# Please help!! Rhogam shot still have questions



## Wendy HS (Jun 9, 2010)

I am o - and husband is o +. I've had 4 pregnancies. My 1st preg. was an early miscarriage, I was bleeding from day one, don't know why. I've since had two o + healthy babies. On my 2nd pregnancy I had two Rhogam shots during pregnancy and one after. On 3rd pregancy I had one during pregnancy and one after, both babies are o +. I was told I had to. I am now pregnant with 4th baby and have learned so much about vaccines and a lot of study about the Rhogam that I am now very nervous about taking it during preganacy, and also confused. I am not sure if my previous Rhogam shots had mercury in them, I didn't even know enough to be scared of this so I proubably would have taken them anyways because I trusted my doctors. My son from my 2nd pregnancy did receive his immunization up to 18 mo. old and we now attribute his unexplained neurological problems to possible vaccine reactions. Of course we can't prove anything and I don't really want to argue about that anyways. LONG STORY!!!! But, alas that is why I've done so much research!!!
My question is: it has been well over the 12 weeks since my last Rhogam shot/ pregnancy (my recent baby is 16 mo. old, I bled with her during the first trimester due to what I was told was low progesterone which they must have taken care of with progresterone pills because it stopped, and she is very healthy)I did not get a Rhogam shot during this time with her, only at 28 weeks and after birth. Isn't my new baby/pregnancy now at risk from conception to 28 weeks from possible bleeds and formation of antibodies? Hasn't that last Rhogam shot worn off so to speak. Is it possible that I could have bled unknowingly (I've been told that it is possible) with this new pregnancy during the first 28 weeks? Why do they wait until 28 weeks if there is any chance of blood mixing before the 28th week at all? I did have the shot after my last pregnancy, so does that mean that this baby is completely safe? if so why on earth do I need a shot at 28 weeks? And if not then why the heck don't they give it every 12 weeks from start to finish if it wears off every 12 weeks? It would seem to me that from the doctors way of looking at things that because I am - and husband is +, and I've already had two positive babies, that if I bleed at anytime during my current pregnancy (even early on, before 28 weeks) I could produce antibodies that could harm not only this baby I am carrying, but any babies to come.
Also I've read an article written by Sheri Nakken, an RN MA who says, quote, " Important point about Rhogam and that is that the antibodies attack all Rh positive cells. If mother's blood mixes with the baby's blood, the antibodies will neutralize the baby's blood cells before the mother can create her own antibodies against the baby. The dilemna is that if the mother's and baby's blood does actually mix it is equally likely that the Rhogam antibodies will cross over and attack the baby itself. This happens frequently but isn't discussed by most doctors." (The whole article can be read by typing in Dangers of Rhogam in Pregancy in your google search). It seems like a pretty straight forward article to me, and it seems to make sense, but yet my RN midwife thinks she is just on her soap box, and she wants me to get the shot. The whole Rhogam during preganancy thing just doesn't make sense to me yet, especially after reading the above referenced article. It seems if this RN is telling the truth,and not just on her soap box (whatever that means) then if I get a Rhogam shot during pregnancy that puts the antibodies in my body ready and waiting to attack/neutralize the + cells that may come over IF our blood mixes, before my body even has a chance to produce antibodies itself, so the shot guareentees the antibodies are their waiting to attack/neutralize any + cells that come across. What the heck keeps them from crossing over the other way and going ahead and attacking the baby? If the + cells can cross over one way, and these antibodies can attack them on one side why can't the antibodies cross over the other way and damage the baby inutero, that is what they say can happen if I don't get the shot and I develope the antibodies myself, what is the big difference between Rhogam antibodies and my own personal antibodies? Please make this make sense because so far it just doesn't. I have no problem getting the shot after pregnancy if this baby is +, but I would sure rather avoid it during pregnancy if at all possible. Surely there has got to be a logical way of answering these questions. I tried to get anwers from my midwife, but all she did was poo poo the article, and say I need the shot. I am fine with you poo pooing the article, but give me specific sufficient reasons why, explain to me that there is no way this can happen. Don't tell me the shot is safe because I've already done research on the shot and I know that there are risks. I just need to figure out which way has more risks, and make the best choice for this baby and future babies. Please reference articles, but realize I've done extensive research on line and have read every article out there it seems.


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## japonica (May 26, 2005)

Hi there...

Just getting the kids off to school, so I can't be as detailed as I'd like right now...

There were a few good threads on rhogam under the Birth/Pregnancy forums. I'd do a search for those and check them out. I recall in one of them a former member discussed this aspect...whether anti-D from the shots could theoretically act in the same manner as one's own antibodies.

And there's a book called Anti-D in midwifery. It might be helpful.

I believe that rhogam has had the thimerosal removed (so trace amounts left).

I was trying to figure out your question. Are you wondering if you're at risk of developing antibodies from not having a shot during the first tri of your current pregnancy? I'm not sure about your care provider, but in my experience, they do not routinely administer rhogam during the first tri unless there has been bleeding or other signs of trauma. It's just not routinely done. And I wasn't aware of a 12 week efficacy period. Someone better tell that to my peris. When I was sent to them for an initial consult after my titer came back positive for being sensitized, one of them brushed me off saying it was probably just residual from my winrho shot (even though it was 7 months later). Then he had to admit I really was sensitized once my titer started going up.

As for why at 28 weeks...it has to do with the greater risk of an internal bleed (even slight) during the third tri. From what I remember, the placenta changes in nature somewhat in the third tri and the risk of this happening is increased. That said, many moms do refuse prenatal shots and wait until after the baby is born and the sensitization rate only increases by 1-2%.

You should be able to have to right to refuse the shot until after birth. Your midwife should support your decision. When I was seeing a midwife for my first, she gave me the option to wait until afterwards or to refuse entirely. FWIW, I did everything "by the book," got all my shots when I was supposed to during pregnancy and ended up sensitized anyway.

Good luck.


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## amnesiac (Dec 28, 2001)

Since this isn't vaccine related I'm moving to Birth & Beyond where I'm sure you'll get more helpful answers.


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## MsBlack (Apr 10, 2007)

Sorry to know that you are wandering around somewhat lost in this rh-factor/RhoGam maze! It can indeed be confusing for anyone who questions conventional 'wisdom' on the matter...I'll try to break it down a bit. This is long, but I hope clarifying for you.

First, it IS known that on the whole, RhoGam has been helpful to most women/babies who use it--we now have far fewer complications/deaths from rh sensitization than before RhoGam was invented.

However, it's also known that it doesn't work for everyone, as one pp has pointed out. And it's known that while RhoGam AFTER birth has been very very helpful, RhoGam administered routinely during pregnancy has not reduced sensitization complications nearly as much as predicted when it was decided to administer it during pregnancy. We still just don't know enough, in spite of the med system's belief in prenatal RhoGam.

So I'm saying that even though most providers do push the prenatal RhoGam, there is not nearly the evidence of it's efficacy as providers like to believe--due to your research, naturally you are a little confused or doubtful. Plus there is the debate over troubles caused by thimerisol (in the past) and by ANY use of blood products (and all RhoGam is still made from blood products).

RhoGam is administered at 28wks because pregnancy is '40wks' or so; it is believed that RhoGam is effective for '12wks or so'. It is also understood that late pregnancy, and most especially during birth, is the most likely time-frame for blood mixing/sensitization to occur.

Have you had antibody screens during this pregnancy? Standard care for rh- moms should include antibody ('titer') screening of your blood every few weeks or so--well, or AT LEAST just before receiving prenatal RhoGam. If you are not carrying any antibodies, then you know you are not sensitized. Of course, if you've had RhoGam in the past 12 or more weeks, then you could test positive for antibodies due to the antibodies in the RhoGam that are now in your bloodstream. Let's say you got a prenatal dose at 16 wks. When it's time for the 28wk dose, you might still have antibodies in your bloodstream from the first dose--so a 'positive antibody screen' at 28wks, before the 2nd shot, would be assumed to be 'positive' due to the first shot.

Yes, the RhoGam antibodies will cross the placenta and can kill some of your babies blood cells. However, prenatal RhoGam is considered 'safe' because the amount of antibodies in a 'standard dose' of RhoGam is considered low enough that not much damage will be done to your babies blood supply--not enough baby blood-cells will be killed to cause your baby any harm. A healthy baby can compensate, can make more blood cells.

However--that standard dose of Rhogam is calculated to 'cover for' blood mixing of about 30 milligrams of your baby's blood mixing with yours. Let's say you got the prenatal shot, then you did suffer some disruption of the placenta during pregnancy or birth. If the amount of baby blood that got into your blood stream was MORE THAN 30 milligrams, then the standard dose of RhoGam would NOT be enough to prevent sensitization.

The way to be sure that the amount of RhoGam you receive is adequate to the task, is to have certain blood tests to actually measure how much baby blood is in your bloodstream. If there is more than 30 milligrams of baby blood present in your bloodstream, then you can get a higher dose of RhoGam--a dose appropriate for the amount of baby blood present. This is only possible IF you know there has been an event that could cause blood mixing/placental disruption: say you had a fall, or a car accident, or some bleeding during pregnancy for unknown reasons--these things can be reason to suspect placental disruption and would be reason to check your blood for the presence of baby's blood cells in your bloodstream.

2 things about this:

1. If you are receiving the 'routine' prenatal RhoGam, you are receiving it because it is already known that you DON'T have blood mixing. At least, providers are *supposed to* give you an antibody screen *before* giving RhoGam--because RhoGam doesn't work if you're already sensitized (and if you're sensitized already, then the RhoGam will just put MORE antibodies in your blood that can harm the baby). Anyway--so the prenatal dose is calculated to cover for a 'potential' blood mixing of about 30 ml. But if, during late pregnancy or birth there is blood mixing of MORE THAN 30ml, then the prenatal shot will NOT cover you. You can end up sensitized anyway.

2. You wouldn't want a higher dose of 'routine RhoGam' prenatally, because you would be crossing that line of assumed safety for baby. A higher dose means more antibodies in your bloodstream, potentially harming your baby. Now, if you DID have an event, and you did get the blood tests to show that your bloodstream was carrying more than 30ml of baby blood cells, then it would be considered safer to have that higher dose of RhoGam, than to ignore it or only get the standard dose.

Let's say there is an event of some kind during your pregnancy, and you are tested and found to be carrying 90ml of baby blood cells in your bloodstream. So, you get a triple dose of RhoGam. This MAY be somewhat of a burden for the baby you are carrying now--but with today's medical technology, it would be thought that most babies could fully survive blood cell destruction caused by the RhoGam. And it would be believed that by getting that triple dose you would be protecting all FUTURE babies--because the RhoGam would prevent sensitization--would prevent your immune system from starting to create it's own antibodies. Because once you start creating antibodies, you will continue to do so over time, it is a 'permanent' condition.

I'm saying that there are no guarantees, no 'absolutes'--but there is a mechanism for 'risk-benefit analysis' in the application of various tests, and the use of RhoGam. Well, that analysis can be useful (if not absolutely helpful to all) IF it is properly put in place. Unfortunately, it is not always properly used. From my own research, I believe that all women should be given the blood tests that actually measure for baby's blood cells in mom's bloodstream, before being given RhoGam after birth. But in most cases, providers go by 'standard protocols' and do not get those tests done. The standard protocol is to simply administer the standard dose of RhoGam--this is cheaper and easier than giving all Rh- moms expensive tests to measure for baby blood cells. Usually, the only time a mom would get those tests is if the provider knew of something during birth that was likely to cause blood mixing--say, placental abruption during labor, or a retained placenta that needed medical extraction.

If those tests were administered to all postpartum rh- moms, then many of them would be shown NOT TO NEED RHOGAM at all--because in most cases, blood mixing does not occur during birth! And for those who did have blood mixing during birth, then those tests would show HOW MUCH blood mixing occurred, and so, how much RhoGam to give the mom.

Anyway--it is my experience that many providers simply follow the protocols of x number of shots given during pregnancy, and everyone gets a shot after birth. They really don't know more in-depth info. Instead of properly applying risk-benefit analysis, it's more about 'cost-benefit analysis'--those thorough blood tests cost more $$, which has to be justified to insurance companies....follow the money.

But you can insist on those tests, yourself.

If I were having a hospital birth, I'd probably get the prenatal shot, because (generally speaking), the way hospitals handle birth and especially placental delivery puts you at higher risk for placental disruption and sensitization. Now, things can happen at home, too--and even some homebirth mws have methods that may increase risk--but I personally would feel the risk was greater in the hospital. Wherever I gave birth, I'd insist on getting postpartum blood tests to see whether or not I was carrying baby blood cells. If not, I'd refuse the postpartum RhoGam. If so, I'd want to be sure to get the right dose of RhoGam.

Most of my clients do NOT get the prenatal shot. None so far have been sensitized. Most do get the postpartum shot, 'just in case'. I don't tell them what to do; I give information and let them make up their own minds. I do urge moms to get those blood tests after birth before deciding whether or not to have the postpartum shot.

Hope this helps! Remember that with birth as with the rest of life, there are no guarantees. We can only make the decisions that seem best to ourselves, with the info and intuitions we have on a subject. Trust yourself, try not to worry about this. You will know what to do.


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## Wendy HS (Jun 9, 2010)

Thank you so much for your help, especially MsBlack. I was told that my antibodies were tested and I am not sensitized as of right now at 21 weeks, which was a comfort due to one miscarriage and two hospital births, with early cord cutting and pulling out the placenta all within minutes of birth. I will be doing this birth with a midwife at her location, and have been assured that the don't cut the cord right away and pull the placenta out.
You did say that the Rhogam during pregnancy could cross over to the placenta and can kill some of the baby's cells. I understand this isn't seriously dangerous with the basic Rhogam amount, but is it possible that can cause Jaundice in the newborn? I've read where they said the Rhogam shot could cause a baby to test direct coombs positive.
I was also told that I could have a small bleed that no one would know about and that would sensitize me and hurt the baby I am carrying now, is that true if I am not sensitized? In otherwords I would never know, but it sounds to me like the safest thing would be if I have any kind of trama or bleeding while carrying this baby to check the level of antibodies and go from there. And I like the suggestion of checking not just the baby's blood (which is all they've ever done for me), but also check to see if there are antibodies present in my blood, and see how much and regulate the Rhogam shot to that. It seems a much better way to protect future pregnancies if by chance I need the shot, and need more of it. Finally I feel like it is making sense and I am getting some answers. Thank you so much, Wendy


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## Emmeline II (Feb 16, 2006)

My understanding is that the 28 week shot is an American practice and that Europe did not have a higher sensitization rate despite only doing the post partum shot.


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## MsBlack (Apr 10, 2007)

Wendy--

Most hospitals do test for maternal antibodies after birth, prior to giving RhoGam, IF the mom has NOT had the prenatal RhoGam. (If you did have the prenatal shot, then antibody testing woud not be conclusive--it would be assumed that any antibodies present are from the prenatal RhoGam itself. Thus you would still be given the postpartum shot).

But understand that the postpartum test that moms can get, to determine whether or not you need RhoGam, is NOT just the antibody screen. The antibody screen only measures antibodies in mom's blood, whether they arose from RhoGam or from mom's own immune system due to actual sensitization. If you did NOT have prenatal RhoGam, and DO carry antibodies after birth, then you are already sensitized and the RhoGam will NOT help you...there has already been blood mixing, and your immune system has already started to create antibodies.

What you want is a blood test that looks for the presence of FETAL BLOOD/hemaglobin within your bloodstream. If you test positive for fetal blood, then you can get a test to determine an approximate amount of baby's blood that is present, so as to give the right RhoGam dose. See, it takes some time for a woman's immune system to 'notice and respond to' the presence of fetal blood. Antibodies are not created instantly, it takes at least 4 days for the immune system to start creating antibodies (no one knows exactly how long--we just know it takes more than 3 days).

So, IF you have NOT had prenatal RhoGam, and IF you do get a negative antibody screen following birth, then you know you were NOT sensitized *during pregnancy*. THEN, ALSO AFTER birth, you can get tested for the presence of fetal blood, to find out if blood mixing occurred *during delivery*. You have these tests in the first couple days following birth, BEFORE your immune system can respond to the presence of fetal blood cells. So, if you do test positive for fetal blood, you can get the RhoGam before your immune system reacts (by creating it's own antibodies that you will create forevermore).

Sensitization from the baby's blood mixing with yours, can happen at any time from about 8-9wks of pregnancy through delivery of the placenta. It can happen during any of your pregnancies. So, you might get a negative antibody screen at 20wks pregnancy, and then a positive screen at 28wks; you might test negative for antibodies through several pregnancies and then positive during another pregnancy. Of course, in normal pregnancy this is quite unusual; normally there is some problem, some event that causes placental disruption and allows baby's blood to leak into mom's bloodstream (including things like amniocentesis and other invasive prenatal med tests).

To be clear, I do not know for sure if a prenatal RhoGam shot can cause a neonate to test positive on direct coombs (antibody test for neonates, to see if maternal antibodies--or antibodies from RhoGam--have caused blood cell destruction in babies). In theory it is possible--but in an otherwise healthy baby, where the mom got only the normal dose of prenatal RhoGam, it seems highly unlikely to be a cause for concern. ANY neonate, even from rh+ moms, can get jaundice, and it is seldom a problem.

This is because in the system of baby-cord-placenta, there is more blood present altogether than the baby actually needs after birth. 'Extra' fetal blood is produced during pregnancy in order to keep up enough pressure within the system of baby-cord-placenta--all 3 have to be 'full' of fetal blood in order for the pressure to be maintained during the continuous flow of blood from baby, through cord, to placenta and back again. At birth, the baby no longer needs all of that blood--only enough for it's own body. Under normal circumstances of birth, the process of cord shutting down, placenta ceasing operation, the amount of blood that remains in the baby is sometimes a bit more than it needs (it's an inexact process, and that is normal). So, a healthy baby's body simply kills off the excess blood cells--the yellow color of jaundice is just evidence that blood cells are breaking down--bilirubin is yellow, bilirubin is a byproduct of blood cell breakdown that mainly exits through the skin, temporarily dying the skin yellowish/orange-y).

Ok, so for babies whose moms are rh+, you don't see 'normal neonatal jaundice' until 24hrs or later, up to about 72hrs onset. For babies of rh- moms, you could see jaundice prior to 24 hrs--this tells us that the blood cell breakdown started BEFORE birth--and is NOT from baby receiving too much blood from cord/placenta, but instead is from maternal antibodies causing baby blood cell death during pregnancy. This is definitely something to watch carefully, through things like the direct coombs test and bilirubin testing. But if that blood cell breakdown is occurring due to RhoGam antibodies from a prenatal shot, then it seems highly unlikely that this jaundice will develop to a dangerous degree.

Healthy babies are growing so fast--this means, all of their cells are dividing/multiplying very rapidly compared to older kids and adults. So, a little blood cell loss from RhoGam should not *in theory* pose a problem--baby is rapidly making new blood cells along with rapidly making all cells.

But I repeat, I don't know for sure, this is not something I've studied in depth and so far, none of my rh- moms--those who did get the prenatal RhoGam--have had babies jaundiced in the first 24 hrs. But this amounts to only a very few moms/babies in my own experience--most of my clients do NOT choose to receive prenatal RhoGam.

I hope this clarifies things.


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## MsBlack (Apr 10, 2007)

by the way--if you are presently NOT sensitized, then you are NOT sensitized! A small unnoticed bleed is NOT necessarily going to cause sensitization; a small amount of fetal blood in your bloodstream may simply be ignored (essentially, simplistically put) by your immune system. Remember that we are talking about your immune system--it's there to protect you from perceived threats. A small unnoticed bleed will not necessarily be seen as a threat needing response from your immune system...that fetal blood will just break down and be excreted through other normal processes of your bloodstream. And again--if you are not sensitized now (seen via antibody screen), then you are NOT sensitized! Could become sensitized later, yes. But a negative antibody screen does mean that your immune system has not yet responded to the 'threat' of fetal blood cells.

Now, a 'small unnoticed bleed' COULD cause sensitization during a pregnancy--it is possible certainly. However, it would be extremely unlikely to harm your presently-carried baby. Even a larger, known bleed is unlikely to harm a presently carried baby! Not impossible, if you have a known and fairly large bleed--especially if it happens early enough in pregnancy to give your immune system several months to go to work creating more and more antibodies...but it's unlikely. This is because it does take time for your immune system to react; and because in MOST cases (but not all, there are individual variations), in most cases a mom's immune system creates more and more antibodies over time--over YEARS. So most often, being sensitized in THIS pregnancy means THIS baby will likely be ok, but your *next* pregnancy puts your *next* baby at higher risk--and the one after that (theoretically) is at even higher risk, and so forth over time and number of pregnancies.

But to be sure, there are no hard and fast rules....only rules of thumb, general trends, LOTS of individual variation.

The main thing seems to be, if you do find that you test positive for antibodies, is to get repeat screens over the course of pregnancy. In some moms, the antibody count rises, posing more danger by the day to their unborn baby. But in some moms, the antibody count does not rise, or rises only a small amount, and does NO harm to the baby. Again, LOTS of individual variation here.

if you are receiving care that includes available antibody testing during pregnancy (something I recommend for all rh- moms, even under hb care), then it is just very unlikely that you will get a 'sneak attack' of antibodies that causes harm without your knowing it's coming.

Not that we can ultimately control this rh- thing...or any aspect of birth or life...but we sure can take steps to gain info, be informed and prepared, to minimize the big surprises and the occurrence of avoidable problems.


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## Pirogi (Apr 5, 2007)

One more thing: the Rhogam package insert states that the rate of sensitization for pregnant Rh D- women who receive NEITHER the 28-week shot nor the shot within 72 hours of birth is 12-13% (so 87-88% of women will not be sensitized even with no anti-D shot at all). When the woman receives the postpartum shot within 72 hours of birth, the incidence drops to 1-2% (98-99% of women will not be sensitized). The prenatal shot at 28 weeks reduces the sensitization rate to 0.1-0.2% (99.8-99.9% of women will not be sensitized). These rates may differ based on location of birth and birth attendant practices.

I was one of the 87-88% who was not sensitized after refusing Rhogam altogether. The previous poster was one of the 0.1-0.2%. That's the problem with statistics; someone will always be a statistic.


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## MsBlack (Apr 10, 2007)

Thanks for those Numbers, Pirogi--I do not have them handy, but what you posted looks right from what I remember of my research a couple years back.


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## Banana731 (Aug 4, 2006)

wow, this is a great thread. Ms black and OP your questions and answers are really clear and accessible. This should be a sticky!


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## Wendy HS (Jun 9, 2010)

To everyone who helped me clear things up about Rhogam. THANK YOU from the bottom of my heart!!!! When you have the information it really helps to make a wise decision and feel more confident in doing the right thing. That is all any of us mom's want. We love our kids and want to do what is best for them. I searched and searched to find solid truthful answers and this is the place that was the most help. Thank you so much, Wendy


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## AlexisT (May 6, 2007)

Quote:


Originally Posted by *Emmeline II* 
My understanding is that the 28 week shot is an American practice and that Europe did not have a higher sensitization rate despite only doing the post partum shot.

The NHS does do 28 week Rhogam. Europe is not a single place. Each country has its own policies and habits.


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## MsBlack (Apr 10, 2007)

I'm glad it was clear....one never knows, and my posts were very long!







The more words, the more possibility of things getting lost in translation....

AlexisT--excellent point! Yes, Europe is many places and policies from nation to nation do vary.

However, to my knowledge the US is a place where maternity care includes various routines (not just rh factor stuff) that have not been adopted by European or other developed nations of the world. GBS testing/protocols, Glucose screening...lots of things. I think this may have to do with both the profit-driven nature of the med/pharm complex in the US, along with our 'litigioius tendencies'. That is, in the US there are numerous standard things that are not so much evidence based as profit and liability based. Sad!

But that is a whole nother discussion....


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## nashvillemidwife (Dec 2, 2007)

Quote:


Originally Posted by *Wendy HS* 
Isn't my new baby/pregnancy now at risk from conception to 28 weeks from possible bleeds and formation of antibodies? Hasn't that last Rhogam shot worn off so to speak. Is it possible that I could have bled unknowingly (I've been told that it is possible) with this new pregnancy during the first 28 weeks?

The baby's blood supply earlier in pregnancy is scant enough that it would be nearly impossible for a bleed small enough to be symptomless would cause your body to trigger an immune response. Remember that the incidence of an unknown bleed is rare to begin with, then consider on top of that how minute risk that a baby with such little blood to trigger a reaction, the risk of sensitization is nearly zero. That's not to say that it never ever happens, but it's so rare that it's not a real concern, even in a culture that is as overly cautious as the U.S. (Remember that we're talking about a symptomless bleed; if you have trauma to your abdomen or vaginal bleeding, the chances and volume of transplacental bleed are much greater.)

Quote:

if so why on earth do I need a shot at 28 weeks? And if not then why the heck don't they give it every 12 weeks from start to finish if it wears off every 12 weeks?
In the third trimester, the baby's blood volume is large enough that it could trigger an immune reaction. 28+12 = 40, so if you get a shot at 28 weeks it should last you until delivery.

Quote:

Also I've read an article written by Sheri Nakken, an RN MA who says, quote, " Important point about Rhogam and that is that the antibodies attack all Rh positive cells. If mother's blood mixes with the baby's blood, the antibodies will neutralize the baby's blood cells before the mother can create her own antibodies against the baby. The dilemna is that if the mother's and baby's blood does actually mix it is equally likely that the Rhogam antibodies will cross over and attack the baby itself. This happens frequently but isn't discussed by most doctors."
This is simply not true and the author is ignorant of how Rhogam actually works. It does not kill the fetal cells, it disguises them from the mother's immune system so they are not recognized and an immune response is not formed. She says herself that the Rh cells are "neutralized", so why does she say the fetal cells are "attacked"? The reason doctors don't talk about it is because it is a lie, not because it's rare. I would not trust anything you read by this author as she's obviously ignorant on the subject.

Quote:

The whole Rhogam during preganancy thing just doesn't make sense to me yet, especially after reading the above referenced article.
It's actually very simple, if you put the above misinformation out of your mind and instead learn the truth (it's not your fault you have misinformation). There is a small chance that in late pregnancy you could have a symptomless transplacental bleed, the risks of which can be greatly reduced with a prophylactic Rhogam shot.

Quote:

I have no problem getting the shot after pregnancy if this baby is +, but I would sure rather avoid it during pregnancy if at all possible.
Of course it's possible to avoid the shot, just say no. It's up to you to determine if the risks of an unknown bleed are worth it to you to have the shot. The risks are small, but don't let anyone tell you they're not real. It's a lie. Also, any risk anyone tells you about Rhogam is purely theoretical. It's your right to decline prenatal Rhogam, but when you do you are weighing small but real risks over theoretical ones. Which outcome are you more comfortable owning?


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## bluebirdiemama (May 2, 2008)

I'm postng here so I can find this thread later. I am o-, and very much against the shot, so interested to read this convo.


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## MsBlack (Apr 10, 2007)

Quote:


Originally Posted by *nashvillemidwife* 

This is simply not true and the author is ignorant of how Rhogam actually works. It does not kill the fetal cells, it disguises them from the mother's immune system so they are not recognized and an immune response is not formed. She says herself that the Rh cells are "neutralized", so why does she say the fetal cells are "attacked"? The reason doctors don't talk about it is because it is a lie, not because it's rare. I would not trust anything you read by this author as she's obviously ignorant on the subject.

Nashvillemidwife--

Can you point me to current literature on this topic? I mean, the part about RhoGam 'disguising' fetal blood cells from the mother's immune system?

From what I could find a couple years back on the topic, while there were a couple different theories about how Rhogam works, it did not seem to me that there was any solid evidence...and some authors were saying, essentially, "no one knows exactly how it works--only that it does work" The 2 working theories out there seemed to be:

1. That the antibodies in Rhogam actually do attack/dismantle Rh+ fetal blood cells in the maternal bloodstream, thus removing a cause for her own immune system to respond to the 'threat' of those Rh+ cells.

2. That the presence of Rhogam antibodies in maternal bloodstream essentially 'tricks' her immune system into 'thinking it had already responded to the threat'--thus rendering mom's immune response unnecessary (by her own immune system's standards).

Or 3, I guess--that both of the above are in operation.

"Neutralizing" fetal blood cells could mean various things; neutralizing is a somewhat open-ended term.

Also--are you saying that you do not think Rhogam crosses the placenta? Are you saying that the antibodies in Rhogam CANNOT kill/neutralize blood cells within fetal circulation? I would like to hear more about this, too, if you have anything on it.

Any directions you could point me to on this would be much appreciated







This is not an easy topic to grasp in entirety and I'm always looking to have a deeper more detailed understanding. Knowledge is ever-changing and expanding, it's good to keep up with the news.


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## momtoafireteam (Aug 8, 2007)

I had both (prenatal and postnatal) rhogam in my first 2 pregnancies, only postnatally with my third and not at all with my fourth pregnancy. I denied it with my fourth pregnancy (fifth baby) because I was sure I would never have another child.

2 years later, pregnant with my 6th child, I really regretted that decision. Thank goodness I was not sensitized when tested at 7 weeks, but the worry was considerable. This time (pending no sensitization later- and my OB is more than willing to keep testing...) I will get postnatal rhogam. Even though this is our last child, I have said that before!!! And to be honest, that 11% is a BIG deal to me. Thats not an inconsequential point-something of a percent, its big. I feel very lucky to have been in that 87% the first time, I am just not willing to do it again.


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## nashvillemidwife (Dec 2, 2007)

I am not claiming that anything doesn't cross the placenta.

Why do I have to be the one to google my evidence for you? Why is no one asking for proof of the false claim that Rhogam attacks fetal cells and the accusations that doctors and researchers are hiding this information from the public? That's the real issue here, so seriously, which claim is more likely? That prenatal Rhogam is a scourge to the public and there's a conspiracy to keep women in the dark about these "dangers"? What would be the purpose?


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## nashvillemidwife (Dec 2, 2007)

Rh O (D Immune Globulin Systemic)

Quote:

*Mechanism of action/Effect:*

By providing passive Rh o(D) antibody, Rh o(D) immune globulin *suppresses the immune response to Rh o(D)-positive blood* in nonsensitized Rh o(D)-negative females. This prevents sensitization to the Rh o(D) erythrocyte factor and the subsequent formation of active Rh o(D) antibody. This in turn prevents the occurrence of Rh hemolytic disease (erythroblastosis fetalis) in Rh o(D)-positive neonates, which results from in utero exposure to maternal Rh o(D) antibody. {01} {02} {03} {05}

The mechanism of action is not fully understood, but *it is thought to be due to the formation of anti-Rh o(D) (anti-D)-coated RBC complexes resulting in Fc receptor blockade, thus sparing antibody-coated platelets.* {21}

*References*
1. HypRho-D Full Dose package insert (Cutter-US), Rev 10/90, Rec 5/93.

2. HypRho-D Mini-Dose package insert (Cutter-US), Rev 9/90, Rec 5/93.

3. RhoGAM (Ortho Diagnostic). In: PDR Physicians" desk reference. 48th ed. 1994. Montvale, NJ: Medical Economics Data Production Company, 1994: 1663.

5. Gamulin Rh package insert (Armour-US), Rev 10/90, Rec 8/93.

21. Product Information: WinRho SDF™, Rho (D) Immune Globulin Intravenous (Human). Nabi, Boca Raton, FL, (PI revised 12/99), reviewed 1/2000.
How can it attack fetal cells when it works by _suppressing_ the mother's immune response to fetal cells? Please explain to me how that makes sense.


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## MsBlack (Apr 10, 2007)

Thanks for the byte of that article, Nashville









I think it is pretty well established on this thread (well, established for me anyway) that RhoGAM supresses a mother's own immune response. However, what is still not clear is whether or not the antibodies in RhoGam, itself, will cross the placenta and cause harm to fetal blood cells.

RhoGam is composed in part from rh antibodies harvested from sensitized women. This means, IN THEORY, that those antibodies could attack fetal blood cells themselves, even while they are busy suppressing mom's own creation of antibodies.

Unless those Rhogam antibodies are somehow 'inactivated'--I just don't know. Seems to be a topic for google search, unless someone else on this thread has already saved a link they wouldn't mind sharing--or perhaps knows a good book whose title/author they would kindly share


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## nashvillemidwife (Dec 2, 2007)

Quote:


Originally Posted by *Wendy HS* 
The dilemna is that if the mother's and baby's blood does actually mix it is equally likely that the Rhogam antibodies will cross over and attack the baby itself. This happens frequently but isn't discussed by most doctors."


Quote:


Originally Posted by *MsBlack* 
RhoGam is composed in part from rh antibodies harvested from sensitized women. This means, IN THEORY, that those antibodies could attack fetal blood cells themselves, even while they are busy suppressing mom's own creation of antibodies.

There is a world of difference between the claim that something that we have no proof of could happen in theory, and the Rhogam is "equally likely" to cause harm to the baby (and the paranoid accusation that doctors are purposely hiding this information from the public). It should bring into the question the accuracy and validity of all the claims in that article.


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## Wendy HS (Jun 9, 2010)

All due respect, " That prenatal Rhogam is a scourge to the public and there's a conspiracy to keep women in the dark about these dangers, what would be the purpose?" MONEY. Many more women now get the shot than before when they were only giving it postnatally. Now all RH - women get the shot before they even know if they are carrying a positive baby. That is double or more the amount of shots the pharm companies and doctors are now getting paid for. With all that said I still believe the doctors are truly out for our best interest, most of them.


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## Wendy HS (Jun 9, 2010)

I really don't want to argue about who is right and who is wrong on the Rhogam front, I really don't know. All I know is I am trying to make the best informed decision I can and yes I want proof from both sides, not speculation and not just somebodys word for it. I appreciate comments from both sides, that is why I continue to study any information offered up to me and I will study some more. Please lets not get personal about this, it is each person's right to make the best decision for their baby, no one needs to make anyone feel guilty about the decision they choose. I already know the risks of not taking the shot, I am trying to find out the risks of taking the shot, that is why I appreciate each point of view. I can tell you that I do not trust a doctor, nurse, the CDC, FDA or Pharma company just because they say I should. I've done enough research to know that they don't always do what is right. I think most doctors and nurses have the best intentions and only want to help, but they can be mislead too, just like me. I don't trust any studies done by the pharm companies or even the CDC or FDA, sorry. Think about Vioxx, think about all the drugs pulled off the market. All I can say about vaccines is I am very leary of any of them. Therefore I am going to research until I feel confident in my decision. I am aware of the risks of not taking the Rhogam. I understand I can become sensitized during this pregnancy without the shot. I know it lowers the chance a small amount "When a woman receives the postpartum shot within 72 hours of birth, the incidence drops to 1-2% (98-99% will not be sensitized). The prenatal shot at 28 weeks reduces the sensitization rate to 0.1%-0.2% (99.8-99.9% of women will not be sensitized)” These rates came from the Rhogam insert so I suspect that unless they are lying and the rates are wrong that is a pretty slim chance that I will be sensitized during pregnancy, even if I don’t take the Rhogam at 28 weeks. I would also love any info on any women who have taken the shot both times and ended up with problems, either their babies or them. I have heard that some women are sueing due to having health problems from the shot, the article I quoted is also not the only article that I have read that talks about problems with the shot prenatally. Another quote, "My biggest objection to antepartum RhoGam is the fact that the baby can be born direct Coombs positive from the Rhogam injection itself. This is one of the contraindications, although rarely mentioned by the drug companies or physicians. I have seen this scenario, where the baby had to be transfused after delivery because of antepartum Rhogam." I hear a lot about why to take the Rhogam, but I do believe there are reasons/risks as to why not to take it, and I do know that the drug companies have great reasons to cover up or pass over any of the risks, they get a lot of money from vaccines and since starting to give it to women prenatally they make even more so there is a bit of conflict of interest there. I am looking for both sides and the truth on both sides. If these things are not a risk that I have mentioned above then just point me to some information that shows there is no chance or any risks of taking the shot. I am more willing to risk my own health than the health of my baby, that is why I am willing to take the postpartum shot if needed. I know the Rhogam shot has Poly 80 in it which is linked to fertility problems. None of this can probably be proven or unproven, but I am sure going to study and ask God for wisdom in making a wise choice. My thing is weighing the risks and seeing which options holds the least amount of risks and going from there. I really appreciate any comments from either side. The reason I ask about any womens own experience with the shot is because I know that all us RH- mom's are bascially the long term study. We are the guinea pigs so the speak. And if there are reactions or problems with women or babies health later on that can be contributed to the shot I personally would like to know. I know I most likely won't get that info from the drug company that makes the shot and proubably not the doctors either. Please keep the info coming. I am not wanting to convince anyone of my beliefs, I just want as much information as I can get. Thanks so much.


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## nashvillemidwife (Dec 2, 2007)

Quote:


Originally Posted by *Wendy HS* 
All due respect, " That prenatal Rhogam is a scourge to the public and there's a conspiracy to keep women in the dark about these dangers, what would be the purpose?" MONEY.

With all due respect in return, most insurance policies in the U.S. barely cover the cost of any Rhogam shot, and sometimes it's difficult to even break even. The NHS in the UK is a government sponsored health program, yet they have found it cost effective for the government to provide this shot for women. I hear this argument about BigPharma all the time and it just doesn't hold water.


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## Wendy HS (Jun 9, 2010)

What I am searching for is the truth, not an arguement, so I wont reply anymore to something that ends up being a dead end arguement about the Rhogam shot. Thank you to all who have been so helpful so far. Can anyone give me more information about the quote "My biggest objection to antepartum Rhogam is the fact that the baby can be born direct Coombs positive from the Rhogam injection itself. This is one of the contraindications, although rarely mentioned by the drug company or physicians. I have seen this scenario, where the baby had to be transfused after delivery because of antepartum Rhogam." This was a quote that was an article reprinted from Midwifery Today, just to give whoever credit. I have no idea who wrote the article. I will try to do some research to find out. The quote concerns me if it is true, that would possibly be a risk factor in taking the shot. Again as I stated I ALREADY know the risk factor of not taking it prenatally, so please don't tell me how horrible of a mom I am because I am considering not taking it while I am pregnant.
Does anyone know about the ingredients, about the poly 80 that is in it? I've been told it causes fertility problems and also immunity problems? Does anyone know of any long term studies done on the Rhogam shot? I've also been told by several women that they did what their doctors said and they took all the recommended Rhogam shots and still ended up sensitized. I now understand why this happens. Are there any women who insist that after their baby is born they go ahead and immediately check their own blood to see if they were sensitized during pregnancy and, then shortly after birth to see how much if any fetal cells are in their blood from delivery and give the shot according to that amount. My understanding is the Rhogam is a one size fits all and only covers up to about 30ml of the babys blood mixing. If I choose to do the extra testing it seems I would have a better chance of not getting sensitized if my baby does end up positive, and our blood does end up mixing. If I go this route with my midwife I need to find out exactly what the tests are, when they need to be done to be accurate, and to even find out if my midwife can do them. I will add the quote about the tests incase anyone can tell me more about them..... "So, personally I think that the most intelligent and safe thing to do for all concerned is to conduct these tests before administering RhoGAM: Kleihauer-Betke (for presence of ANY fetal cells); and if KB is positive, then Rosette test (actual/estimated # of fetal cells). If no fetal cells are found, RhoGAM is not needed. But if they are found in mom's bloodstream, then it is very good to have an idea HOW MANY--because this determines the proper dosage of RhoGAM to give. Most care providers do not do any of these tests, just administer a 'standard dose' of RhoGAM to any Rh- woman during pg and following any of above 'events'. With no fetal blood cells present, again, RhoGAM is unnecessary. AND, one 'standard dose' of RhoGAM only 'covers' the 'average amt' of blood mixing (about 30 mls)--but if mom's blood contains MORE THAN 30mls of baby's blood, then she could still create antibodies after the 'standard dose'. So, knowing how much fetal blood is present helps determine how much RhoGAM to give.

there are cases of women who received RhoGAM and still made antibodies--it is understood for at least some of them, that this occurred because they were not given enough RhoGAM. Care providers made an assumption rather than testing her blood thoroughly. It is also likely that RhoGAM simply doesn't work for everyone--nothing does!
So with all that said, I am still on a quest for more info. on making the best decision. As a happy end to this post my 4 year old precious son saw all the smiley faces and wanted me to put this one on the end of this post.


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## MsBlack (Apr 10, 2007)

Wendy--

I tell moms that the best thing to do postpartum is ask for those tests you mentioned (KB and sheep's rosette) before getting RhoGam--to see if they need the shot in the first place, and if so, then to know how much Rhogam is called for. I have an informed consent doc that they see prenatally (and have to sign off on) to try to be sure that they really understand the issues. I can see that you have already gathered even more info than I provide to clients--that is great, IMO.

Anyway--the cost of those tests, not covered by many insurance companies, is prohibitive to many families. Yes, the money is involved, unfortunately, on all sides. This is the terrible thing about a profit oriented oriented health care system, IMO....and it is so terribly ironic, having read articles lately about the gigantic costs incurred with end-of-life med care for the elderly or terminally ill (trying to keep people alive as long as possible no matter what the cost, even when death is clearly imminent). Ironic that we will spend millions or more such care, but not far less on things like the KB test and so forth.

But it does sound like you know enough to make good decisions about Rh and Rhogam. There are no guarantees, again--only having enough info to make the best possible decisions--then trusting yourself and life as much as you can.


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## Wendy HS (Jun 9, 2010)

Thanks Ms Black for your help and encouragement. It is a hard decision and takes a lot of study and prayer. I have definetly learned a lot here and there's so much more to learn, but I do feel more so much more equipped to make a better decision about me and my baby's health. Thanks so much.


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## honeybee (Mar 12, 2004)

There is a lot of great info here! Thanks!

I am rh negative. I had the rhogam during pg and after birth with ds1. I chose not to have it during pg with ds2 and ds3, who both turned out to be rh-, but had they been positive, I would've gotten the postnatal shot. Now I know I could also ask for the fetal blood tests to see if the shot is necessary after birth.


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## Theogirl (May 28, 2008)

So glad I found this thread. I'm 7 weeks pregnant with baby #3 and trying to make a wise decision. With my first pregnancy, I did take the shot but my son was - as well, so I didn't get the after one. With my second, I decided against the prenatal shot and my daughter turned out to be +. I got tests done and apparently have no antibodies.
So, in summary my understanding is that this baby is okay unless our blood mixes for some reason in time for my body to develop antibodies before it is born. As this will be our last pregnancy, there won't be any future babies to wonder about.
I am planning for a home birth with a midwife, who we'll meet in July. I'll be sure to discuss this with her of course, but I'm curious as to common sense practices to ensure my blood doesn't sensitize. (i.e. no amnio testing, don't get into any car accidents...!)


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## owlgirl (May 9, 2010)

WOW!! Thanks for the lesson! I am O Neg and don't take any shots or meds, just leary. I am faced with the 28 week shot and just found this great info! Thanks!!


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## terra-pip (Aug 30, 2008)

I've had Rhogam shots every pregnancy and after every birth. My third was born about 3 weeks ago and somehow our blood did mix either in pregnancy or labor. And I had an easy normal pregnancy and an easy normal birth. She was jaundiced quicker than is usually seen in newborns. everything was fine...but what if I had not had my Rhogam shot in pregnancy? What ifs I don't wanna think about. I'm o- and my husband and all three kids are A+. With my first two pregnancies I never tested positive in my titers prenatally. And I didn't this time either. But I had positive coombs after this birth. I see no way to prove one way or the other whether that positive coombs was because of my 28 week rhogam. But having had two previous pregnancies without issue makes me think possibly not. I was okay with all the extra blood tests because imo the risk is there. As rare as an unnoticed bleed is, it happened to me somewhere somehow. And I had no pregnancy complications or placental complications with all three of my births. This last time the placenta was 45 minutes in coming but came intact. I passed a very large clot with my second hours after birth but was fine after that. I don't vaccinate my children either because my first is on the spectrum...but imo rhogam is a whole different thing. I've had 6 shots of rhogam, 3 pregnancies and only one to worry us for a minute. Like I've said...I rather do something to prevent the rare thing that my children are at risk for than to face the rare thing actually occuring.

My advice: take your Rhogam shots! You never know.


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