What are the management options for an Rh-negative pregnant patient who refuses Rho(D) immune globulin (WinRho)?

Management of Rh-Negative Pregnant Patient Who Refuses RhIg

When an Rh-negative pregnant patient refuses WinRho (RhIg), document the refusal thoroughly, counsel extensively on the severe risks of hemolytic disease of the fetus and newborn in future pregnancies, and implement enhanced monitoring protocols including serial antibody screening and consideration of cell-free fetal DNA testing to determine fetal RhD status. 1

Understanding the Critical Stakes

The consequences of refusing RhIg prophylaxis are substantial and must be clearly communicated:

• Without RhIg prophylaxis, approximately 17% of Rh-negative women will become alloimmunized after pregnancy with an Rh-positive infant 2
• Postpartum RhIg alone decreases alloimmunization rates from 13-17% to 1-2%, and adding the antenatal dose at 28 weeks further reduces this from 1.8% to 0.1-0.2% 1
• Prior to RhIg availability, Rh hemolytic disease caused fetal mortality of 120 per 100,000 live births, which dropped to 1.5 per 100,000 after prophylaxis programs were implemented 2
• As little as 0.1 mL of Rh-positive fetal cells can cause alloimmunization, and fetomaternal hemorrhage occurs in approximately 50% of all deliveries 2

Immediate Counseling Protocol

Document the following discussion points in detail:

• Explain that fetal RBCs display RhD antigens from as early as 6 weeks gestation, making sensitization possible at any point in pregnancy 1, 2
• Emphasize that alloimmunization in this pregnancy will create antibodies that attack Rh-positive babies in all future pregnancies, potentially causing severe anemia, hydrops fetalis, stillbirth, and need for intrauterine transfusions 1
• Clarify that the risks of RhIg administration are extremely low compared to the devastating potential consequences of sensitization 1
• Address specific patient concerns about the blood product nature of RhIg, as informed consent is required prior to administration 3

Alternative Risk Mitigation Strategies

If the patient maintains refusal, implement the following protocol:

1. Determine Fetal RhD Status

• Offer cell-free fetal DNA testing from maternal plasma after 11 weeks gestation, which can detect fetal RhD positivity with accuracy exceeding 99% 1
• If the fetus is confirmed RhD-negative, no prophylaxis is needed and the patient faces no alloimmunization risk 1
• When paternity is certain, offer Rh testing of the baby's father to potentially eliminate the need for prophylaxis if he is Rh-negative 3

2. Enhanced Antibody Monitoring

• Perform antibody screening at the first prenatal visit, at 28 weeks, and consider additional testing at regular intervals throughout pregnancy 3
• If antibodies develop, immediately refer to maternal-fetal medicine for specialized management 1

3. Minimize Sensitizing Events

• Counsel the patient to seek immediate care for any vaginal bleeding, as fetomaternal hemorrhage occurs in 48% of threatened abortions 1
• Avoid unnecessary invasive procedures when possible 3
• For any potentially sensitizing event (trauma, bleeding, procedures), strongly reconsider RhIg administration with renewed counseling 1

Critical Timing Considerations

If the patient changes their mind:

• RhIg should ideally be given within 72 hours of any sensitizing event, but can still provide benefit up to 28 days after delivery or other potentially sensitizing events 1, 3
• The standard antenatal dose at 28 weeks remains the priority timing if the patient reconsiders 1, 3

Documentation Requirements

Your medical record must include:

• Detailed documentation of the counseling provided, including specific risks discussed 3
• The patient's stated reasons for refusal
• Confirmation that the patient understands the implications for future pregnancies
• The alternative monitoring plan implemented
• Repeated offers of RhIg at subsequent visits

Common Pitfalls to Avoid

• Do not assume that early gestational age eliminates risk—sensitization is possible from 6 weeks onward 1
• Do not fail to offer RhIg again at delivery, even if refused antenatally—postpartum administration alone still reduces alloimmunization from 13-17% to 1-2% 1
• Do not neglect to test cord blood at delivery to confirm infant's Rh status, as this information is critical for counseling about future pregnancies 3
• Do not confuse "weak D" (Du-positive) patients with true Rh-negative patients—weak D patients should not receive RhIg 3