The ethical implications of administering RhD-positive blood products to women of childbearing potential with life-threatening hemorrhage in the context of acute trauma have been recently explored in a recently published essay in Transfusion.
Hemolytic disease of the fetus and newborn (HDFN) is caused by maternal antibodies that cross the placental barrier and destroy fetal red blood cells in pregnancies where the mother is RhD negative and the fetus RhD positive.
In most cases, these antibodies are formed after the maternal immune system enters in contact with fetal red blood cells containing the RhD antigen in a first pregnancy. However, these antibodies can also be created when the mother receives a blood transfusion of a RhD positive blood donor.
In the context of acute trauma associated with life-threatening hemorrhage, the blood type of the patient is usually unknown; therefore, type O RhD negative blood is preferred to avoid transfusion adverse reactions and the production of HDFN-causing antibodies. However, O-negative blood is not always available, and in settings where time is pressing, RhD-positive blood is often used despite the risk of HDFN in the future.
This scenario was illustrated by a case involving a 34-year-old patient with a history of a gunshot wound to the chest at age 19 that required several transfusions of RhD-positive blood. This resulted in a pregnancy complicated with HDFN, which resulted in miscarriage.
As a consequence, the patient developed depression and a substance abuse disorder. In a second pregnancy, the patient told the attending physician: “I would rather have died after the shooting than deal with this again. How could they make that decision without my permission?”
The author argues that in the trauma context, where the patient is unconscious or otherwise unable to answer the question of whether to receive the transfusion with its associated risks, and the physician must make the decision based on what decision is better for the patient, as he lacks enough information to know what the patient would have preferred.
“While we cannot claim individual absolute certainty, an ethical analysis provides strong justification that transfusion of RhD-positive blood to RhD-negative or RhD-unknown females of childbearing potential with life-threatening hemorrhage is an ethically appropriate strategy,” the author wrote.
The author emphasized the importance of appropriate counseling to women of childbearing potential receiving an RhD-positive transfusion as well as screening to determine if they have developed harmful antibodies.
