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RhD-Positive Whole Blood for Patients With Reproductive Potential After Two Randomized Trials of Prehospital Trauma
Jeremy W Jacobs1, Jeannie Callum, Brian D Adkins
1Division of Transfusion Medicine, Department of Pathology, Microbiology, and Immunology, the Division of Hematology/Oncology, Department of Medicine, and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee; the Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, and Canadian Blood Services, Medical Affairs and Innovation, and the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; the Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, and Children's Health, Dallas, and the Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, Houston, Texas; the Division of Pediatric Hematology, Oncology, Bone Marrow Transplant, and Cellular Therapy, University of Washington, and the Washington Center for Bleeding Disorders, Seattle, Washington; and the Ethics Consultation Service & Pulmonary & Critical Care Medicine Section, Veterans Affairs Loma Linda Healthcare System, and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California.
Abstract:
Low-titer group O whole blood is increasingly used in civilian trauma resuscitation and is usually RhD-positive because RhD-negative whole blood is scarce. For RhD-negative patients and patients of unknown RhD type who retain reproductive potential, transfusion of RhD-positive red cells can cause anti-D alloimmunization and place a future pregnancy at risk for hemolytic disease of the fetus and newborn, a harm that may emerge years after the trauma encounter. The ethical and clinical justification for accepting this risk has depended on the idea that whole blood provides a survival advantage large enough to outweigh the possibility of future reproductive harm. However, two recently published randomized trials of prehospital traumatic hemorrhage found no survival advantage for whole blood over component therapy. Reflecting this evidence, RhD-positive whole blood is ethically unjustified for RhD-negative patients with reproductive potential when compatible products are available. The reproductive harm is distinctive in being preventable through product selection, concentrated in patients who cannot consent during resuscitation, and often compounded by limited access to obstetric care. Institutions should default patients with reproductive potential to RhD-negative products when available until the RhD type is confirmed, guarantee standardized and cost-free follow-up when RhD-incompatible transfusion occurs, and ensure ethical standards within trial protocols.
