Emergent Transfusion and Hemolytic Disease of the Fetus and Newborn Risk Mitigation in Females of Childbearing Potential with Life-Threatening Bleeding: A Clinical Practice Guideline

BACKGROUND: Timely resuscitation of patients in hemorrhagic shock is lifesaving. Blood product composition for massive transfusion protocols varies (whole blood vs conventional component therapy). Current whole blood inventory is predominantly RhD-positive, raising questions about the transfusion approach for females of childbearing potential (FCP). STUDY DESIGN: Working groups were assembled that included experts in trauma surgery, transfusion medicine, hematology, maternal and fetal medicine, emergency medicine, anesthesiology, neonatology, and pediatrics. Patient stakeholders and ethics representatives were included in each working group. An evidence review team at Johns Hopkins University performed systematic reviews and provided final reports. The Delphi method was used to refine recommendations and practice points for each key question that reflected consideration of the following factors: balance of benefits and harms, certainty of evidence, values and preferences, resource use and costs, ethics, equity, and feasibility. RESULTS: Key questions addressed were strategies to increase blood donation and availability of RhD-negative blood products; optimal blood product for FCPs in hemorrhagic shock whose RhD type is not known and RhD-negative low-titer group O whole blood is not available; indications for Rh immune globulin for postexposure D-alloimmunization prophylaxis in RhD-negative FCPs who received RhD-positive blood products; and timing and performance of antibody screening after RhD-positive blood transfusion in RhD-negative FCPs. Here, we report the detailed literature review and analysis, including articles screened, retrieved, assessed, and included, as well as the recommendations with their rationale. Consensus was achieved for all recommendations and practice points. CONCLUSIONS: These recommendations provide guidance for the optimal resuscitation and postresuscitation care of FCP with life-threatening bleeding.