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The debate on anti-D prophylaxis rages on. Recently the subject was discussed in a green top guideline from the Royal College of Obstetricians and Gynaecologists.1 There are still approximately 50 deaths per annum attributable to rhesus isoimmunisation in the UK. In reviewing the reasons why these deaths still occur, the Consensus Conference on Anti D in 1997 admitted that the 1991 Recommendations are not being adhered to by all units and that a substantial proportion of accident and emergency (A&E) departments did not administer anti-D when appropriate (Consensus Conference on Anti-D Prophylaxis, Edinburgh, UK 8–9 April, 1997).
The conference discussed but did not conclude on the need for anti-D prophylaxis where threatened miscarriage and resolution occurs in the first trimester, or when spontaneous miscarriage occurs at this time without instrumentation. The College guidelines go further in advocating non-use of anti-D when pregnancy bleeding occurs in the first trimester with a viable fetus and supports the use of anti-D when “bleeding is heavy or repeated, when abdominal pain is present or when gestation approaches 12 weeks”.
There is a need here for more precision. Many SHOs in A&E have limited gynaecological experience and under the new guidelines will be expected to determine which patients require anti-D.
Furthermore, the present recommendation for non-use of anti D is based largely on two observational studies, (Grade C recommendation). In this era of evidence based medicine is this sufficient basis for a change in policy?
In the past anti-D immunoprophylaxis was routinely given to all rhesus negative women with early pregnancy bleeding. This has not been shown so far to be significantly associated with adverse side effects and the cost implications are not prohibitive.
Perhaps the way forward is shown in a more recent RCOG guideline, on the management of early pregnancy loss.2 The same dilemma is dealt with in a caveat “if there is clinical doubt then anti D should be given”. Until more conclusive information is to hand, rather than obfuscating the issue, a return to a policy of administering anti-D to all rhesus negative women with early pregnancy bleeding seems a more plausible option.
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