The role of RhD agglutination for the detection of weak D red cells by anti-D flow cytometry

Anti-D flow cytometry is an accurate method for quantifying feto-maternal haemorrhage (FMH). However, weak D red cells with <1000 RhD sites are not detectable using this methodology but are immunogenic. As quantitation of RhD sites is not practical, an alternative approach is required to identify those weak D fetal red cells where anti-D flow cytometry is inappropriate. We describe a simple algorithm based on RhD agglutination and flow cytometry peak separation. All weak D (n = 34) gave weak agglutination with RUM-1 on immediate spin (grading ≤2.5). In Diamed-ID Diaclon ABO/D or ABO/Rh for Newborn cards two subgroups of weak D were observed. In one subgroup, weak agglutination (grading 3) was observed and the red cells were undetectable by flow cytometry. In the second subgroup, agglutination was strong (grading 4) and the red cells were detectable by anti-D flow cytometry. The accuracy of the quantitation was dependent on adequate separation of the weak D and RhD-negative peaks as in seven of 11 samples <1.11% of an expected 2% red cells were detectable. Monitoring RhD agglutination and flow cytometric peak separation are pivotal if anti-D flow cytometry is to be maintained as the primary technique for FMH quantitation in the routine laboratory.