Dr Mohd Shaiful Ehsan Bin Shalihin, November 2017

Algorithm of approaching Rhesus Negative Mother at Primary Care:

Rhesus Negative mother at booking.
Do Coombs test at 1st visit.

Check / Verified Husband rhesus Status (if possible)

Verified prior blood transfusion history

Husband Rhesus negative Husband Rhesus positive / Unable to

verified / unknown

If yes,
Verified prior history of blood
transfusion with rhesus +ve blood Check indirect Coombs test result
Potential event
product at booking
If none

Treat as other normal / low If +ve

If -ve
risk pregnancy & review
Coombs test result
Repeat Coombs test at
24-26 weeks
Verified potential sensitizing event or
inadequate IM Rhogam coverage in
previous pregnancy or prior sensitizing
event
If +ve If -ve
Refer O+G for level of antibody & further
management (fetal monitoring)

Give IM
Rhogam
**
Dr Mohd Shaiful Ehsan Bin Shalihin, November 2017

Flow of IM Rhogam administration (based on theory)

IM Rhogam
At 28 weeks

500 IU 1000 IU 1500 IU

Repeat Repeat Coombs No need to give

500 IU at 32- 34 test at 32-34 another Rhogam
weeks or at least 4 weeks, if negative or repeat Coombs
weeks gap need to give test post Rhogam
another Rhogam unless there is
sensitizing event

No need to repeat
Coombs test in
between Rhogam or
after given Rhogam
unless there is
sensitizing event
Dr Mohd Shaiful Ehsan Bin Shalihin, November 2017

Flow of IM Rhogam (practice at our Clinic KK Jaya Gading )

IM Rhogam
At 28 weeks

500 IU 1000 IU 1500 IU

Repeat Coombs Repeat Coombs

Repeat test at 32-34 test post Rhogam
500 IU at 32- 34 weeks, if negative at 32-34 weeks, if
weeks or at least 4 need to give negative, need to
weeks gap another Rhogam give another
Rhogam.

Repeat Coombs test

prior to second
Rhogam.

Further Information:

1) At our clinic, we need to monitor again Coombs test post given Rhogam regardless of the dose. This
is because, even though theoretically the above mentioned dose able to cover any potential micro
sensitizing event / cross over circulation between fetus and mother in late trimester, however we still
monitor in case there is inadequate response / cover by the first Rhogam.

2) It is suggested to do the Coombs test at around 32-34 weeks. The benefit of monitoring the Coombs
test is more (superior) compared to the risk of getting inadequate coverage of Rhogam and Hydrops
fetalis.
 Dr Mohd Shaiful Ehsan Bin Shalihin, November 2017

Approach to Sensitizing Event in Rhesus negative mother at primary care:

Sensitizing events
verified

Determine gestational
weeks

Less than 12 weeks 12 weeks to 20 weeks Completed 20 weeks

completed 12 and above
weeks

Complete Miscarriage
miscarriage / require Give IM Rhogam at Give IM Rhogam at
threatened instrumentation least 250 unit, no least 500 unit stat,
miscarriage or / ectopic need refer for refer hospital for
bleeding without Kelihaurer test. Kelihaurer test and
instrumentation further Rhogam
Ectopic or further according to
need of
requirement
No need Rhogam Give Rhogam at instrumentation
least 250unit stat required referral
(and refer hospital
according to case
– eg ectopic)

REFERENCES:

1) Power Point Presentation Dr Siti Azlin (KK Jaya Gading)– Approach to Rhesus Negative Mother in
Pregnancy

2) RCOG – The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis.

3) Uptodate: Prevention of Rhesus (D) alloimmunization in pregnancy.

4) Sabah Obstetric Shared Care Guidelines 2016