Queensland Health

Queensland Clinical Guidelines short GUIDE

Rh D negative women and pregnancy

IMPORTANT: Consider individual clinical circumstances. Consult a pharmacopeia for complete drug information. Read
the full disclaimer at [Link]/qcg

Introduction
Aspect Consideration
• Early pregnancy screening, recognition of risk and timely management reduces incidence of fetal
death and adverse neonatal outcomes1
Context
• Rh D negative women are at risk of alloimmunisation that may affect future pregnancies2
• In Australia, approximately 15% of Australians are Rh D negative3,4
• Alloimmunisation: immune system response of Rh D negative woman to Rh D positive fetal red
cells expressing the Rh D antigen2,5,6
• Anti-D antibody: circulating Rh D antibodies6
o Passive antibodies are acquired from an external source (e.g. Rh D immunoglobulin (Ig))
o Preformed antibodies are acquired when Rh D negative woman is exposed to Rh D positive
red cells and develops antibodies (sensitising event)
• Direct antiglobulin test (DAT): determines whether there is binding of maternal immunoglobulin
antibodies (Rh D antibodies) to baby’s red cell antigens7 (known historically as direct Coombs
test (DCT))
• Flow cytometry: most accurate and method of choice for quantification of feto-maternal
haemorrhage (FMH)6
• Haemolytic disease of the fetus and newborn (HDFN): maternal Ig G antibodies are causing
destruction of baby’s red cells, and if severe can cause anaemia and hydrops
Definitions • Kleihauer-Betke test: detects and quantifies FMH8
• NIPA: non-invasive prenatal analysis for fetal RHD gene used to predict the baby’s Rh D status9
(also referred to as NIPT (non-invasive prenatal test) by National Blood Authority6)
• Rh D Ig: the product administered to Rh D negative woman with no preformed anti-D antibodies6
• Rh D positive or negative: blood group6 (if positive the D antigen is present on red cells)
• Rh D (previously known as Rhesus) positive person: carries D antigen on their red cells10
• Rh incompatibility: mother and fetus incompatible for Rh D group
• RHD: name given to the gene that encodes Rh D blood group, and used to refer to the genotype
in the fetus determined by non-invasive prenatal test to analyse cell-free fetal DNA in maternal
blood6,11,12
• Woman/women: QCG recognise that individuals have diverse gender identities. In QCG
documents, although the terms woman and women are used, these guidelines are inclusive
of people who are pregnant or give birth and who do not identify as female.
• Pathogenesis of alloimmunisation2:
o D antigen is expressed on fetal red cells by 38 days of gestation in Rh D positive fetus
o If maternal alloimmunisation occurs as a result of sensitising event, anti-D IgG antibodies
cross the placenta and may result in fetal anaemia in the Rh D positive fetus in subsequent
pregnancies–may also be caused by incompatible blood transfusion (rare)
• Outcome from alloimmunisation:
o May cause HDFN from transplacental passage of anti-D antibodies from Rh D negative
Alloimmunisation
woman to an Rh D positive fetus13, resulting in potential fetal compromise or neonatal and
long-term morbidity1
o Generally no apparent adverse maternal health outcomes6, unless severe HDFN causing
hydrops when maternal mirror syndrome may develop14
• Immunoprophylaxis occurs when injection of Rh D immunoglobulin (Rh D Ig) (to the woman)
destroys fetal Rh D positive red cells in the maternal circulation before alloimmunisation can
occur in the woman15
• Refer to Queensland Clinical Guideline Standard care16 for care considered ‘usual’ or
‘standard’—includes for example: privacy, informed consent, decision making, sensitive
communication, medication administration, staff education and support, culturally appropriate
care and documentation
Clinical standards • Determine the blood group (ABO Rh) and antibody status (e.g. anti-D, anti-C, Kell) for all
pregnant women at booking appointment, and at approximately 28 weeks gestation6,12,17—can
coincide with other routine tests e.g. oral glucose tolerance test (OGTT)
• Offer anti-D immunoglobulin (Ig) to Rh D negative women (with no preformed antibodies) for
routine prophylaxis, and for invasive procedures and other sensitising events12

Available from: [Link]/qcg

Effective: April 2024 | Review: March 2028 | Doc No: MN23.74-V2-R28
Queensland Clinical Guidelines short GUIDE

Incidence and risk

Aspect Consideration
• If no immunoprophylaxis, the rate of alloimmunisation in Rh D incompatible pregnancy is
Incidence of approximately 16%18
alloimmunisation • Rate of alloimmunisation in Rh D negative women in Queensland due to feto-maternal
haemorrhage of greater than 6 mL is approximately 4%19
• Incompatible blood groups—occurs if Rh D negative woman has an Rh D positive fetus
Risk factors for D
• Sensitising events in pregnancy [refer to Sensitising events]
alloimmunisation
• Incompatible blood transfusion (including IV drug use/needle sharing)
• Severe anaemia resulting from HDFN20,21–if anti-D level12
o Greater than 4 international units (IU) per mL and less than 15 IU per mL, moderate risk
of HDFN (unlikely to be severe)
Fetal/neonatal risk
o Greater than 15 IU per mL, HDFN may be severe
after maternal
• If other blood group antibodies, HDFN incidence and the critical antibody titres for risk are
alloimmunisation
different—if alloimmunisation suspected, consult with a specialist obstetrician
• Hydrops fetalis22
• Fetal thrombocytopenia23

Antenatal management
Aspect Consideration
• Rh D status and potential risk to future babies
• Blood test surveillance including indications/opportunity for NIPA
Information to
• Sensitising events
Rh D negative
woman • Prophylaxis and other indications for Rh D Ig [refer to Sections Routine Rh D
immunoglobulin prophylaxis and Sensitising events]
• Provide written consumer information about Rh D Ig; discuss benefits and risks
• Fetal RHD test (NIPA) available for Rh D negative pregnant women who24:
o Are Rh D alloimmunised (have pre-formed anti-D antibodies)
NIPA indications o Have previous obstetric indications (e.g. FMH, intra-uterine fetal death)
o Are non-sensitised and have a relative contraindication to Rh D Ig (e.g. prior allergic
reaction; cultural/religious beliefs)
• ABO Rh blood group at first appointment (if possible in first trimester)6
• If Rh D negative woman, antibody screen for preformed anti-D antibodies24 at first
appointment and repeat at 28 weeks (prior to administration of Rh D Ig)
Blood tests • Fetal RHD test from 12 weeks gestation6
o Not currently available as routine care for women in Australia25
o If available, follow local protocols for offering Rh D negative women self-funded NIPA
• Note date of administration of anti-D product on pathology request forms
• Routine blood tests6
• Identify Rh D alloimmunisation risk
o Previous pregnancy history (e.g. previous baby requiring blood transfusion, or known to
have HDFN)26
Management • Administer prophylactic Rh D Ig at 28 and 34 weeks gestation to Rh D negative woman if6:
o No preformed anti-D antibodies12 [refer Anti-D immunoglobulin regimen]
o Fetal RHD test (NIPA) predicts fetus to have RHD positive genotype6 (if completed)
• Identify sensitising events that may cause alloimmunisation (if antibody status not known,
give Rh D Ig) [refer to Sensitising events]
• Check history:
o Previous pregnancies
o Blood transfusion
o IV drug use/needle sharing
Positive anti-D o Recent Rh D Ig administration
antibody screen6,17 • Confirm with laboratory whether preformed antibodies present (not passive from Rh D Ig
administration)—if antibodies are preformed, Rh D Ig not required
• Consult with specialist obstetrician/maternal-fetal medicine specialist for management
including ongoing serial monitoring of antibody titres and regular ultrasound scans12
• Consider testing for fetal RHD by NIPA
Blood transfusion • If woman requires transfusion use Rh D negative blood27

© State of Queensland (Queensland Health) 2024

Rh D negative women and pregnancy
Available from: [Link]/qcg

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Queensland Clinical Guidelines short GUIDE

Anti-D products
Aspect Consideration
• Obtain informed consent before administration of anti-D product
o Refer to Queensland Clinical Guideline Standard care16
• Documentation–record the name of product and batch number in woman’s medical record
• Interactions with other medications–do not mix with medications or diluents
• Observe woman for at least 20 minutes after administration
• Product safety:
o No fetal effects of prophylactic anti-D products
o Suitable to use in breastfeeding women
Context28,29
• Body mass index (BMI) greater than or equal to 30 kg/m2
o No additional dose required6
o Consider length of needle6 and administration site (deltoid is suggested)
o Consider Rhophylac®* intravenous (IV) injection28
• No time interval required between IM (intramuscular) Rh D Ig administration and vaccination
for measles, mumps, rubella and/or varicella30
• Same dose and regimen (routine prophylaxis and sensitising events) for singleton and
multiple pregnancies6
• Human Anti-D Rh0 immunoglobulin
• Bring to room temperature before use
• Administer by slow, deep intramuscular (IM) injection
Rh (D) o Draw back to ensure not in blood vessel
immunoglobulin- o Best sites are deltoid or anterolateral thigh31
VF (single vial)6,29 • Divide doses of more than 5 mL volume
• Do not administer IV
• If extra dose(s) for FMH round up volume to nearest full vial or vials
• If more than two IM injections are required, consider IV Rhophylac®
• Human Anti-D (Rh0) immunoglobulin
• Usually used for large fetal maternal haemorrhage (greater than 6 mL of fetal cells)
Rhophylac®
• Bring to room temperature immediately before administration
(prefilled syringe)6,28
• Administer IM or IV injection (if dose larger than 5 mL)
• Consider IV use for woman who has haemorrhagic disorder precluding IM injection

Routine Rh D immunoglobulin prophylaxis

Aspect Consideration
• Indicated for all Rh D negative women with no pre-formed anti-D antibodies
o Not required if fetal RHD test predicts fetus is Rh D negative
• Administer Rh (D) immunoglobulin-VF* 625 international units (IU) IM injection at 28 weeks
Routine antenatal (after blood for group and antibody collected from the woman, but do not need to wait for
immune- results) and 34 weeks gestation
prophylaxis6 • If not logistically possible to give anti-D at 28 and 34 weeks
o Give as soon as practicable within two weeks of due administration date
o If 28 week dose missed, give as soon as recognised and then second dose six weeks
later
• Indicated for all Rh D negative women with no preformed anti-D antibodies who give birth to
an Rh D positive baby
o Rh D group from cord or neonatal blood
• Administer Rh (D) immunoglobulin-V* 625 international units (IU) intramuscular (IM)
Routine postnatal
injection (unless baby is Rh D negative)
prophylaxis6
• If baby is born at term or preterm and is Rh D positive, administer routine postnatal dose of
Rh (D) immunoglobulin-VF* to woman within 72 hours of birth–regardless of when routine
antenatal prophylaxis or sensitising dose given
o If not given within 72 hours after birth (preferred), may be given up to 10 days postnatally
*Refer to product information

© State of Queensland (Queensland Health) 2024

Rh D negative women and pregnancy
Available from: [Link]/qcg

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Queensland Clinical Guidelines short GUIDE

Sensitising events
Aspect Consideration
• Miscarriage26
o Excludes threatened miscarriage—consider confirming gestational age by ultrasound
scan
First 12+6 weeks
• Termination of pregnancy26 (medical or surgical) from 10+0 weeks gestation32
of pregnancy6
• Ectopic pregnancy26
• Molar pregnancy26
• Chorionic villus sampling26
• Genetic studies26
o Chorionic villus sampling
o Amniocentesis
o Cordocentesis
• Abdominal trauma26
From 13+0 weeks
• Revealed or concealed antepartum haemorrhage
gestation6
o Consider in woman with unexplained uterine pain—possible concealed antepartum
haemorrhage (APH)
• External cephalic version (successful or attempted)
• Miscarriage or termination of pregnancy26
• Birth of baby regardless of mode26—greatest risk
• Check bloods for:
o Maternal blood group (if required) and anti-D antibodies
o Quantify FMH size by Kleihauer-Betke or flow cytometry6,8
Sensitising event • If maternal blood group is Rh D negative, administer Rh D Ig as soon as possible after blood
(or unknown sample taken (most effective within 72 hours of sensitising event6)
maternal blood o Do not wait for test results before administering first dose8
group) o May be given up to 10 days from sensitising event but may have lower efficacy6
o Administer for all new sensitising events and regardless of time of routine prophylaxis
o Administer routine 28 and 34 week Rh D Ig regardless of extra doses for sensitising
event
• If 20+1 weeks or more gestation, measure FMH size following sensitising event and at birth
for all Rh D negative women6
• Use method that can quantify a haemorrhage greater than or equal to 6 mL (equivalent to
12 mL of whole blood)6
Measuring FMH
• Flow cytometry most useful and accurate quantitative test for FMH6,33
o If available, method of choice6
o Includes antenatal and postnatal periods6
• Offer follow up testing as per laboratory or specialist obstetric advice6
• If large FMH (≥ 6 mL) repeat flow cytometry after Rh D Ig administration at6:
Follow up testing o 48 hours post IV administration
o 72 hours post IM injection administration
• If baby tests Rh D positive at birth [refer to Neonatal care]
Postnatally o Obtain maternal bloods to detect and quantify FMH after 45 minutes and within 2–72
hours of birth8,17
o Collect blood specimen before administering Rh D Ig8

© State of Queensland (Queensland Health) 2024

Rh D negative women and pregnancy
Available from: [Link]/qcg

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Queensland Clinical Guidelines short GUIDE

Rh D immunoglobulin for sensitising event

Aspect Consideration
• Indicated for Rh D negative women with no pre-formed anti-D antibodies
o If test for fetal RHD predicts fetus is Rh D negative—Rh D Ig is not required
• Administer dose as soon as practical within 72 hours of sensitising event
Context6
• If dose not given within 72 hours, may be administered up to 10 days from event
o May have lower efficacy
• Quantify size of FMH after 20 weeks gestation and after birth
• If bleeding is repeated, heavy, or associated with abdominal pain or significant pelvic trauma
administer Rh D immunoglobulin
Sensitising event
• Administer Rh (D) immunoglobulin-VF* 250 IU IM injection
first 12+6 weeks
• If maternal bleeding is ongoing, further dose may be given after interval of six weeks–if less
gestation6
than 13+0 weeks gestation administer Rh (D) immunoglobulin-VF* 250 IU IM injection29
• Insufficient evidence to support routine use of Rh D Ig following threatened miscarriage
• Administer Rh (D) immunoglobulin-VF* 625 IU IM injection29
Sensitising event
• If ongoing uterine bleeding further doses may be given at intervals of 6 weeks
from 13+0 weeks
gestation6 • If gestation unknown and possibly greater than or equal to 13 weeks administer Rh (D)
immunoglobulin-VF* 625 IU IM injection29
• Administer Rh (D) immunoglobulin-VF* 625 IU IM injection
• Additional doses following laboratory or specialist obstetric advice
o If required, usually an additional dose of Rh (D) immunoglobulin-VF* 100 IU IM injection
FMH greater than
per 1 mL fetal red cells greater than or equal to 6 mL
or equal to 6 mL of
fetal cells6 • If IM injection not practical (e.g. volume of Rh D immunoglobulin to be injected is greater
than 5 mL) or is contraindicated (e.g. woman has haemorrhagic disorder)
o Administer Rhophylac®* 1500 IU IV injection or as advised by laboratory or specialist
obstetrician/feto-maternal specialist29
• If woman requires blood transfusion—use red cells of the same ABO Rh D group, and K
negative12
Blood transfusion • If Rh D negative woman receives Rh D positive blood transfusion, consult with a
haematologist for specialist advice regarding individual woman’s situation
o Rhophylac®* 1500 IU IV injection28 may be considered or other interventions
*Refer to product information

Neonatal care
Aspect Consideration
• Check Rh D group and DAT of all babies born to women who are Rh D negative regardless
of immunoprophylaxis or alloimmunisation history17
Screening of baby o Including if woman had fetal RHD test performed and result predicted baby to be Rh D
at birth negative6
• If clinically significant antibodies in woman or increased risk of haemolysis–also test cord
blood for haemoglobin and bilirubin12,17
• Usual newborn baby care and observations
• If alloimmunised mother (risk of HDFN), assessment of neurobehavioral state, jaundice
and/or anaemia12
• If weak positive DAT:
o May be due to maternal antenatal immunoprophylaxis
Management
o Usually no adverse effects on newborn baby
o If in doubt about significance of DAT result discuss with testing laboratory or
neonatologist/paediatrician
• Refer to Queensland Clinical Guidelines: Routine newborn assessment34 and Jaundice-
neonatal35

© State of Queensland (Queensland Health) 2024

Rh D negative women and pregnancy
Available from: [Link]/qcg

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Queensland Clinical Guidelines short GUIDE

Flowchart Routine management of Rh D negative woman excluding NIPA

Management of woman with Rh D negative blood group (excluding NIPA)

• Confirm if anti-D antibodies:

o Passive–due to
administration of Rh D in Antibody screen Assess for sensitising events
No throughout pregnancy
previous 12 weeks negative for
o Preformed–due to anti-D antibodies?
First 12 weeks gestation
sensitising event
• Miscarriage
• Review clinical history
• ToP (from 10+0 weeks)
Yes • Ectopic pregnancy
• Molar pregnancy
• CVS
At 28 weeks gestation
• Retest for anti-D antibodies After 12+6 weeks gestation
prior to Rh (D) Ig • Miscarriage
administration • ToP
• Administer first dose of • CVS, amniocentesis,
Rh (D) Ig 625 IU IM§ cordocentesis
o Can be given before results • Abdominal trauma
are available • APH (revealed, concealed,
o In addition to any doses for unexplained uterine pain)
sensitising events • ECV

At 34 weeks gestation Sensitising events

Preformed No • Administer second dose of • If indicated administer Rh D Ig
anti-D antibodies? Rh (D) Ig 625 IU IM§ as soon as practical within
o In addition to any doses for 72 hours of event
sensitising events o Do not wait for FMH result
After birth (when measured)
• Determine baby’s Rh D type o Give up to 10 days from the
Yes from cord or neonatal blood sensitising event (may have
lower efficacy)
• Rh D Ig not required o Doses in addition to
• Seek specialist obstetric prophylaxis
advice First 12 weeks gestation
• Manage as Rh D sensitised • Dose: Rh D Ig 250 IU IM§

Baby 13+0 weeks gestation

No (one or more) • Dose: Rh D Ig 625 IU IM§
• Rh D Ig not required
Rh D positive? After 20 weeks gestation
• Maternal blood sample for
volume of FMH
• Dose: Rh (D) Ig 625 IU IM§
Yes • If confirmed FMH ≥ 6 mL of
fetal red cells (12mL of whole
blood), administer additional
Maternal care Rh D Ig as advised*
• Blood sample for volume of FMH o If Rh D Ig volume > 5 mL–
• Administer Rh (D) Ig 625 IU IM§ administer Rhophylac®
o Do not wait for FMH result 1500 IU IV as advised*
o Give up to 10 days from birth
o In addition to doses for sensitising events or prophylaxis
o If FMH ≥ 6 mL, dose as per expert advice

Neonatal care
• Blood sample for DAT
• Refer to QCG Neonatal jaundice and Newborn assessment

* as advised by laboratory or specialist obstetrician/feto-maternal specialist.

§ draw back on plunger of syringe before injection to ensure the needle is not in a blood vessel and administer by deep IM injection.
APH: antepartum haemorrhage CVS: chorionic villus sampling ECV: external cephalic version FMH: feto-maternal haemorrhage,
Ig: immunoglobulin IM: intramuscular IV intravenous NIPA: non-invasive prenatal analysis Rh D Ig: Rh (D) immunoglobulin-VF
ToP: termination of pregnancy ≥: greater than or equal to
Flowchart F23.74-1-V2-R28

© State of Queensland (Queensland Health) 2024

Rh D negative women and pregnancy
Available from: [Link]/qcg

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Queensland Clinical Guidelines short GUIDE

Flowchart Management of Rh D negative woman including NIPA

Management of woman with Rh D negative blood group (including NIPA)

• Screen woman for anti-D From 11 weeks gestation: Assess for sensitising events
antibodies • If indicated determine fetal throughout pregnancy
• If anti-D antibodies present Rh D status by NIPA
confirm if: First 12 weeks gestation
o Previous obstetric history
o Passive–due to
• Miscarriage
(e.g. severe FMH, IUFD)
administration of Rh D in • ToP (from 10+0 weeks)
o Non-sensitised with relative
previous 12 weeks • Ectopic pregnancy
contraindication to Rh D Ig
o Preformed–due to • Molar pregnancy
(e.g. prior allergic reaction)
sensitising event • CVS
• Review clinical history After 12+6 weeks gestation
• Miscarriage
• ToP
• CVS, amniocentesis,
No Yes If baby predicted to be cordocentesis
Baby predicted
Rh D negative?
Rh D negative, antenatal • Abdominal trauma
immunoprophylaxis not required • APH (revealed, concealed,
unexplained uterine pain)
• ECV
No

Likely preformed
If baby predicted Rh D positive
anti-D antibodies?
or test inconclusive results or
unavailable/uncertain Sensitising events
• If indicated administer Rh D Ig
as soon as practical within
72 hours of event
At 28 weeks gestation o Do not wait for FMH result
• Retest for anti-D antibodies (when measured)
• Administer first dose of o Give up to 10 days from the
Rh (D) Ig 625 IU IM§ sensitising event (may have
o Can be given before results lower efficacy)
are available
First 12 weeks gestation
Yes
• Dose: Rh D Ig 250 IU IM§
13+0 weeks gestation
• Dose: Rh D Ig 625 IU IM§
• Rh D Ig not required
• Seek specialist obstetric Yes Likely preformed
After 20 weeks gestation
advice • Maternal blood sample for
anti-D antibodies?
• Manage as Rh D sensitised volume of FMH
• Consider NIPA • Dose: Rh (D) Ig 625 IU IM§
• If confirmed FMH ≥ 6 mL of fetal
No red cells (12mL of whole blood),
administer additional
Rh D Ig as advised*
At 34 weeks gestation After birth o If Rh D Ig volume > 5 mL–
• Administer second dose of • Determine baby’s Rh D type administer Rhophylac®
Rh (D) Ig 625 IU IM§ from cord or neonatal blood 1500 IU IV as advised*

Maternal care
• Blood sample for volume of FMH
Baby • Administer Rh (D) Ig 625 IU IM§
(one or more) o Do not wait for FMH result
No Yes
• Rh D Ig not required Rh D positive o Give up to 10 days from birth
at birth? Baby care
• Blood sample for DAT
• Refer to QCG Neonatal jaundice
and Newborn assessment

* as advised by laboratory or specialist obstetrician/feto-maternal specialist

§ draw back on plunger of syringe before injection to ensure the needle is not in a blood vessel and administer by deep IM injection
APH: antepartum haemorrhage CVS: chorionic villus sampling ECV: external cephalic version
FMH: feto-maternal haemorrhage Ig: immunoglobulin IM: intramuscular IUFD: intrauterine fetal death IV intravenous NIPA: non-invasive
prenatal analysis Rh D Ig: Rh (D) immunoglobulin-VF ToP: termination of pregnancy ≥: greater than or equal to

Flowchart F23.74-2-V2-R28

© State of Queensland (Queensland Health) 2024

Rh D negative women and pregnancy
Available from: [Link]/qcg

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Queensland Clinical Guidelines short GUIDE

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© State of Queensland (Queensland Health) 2024

Rh D negative women and pregnancy
Available from: [Link]/qcg

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