What is Rhogam?

Raise your hand if you know a baby who died of erythroblastosis fetalis.

Not too long ago, there would have been a lot of raised hands. Before 1968, approximately 10,000 babies died each year of erythroblastosis fetalis, also known as hemolytic disease of the newborn (HDN). Then Rhogam was introduced.

It is fashionable in homebirth midwifery circles to determine what the scientific evidence shows and then reflexively recommend the opposite. Therefore, many homebirth midwives and advocates are now suggesting that women forgo Rhogam without having any understanding of what Rhogam is, what it does, and the nature, incidence and mortality rate of the disease that it prevents.

What is hemolytic disease of the newborn (HDN) It is a relatively common condition in which a mother produces antibodies that cross the placenta and destroy the baby’s red blood cells. The baby becomes profoundly anemic, develops severe jaundice and heart failure. The mortality rate used to be approximately 50%.

Why would a mother make antibodies to her baby’s blood cells? It happens when the mother and baby’s blood type differ in an important way. Usually the difference is that the baby is Rh+ (has the RhoD antigen on its red cells) and the mother is Rh-. The baby of an Rh- mother will be Rh+ only if its father is also Rh+, but not all babies of Rh+ fathers will be Rh+.

How does the mother make antibodies against the baby’s blood if the placenta prevents the mother’s blood from mixing with the baby’s blood? The answer is there are often small leaks of fetal blood into the maternal circulation, particularly at the time of birth. They are not large enough to have any impact on the baby, but only a small amount of Rh+ fetal red cells are needed to produce an immune response in the mother.

When such a response develops, the results are often devastating to the baby, not in the current pregnancy (especially if the sensitization occurs at delivery) but in subsequent pregnancies. What happens in future pregnancies?

… [M]aternal anti-D antibodies cross the placenta into fetal circulation and attach to Rh antigen on fetal RBCs … These antibody-coated RBCs are [destroyed] by lysosomal enzymes released by macrophages and natural killer lymphocytes …

… Tissue hypoxia develops as fetal anemia becomes severe… Hydrops fetalis … starts as fetal ascites and evolves into pleural effusions and generalized edema…

… Destruction of RBCs releases heme that is converted to unconjugated bilirubin. Hyperbilirubinemia becomes apparent only in the delivered newborn because the placenta effectively metabolizes bilirubin…

This is an unmitigated disaster for the baby:

Before any interventions were available, the perinatal mortality rate was 50%. Wallerstein introduced exchange transfusion in 1945 and reduced the perinatal mortality rate to 25%. Later, Chown suggested the early delivery of those severely affected nonhydropic fetuses by 34 weeks’ gestation followed by prompt exchange transfusion helped improve survival. The introduction of intraperitoneal transfusion by William Liley in 1963 and intravascular transfusion (IVT) by Rodeck in 1981 reduced the perinatal morbidity and the mortality rate was further reduced to the current rate of 16%.

Treatment for HDN has clearly improved dramatically, but a death rate of 16% is still extraordinarily high. Imagine if you could prevent your baby from ever getting HDN in the first place, and all it took was two small injections. Since 1968, when Rhogam was introduced, there has been no need to imagine.

Rhogam is human antibody to the Rh antigen. If any fetal blood cells escape into the maternal circulation, Rhogam binds to the Rh antigen and makes it “invisible” to the mother’s immune system. One dose at 28 weeks, and another at the time of delivery is enough to prevent the mother becoming sensitized. Additional injections are given whenever there is any other chance of fetal cells leaking into the maternal circulation, such as at the time of miscarriage, ectopic pregnancy, or episodes of significant vaginal bleeding.

Rhogam has dramatically reduced the incidence of HDN. The incidence is still not zero, however, because there are other less common antigens that can also cause sensitization.

What are the side effects of Rhogam? Sometimes there is a localized skin reaction and occasionally, in people who are sensitive to blood products, there can be an allergic reaction to Rhogam itself.

So why are homebirth midwives suggesting that women refuse Rhogam? Because, as usual, they have no idea what they are talking about.

They are motivated by their insistence that nature is perfect and technology is harmful. First, they insist, bizarrely, that the no fetal blood cells will ever find their way into the maternal circulation unless “interventions” occur during birth. Ignorant of history, they are apparently unaware that HDN was first reported by a French midwife in 1609.

Ignorant of the scientific facts, as always, they are unaware of the Kleihauer-Betke test, a that allows us to quantify exactly how many fetal cells are in the maternal circulation at any given time. That’s how we KNOW that small quantities of fetal cells often slip into the maternal circulation.

Then there is their pathological fear of technology. They are absolutely sure that Rhogam might cause some damage of some kind to babies who never needed it the first place since they had a perfect placenta. They offer no scientific facts to support this claim, since there is no evidence that it is true.

What about the benefits? They don’t appear to understand that nearly 10,000 babies are saved from death by Rhogam each and every year. They have apparently forgotten, if they ever knew, about hemolytic disease of the newborn.

This is yet another example of how modern obstetrics is often stymied by its own success. A dread infant killer is easily prevented by a simple injection, so easily that homebirth midwives have no idea that the risk of death is very real and still exists.

  • Kathleen Elisabeth

    To tar ALL ‘midwives’ with the same brush is rather ludicrous and ‘ignorant’ in itself. Whilst I agree 100% with Dr Tuteur’s informative explanation regarding RhoGAM, and its remarkable advantages in preventing hemolytic disease of the newborn, we must make it very clear that all ‘midwives’ are not created ‘equal’. Properly trained midwives and ultimately state licensed, as such, are first trained as and then registered nurses, who further train and prepare to sit state board examinations which license them as certified midwives. Such a person would totally understand the scientific concept of why it would be necessary for a Rh- mother to receive RhoGAM. There have, of course, since time began, always been women who have assisted at home births, both in third world and also westernized countries, who are medically untrained, who have little to no scientific knowledge, and who have historically called themselves and been known as ‘midwives’.

    • Trixie

      Are you a new reader? She uses “homebirth midwives” as shorthand for lay, DEM, and CPM midwives, to distinguish them from hospital-based CNMs and CMs who, as you say, have the proper training.

      • Kathleen Elisabeth

        Yes, I am. OK. Thanks

  • http://fishyluv.com/ FishyLuv

    Midwives are to obstetricians what LPN’s are to RN’s. They know just enough to get everyone in trouble if they stray outside their scope of practice.

  • drhoob

    It is the amount of IgG your body can produce, continuously and increasingly, after detecting the antigen. RhoGAM is one amount of IgG given once or twice, to neutralize any of the baby’s blood that may be circulating in your system. It does not increase in amount or duration as immune anti-d IgG will. It is out of you system in about a month. Ant-d IgG from your immune system increases in amount until the antigen is gone- and if you’re pregnant- it could be the duration of your pregnancy. If your anti-d levels are increasing, then inducing is an option that could be safer than waiting until they reach a devastating level.

  • saramaimon

    yes blood type and rh are routine in the US. Haley perhaps you can explain? also just wondering why you were seeing both a midwife and a dr? not that i have any problem with that, just wondering.

  • saramaimon

    great comment. i have a friend who is an activist on both these issues- autism and vaccine, and im sure she’d appreciate your comment. would you mind if i cut and paste it to her on facebook?

  • rstikyfiner

    lol

  • stewart p flemming

    Absolutely correct- when RhoGAM seems to have failed, it is because it was not given properly- lots of easily found research have backed this up as well (PubMEd/NCBI etc.)

  • SilbKL

    Just like MMR and dTAP and other vaccines these days- people think the problem doesn’t exist because they haven’t seen it. HUGE mistake to make.

  • Penelope Shiraz, MD

    RhoGAM is not prepared that way at all. RhoGAM (Rho (D) IgG antibodies) is made by the immune systems of women who are RH – but have been sensitized to the Rho (D) antigen and thus produce antibodies against it-it is filtered out and purified and sterilized and tested before ever getting to your Dr. It is impossible for your blood to make RhoGAM (Rho (D) IgG antibodies) if you have never been exposed to Rho (D) / Rh factor (i.e. Rh + blood). There is no way an immune system can produce antibodies that quickly either, unless it has already been exposed to the antigen before. It literally takes two or more weeks from the first exposure of the antigen to produce antibodies. So what you described is impossible.

  • another ge

    If she didn’t go through the trauma = no illness. The trauma, including the pychological aspect of it, is what caused her illness. If she had an epidural, then she would not have felt the pain that caused the trauma in the first place.

  • Sheesh

    Because those are logical options for everyone..

  • Haley

    Well I was enjoying this article until I got to the part about Midwives knowing “nothing as usual” which is where I stopped reading. My Midwife agreed that I take the Rhogam after my doctor suggested it, so not ALL MW’s are uninformed. She has also given me natural alternatives to small ailments that completely cleared up the issue where a GP would have prescribed unnecessary and potentially harmful drugs. This article went from interesting and factual to ridiculous generalization and overblown. As with all professionals, try to find someone who knows what they’re talking about and is educated in ALL methods (sounds like this skeptical OB is one of the close-minded and the kind I avoid like the plague).

    • Young CC Prof

      Your midwife waited for the doctor to suggest it? She should be urging all women to be checked for Rh incompatibility.

      And the article doesn’t say that midwives know nothing, it says homebirth midwives know nothing. There are thousands of smart, well qualified midwives working in medical offices and hospitals, it’s only the ones who take on home births who lack knowledge and/or good judgement.

      • saramaimon

        actually there are plenty of midwives who practice in hospitals alongside their homebirth practices. (although this is likely to dwindle after the most recent study).

        • Trixie

          There are a few CNM practices that offer home birth and gave hospital privileges. I can’t imagine there’s more than a dozen or two practices in the whole country. I’d hardly call it “plenty.”

      • Erika

        Guess what? Doctors should be more aware of Rh incompatibility as well. I had a miscarriage one year ago. Even though the ER doctor did a blood test and was aware that I was Rh negative, he ‘forgot’ to give me a Rhogam shot. Fortunately, I caught it and squeaked back into the ER before the recommended 72 hours lapsed. The nurse (RN) there had the nerve to tell me that some studies suggested I didn’t even need it (so not really a big deal). Seriously.

        My husband and I tried again after the miscarriage. Both our new midwife AND new OBGYN missed my Rh negative status… I had to fill them in once I realized they didn’t pick it up from bloodwork. I also had a light episode of bleeding around 21 weeks. The ER docs missed it too (in a different hospital)! When I knew they were going to release me, I requested a rhogam shot.

        Each time I’ve informed a doc of my Rh status they seem skeptical and demand proof…of which I respond, “could you please check my blood type in your lab work? Thanks.”

        • Elizabeth A

          ER docs are often terrible at OB issues. Their training requires that they be more generalized, and they often just aren’t comfortable with pregnant patients. My observation was that they would kick me up to L&D as soon as they suspected I was pregnant, but different hospitals have different polices for handling OB cases in the ER. Some seem to try to keep patients out of L&D until the middle of the 2nd trimester. The results of this are very mixed.

          Last time I was pregnant, I had a lot of bleeding issues, and the hospitals I was at all began to insist on rechecking blood types at every admission. Because, I guess, they might have mistyped the lab results all those other times they ran a blood type on me, at previous admissions in the same pregnancy, when I miscarried, when I delivered my son, and when I was born myself. I guess they had some problem with misapplication of something and got twitchy.

          I periodically get pushback from asking for what seems like an innocuous drug from doctors I don’t know. (Is there some kind of black market for diflucan? Is someone, somewhere, getting dangerously high off of Rhogam? What do they think I’m going to do with a refill of heparin or neulasta, besides use as prescribed?) I think some of them are reflexively negative, either by nature or as a result of dealing with a lot of drug-seeking patients (especially in the ER). In all of these cases, once they confirm that I have the need I say I have, I wind up with the prescription.

          • Kathleen Elisabeth

            An ER doctor, attending a new patient, regardless of previous hospital admissions and records, as protocol will run new blood tests to check a myriad of potential concerns which are not necessarily obvious. Furthermore, they are trained for all medical emergencies and after the crucial phase and/ or during, will bring in a subspecialty referral to continue the specialized care of the patient.

    • Trixie

      Haley, out of curiosity, is your midwife a CPM or a CNM?

    • Mishimoo

      Natural does not mean safe. I hope you double-checked her alternatives with a reputable source.

    • saramaimon

      “This article went from interesting and factual to ridiculous generalization and overblown.” yes haley that is pretty much par for the course for this blog. me too, i am rh neg and the homebirth midwives i consulted with during my own pregnancy- as well as have worked with in the past- all gave rhogam without fail.

    • thesouthway

      I read through this article several times trying to find where Dr. Amy accused ALL midwives of being ignorant/uninformed about Rhogam. In fact, she specifically accuses homebirth midwives which, more often than not on this blog, is specifically referring to un(der)educated lay midwives (CPMs, DEMs, etc). Further, she is only accusing those HB MWs who are recommending against Rhogam of ignorance and endangering their patients.

      What I find disconcerting, however, is that you would rather chastise Dr. Amy for her tone and supposed sweeping generalizations than focus on the actual problem at hand. There are HB MWs who are advising their patients against a course of treatment that saves lives. Whatever the reason why, their advice is actually putting their patients and their babies in danger. Unlike Dr. Amy, whose words are only a danger to fragile egos, these HB MWs could KILL. Why aren’t you more outraged about that? Why are you more concerned with asserting that not all MWs are “like that” then you are with the willful spreading of false information that could result in deaths?

      IMO, any competent MW would do absolutely everything in her power to distance and discredit herself from the kind of rogue birth junkies that Dr. Amy condemns. These faux-HCPs do far more damage to midwifery then Dr. Amy could ever imagine. And by choosing to focus on tone or characterizations instead of condemning these women and their practices, you are helping them hurt people.

      • Kathleen Elisabeth

        Doctor Amy could have avoided criticism by perhaps clarifying the differences between the title of an untrained and a clinically trained. ‘Midwife’

  • Lindy

    But obviously, if both parents are negative, you don’t need the shot. I wasn’t informed of this…I was basically told to get this shot or my baby would die. Both of my children were negative bloodtype (because two negative parents CAN’T make a positive). I wish I had been informed of this…but then I guess the hospital wouldn’t have gotten the $750 for each child I had for the shot.

    • Trixie

      Because there’s never 100% certainty that the father is who the mother says it is, it’s not worth gambling with a baby’s life. Rhogam for everyone.

      • jennie R

        i am not a lawyer but i believe you are mistaken according to US law and that your statement violates the doctrine of informed consent.

        • http://gamesgirlsgods.blogspot.com/ Feminerd

          No, it’s smart doctors who know that patients lie. Often. Repeatedly. And with very bad results.

          Doctors who assume a patient could be lying, and treat accordingly, are just practicing smart medicine. Any lawyer will tell you so. Now, they do need to inform you of what they are doing and what the possible side effects are, but they do not have to tell you that they’re doing it because patients lie a lot.

          • Young CC Prof

            And even patients who are trying to tell the truth may mix things up, or might not accurately know their medical history. When I advise professionally, I always like to see in writing what the situation is, sometimes because students lie, sometimes because they remember wrong, sometimes because they misunderstand the question.

            If I worked in the medical profession, I’d never bet a patient’s life on the accuracy of information conveyed verbally by the patient or patient’s relative if there was reasonably easy precaution to avoid the whole problem.

          • Elizabeth A

            And even patients who are trying to tell the truth may mix things up, or might not accurately know their medical history.

            Yup. I was talking to my husband this morning, and despite the fact that he *ordered* me a RoadID tag that has my correct blood type on it, he misremembered my blood type. He cannot for the life of him remember our children’s Rh status. (I am reasonably confident of his blood type only because it’s the only option that gets us to our children’s phenotypes. Blood type is clearly not the sort of thing he remembers.) I am sure that plenty of people “know” their blood type by parental report, and I am sure that plenty of those are accidentally misreported.

            The hospital’s cut of the cost of a Rhogam shot is much, much smaller than the hospital’s cut of the cost of NICU treatment for HDN, or of the treatments to prevent HDN where Rh sensitization has occurred. They could make far more money by not bothering with Rhogam.

          • Kathleen Elisabeth

            Exactly. In the ER patients often lie. Physicians are well aware of this and it is a great hazard, both to the physical well being and outcome of the patient’s treatment and also the outcome of the physician’s career, should they trust and act upon the misinformation provided by a patient whose purpose for lying is self serving.

      • Kathleen Elisabeth

        EXACTLY

    • Kathleen Elisabeth

      A doctor cannot ascertain, second guess, or prove the genetic paternity of the fetus purely because the mother states it to be so. If doctors relied and acted upon all information provided by patients, alone, there would be chaos. Your doctor gave you prophylactic RhoGAM, which is the standard treatment.

  • Becky

    With my first two pregnancies I had CPMs. Both times the CPM was absolutely insistent that I must get a rhogam shot.

  • L

    In this article you noted that mothers only need to get the RhoGAM shot if the father is positive. In my understanding (I work at a Maternity clinic) that there have been a few cases where the father was tested and was positive so the mother did not get the shot. Because there was a positive blood type somewhere in the family and the babies were positive and they passed away. This is probably very rare but in the clinic I work in EVERY mother who tests negative is given the shot.

    • Dr Kitty

      There are plenty of cases where the “father” was not the father.
      The only reason a RH negative women shouldn’t get Rhogam is because her BABY is RH negative too.

    • Lindy

      Two negative parents CAN’T make a positive…it’s not possible. Therefore, either the father isn’t who she says the father is, or they were wrong about his bloodtype. They give every RH- mother the shot because they want the $800 it brings in.

    • saramaimon

      my son’s results came back negative just like mine… and yet i begged the hospital for a dose of rhogam because i didn’t trust them not to mix up the results, like other things they mixed up… they refused to give it to me. well i hope for the best.

      • Young CC Prof

        If you are worried about it, (I assume this was something that happened some time ago, not within the past few days) you can have your son’s blood type tested privately. You can also have yourself tested to see if you are sensitized.

  • Allie, CNM, WHNP

    I find this rant against Midwives highly offensive. The comment of: “Midwives don’t know what they’re talking about” is especially condescending. As a Midwife with 2 Masters Degrees would like to say that I DOknow what I’m talking about and I am highly prepared to assist women in their planned home deliveries.

    • Dr Kitty

      Good. You know what you’re talking about.
      Does the average CPM or DEM?
      No.

      Carry on.

    • Haley

      Yes! My midwife is amazing and educated in both natural and conventional methods and tells me when the conventional is necessary and when it is not! This article is just some angry windbag who thinks they know everything. It’s crap.

      • Young CC Prof

        Wait, your midwife tells you when to listen to your doctor and when to ignore your doctor.

        Why don’t you just find an actual doctor you trust and cut out the middleman?

      • Amazed

        Why do you even bother with a doctor? Go off with your amazing midwife! Have your baby at home! Surely this Wonder Woman can set up an OR in your kitchen?

  • Desi_redux

    Oh, I couldn’t help sharing this link on here even though this is an older post. Since my MIL almost lost my husband to HDN, it makes me mad to see idiots come up with woo like this: http://www.unhinderedliving.com/rhogam.html

  • amir

    hello, I want to get this medicine. Please guide me how to do it and mention its price

    • http://www.facebook.com/profile.php?id=100002171364303 Anj Fabian

      ^^
      SPAM

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