U.S. Preventive Services Task Force

Recommendation Statement

Screening for Rh(D) Incompatibility: Recommendation Statement



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Am Fam Physician. 2005 Sep 15;72(6):1087-1088.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available online at www.ahrq.gov/clinic/3rduspstf/rh/rhup.htm.

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for Rh(D) incompatibility and the supporting scientific evidence and updates the 1996 recommendations contained in the Guide to Clinical Preventive Services, 2d ed.1 In 1996, the USPSTF recommended Rh(D) blood typing and antibody screening for all pregnant women at their first prenatal visit (A recommendation).1 Since then, the USPSTF criteria to rate the strength of the evidence have changed.2  Therefore, this recommendation statement has been updated and revised based on the current USPSTF methodology and rating of the strength of the evidence. Explanations of the current USPSTF ratings and of the strength of overall evidence are given in Tables 1 and 2, respectively.

The complete information on which this statement is based, including evidence tables and references, is available in the brief update3 on this topic on the USPSTF Web site (http://www.uspreventiveservicestaskforce.org). The recommendation also is posted on the Web site of the National Guideline Clearinghouse (http://www.guideline.gov).

Summary of Recommendations

The USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. A recommendation.

The USPSTF found good evidence that Rh(D) blood typing, anti-Rh(D) antibody testing, and intervention with Rh(D) immunoglobulin, as appropriate, prevent maternal sensitization and improve outcomes for newborns. The benefits substantially outweigh any potential harms.

TABLE 1

USPSTF Recommendations and Ratings

The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, or I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A.

The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B.

The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C.

The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D.

The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I.

The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.


USPSTF = U.S. Preventive Services Task Force.

TABLE 1   USPSTF Recommendations and Ratings

View Table

TABLE 1

USPSTF Recommendations and Ratings

The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, or I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A.

The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B.

The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C.

The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D.

The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I.

The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.


USPSTF = U.S. Preventive Services Task Force.

The USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks’ gestation, unless the biologic father is known to be Rh(D) negative. B recommendation.

The USPSTF found fair evidence that repeated antibody testing for unsensitized Rh(D)-negative women (unless the father also is known to be Rh[D] negative) and intervention with Rh(D) immunoglobulin, as appropriate, provide additional benefit over a single test at the first prenatal visit in preventing maternal sensitization and improving outcomes for newborns. The benefits of repeated testing substantially outweigh any potential harms.

The USPSTF found no new evidence addressing the role of screening, new screening tests, new treatment protocols, or potential harms associated with screening and treatment of Rh(D) incompatibility. However, there is preexisting good evidence for the efficacy and effectiveness of blood typing, anti-Rh(D) antibody screening, and postpartum Rh(D) immunoglobulin prophylaxis.

TABLE 2

USPSTF Strength of Overall Evidence

The USPSTF grades the quality of the overall evidence for a service on a three-point scale (good, fair, or poor).

Good:

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair:

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes.

Poor:

Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.


USPSTF = U.S. Preventive Services Task Force.

TABLE 2   USPSTF Strength of Overall Evidence

View Table

TABLE 2

USPSTF Strength of Overall Evidence

The USPSTF grades the quality of the overall evidence for a service on a three-point scale (good, fair, or poor).

Good:

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair:

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes.

Poor:

Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.


USPSTF = U.S. Preventive Services Task Force.

Clinical Considerations

• Administration of a full (300 mcg) dose of Rh(D) immunoglobulin is recommended for all unsensitized Rh(D)-negative women after repeated antibody testing at 24 to 28 weeks’ gestation.

• If an Rh(D)-positive or weakly Rh(D)-positive (e.g., Dμ-positive) infant is delivered, a dose of Rh(D) immunoglobulin should be repeated postpartum, preferably within 72 hours after delivery. Administering Rh(D) immunoglobulin at other intervals after delivery has not been studied.

• Unless the biologic father is known to be Rh(D) negative, a full dose of Rh(D) immunoglobulin is recommended for all unsensitized Rh(D)-negative women after amniocentesis and after induced or spontaneous abortion; however, if the pregnancy is less than 13 weeks, a 50-mcg dose is sufficient.

• The benefit of routine administration of Rh(D) immunoglobulin after other obstetric procedures or complications, such as chorionic villus sampling, ectopic pregnancy termination, cordocentesis, fetal surgery or manipulation (including external version), antepartum placental hemorrhage, abdominal trauma, antepartum fetal death, or stillbirth, is uncertain because of inadequate evidence.

Address correspondence to Ned Calonge, M.D., M.P.H., Chair, U.S. Preventive Services Task Force, c/o Program Director, USPSTF, Agency for Healthcare Research and Quality, 540 Gaither Rd., Rockville, MD 20850 (e-mail: uspstf@ahrq.gov).

The U.S. Preventive Services Task Force recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

REFERENCES

1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2d ed. Baltimore, Md.: Williams & Wilkins, 1996. Accessed online July 5, 2005, at: http://www.ahrq.gov/clinic/cpsix.htm.

2. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med. 2001;20(3 suppl):21–35.

3. Screening for Rh(D) incompatibility: a brief evidence update for the U.S. Preventive Services Task Force. Rockville, Md.: Agency for Healthcare Research and Quality, 2004. Accessed online July 8, 2005, at: http://www.ahrq.gov/clinic/3rduspstf/rh/rhup.htm.

This is one in a series excerpted from the Recommendation Statements released by the U.S. Preventive Services Task Force (USPSTF). These statements address preventive health services for use in primary care clinical settings, including screening tests, counseling, and chemoprevention. This statement is part of AFP’s CME. See “Clinical Quiz” on page 995.

The series coordinator is Charles Carter, M.D., University of South Carolina Family Medicine Residency, Columbia, S.C.


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