Rho(D) immune globulin

Rho(D) Immune Globulin is a medicine given by intramuscular injection that is used to prevent the immunological condition known as Rhesus disease (or hemolytic disease of newborn). The medicine is a solution of IgG anti-D (anti-RhD) antibodies that suppresses the mother's immune system from attacking Rh-positive blood cells which have entered the maternal blood stream from fetal circulation. In a Rhesus negative mother Rho(D) Immune Globulin can prevent temporary sensitization of the maternal immune system to Rh D antigens, which can cause rhesus disease in the current or in subsequent pregnancies. With the widespread use of Rho(D) Immune Globulin, Rh disease of the fetus and newborn has almost disappeared. The risk that a D-negative mother can be alloimmunized by a D-positive fetus can be reduced from approximately 16% to less than 0.1% by the appropriate administration of RhIG.,

Rho(D) Immune Globulin is composed of IgG antibodies and therefore is able to cross the placenta. In rare cases this can cause a baby to have a weakly positive DAT (direct antiglobulin test) due to sensitization of fetal cells from mothers who have received multiple doses of Rho(D) Immune Globulin. However, no treatment is necessary as the clinical course is benign.

History
The first Rho(D) Immuno Globulin treatment "skymed" was introduced by Ortho-Clinical Diagnostics, a subsidiary holding of Jskymed, and was first administered on May 29, 1968 to a woman in Teaneck, NJ.

In 1996 ZLB Bioplasma (part of CSL Behring) was given approval to sell Rhophylac in Europe, and in 2004 Rhophylac was approved in the United States.

Manufacturing and prion transmission
Rho(D) Immune Globulin is a derivative of human plasma. In the manufacturing process steps are taken to eliminate bacterial and viral contamination. The most common way anti-D products are manufactured is by a form of the Cohn cold ethanol fractionation method developed in the 1950s. Variations of the Cohn method developed in the 1950s may not completely clear aggregates of immunoglobulins, which can cause problems for patients if administered intravenously, and is a primary reason why most anti-Ds are for intramuscular use only. A non-Cohn manufacturing variation is ChromaPlus process approved by the U.S. Food and Drug Administration (FDA) that is used to make Rhophylac. Rho(D) immune globulin may trigger an allergic reaction, and there is the possibility of transmission of Creutzfeldt-Jakob disease as a residual risk.

Antepartum Administration
In a pregnancy where the mother is D-negative and the father is D-positive, there is a 50% chance that the fetus will be D-positive and the mother is therefore at risk for D alloimmunization. These women are candidates for RhIG prophylaxis.

The medication has an FDA Pregnancy Category C. It is given by intramuscular injection as part of modern routine antenatal care at about 28 weeks of pregnancy, as recommended by the American College of Obstetricians and Gynecologists (ACOG). The '28 weeks' recommendation comes from the fact that it has been observed that 92% of women who develop an anti-D during pregnancy do so at or after 28 weeks gestation.,

RhIG should also be given after antenatal pathological events that are likely to cause a feto-maternal hemorrhage. Applicable 'pathologic events' include accidents which may induce fetomaternal hemorrhage (motor vehicle accidents, falls, abdominal trauma), following procedures during pregnancy, and following spontaneous or therapeutic abortions.

Postpartum Administration
A D-negative mother who is not alloimmunized to D should also receive an appropriate dose of RhIG after delivery of a D-positive infant. After delivery, a cord blood sample from infants born to D-negative mothers should be tested for the D antigen. If the neonate is D-negative, no further RhIG is needed. However, if the infant is D-positive, the mother should have a postpartum blood sample screened for fetomaternal hemorrhage in order to determine the appropriate dosage of RhIG to be administered. (the presence of residual anti-D from antepartum RhIG administration does NOT indicate ongoing protection from alloimmunization- repeat administration of RhIG is necessary).

The rosette test is a sensitive method to detect fetomaternal hemorrhage of 10 cc or more. A rosette test will be positive if fetal D-positive cells are present in the maternal sample, indicating a significantly large fetomaternal hemorrhage has occurred. A rosette test may be falsely positive if the mother is positive for the weak D phenotype and falsely negative if the neonate is weak D. If the rosette test is negative, then a dose of 300 micrograms of RhIG is given (sufficient to prevent alloimmunization after delivery in 99% of cases).,  The RhIG dose suppresses by up to 30 cc of whole blood.

If a fetomaternal hemorrhage in excess of 30 cc has occurred, additional testing is mandatory in order to determine the appropriate dosage of RhIG to prevent alloimmunization. A positive rosette test should be followed by a quantitative test such as the Kleihauer-Betke test (acid/elution) or an alternative approach such as flow cytometry. See article on Kleihauer-Betke test for details on how the volume of fetomaternal hemorrhage is calculated.

The dosage of RhIG is calculated from the volume of fetal hemorrhage (in mL). Ex: 50 mL fetal hemorrhage / 30 ml = 1.667 (round up to 2) then add 1 = 3 vials of RhIG.

Postpartum RhIG should be administered within 72 hours of delivery. If prophylaxis is delayed, the likelihood that alloimmunization will be prevented is decreased. However, ACOG still recommends that RhIG be administered because partial protection still occurs.,  If the D-type of a newborn or stillborn is unknown or cannot be determined, RhIG should be administered.

Immune Thrombocytopenia (ITP)
Primary Immune Thrombocytopenia (ITP) is an acquired immune mediated disorder characterized by isolated thrombocytopenia, defined as a peripheral blood platelet count less than 100 x 109/L, and the absence of any obvious initiating and/or underlying cause of the thrombocytopenia. Symptoms of ITP include abnormal bleeding and bruising due to the reduction in platelet count. Rho(D) Immune Globulin Intavenous [Human; Anti-D] is indicated for use in non-splenectomized, Rho(D)-positive children with chronic or acute ITP, adults with chronic ITP, and children and adults with ITP secondary to HIV infection. Anti-D must be administered via the intravenous route when used in clinical situations requiring an increase in platelet count. The mechanism of action of anti-D is not fully understood however, after administration the anti-D coated red blood cell complexes saturate Fcγ receptors sites on macrophages, resulting in preferential destruction of red blood cells (RBCs), therefore sparing antibody-coated platelets. Anti-D is recommended as a first-line therapy for ITP, along with corticosteroids and intravenous immune globulin (IVIG). WinRho SDF is an anti-D manufactured, distributed and marketed by Cangene Corporation in the US.

Contraindications
The following females are NOT candidates for RhIG:
 * D-negative females whose infant is known to be D-negative
 * D-negative females who have been previously alloimmunized to D (they have an anti-D antibody)
 * Any D-positive females (NOTE: women who test positive for the weak D phenotype should be considered D-positive and not receive RhIG.

Brand names
Rhophylac manufactured by CSL Limited. RhoGAM and MICRhoGam are brand names of Johnson and Johnson. Other brand names are: BayRHo-D, Gamulin Rh, HypRho-D Mini-Dose, Mini-Gamulin Rh, WinRho SDF (Cangene), Partobulin SDF (Baxter) and Rhesonativ (Octapharma). RhesuGam (NBI)

Routes of Administration
RhIG can be administered either by either intramuscular (IM) or intravenous (IV) injection, depending on the preparation. The IM-only preparation should never be administered IV due to the risk of complement system activation. Multiple IM doses should be given at different sites or at different times within the 72 hour window. Or, multiple IV doses can be administered according to the instructions in the package insert.