Does antenatal Anti-D help the current baby?

A number of people have asked me variations on the question, “Does antenatal Anti-D help the current baby?”

And no it does not.

Anti-D is ‘all about the next baby’.

In this blog post, I explain why that is.

Much of the information in this blog post is from my book, Anti-D Explained. If you’d like to know more, you can find out about the book here.

Meet the antigens

First, it’s important to know what an antigen is. An antigen is a substance that is foreign to the body. When an antigen is detected by your body, your body mounts an immune response to it. In simple terms, your body starts to generate antibodies to counteract the antigen. This is called a primary immune response. It leads to the production of antibodies, which we call immunoglobulin M, or IgM antibodies.

Once these IgM antibodies have counteracted the antigen, the body stops producing them. Cleverly, though, your body retains a memory of how it needs to respond if it encounters the same antigen again. That ability stops us from passing the same cold around forever. Once somebody has developed antibodies to a particular antigen, if the same antigen does enter the body again, the body mounts what is known as a secondary immune response. A secondary immune response usually occurs much faster than a primary immune response. The antibodies that it produces will come in a slightly different form. This time, they are called immunoglobulin G or IgG.*

* Yes, I know it’s a bit more complex than this if you dig into the science. Don’t write in. I’m not writing a PhD thesis in immunology. One thesis was enough! I’m writing a blog post because I explain this stuff to lay people and busy professionals who need the basics.

A primary response is what can happen if a rhesus negative woman encounters rhesus positive blood and her body responds to it by creating antibodies.

What would happen naturally?

Sara explains the issues and evidence, answers key questions and shares information about what we do and do not know about Anti-D and related topics from research evidence and current thinking. A vital resource for parents, professionals and birth workers.

Let’s pretend for a moment that we don’t have any injectable Anti-D (Rhogam®). What would happen ‘naturally’?

Well, the woman’s body will recognise the anti-D as foreign.

When that happens, her body will mount a primary immune response. She will make IgM antibodies to the rhesus positive cells. Once the rhesus positive blood cells have all been cleared from her bloodstream, her antibody production will slow down and then stop. But her body will retain the memory of how to create them.

But now we have a problem.

Because if she becomes pregnant with another rhesus positive baby in the future, her body now has a ‘template’ to make IgG antibodies against a substance which might be present in a future rhesus positive baby’s blood. It won’t affect a later baby who is rhesus negative. But if in the future the same woman becomes pregnant with a rhesus positive baby, problems can sometimes follow.

All of this explains why women are offered an injection of Anti-D in various situations. The manufactured version of Anti-D is actually a medicine made from blood containing other people’s antibodies. The blood donors’ Anti-D antibodies ‘clear’ any antigens that a pregnant woman may have in her bloodstream from her rhesus positive baby’s blood.

The manufactured Anti-D prevents the need for the woman’s body to make natural anti-D antibodies. And that means that any future rhesus positive babies the woman might become pregnant with are not at risk from those antibodies.

Why antibody size matters

A very important thing to know at this point is this: IgM antibodies are about six times as big as IgG ones.

IgG antibodies can cross the placenta. IgM antibodies can’t.

So a woman who is mounting a primary immune response to rhesus positive blood cells is not going to be producing the type of antibody that can cross the placenta to harm her growing baby.

But a woman who is mounting a secondary immune response will produce the far smaller IgG antibodies. Those can cross the placenta.

The take home message is this: During the primary immune response which involves the bigger IgM antibodies, the baby in utero is not at risk.

Why timing is key

But the difference between the primary and secondary immune responses is only one part of the answer to this question.

Another element of this is the timeframe of the process of antibody production. Which varies, depending on the antibodies.

Some antibodies can be produced within days. But the primary immune response to the rhesus factor can take up to six months. The rhesus factor isn’t produced in a baby’s blood until near or during the second trimester of pregnancy. And it can take up to six months for the primary immune response to stop.

Don’t forget that the primary immune response doesn’t pose a threat to the current baby because IgM is too big to cross the placenta.

By the time all of these timeframes have been added together, there’s not much chance of that same baby encountering IgG through a secondary immune response. He or she has almost certainly been born before that happens. Future siblings may encounter problems if they are rhesus positive, though. That’s because now their mother has a template for creating IgG antibodies that are small enough to cross the placenta into the baby’s bloodstream.

But Does antenatal Anti-D help the current baby?

No.

Antenatal Anti-D is not about protecting the current baby.

Into the unknown

There is still a lot we don’t know in this area. We know that pregnant women have altered immune systems. This is so that their bodies do not reject their babies. Because at least half of a baby’s genetic material comes from someone else. Sometimes more, when assisted fertility methods are used.

But we don’t know enough about how that works. We are beginning to form some theories about how the altered immunity of a pregnant woman might be related to some of the problems that pregnant women occasionally face. But there is much we don’t know about maternal and fetal immunity in general.

There are also big gaps in our knowledge about Anti-D, sensitisation and related issues. More in my book.

What don’t we know?

As I said above, we know that IgG can cross the placenta. This is generally a good thing. It means that babies in utero gain immunity to things that their mother has already gained immunity to. But it’s not ideal in relation to the creation of anti-D. Given that nature generally gets it right most of the time, is there more that we don’t yet understand about this? Are there things that might affect a woman’s immune response to anti-D?

When a woman decides to have manufactured Anti-D during pregnancy in order to possibly protect her future babies, this will enter the bloodstream of her current baby. We think that about ten per cent of it crosses the placenta. But we don’t know what effect/s this might have on that baby. It’s possible that it might have a different effect on rhesus positive and rhesus negative babies. We don’t know.

There are always more questions. For now, I hope that this has explained why manufactured Anti-D given routinely in pregnancy does not benefit the current baby. It may indeed benefit future babies, if they are rhesus positive, and it is only one tiny element of a bigger picture.

Please also let me finish with a caveat: I am not a haematologist, and our understanding of this area is growing. There is much we don’t know, but things also change. Please always look carefully and critically at information you’re being offered. If your situation is complex and you need expert input that your midwife or doctor can’t offer, you may wish to ask to talk to a haematologist.

For lots more information on Anti-D and related decision-making, see my book, Anti-D Explained. It has been written to explain the issues, answer key questions and share information about what we do and do not know about Anti-D. I look at the pros and cons of this from research evidence and current thinking. I help you understand the risks and benefits and explore what we can and cannot know. The aim is to help you to make the decision that’s right for you.