Clinical validation of routine antenatal anti-D prophylaxis questions the modelling predictions adopted by NICE for Rhesus D sensitisation rates: results of a longitudinal study.

OBJECTIVE: To compare the rates of Rh(D) sensitisations with a policy of restricted routine antenatal anti-D prophylaxis (first pregnancy only) with the rates predicted with universal routine antenatal anti-D prophylaxis (all pregnancies). STUDY DESIGN: A retrospective longitudinal observational study involving 15,500 confinements in Rhesus D negative (Rh(D)-ve) women between 1990 and 2003 in a single health district was conducted. All Rh(D) sensitised pregnancies were identified and evidence for routine antenatal anti-D prophylaxis administration during the first pregnancy was investigated. The rate of Rh(D) sensitisations following a policy of restricted prophylaxis was compared with that predicted with mathematical modelling following universal prophylaxis. RESULTS: There were 50 newly sensitised and 37 previously sensitised pregnancies among 15,596 Rh(D)-ve women. For the calculated 13,575 Rh(D)-ve women whose first confinement was in Oxford and who were eligible for restricted prophylaxis, there were 30 new and 26 previously sensitised pregnancies. Of these 30 new sensitisations, 10 were nulliparae, 12 parity 1, and eight parity 2 or greater (third or later continuing pregnancy); only one of these latter eight women had received routine prophylaxis, four had delivered their first baby before the programme was introduced, and in three documentary evidence could not be confirmed that prophylaxis had been given. There was no difference between a policy of restricted and universal routine antenatal anti-D prophylaxis in the sensitisation rates for women during their third or subsequent pregnancy. CONCLUSIONS: This study has shown that restricted routine antenatal prophylaxis provides continuing protection for subsequent pregnancies although the mechanism for this is unclear. These results challenge the wisdom and expense of a policy of universal prophylaxis and prompt a need for further similar analyses to test the appropriateness of the NICE guideline.

Spiral fracture of the radius: an unusual case of shoulder dystocia-associated morbidity.

BACKGROUND: The most common neonatal complications associated with shoulder dystocia include transient brachial plexus palsy, clavicular fracture, and humeral fracture. Fracture of the fetal radius has not been previously reported. CASE: We encountered a shoulder dystocia with the fetal head in the right occiput anterior position that necessitated the McRoberts maneuver, suprapubic pressure, the Wood and Rubin maneuvers, and extraction of the posterior fetal arm to effect delivery. The 4610-g infant experienced a spiral fracture of the right (anterior) radius and a fracture of the left (posterior) midhumeral shaft. CONCLUSION: Neonatal radial fracture can result from shoulder dystocia or the maneuvers employed for the alleviation of the shoulder dystocia.

Anticonvulsant hypersensitivity reaction in pregnancy.

BACKGROUND: Anticonvulsant hypersensitivity reaction is a multisystem disorder that occurs after exposure to aromatic anticonvulsants. It is potentially fatal, with a mortality rate up to 50%. We report a case of an anticonvulsant hypersensitivity reaction that occurred during pregnancy at 10 weeks' gestation. CASE: A grand multipara was being treated with carbamazapine for a seizure disorder. She developed a maculopapular rash, elevated liver enzymes, and pancytopenia. Withdrawal of aromatic anticonvulsants and supportive therapy resulted in resolution of her illness. The remainder of her pregnancy was uneventful, and she delivered a healthy infant at term. CONCLUSION: All pregnant women treated with aromatic anticonvulsants are at risk for anticonvulsant hypersensitivity reaction, and a high degree of clinical suspicion is essential for diagnosis.

The kinetics of routine antenatal prophylactic intramuscular injections of polyclonal anti-D immunoglobulin.

OBJECTIVE: To observe the pharmacokinetics of intramuscular anti-D immunoglobulin (IgG) given for routine antenatal prophylaxis. DESIGN: Prospective observational study. SETTING: Maternity unit and antenatal serology laboratory in a district teaching hospital. POPULATION: Forty-five rhesus-D-negative pregnant women not sensitised to RhD. METHODS: Serial serum quantitations of anti-D IgG following the intramuscular injections of anti-D IgG 100 microg (500 IU) at 28 and 34 weeks of gestation. Anti-D IgG concentrations were assayed with the RFA-300 continuous flow analyser. MAIN OUTCOME MEASURES: The kinetic profile and duration of detectable anti-D IgG in maternal serum following the first and second injections of anti-D IgG. RESULTS: For the 43 women in whom serial data were collected, there were no detectable differences between pregnancies with an RhD-positive (26) or -negative (17) fetus. Maximum IgG concentrations were detected two to five days following the first anti-D IgG injection and ranged between 0 and 28 ng/mL. Only 30% of women still undelivered at 40 weeks of gestation had detectable IgG at 2 ng/mL or greater. There was a significant relationship between higher maximum values and low maternal surface body area (R2 = 0.204, P = 0.002), but this did not influence duration of persistent IgG. CONCLUSION: Using previously published data, 70% women are not adequately protected with anti-D IgG 12 weeks after the first prophylactic injection. Despite this, previous clinical results suggest that the antenatal prophylaxis schedule used provides adequate protection and that the recommendation for the lowest concentration of protective anti-D IgG antibody levels currently in use is probably overestimated.