emergency (A&E) staff of the risks of rhesus sensitisation as a consequence of threatened miscarriage.¹ Similar findings were reported in previous studies on anti-D immunoglobulin use in A&E.² This problem also exists in cases of maternal trauma in early pregnancy. We conducted a telephone survey of A&E SHOs in the North West region. A clinical scenario was given of a patient of 18 weeks’ gestation with closed abdominal trauma due to domestic violence. SHOs were asked regarding their management of this case. Sixty two responses were obtained. The possibility of rhesus alloimmunisation was identified by 19 (31%) doctors. Three of these 19 would request a Kleihauer test while the remainder would check maternal rhesus status. If rhesus negative, nine would give anti-D immunoglobulin in the A&E department. The other nine SHOs would refer the patient to the obstetricians on call for further evaluation. Our survey then prompted the remaining 44 doctors with regard to rhesus incompatibility by bringing to attention previously documented rhesus negativity in the patient’s case notes. Equiped with this knowledge, only eight doctors would then give anti-D immunoglobulin in A&E, while 11 would refer the patient for this purpose. Even then, the need for anti-D immunoglobulin was still unrecognised by 25 of 44 (57%) SHOs. Our study is in agreement with the author’s findings that guidelines for rhesus prophylaxis are not being followed. In the revised guidelines, unlike threatened abortion at less than 12 weeks’ gestation, closed abdominal injury is recognised as a sensitising event in the revised guidelines.³ Without continuing educational initiatives aimed at A&E doctors, these guidelines will continue to be ignored.