RhD-Positive Whole Blood for Patients With Reproductive Potential After Two Randomized Trials of Prehospital Trauma Resuscitation

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.