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Written by Amanda Mathews
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In this new clinical practice guideline, the American College of Obstetrics and Gynecology (ACOG) recommends foregoing routine Rh screening and RhIg prophylaxis for patients undergoing abortion or experiencing pregnancy loss at less than 12 weeks gestation.
ACOG goes negative on Rh screening
Historically, based on expert opinion and indirect evidence of RhIg benefit in full term pregnancies, ACOG recommended giving RhIg to all Rh-negative patients after abortion or pregnancy loss at less than 12 weeks gestation. However, new evidence from higher quality studies in 2020 and 2023 using flow cytometry demonstrated that the level of circulating fetal RBCs in pregnant patients post pregnancy loss was below the threshold for Rh sensitization. Multiple international organizations have also recommended against routine Rh screening and prophylaxis, including the World Health Organization, national societies in the UK and Canada, and the National Abortion Federation. If a patient requests, ACOG recommends utilizing shared decision making with patients regarding Rh screening and RhIg prophylaxis. There still aren’t high-quality clinical studies looking at outcomes such as fetal demise in future pregnancies, so patients may feel that their individual risk is too high to forego testing and prophylaxis. ACOG offers patient education on their website regarding Rh sensitization.
How will this change my practice?
I find this new guideline from ACOG compelling and practice-changing for emergency medicine. I will no longer be ordering routine Rh screening for patients who present with first trimester vaginal bleeding and potential miscarriage. However, due to lack of data on long-term effects on future pregnancies, if a patient requests testing, I still think it is reasonable to do so.
Source
Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation. Obstet Gynecol. 2024 Dec 1;144(6):e140-e143. doi: 10.1097/AOG.0000000000005733. Epub 2024 Sep 10. PMID: 39255498
If we don’t know the long term effects on future pregnancies, why wouldn’t we continue to test and treat if necessary? At worst we’ve ordered an unnecessary test, at best we prevented a future fetal demise.