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 Table of Contents  
SHORT ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 84-86

Impact of awareness on routine antenatal antibody screening: A prospective study


1 Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Web Publication22-Apr-2019

Correspondence Address:
Dr. Soumya Das
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_25_19

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  Abstract 


Introduction: A screening test is performed to detect potential health disorders or diseases in people who do not have any symptoms of disease. The major objective of a screening program is to reduce morbidity, mortality and the disease burden. Antenatal antibody screening in India is mainly focused on the detection of anti-D in RhD-negative mother. Hemolytic disease of the fetus and newborn can also be caused by the antibodies directed against other minor red cell antigens among RhD-positive women. Hence, the study was planned to analyze the influence of creating awareness among clinicians and patients towards implementing the universal antibody screening for pregnant women. Materials and Methods: The obstetricians as well as the patients were made aware of the benefits of the screening test at regular intervals during the study period regarding the universal antenatal antibody screening. Results: During the study period, a total of 2336 samples from antenatal cases were screened for red cell antibodies. A positive outcome was evident by the rise in number of RhD-positive samples received in the laboratory for antenatal antibody screening from 18.2% during the prestudy phase to 72.8% in the second phase of the study after the intervention. Conclusion: In a developing country like India, extra efforts should be put by the transfusion service in collaboration with hospital transfusion committee to sensitize the obstetricians about the need and obvious benefits of performing antibody screening in all antenatal cases.

Keywords: Alloimmunization, antenatal antibody screening, awareness


How to cite this article:
Das S, Shastry S, Baliga PB. Impact of awareness on routine antenatal antibody screening: A prospective study. Glob J Transfus Med 2019;4:84-6

How to cite this URL:
Das S, Shastry S, Baliga PB. Impact of awareness on routine antenatal antibody screening: A prospective study. Glob J Transfus Med [serial online] 2019 [cited 2019 Jul 23];4:84-6. Available from: http://www.gjtmonline.com/text.asp?2019/4/1/84/256743




  Introduction Top


A screening test is performed to detect potential health disorders or diseases in people who do not have any symptoms of disease with the major objective of reducing morbidity and mortality.[1] Screening for red cell antibodies is one of such tests recommended during antenatal period.[2] More than 60 different red blood cell (RBC) antigens are capable of eliciting an antibody response; hence, performing antibody screening is a more practical approach than phenotyping for all the antigens.[3] Since the advent and routine administration of RhIg in RhD-negative pregnancies, the prevalence of alloimmunization to D antigen is reduced.[4],[5] The overall prevalence of antibodies to red cell antigens other than “D” antigen as per the available Western literature varies from 0.5% to 2.2%. Some of these red cell alloantibodies do not have a significant impact during pregnancy, whereas others may cause hemolytic disease of the fetus and newborn (HDFN), and its incidence is about 1 in 500 pregnancies.[5],[6],[7] Guidelines to screen all pregnant women for irregular erythrocyte antibodies are well established in various developed countries.[5],[8],[9] There are limited data on alloimmunization rates among pregnant women in a developing country like India, China, and Taiwan.[10] Antenatal antibody screening in India is mainly focused on the detection of anti-D in RhD-negative mothers.[11] HDFN can also be caused by the antibodies directed against other minor red cell antigens among RhD-positive women.[12],[13] Hence, the study was planned to observe the influence of creating awareness among clinicians and patients for universal antibody screening for pregnant women.


  Materials and Methods Top


A prospective study was planned by the department of immunohematology and blood transfusion, from October 2013 to May 2015 at our tertiary care center from South India. The obstetricians as well as the patients were made aware of the benefits of the screening test at regular intervals during the study period. The obstetricians were educated regularly through continuous medical education (CMEs), hospital transfusion committee (HTC) meetings, distributing educational brochures, and one-to-one interaction. For the patients, information sheet was distributed, and display charts were put across the outpatient department. All the data were tabulated in Microsoft Excel sheet. Data were analyzed using SPSS statistical software data sheet (version 14.0, SPSS Inc., Chicago, USA). Data were expressed using descriptive statistics such as frequencies and percentages.


  Results Top


During the study period, a total of 2336 samples from antenatal cases were screened for red cell antibodies. Data were collected and analyzed in three phases: before the initiation (January 2013–September 2013), during the first half (October 2013–July 2014), and during the second half (August 2014–May 2015) of the study period. The median antenatal cases' registration was 2000 (range: 1555–2445) during the three phases. A positive outcome was evident by the rise in number of RhD-positive samples received in the laboratory for antenatal antibody screening, as shown in [Figure 1], from 18.2% during the prestudy phase to 72.8% in the second phase of the study after the intervention.
Figure 1: Number of samples received for antenatal antibody screening

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  Discussion Top


Immune-mediated destruction of the red cell is one of the common reasons for fetal and neonatal anemia. The immune-mediated destruction occurs by maternal antibodies formed against various red cell antigens, in response to fetomaternal incompatibility.[2] It is still a challenge on the part of obstetricians and transfusion specialists to tackle these red cell-alloimmunized pregnancies.

Universal screening of all antenatal women, including Rh-positive women, is highly debated and controversial. Guidelines to screen all pregnant women for irregular erythrocyte antibodies are well established in various developed countries.[5],[8],[9] Majority (71.3%) of samples for antenatal antibody screening were received in the laboratory in the third trimester. Both BCSH and AABB recommend to screen all the pregnancies for unexpected antibodies, at the initial visit, irrespective of the Rh status and a repeat screening at 28 weeks.[8],[9] Koelewijn et al. in the nationwide program in the Netherlands showed that first-trimester screening allows timely interventions for the treatment of HDFN due to non-anti-D antibodies.[14] While Dajak et al. showed that 37% of RBC antibodies missed in the first trimester were detected in the third trimester.[15] There are limited data on alloimmunization rates among pregnant women in a developing country like India.[10] Antenatal antibody screening in India is mainly focused on the detection of anti-D in Rh-negative mothers. The routine and regular antibody screening is mostly performed in RhD negative mothers only.[11] HDFN can also be caused by the antibodies directed against other minor red cell antigens.[12],[13] Some of these have been described in RhD-positive women. In developed countries, already screening comprises with two or even three times during antenatal period, to ascertain detection of all clinically significant antibodies.[5] In a developing country like India, it is still a matter of debate among the obstetricians regarding the cost-effectiveness of the regular antenatal antibody screening.[5] Hence, formulating guidelines for universal antibody screening for pregnant women in India is the need of the hour.

One of the criteria for validity of a screening program is the acceptability by the population, as set by the WHO.[16] Cost–benefit ratio is a major obstacle, in a developing country. In India, only 76.9% of antenatal mothers receive at least one antenatal checkup, according to the National Family Health Survey-III.[17] Antenatal antibody screening is mostly focused for detecting anti-D in D-negative pregnancies. Unlike Western countries, no long-term extensive studies have been conducted in India to assess the severity of non-RhD alloimmunization in causing HDFN. In a developing country an extra effort by the transfusion service in collaboration with the obstetric unit may help in implementing the universal antibody screening in antenatal cases. The present study shows that constant interaction and one to one discussion with obstetricians improved the screening rate among RhD positive pregnancies. Timely diagnosis of alloimmunization in antenatal mother will ensure better patient care and outcome. This rate is high enough to recommend antenatal antibody screening in all cases irrespective of the D antigen status.


  Conclusion Top


The present study supports the existing evidence on the importance of implementing routine antenatal antibody screening in all the cases irrespective of the Rh status. Interventions to change existing clinical practices always go hand in hand with the monitoring of outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Maxim LD, Niebo R, Utell MJ. Screening tests: A review with examples. Inhal Toxicol 2014;26:811-28.  Back to cited text no. 1
    
2.
Murray NA, Roberts IA. Haematology. In: Rennie JM, editor. Rennie & Robertson's Textbook of Neonatology. 5th ed. China: Elsevier Ltd.; 2012. p. 755-90.  Back to cited text no. 2
    
3.
Maheshwari A, Carlo WA. Hemolytic disease of the newborn (erythroblastosis fetalis). In: Kliegman RM, Stanton BF, Schor NF, Geme JW 3rd, St. Behrman RE, editors. Nelson Textbook of Pediatrics. 19th ed. New Delhi: Thomas Press India Ltd.; 2012. p. 615-9.  Back to cited text no. 3
    
4.
Klein HG, Anstee DJ, editors. Haemolytic transfusion reactions. In: Mollison's Blood Transfusion in Clinical Medicine. 12th ed. West Sussex, UK: John Wiley & Sons, Ltd.; 2014. p. 458-98.  Back to cited text no. 4
    
5.
de Haas M, Thurik FF, Koelewijn JM, van der Schoot CE. Haemolytic disease of the fetus and newborn. Vox Sang 2015;109:99-113.  Back to cited text no. 5
    
6.
Basu S, Kaur R, Kaur G. Hemolytic disease of the fetus and newborn: Current trends and perspectives. Asian J Transfus Sci 2011;5:3-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Poole J, Daniels G. Blood group antibodies and their significance in transfusion medicine. Transfus Med Rev 2007;21:58-71.  Back to cited text no. 7
    
8.
Judd WJ; Scientific Section Coordinating Committee of the AABB. Practice guidelines for prenatal and perinatal immunohematology, revisited. Transfusion 2001;41:1445-52.  Back to cited text no. 8
    
9.
British Committee for Standards in Haematology Blood Transfusion Task Force, Gooch A, Parker J, Wray J, Qureshi H. Guideline for blood grouping and antibody testing in pregnancy. Transfus Med 2007;17:252-62.  Back to cited text no. 9
    
10.
Pahuja S, Gupta SK, Pujani M, Jain M. The prevalence of irregular erythrocyte antibodies among antenatal women in Delhi. Blood Transfus 2011;9:388-93.  Back to cited text no. 10
    
11.
Suresh B, Babu KV, Arun R, Jothibai DS, Bharathi T. Prevalence of “unexpected antibodies” in the antenatal women attending the government maternity hospital, Tirupati. J Clin Sci Res 2014;4:22-30.  Back to cited text no. 11
    
12.
Wong KF, Tse KT, Lee AW, Mak CS, So CC. Is antenatal antibody screening worthwhile in Chinese? Br J Haematol 1997;97:917-9.  Back to cited text no. 12
    
13.
Lee CK, Ma ES, Tang M, Lam CC, Lin CK, Chan LC, et al. Prevalence and specificity of clinically significant red cell alloantibodies in Chinese women during pregnancy – A review of cases from 1997 to 2001. Transfus Med 2003;13:227-31.  Back to cited text no. 13
    
14.
Koelewijn JM, Vrijkotte TG, van der Schoot CE, Bonsel GJ, de Haas M. Effect of screening for red cell antibodies, other than anti-D, to detect hemolytic disease of the fetus and newborn: A population study in the Netherlands. Transfusion 2008;48:941-52.  Back to cited text no. 14
    
15.
Dajak S, Stefanović V, Capkun V. Severe hemolytic disease of fetus and newborn caused by red blood cell antibodies undetected at first-trimester screening (CME). Transfusion 2011;51:1380-8.  Back to cited text no. 15
    
16.
Wilson JMG, Junger G. Principles and Practice of Screening for Disease. Geneva: World Health Organization Public Health Paper; 1968.  Back to cited text no. 16
    
17.
Ministry of Health and Family Welfare, Government of India. Maternal health. In: National Family Health Survey-4. Mumbai: Ministry of Health and Family Welfare, Government of India; 2014-15. p. 191-249. Available from: http://www.rchiips.org/NFHS/NFHS-4Reports/India.pdf.  Back to cited text no. 17
    


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