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FACTORS AFFECTING SEVERITY
Thesis submitted for partial fulfillment of master degree in pediatrics
BY
HAGAR FAWZEY HASAN EL TAWEEL
(M.B.B.Ch)
Under Supervision by
PROF.Dr. AHMED KHASHBAProfessor of pediatrics
Faculty of Medicine
BENHA University
Dr. MOHAMED BAYOUMYLecturer of pediatrics
Faculty of Medicine
BENHA University
Faculty of Medicine
BENHA University
2012
1
الرحيم الرحمن الله بسم
((علما زدنى ربى وقل))
العظيم الله صدق
(114 طه سورة)
Acknowledgement
2
First, thanks to god for helping me to complete this study.
I would like to express my sincere gratitude and respect to
PROF.Dr. AHMED KHASHBA Professor of pediatrics
Faculty of Medicine BENHA University, for the continuous guidance, supervision and his kind encouragement and support throughout the entire period of the study. It was indeed an honor to work under his supervision.
I also wish to thank Dr. MOHAMED BAYOUMY Lecturer of pediatrics, Faculty of Medicine, BENHA University for his guidance, extreme generosity and valuable advice through this study.
Last but not least, I am very grateful to all the babies that were included in my study and I wish all the best to all babies everywhere.
Table of Contents
Page
3
List of tables 5
List of figures 6
List of abbreviations 7
Aim of work 8
Introduction 10
Part 1: Review of literature Chapter 1: Neonatal hyperbillirubineamia
Chapter 2: ABO blood group system
Chapter 3: ABO hemolytic disease of newborn
Chapter 4: Coombs' test
1314
37
44
56
Part 2: Practical work
Patients and method
Results and analysis of data
6162
66
Part 3: Discussion
Part 4: Summary and Conclusion
Conclusion and recommendation
Summary
References
Arabic summary
List of Tables
Table No.
TitlePage No.
4
1 Causes of Unconjugated Hyperbilirubinemia 23
2 Causes of Conjugated Hyperbilirubinemia 24
3 Differential diagnosis of hyperbilirubinemia 28
4 Suggested maximum indirect serum bilirubin concentrations )mg per/dL( in preterm infants
30
5 Interference according to total bilirubin levels
30
6 Bilirubin / Albumin ratio as an additional factor in determining the need for exchange transfusion
38
7 Antigens of the ABO blood group 41
8 Antibodies produced against ABO blood group antigens
42
9 Phenotype of ABO Blood Group System 42
10 Inheritance of ABO Blood Group 43
List of figures
FIGURE No.
TitlePage No.
1 The pathophysiology of neonatal 20
5
hyperbilirubinemia
2 Kramer’s rule 28
3 Total serum bilirubin and age chart 29
4 The management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation
31
5 Baby under phototherapy 36
6 Guidelines for exchange transfusion in infants 35 or more weeks’ gestation
37
7 Bombay phenotype inheritance 44
8 Direct Coombs' test 57
9 Indirect Coombs' test 58
List of abbreviations
6
7
Aim of work
8
AIM OF THE WORK
The aim of the work is to:
1-Identify maternal, neonatal and environmental factors affecting the course of ABO incompatibility neonatal jaundice and its severity
2- Compare between O–A & O-B blood subgroups incompatibilities in incidence and severity
9
Introduction
Introduction
Jaundice is one of the most common conditions requiring medical attention in
newborn babies. Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life, and about 10% of breastfed babies are still jaundiced at 1 month of age. (Piazza A.J and Stoll B. J., 2007)
Severe hyperbilirubinemia continues to be the most common cause of neonatal readmission to hospitals. Long-term results of severe hyperbilirubinemia, including bilirubin encephalopathy and kernicterus, were thought to be rare since the advent of
10
exchange transfusion, maternal rhesus immunoglobulin prophylaxis and phototherapy. (Michael Sgro et al.; 2006)
The risk factors of neonatal hyperbilirubinemia include race of the patient as Asians have the highest risk followed by Caucasian while the black infant have the lower risk. Other risk factors include breast feeding, pregnancy induced hypertension, diabetes mellitus, obstructed labor, oxytocin use, blood group incompatibility between mother and her baby, passive smoking and prolonged premature rupture of membranes. Family history of previously jaundiced baby as a child whose sibling needed phototherapy is 12 times more likely to also have significant jaundice. Neonatal risk factors include prematurity, sepsis, perinatal asphyxia, delayed passage of meconium and congenital infections, infant with bruising or cephalheamatoma. (Wennberg et al.; 2006)
In a study conducted to Michael sgro, douglas Campbell and vibhuti shah 2006 showed that the percentage of ABO incompatibility as a cause of severe neonatal hyperbilirubinemia is about 51% followed by G6PD about 21.5% other antibody incompatibility about 13% and other causes about 14.5% ABO hemolytic disease of newborn occurring in about 15% of infants with A or B blood type born to blood type O mothers and, unlike non- hemolytic disease of newborn. ABO incompatibility is usually a problem of the neonate rather than of the fetus, A and B antigens are only weakly expressed on neonatal RBCs. ABO hemolytic disease of newborn therefore usually mild and characterized by negative or weakly positive Coombs' test. ABO hemolytic disease of newborn rarely requires whole blood exchange transfusion, in contrast to hemolytic disease of newborn due to anti-D or other antibodies.(Kathryn Drabik-Clary et al; 2006)
In a study of demographic characteristic of newborn who did and who did not develop significant hyperbilirubinemia following serum bilirubin measurement and the use of the critical bilirubin levels of 4 mg/dl and 6mg/dl at the sixth hours of life will predict that the incidence of O-A blood group incompatibility is higher than that of O-B blood group incompatibility in newborns who will develop significant hyperbilirubineamia. (Olcay Oran et al.; 2002)
Several studies have established that ABO hemolytic disease is more common in blacks and in children of mixed racial origin than among other races. For Caucasian
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populations about one fifth of all pregnancies have ABO incompatibility between the fetus and the mother. (Wang, M. et al.; 2005)
In a study of hemolysis and hyperbilirubinemia in ABO blood group incompatibility in neonates it was documented that 62% of O-B incompatibility hemolytic disease develop hyperbilirubinemia in contrast to 46.8% of O-A blood group incompatibility hemolytic disease and it appear earlier in O-B incompatibility than O-A incompatibility despite that hyperbilirubinemia in the first 24 hour about 48.1% caused by O-B incompatibility while about 93.9% caused by O-A incompatibility. (Johnson l et al.; 2009)
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Review of literature
Chapter 1: Neonatal Hyperbilirubinemia
Historical background
Neonatal jaundice may have first been described in a Chinese textbook 1000 years ago. Medical theses, essays, and textbooks from the 18th and 19th centuries contain discussions about the causes and treatment of neonatal jaundice. In 1875, Orth first described yellow staining of the brain, in a pattern later referred to as kernicterus. (Thor W.R. Hansen, 2011)
Definition Jaundice is a yellowish discoloration of skin and mucous membranes. It is caused by elevated serum concentration of bilirubin. Newborns appear jaundiced when it is >7mg/dl., (Martin and Cloerty, 2008)
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Neonatal jaundice usually happens during the first weeks of life. There are many types of jaundice, including:
* Physiologic jaundice * Breast-feeding jaundice
* Breast milk jaundice (human milk jaundice syndrome)
* Jaundice caused by hemolysis or increased bilirubin production
* Jaundice caused by inadequate liver function (due to inborn errors of metabolism, prematurity, or enzyme deficiencies). The yellow coloring is caused by bilirubin, a waste product created by the body when it breaks down red blood cells in the normal course of metabolism. (J. Thomas Megerian, 2011)
Incidence Hyperbilirubinemia is a common and, in most cases, benign problem in neonate. Jaundice is observed in 1st week of life in approximately 60% of term infant and 80% of preterm infant. (Piazza and Stoll, 2007) The incidence of Jaundice is higher in breast- fed babies than in the formula- fed ones. Asian male babies and Native American ones are reported to be most affected by Neonatal Jaundice. They are followed by Caucasian infants who in turn are followed by African Neonates. Babies who are either small or large for gestational age are at an increased risk of developing Neonatal Jaundice. (Sumana, 2011)
Pathophysiology of hyperbilirubinemia
Bilirubin
Bilirubin (formerly referred to as hematoidin) is the yellow breakdown product of normal heme catabolism. Heme is found in hemoglobin, a principal component of red blood cells. Bilirubin is excreted in bile and urine, and elevated levels may indicate certain diseases. It is responsible for the yellow color of bruises, the yellow color of urine (via its reduced breakdown product, urobilin), the brown color of feces (via its conversion to stercobilin), and the yellow discoloration in jaundice. (Pirone C. et al; 2009)
During the neonatal period, metabolism of bilirubin is in transition from the fetal stage during which the placenta is the principal route of elimination of the lipid-soluble (unconjugated bilirubin) to the adult stage, during which the water-soluble (conjugated form) is excreted from hepatic cells into biliary system and gastrointestinal tract. (Piazza and Stoll, 2007)
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Source of Bilirubin
Bilirubin is formed by breakdown of heme present in hemoglobin, myoglobin, cytochromes, catalase, peroxidase and tryptophan pyrrolase. Enhanced bilirubin formation is found in all conditions associated with increased red cell turnover such as intramedullary or intravascular hemolysis as (hemolytic, dyserythropoietic, and megaloblastic anemias). Heme consists of a ring of four pyrroles joined by carbon bridges and a central iron atom (ferroprotoporphyrin IX). Bilirubin is generated by sequential catalytic degradation of heme mediated by two groups of enzymes: Heme oxygenase & Biliverdin reductase. (Namita Roy-Chowdhury et al; 2012)
Metabolism of bilirubin
Bilirubin metabolism includes 5 steps:
1) Production 2) Transport
3) Uptake 4) Conjugation
5) Excretion
1-Production of Bilirubin
Heme oxygenases are the initial and rate-limiting enzymes in the breakdown of heme (iron protoporphyrin IX) that itself plays an essential role in the transport of oxygen and mitochondrial electron transport as a cofactor of hemoglobin, myoglobin, and cytochromes. Degradation of heme generates carbon monoxide, iron, and biliverdin, the latter of which is subsequently converted to bilirubin by biliverdin reductase. (Stuart T. Fraser et al; 2011)
a) The Fe released is reincorporated into hemoglobin. b) The CO is excreted unchanged in the lung, where the amount serves as a measure of
bilirubin synthesis. (Shapiro, 2003) Catabolism of 1 mol of hemoglobin produces 1 mol CO and bilirubin. Increased bilirubin production as measured by CO excretion rate accounts for the higher bilirubin level seen in Asian, Native American, and Greek infants. (Agarwal & Deorari, 2002)
2- Bilirubin Transport 15
Unconjugated bilirubin is extremely poorly soluble in water; it is present in plasma strongly bound to albumin. The dissociation constant for the first albumin-binding site. (Johan Fevery, 2008)
If the albumin-binding sites are saturated, or if unconjugated bilirubin is displaced from the binding sites by medications (e.g. sulfisoxazole [Gantrisin], streptomycin, vitamin K), free bilirubin can cross the blood-brain barrier. (Mocrschel et al., 2008)
Bilirubin Exists in 4 Different Forms in Serum:
1. Unconjugated bilirubin reversibly bound to albumin which makes up the major portion of unconjugated bilirubin in serum.
2. A tiny fraction of unconjugated bilirubin not bound to albumin "free" bilirubin. 3. Conjugated bilirubin, water soluble and easily excreted in both urine and bile. 4. Conjugated bilirubin covalently bound to albumin called delta bilirubin. This fraction is
virtually absent in the first 2 weeks of life, but account for a significant portion of the
total bilirubin in patients with cholestatic jaundice. (Chung et al., 2004)
3-Uptake of Bilirubin:
In the liver, bilirubin dissociates from albumin and enters the hepatocyte probably by carrier mediated diffusion. There is a significant amount of evidence indicating that bilirubin movement across the hepatocyte membranes is bi-directional; it has been estimated that up to 40% of the bilirubin taken up by the hepatocyte refluxes unchanged back into plasma. Efficient hepatic uptake of bilirubin is dependent on adequate hepatic blood flow. Conditions associated with a persistent ducts venous shunt, hyperviscosity or hypovolemia can lead to decreased hepatic perfusion, decreased hepatic bilirubin uptake and unconjugated hyperbilirubinaemia. (Doumas et al., 2004)
4-Conjugation of Bilirubin:
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In the liver it is conjugated with glucuronic acid by the enzyme glucuronyltransferase, making it soluble in water. Much of it goes into the bile and thus out into the small intestine. Some of the conjugated bilirubin remains in the large intestine and is metabolised by colonic bacteria to urobilinogen, which is further metabolized to stercobilinogen, and finally oxidised to stercobilin. This stercobilin gives feces its brown color. Some of the urobilinogen is reabsorbed and excreted in the urine along with an oxidized form, urobilin. Although the terms direct and indirect bilirubin are used equivalently with conjugated and unconjugated bilirubin, this is not quantitatively correct, because the direct fraction includes both conjugated bilirubin and delta bilirubin which appears in serum when hepatic excretion of conjugated bilirubin is impaired in patients with hepatobiliary disease). (Kliegman & Behrman, 2007)
5-Bilirubin Secretion and Excretion
Conjugation is an important step in unconjugated bilirubin (UCB) catabolism. A very small amount of UCB is excreted into bile without conjugation. Unconjugated bilirubin in bile is seldom more than 2% of total bilirubin and is believed to be derived in large part from hydrolysis of secreted conjugates in the biliary tree. (Kuroda et al., 2004)
Enterohepatic circulation
Conjugated bilirubin is hydrolyzed in the intestine to UCB, which can be reabsorbed into the enterohepatic circulation. Hydrolysis of conjugated bilirubin to UCB can occur none enzymatically under the influence of mild alkaline conditions as in the duodenum or jejunum (Halamek and Stevenson, 2002), and enzymatically by beta-glucuronidase. (Martin and Cloerty, 2008)
Conjugated bilirubin must be hydrolyzed to UCB before the tetrapyrrole ring be reduced to the colorless urobilinogens by the intestinal anaerobic bacteria (3 Clostridia species and Bacteroides fragilis). Intestinal bacteria can prevent enterohepatic circulation of bilirubin by converting CB to urobillinoids, which are not substrates for beta-glucuronidase. (Martin and Cloerty, 2008)
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Fetal Bilirubin Metabolism
Aged or damaged foetal RBCs are removed from the circulation by reticuloendothelial cells, which convert heme to bilirubin. This bilirubin is transferred into hepatocytes. Glucuronyl transferase then conjugates the bilirubin with uridine diphosphoglucuronic acid to form bilirubin diglucuronide which is secreted actively into the bile ducts. Bilirubin diglucuronide makes its way into meconium in gut but cannot be eliminated from the body, because the fetus does not normally pass stool. The enzyme β-glucuronidase, present in the fetus' small-bowel is released into the intestinal lumen, where it deconjugates bilirubin glucuronide; free (unconjugated) bilirubin is then reabsorbed from the intestinal tract and re-enters the fetal circulation. Fetal bilirubin is cleared from the circulation by placental transfer into the mother's plasma. The maternal liver then conjugates and excretes the fetal bilirubin. (Merck, 2010) At birth, the placenta is “lost,” and although the neonatal liver continues to take up, conjugate, and excrete bilirubin into bile so it can be eliminated in the stool, neonates lack proper intestinal bacteria for oxidizing bilirubin to urobilinogen in the gut; consequently, unaltered bilirubin remains in the stool, imparting a typical bright-yellow color. In many neonates, feedings cause the gastrocolic reflex, and bilirubin is excreted in stool before most of it can be deconjugated and reabsorbed. However in many other neonates, the unconjugated bilirubin is reabsorbed and returned to the circulation from the intestinal lumen (enterohepatic circulation of bilirubin), contributing to physiologic hyperbilirubinemia and jaundice.(Merck, 2010)
Bilirubin as Antioxidant
Bilirubin has the ability to function as an antioxidant in the brain, scavenging free radicals and protecting the brain against oxidative damage. (Jay Gordon, 2011)
The proposed mechanisms by which heme oxygenase exerts cytoprotective effects include its abilities to degrade the pro oxidative heme to produce biliverdin and subsequently bilirubin and to generate carbon monoxide, which has anti proliferative and anti inflammatory as well as vasodilator properties (Morita, 2005).
Pathophysiology of neonatal hyperbilirubinemia
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Figure (1): The pathophysiology of neonatal hyperbilirubinemia (Maisels, 2005).
Risk factors of neonatal hyperbilirubinaemia
The following factors increase babies’ chances of developing newborn jaundice:
Premature babies born before 36 weeks of pregnancy. Babies who had a brother or sister treated for jaundice. Baby has a different blood type than mother, resulting in hemolysis. Babies of East Asian, Mediterranean, or Native American descent. Babies who are not feeding well, breast or bottle. Babies with large bruises or a condition called cephalhematoma (bleeding under the scalp
related to labor and delivery). Since many red blood cells are broken down when large bruises heal, more bilirubin than usual is traveling in the blood.
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Babies with high bilirubin levels or signs of jaundice in the first 24 hours of life (before leaving the hospital) will be watched carefully by the doctor even after they have left the hospital.
Certain liver enzyme deficiencies. Infection.
(J. Thomas Megerian, 2011)
Classification of neonatal hyperbilirubinaemia
The causes of neonatal hyperbilirubinaemia can be classified into three groups based on mechanisms of accumulation:
a) Increased bilirubin production: This may occurs due to decreased RBC survival,
increased ineffective erythropoiesis and increased enterohepatic circulation.
b) Defective uptake of bilirubin
c) Defective conjugation of bilirubin
d) Decreased hepatic excretion of bilirubin.
(Camilla and Clohert, 2003)
Neonatal hyperbilirubinaemia can also be classified into:
A) Physiological jaundice.
B) Pathological jaundice "Non - physiological ".
A) Physiological jaundice:
Most infants develop visible jaundice due to elevation of unconjugated bilirubin concentration during their first week. This common condition is called physiological jaundice.
Essentials of diagnosis and typical features of physiologic jaundice:-
Visible jaundice appearing after 24 hours of age. Total bilirubin rises by < 5 mg/dl (86 mmol/L) per day. Peak bilirubin occurs at 3-5 days of age, with a total bilirubin of no more than 15 mg/dl
(258 mmol/L).
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Visible jaundice resolves by 1 week in the full-term infant and by 2 weeks in the preterm
infant. (Thilo and Rosenberg, 2009)
This pattern of jaundice classified into two periods:
In phase one the term infants' jaundice lasts for about 10 days with a rapid rise of serum bilirubin up to12 mg/dL, but preterm infants' jaundice lasts for about two weeks, with a rapid rise of serum bilirubin up to15 mg/dL.
In phase two bilirubin levels decline to about 2 mg/dL for two weeks. Preterm infants can last more than one month.
(McDonagh.; 2007)
B) Pathological jaundice
Any of the following features characterizes pathological jaundice:
1. Clinical jaundice appearing in the first 24 hours or greater than 48hrs of life.2. Increases in the level of total bilirubin by more than 8.5 umol/l (0.5 mg/dL) per hour or
(85 umol/l) 5 mg/dL per 24 hours.3. Total bilirubin more than 331.5 umol/l (19.5 mg/dL) (hyperbilirubinemia).4. Direct bilirubin more than 34 umol/l (2.0 mg/dL).
(Miguel Helft, 2007)
Neonatal hyperbilirubinaemia can also be classified into:** Unconjugated hyperbilirubinemia:Table (1) Causes of Unconjugated HyperbilirubinemiaHemolytic disease (hereditary or acquired)-lsoimmune hemolysis (neonatal; acute or delayed transfusion reaction; autoimmune)-Rh incompatibility, AB0 incompatibility and other blood group incompatibilities-Congenital spherocytosis -Hereditary elliptocytosis -Infantile pyknocytosisErythrocyte enzyme defects-G6PD deficiency -Pyruvate kinase deficiencyHemoglobinopathy-Sickle cell anemia -ThalassemiaOthers
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-Sepsis -Hemolytic Uremic syndrome-Drugs as vitamin K and maternal oxytocin-infection -Polycythemia as in Diabetic mother, Fetal transfusion (recipient) and Delayed cord clampingDecreased delivery of UCB (in plasma) to hepatocytes:-Right-sided congestive heart failure -Portacaval shuntDecreased bilirubin uptake by hepatocytes membrane:-Breast milk jaundice -Lucey- Driscoll syndrome-Hypothyroidism -Hypoxia -AcidosisDecreased storage of UCB in cytosol:-Competitive inhibition -Fever Decreased conjugation:-Neonatal jaundice (physiologic) -inhibition (drugs) -Gilbert disease-Hereditary (Crigler-Najjar) Type I (complete enzyme deficiency) and Type Il (partial deficiency)INCREASED ENTEROHEPATIC CIRCULATION-Breast milk Jaundice -intestinal obstruction-Hirsch sprung disease -Cystic fibrosis-Pyloric stenosis -Antibiotic administration
(Balistreri, 2008)
** Conjugated hyperbilirubinemia:
Conjugated hyperbilirubinemia is a sign of hepatobiliary dysfunction. It usually appears in the newborn infants after the first week of life, when the direct bilirubin level is > 2.0 mg per dL and > 20% of the TsB. It is always pathologic. (Barasotti, 2004) Table (2): Causes of Conjugated Hyperbilirubinemia
INFECTIOUSGeneralized bacterial sepsis, viral hepatitis, cytomegalovirus, rubella virus, herpes virus: H5V, HHV 6 and 7, varicella virus, coxsackie virus, echovirus, parvovirus B19, HIV, syphilis and tuberculosis.
22
TOXICParenteral nutrition related, sepsis (urinary tract) with end-toxemia and drug relatedMETABOLICDisorders of amino acid metabolismTyrosinemia, Wolman disease, Niemann- Pick disease&Gaucher disease,Disorders of carbohydrate metabolismGalactosemia, fructosemia and glycogenesis lVDisorders of bile acid biosynthesisOther metabolic defectsα1-Antitrypsin deficiency, cystic fibrosis, idiopathic hypopituitarism, hypothyroidism and childhood cirrhosis.GENETIC/CHROMOSOMAL.Trisomy E and Down syndromeINTRAHEPATIC CHOLESTATIC SYNDROME"ldiopathic neonatal hepatitis, familial intrahepatic cholestasis and congenital hepatic fibrosisEXTRAHEPATIC DISEASESBiliary atresia, sclerosing cholangitis, choledochal- pancraeaticoductal junction anomaly, choledochal cyst & bile/ mucous plug ('lnspisated bile')MISCELLANEOUS-Shock and hypo perfusion-Associated with enteritis-Associated with intestinal obstruction-Neonatal lupus erythematosus-Myeloproliferative disease (trisomy 21 )
(Bezerra &Balistreri, 2008)
Complications of Neonatal Jaundice
** Acute bilirubin encephalopathy
Bilirubin is toxic to cells of the brain. If a baby has severe jaundice, there's a risk of bilirubin passing into the brain, a condition called acute bilirubin encephalopathy. Prompt treatment may prevent significant permanent damage. The following signs may indicate acute bilirubin encephalopathy in a baby with jaundice:
Listless, sick or difficult to wake High-pitched crying
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Poor sucking or feeding Backward arching of the neck and body Fever Vomiting (Lease M. et a; 2010)
** KernicterusCauses It is a neurological syndrome resulting from the deposition of UCB in brain nuclei. In the past UCB was shown to impair mitochondrial tissues in the brain. Paper showed that UCB decrease cell membrane potential and disrupts transport of neurotransmitters. UCB also inhibits protein phosphorylation in brain membranes and glycolysis in brain as well as interferes with intracellular calcium homeostasis and glutamate efflux.(Shapiro 2005) Microglia cells and astrocytes damaged by UCB produce cytokines that may contribute to brain toxicity. (Fernandes et al., 2006)
Symptoms
The symptoms depend on the stage of kernicterus.Early stage:
- Extreme jaundice - Poor feeding or sucking- Extreme sleepiness (lethargy)
Mid stage:- High-pitched cry - Seizures- Arched back with neck hyperextended backwards
Late stage (full neurological syndrome):- High-frequency hearing loss - Mental retardation- Muscle rigidity - Speech difficulties
(Milton S. Hershey, 2011 )
** Neonatal cholestasis Assessment:History
- Scleral icterus may be apparent at conjugated bilirubin levels as low as 2 mg/dL.
- Dark urine at higher levels of conjugated bilirubin.- Cutaneous jaundice - Severe pruritus secondary to elevated bile acids.
(Poddar U. et al., 2009)
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Physical- Physical evidence of scratching or excoriation if they also have severe bile acid
retention.- Xanthomas look like small white papules or plaques - Failure to thrive with altered anthropometrics, such as reduced height and
reduced weight for height due to fat malabsorption. (Poddar U et al, 2009)
Laboratory Studies- Serum bilirubin levels (total and direct bilirubin levels) - Total serum bile salt concentration levels - Qualitative serum and urine bile acids - The total serum cholesterol level - Serum lipoprotein-X levels - Serum alkaline phosphatase levels - Serum 5'-nucleotidase levels - Serum gamma-glutamyl transferase (GGT) levels
(Suchy FJ. 2004)Imaging Studies
- Ultrasonography of liver and bile ducts - Abdominal CT scanning - Biliary nuclear medicine study (i.e., hepatoiminodiacetic acid [HIDA] scanning) - Endoscopic retrograde cholangiography - Percutaneous trans-hepatic cholangiography
(Suchy FJ, 2004)Procedure
- Liver biopsy - Exploratory surgery - Operative cholangiography is simple, straightforward, time-efficient, and
definitive. (Arnon R et al., 2012)
Diagnosis of Hyperbilirubinaemia
A-History:
• Family history:
A family history of anemia, splenectomy, or early gall bladder stones may be suggestive of hereditary haemolytic blood disorder. A history of previous siblings with jaundice and anemia may suggest blood group incompatibility, breast milk jaundice or G-6PD deficiency. A family
25
history of liver diseases may suggest galactosemia, alph1-antitrypsin deficiency or cystic fibrosis. (Bhutani and Johnson, 2004)
• Maternal history:
Maternal illnesses during pregnancy may point to maternal diabetes, congenital viral infection or toxoplasmosis, and maternal medications should be reviewed. History of instrumental delivery, oxytocin induced labor, delayed cord clamping, and Apgar score should be obtained. (Diane and Madlon-Kay, 2002)
• Neonatal history:
History of delayed passage of meconium or infrequent stool may suggest increased enterohepatic circulation of bilirubin. History of vomiting may indicate sepsis, galactosemia, or pyloric stenosis. (Bhutani and Johnson, 2004)
B-Physical Examination:
The jaundiced neonate requires a full physical examination with emphasis on the following:
General: Child look and difficulty feeding.
Vitals: In hemolytic states, there can be an increase in heart rate and respiration rate as well as poor perfusion. Fever also detected.
Growth Parameters: Obtain length, weight and head circumference and compare to measurements taken at birth.
Surface: Is there pallor? Sclerae and mucous membranes should be closely inspected for jaundice. Look for cephalohematoma or bruising.
Cardiovascular: Heart rate, pulse, blood pressure, apex site, perfusion. Severe haemolytic processes can result in heart failure.
Respiratory: Respiration rate and rhythm and oxygen saturation. If the neonate is in heart failure, there may be respiratory signs.
Abdomen: Is the abdomen distended? Are there any masses? Check for hepatomegaly and splenomegaly and or areas of tenderness?
Neurologic: Level of consciousness. Cranial nerves, tone, gross motor movements, quality of the cry, and primitive reflexes (Moro, grasps, tonic-neck and step).
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Figure (2): dermal zones and indirect bilirubin levels (Maisels, 2006)
Differential DiagnosisThe differential diagnoses of neonatal hyperbilirubinemia are summarized in (Table 3).
Table (3): Differential diagnosis of hyperbilirubinemia.
Jaundice appearing at birth or within 24 hours: sepsis, erythroblastosis fetalis, concealed hemorrhage, rubella, congenital toxoplasmosis.
Jaundice appearing on the 2nd or 3rd day: physiologic jaundice of the newborn -severe type-, Crigler- Najjar syndrome.
Jaundice appearing after the 3rd day, within the 1st week: septicemia, syphilis, and toxoplasmosis.
Jaundice appearing after the 1st week: breast milk jaundice, septicemia, hepatitis, biliary atresia, galactosemia, hypothyroidism, spherocytosis (congenital hemolytic anemia) and G6PD
Jaundice persisting during the 1st month: inspissated bile syndrome, hepatitis, syphilis, toxoplasmosis, familial non-hemolytic icterus, congenital atresia of bile ducts, galactosemia, rarely physiologic jaundice, pyloric stenosis, and hypothyroidism).
(Stoll and Kliegman, 2004)
C- Laboratory Evaluation of Neonatal Hyperbilirubinemia:
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Laboratory Studies A. Serum bilirubin is conventionally measured by spectrophotometry based on the Van den
Bergh (diazo) reaction. Conjugated (direct) bilirubin reacts rapidly with diazo reagents. Unconjugated (indirect) bilirubin reacts slowly. Indirect bilirubin is calculated as the difference between total bilirubin and direct bilirubin fraction. Direct bilirubin consists of conjugated bilirubin and δ-bilirubin.
B. Complete blood count: Useful in detecting hemolysis, indicated by the presence of anemia with fragmented erythrocytes and increased reticulocytes on the smear. Thrombocytopenia is typically seen in patients with portal hypertension.
C. Liver function tests: Isolated hyperbilirubinemia with otherwise normal liver function suggests hemolytic disease or bilirubin metabolism defects.
D. Coagulation profile (Bhutani VK, 2011)D-Imaging Studies:
Ultrasonography: Ultrasonography of the liver and bile ducts is warranted in infants with laboratory or clinical signs of cholestatic disease.
Radionuclide scanning: A radionuclide liver scan for uptake of hepatoiminodiacetic acid (HIDA) is indicated if extrahepatic biliary atresia is suspected. At the author's institution, patients are pretreated with phenobarbital 5 mg/kg/d for 3-4 days before performing the scan. (Ahlfors CE & Parker AE. 2008)
Figure (3:) total serum bilirubin and age chart (AAP .; 2005)
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Management of Neonatal Hyperbilirubinemia Regardless of etiology, the goal of therapy is to prevent the concentration of indirect-reacting bilirubin in the blood from reaching levels at which neurotoxicity may occur. It is recommended that phototherapy and, if unsuccessful, exchange transfusion be used to keep the maximum total bilirubin below the toxic levels. (Valaes and Harvey-Wilkes, 1999)1- Preterm Infants: Table (4): Suggested maximum indirect serum bilirubin concentrations (mg per/dL) in premature infants
Birth weight (gm) Uncomplicated Complicated1000 12-13 10-12
1000-1250 12-14 10-121251-1499 14-16 12-141500-1999 16-20 15-172000-2500 20-22 18-20
(Stoll and Kliegman, 2000).2- Newborn infant 37 or more weeks of gestation:
Age (hours)
Bilirubin measurement (micromole/litre) divide the score in micromol/L by 88.4 to get mg/dL
0 - - >100 >100
6 >100 >112 > 125 > 150
12 > 100 > 125 > 150 > 200
18 > 100 > 137 > 175 > 250
24 > 100 > 150 > 200 > 300
30 > 112 > 162 > 212 > 350
36 > 125 > 175 > 225 > 400
42 > 137 > 187 > 237 > 450
48 > 150 > 200 > 250 > 450
54 > 162 > 212 > 262 > 450
60 > 175 > 225 > 275 > 450
66 > 187 > 237 > 287 > 450
72 > 200 > 250 > 300 > 450
78 - > 262 > 312 > 450
84 - > 275 > 325 > 450
90 - > 287 > 337 > 450
96+ - > 300 > 350 > 450
ActionRepeat bilirubin measurement in 6–12 hours
Consider phototherapy and repeat bilirubin measurement in 6 hours
Start phototherapy
Perform an exchange transfusion unless the bilirubin level falls below threshold while the treatment is being prepared
Table (5) Interference according to total bilirubin levels (Michael Rawlins et al.; 2010)
29
The management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation is summarized in Figure (4).
30
Current accepted modes of intervention:
Hydration. Phototherapy. Exchange transfusion. Pharmacological agents. Drug that increase conjugation. Inhibiting reabsorption (binding in the gut). Inhibiting bilirubin production (Valaes and Harvey-Wilkes, 1999).
I- Hydration:
It is important to maintain adequate hyration and urine output during phototherapy since urinary excretion of lumirubin is the principle mechanism by which phototherapy reduces TsB. Thus, during phototherapy, infants should continue oral feeding by breast or bottle. For TsB levels that approach the exchange transfusion level, phototherapy should be continuous until the TsB has declined to about 20 mg/dL (342 micromol/L). Thereafter phototherapy can be interrupted for feeding. Intravenous hydration may be necessary to correct hypovolemia in infants with significant volume depletion whose oral intake is inadequate; otherwise, intravenous fluid is not recommended. (Buhutani VK, 2004)
II-Phototherapy:
A) Background:
Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia. This therapeutic principle was discovered rather serendipitously in England in the 1950s and is now arguably the most widespread therapy of any kind (excluding prophylactic treatments) used in newborns. ) Kumar P. et al; 2011(
B) Consideration should be taken:
The level of total serum bilirubin The gestational age of the infant The age of the infant in hours since birth The presence or absence of risk factors, including isoimmune hemolytic disease, glucose-
6-phosphate dehydrogenase deficiency, asphyxia, lethargy, temperature instability, sepsis, acidosis, and hypoalbuminemia.
(M. Jeffrey Maisels et al; 2008)
31
C) Indications of phototherapy:1- Phototherapy should be used when the level of bilirubin may be harmful to the
infant , and has not reached levels requiring exchange transfusion.2- Prophylactic phototherapy may be indicated in special circumstances, such as
extremely low - birth weight infants or severely bruised infants. In hemolytic disease of the newborn, phototherapy is stared immediately and while waiting for exchange transfusion. (McDonagh et al.; 2008)
D) Mechanism of Action Phototherapy uses light energy to change the shape and structure of bilirubin, converting it to molecules that can be excreted even when normal conjugation is deficient. Absorption of light by dermal and subcutaneous bilirubin induces a fraction of the pigment to undergo several photochemical reactions that occur at very different rates. These reactions generate yellow stereoisomers of bilirubin and colorless derivatives of lower molecular weight. The products are less lipophilic than bilirubin, and unlike bilirubin, they can be excreted in bile or urine without the need for conjugation. Bilirubin elimination depends on the rates of formation as well as the rates of clearance of the photoproducts. Photoisomerization occurs rapidly during phototherapy, and isomers appear in the blood long before the level of plasma bilirubin begins to decline. Bilirubin absorbs light most strongly in the blue region of the spectrum near 460 nm, a region in which penetration of tissue by light increases markedly with increasing wavelength. Only wavelengths that penetrate tissue and are absorbed by bilirubin have a phototherapeutic effect. Taking these factors into account, lamps with output predominantly in the 460-to-490-nm blue region of the spectrum are probably the most effective for treating hyperbilirubinemia. A common misconception is that ultraviolet (UV) light (<400 nm) is used for phototherapy. Phototherapy lights in current use do not emit significant erythemal UV radiation. In addition, the plastic covers of the lamp and, in the case of preterm infants, the incubator, filter out UV light. (Maisels et al.; 2008) The dose and efficacy of phototherapy are also affected by the infant's distance from the light (the nearer the light source, the greater the irradiance) and the area of skin exposed, hence the need for a light source beneath the infant for intensive phototherapy. Although controlled trials have demonstrated that the more surface area exposed, the greater the reduction in the total demonstrated that the more surface area exposed, the greater the reduction in the total serum bilirubin level, it is usually unnecessary to remove the infant's diaper. If, however, the total serum bilirubin level continues to rise despite treatment, the diaper should be removed until there is a clinically significant decline. Aluminum foil or white cloth placed on either side of the infant to reflect light will also improve the efficacy of
32
phototherapy. Because light can be toxic to the immature retina, the infant's eyes should always be protected with opaque eye patches. (Maisels et al.; 2008)
E) Adverse effects: Insensible water loss may occur, but data suggest that this issue is not as important as
previously believed. Rather than instituting blanket increases of fluid supplements to all infants receiving phototherapy, the author recommends fluid supplementation tailored to the infant's individual needs, as measured through evaluation of weight curves, urine output, urine specific gravity, and fecal water loss.
In the NRN phototherapy trials in premature infants of less than 1000 gram birthweight, mortality was increased by 5 percentage points in the subgroup of 501-750 gram birth weight receiving aggressive phototherapy.[ Morris BH, Oh W, Tyson JE, 2008] Although not significant, it should be noted that the study was underpowered for this analysis, and a negative effect of aggressive phototherapy on the smallest and most immature infants cannot be ruled out with certainty.
Phototherapy may be associated with loose stools. Increased fecal water loss may create a need for fluid supplementation.
Retinal damage has been observed in some animal models during intense phototherapy. In an NICU environment, infants exposed to higher levels of ambient light were found to have an increased risk of retinopathy. Therefore, covering the eyes of infants undergoing phototherapy with eye patches is routine. Care must be taken lest the patches slip and leave the eyes uncovered or occlude one or both nares.
The combination of hyperbilirubinemia and phototherapy can produce DNA-strand breakage and other effects on cellular genetic material. In vitro and animal data have not demonstrated any implication for treatment of human neonates. However, because most hospitals use (cut-down) diapers during phototherapy, the issue of gonad shielding may be moot.
Skin blood flow is increased during phototherapy, but this effect is less pronounced in modern servo controlled incubators. However, redistribution of blood flow may occur in small premature infants. An increased incidence of patent ductus arteriosus (PDA) has been reported in these circumstances. The appropriate treatment of PDA has been reviewed.
Hypocalcaemia appears to be more common in premature infants under phototherapy lights. This has been suggested to be mediated by altered melatonin metabolism. Concentrations of certain amino acids in total parenteral nutrition solutions subjected to phototherapy may deteriorate. Shield total parenteral nutrition solutions from light as much as possible.
Regular maintenance of the equipment is required because accidents have been reported, including burns resulting from a failure to replace UV filters.
(Madan JC, Kendrick D., etc. 2009)
33
F) Methods of administration:i - Conventional phototherapy: With "Conventional phototherapy", the irradiance of the light is less, but actual numbers vary significantly between different manufacturers. In general, it is not necessary to routinely measure irradiance when administering phototherapy, but units should be checked periodically to ensure that the lamps are providing adequate irradiance, according to the manufacturer's guidelines. (Bernstein JA, 2012)
ii-Fiber optic phototherapy: Fiberoptic light is also used in phototherapy units. These units deliver high energy levels, but to a limited surface area. Efficiency may be comparable to that of conventional low-output overhead phototherapy units but not to that of overhead units used with maximal output. Advantages include the following:
Low risk of overheating the infant No need for eye shields Ability to deliver phototherapy with the infant in a bassinet next to the mother's
bed Simple deployment for home phototherapy The possibility of irradiating a large surface area when combined with
conventional overhead phototherapy units (double/triple phototherapy)(Kumar P. et al.; 2011)
iii-Double & Triple phototherapy:
"Double" and "triple" phototherapy, which implies the concurrent use of 2 or 3 phototherapy units to treat the same patient, has often been used in the treatment of infants with very high levels of serum bilirubin. The studies that appeared to show a benefit with this approach were performed with old, relatively low-yield phototherapy units. Newer phototherapy units provide much higher levels of irradiance, which may in fact be close to the apparent saturation level of bilirubin photoisomerization. Whether double or triple phototherapy also confers a benefit with the newer units, has not been tested in systematic trials.
(Huizing K. et al.; 2008)
34
v-Home phototherapy:
Home phototherapy for a term infant with neonatal jaundice is considered medically appropriate if ALL of the following criteria are met:
Elevated bilirubin not due to any primary hepatic disorder Hospitalization is no longer required Diagnostic evaluation is performed prior to the therapy and should include ALL of the
following: History and physical examination Hemoglobin concentration or hematocrit WBC count and differential count Blood smear for red cell morphology platelets Reticulocyte count Total and direct-reacting bilirubin concentration Maternal and infant blood typing and Coombs test Urinalysis including a test for reducing substances(Watchko J.; 2009)
vi-LASER phototherapy:
The word LASER is derived from English and means "Light Amplification by Stimulated Emission of Radiation". The LASER converts electrical energy into optical energy. This energy commonly referred to as the LASER beam is carried to the tissues through fiber optic as in the case of Argon LASER or a series of hollow tubes as in the case of Carbon dioxide LASER to be absorbed by the tissues or cellular components. All LASER machines have three elements, the LASER medium, power supply and .mirrors. The medium is stimulated by the power supply to emit light that is amplified as it reflects between mirrors, reaching a critical energy level and emerging through a partially transmitting mirror. The energy is released as an intense beam of monochromatic coherent light. The LASER emits a narrow beam of photons, all of which have the same energy, therefore a very pure light of single color and wavelength is produced, the Argon LASER emits a blue green light. (Palmieri, 1985).
Figure (5) baby under phototherapy
35
III. Exchange transfusion:
AIMTo modify abnormal values of the circulating bloods composition, by removing one or more components whilst maintaining a close to constant blood volume.
INDICATIONS Hyperbilirubinaemia – to lower serum bilirubin (SBR) levels and prevent Kernicterus Rhesus/ABO incompatibility – removal of red blood cells with antibodies or free circulating
antigens to reduce degree of red cell destruction Severe Anaemia – replace volume with that containing a higher red blood cell mass Hydrops Foetalis – to regulate blood volume and allay potential heart failure Other rare indications – Hyperkalaemia, Drug toxicity, Disseminated Intravascular
Coagulation (DIC) (Jennifer Orms.; 2011)
RisksBlood clotsChanges in blood chemistry (high or low potassium, low calcium, low glucose, change in acid-base balance in the blood)
Heart and lung problemsInfection (very low risk due to careful screening of blood)Shock if not enough blood is replaced (Maheshwari A., 2011)(Saunthararajah S.,2008.)
Fig. (6): Guidelines for exchange transfusion in infants 35 or more weeks’ gestation.
36
The following Bilirubin/Albumin ratios can be used together with but in not in lieu of the TSB level as an additional factor in determining the need for exchange transfusion.
Table (6): Bilirubin / Albumin ratio as an additional factor in determining the need for exchange transfusion.
Risk CategoryB/A Ratio at Which Exchange TransfusionShould be ConsideredTSB mg/dL/Alb, g/dL TSB _mol/L/Alb, _mol/L
- Infants _38 0/7 wk- Infants 35 0/7–36 6/7
wk and well or _38 0/7 wk if higher risk or isoimmune hemolytic disease or G6PD deficiency
- Infants 35 0/7–37 6/7 wk if higher risk or isoimmune hemolytic disease or G6PD deficiency
8.07.2
6.8
0.94
0.84
0.80
If the TsB is at or approaching the exchange level, send blood for immediate type and cross match. Blood for exchange transfusion is modified whole blood (red cells and plasma) cross-matched against the mother and compatible with the infant. (Bhutan et al.; 2004)
IV. Pharmacological Treatments: Phenobarbitone. Intravenous immunoglobins. Albumin. Others (e.g. Agar therapy and Charcoal feeds)
* Phenobarbital: Phenobarbital, an inducer of hepatic bilirubin metabolism, has been used to enhance bilirubin metabolism. Several studies have shown that phenobarbital is effective in reducing mean serum bilirubin values during the first week of life. Phenobarbital may be administered prenatally in the mother or postnatal in the infant. In populations in which the incidence of neonatal jaundice or kernicterus is high, this type of pharmacologic treatment may warrant consideration. However, concerns surround the long-term effects of phenobarbital on these children. Therefore, this treatment is probably not justified in populations with a low incidence of neonatal jaundice. (Thor. WR Hansen., 2011)* Intravenous Immunoglobulin:
37
The American Academy of Pediatrics routinely uses 500 mg/kg infused intravenously over a period of 2 hours for Rh or ABO incompatibility when the total serum bilirubin levels approach or surpass the exchange transfusions limits. The author has, on occasion, repeated the dose 2-3 times. In most cases, when this is combined with intensive phototherapy, avoiding exchange transfusion is possible. In the authors' institution, with about 750 NICU admissions per year, the use of exchange transfusions has decreased to 0-2 per year following the implementation of IVIG therapy for Rh and ABO isoimmunization. (Huizing K. and Roislien J., 2008)
*Albumin: Bilirubin in circulation is predominantly bound to albumin. Although the binding ratio is potentially 1:1 and avid, albumin levels are lower in premature and sick infants, and binding affinity is often diminished. Furthermore, some drugs can compete with bilirubin for binding to albumin, causing displacement of bilirubin, therefore, prior to exchange transfusion albumin can be administrated 1g per Kg to improve the efficacy of the exchange.(Stevenson et al., 2005)
*Others: Oral bilirubin oxidase can reduce serum bilirubin levels, presumably by reducing enterohepatic circulation; however, its use has not gained wide popularity. The same may be said for agar or charcoal feeds, which act by binding bilirubin in the gut. Bilirubin oxidase is not available as a drug, and for this reason, its use outside an approved research protocol probably is proscribed in many countries. (Hansen, 2003)
V. Surgical Care: Surgical care is not indicated in infants with physiologic neonatal jaundice. Surgical therapy is indicated in infants in whom jaundice is caused by bowel or external bile duct atresia. (Thor WR H., 2004)
Mortality and Morbidity Death from physiologic neonatal jaundice not occurs. Death from kernicterus may occur, particularly in countries with less developed medical care system. Mortality figures in this setting are not available. (Bhutani et al., 2004)
Chapter 2 : ABO blood group system
38
History of discoveries
At the beginning of the 20th century an Australian scientist, Karl Landsteiner,
noted that the RBCs of some individuals were agglutinated by the serum from
other individuals. He made a note of the patterns of agglutination and showed that
blood could be divided into groups. This marked the discovery of the first blood
group system, ABO, and earned Landsteiner a Nobel Prize.
(Dean L. Bethesda 2005)
Thirty major blood group systems (including the AB and Rh systems) are currently
recognised by the International Society of Blood Transfusion (ISBT). Thus, in
addition to the ABO antigens and Rhesus antigens, many other antigens are
expressed on the red blood cell surface membrane. For example, an individual
can be AB RhD positive, and at the same time M and N positive (MNS system), K
positive (Kell system), and Lea or Leb positive (Lewis system).
(Dr GL Daniels et al.; 2009)
The ABO blood group system is the most important blood type system (or blood
group system) in human blood transfusion. The associated anti-A and anti-
B antibodies are usually IgM antibodies, which are usually produced in the first
years of life by sensitization to environmental substances such as food, bacteria,
and viruses. ABO blood types are also present in some other animals, for
example apes such as chimpanzees, bonobos, and gorillas.
(Maton et al.; 1993)
ABO antigens & antibodies
39
** Antigens of the ABO blood group
Number of antigens
4: A, B, AB, and A1
Antigen specificity
CarbohydrateThe sequence of oligosaccharides determines whether the antigen is A, B, or A1.
Antigen-carrying
molecules
Glycoproteins and glycolipids of unknown functionThe ABO blood group antigens are attached to oligosaccharide chains that project above the RBC surface. These chains are attached to proteins and lipids that lie in the RBC membrane.
Molecular basis
The ABO gene indirectly encodes the ABO blood group antigens.The ABO locus has three main allelic forms: A, B, and O. The A and B alleles each encode a glycosyltransferase that catalyses the final step in the synthesis of the A and B antigen, respectively. The A/B polymorphism arises from several SNPs in the ABO gene, which result in A and B transferases that differ by four amino acids. The O allele encodes an inactive glycosyltransferase that leaves the ABO antigen precursor (the H antigen) unmodified.
Frequency of ABO
blood group antigens
A: 43% Caucasians, 27% Blacks, 28% AsiansB: 9% Caucasians, 20% Blacks, 27% AsiansA1: 34% Caucasians, 19% Blacks, 27% AsiansNote: Does not include AB blood groups.
Frequency of ABO
phenotypes
Blood group O is the most common phenotype in most populations.Caucasians: group O, 44%; A1, 33%; A2, 10%; B, 9%; A1B, 3%; A2B, 1%Blacks: group O, 49%; A1, 19%; A2, 8%; B, 20%; A1B, 3%; A2B, 1%Asians: group O, 43%; A1, 27%; A2, rare; B, 25%; A1B, 5%; A2B, rareNote: Blood group A is divided into two main phenotypes, A1 and A2
Table (7): Antigens of the ABO blood group (Reid ME. et al.; 2004)
40
** Antibodies produced against ABO blood group antigens
Antibody type IgG and IgMNaturally occurring. Anti-A is found in the serum of people with blood groups O and B. Anti-B is found in the serum of people with blood groups O and A.
Antibody reactivity
Capable of haemolysisAnti-A and anti-B bind to RBCs and activate the complement cascade, which lyses the RBCs while they are still in the circulation (intravascular haemolysis).
Haemolytic disease of the
newborn
No or mild diseaseHDN may occur if a group O mother has more than one pregnancy with a child with blood group A, B, or AB. Most cases are mild and do not require treatment.
Table (8) Antibodies produced against ABO blood group antigens (D.L. Bethesda., 2005)
Phenotypes The table below shows the possible permutations of antigens and antibodies with the corresponding ABO type ("yes" indicates the presence of a component and "no" indicates its absence in the blood of an individual).
ABOBlood Type Antigen A
Antigen B
Antibody Anti-A
Antibody Anti-B
A yes no no yes
B no yes yes no
O no no yes yes
AB yes yes no no
Table (9) Phenotype of ABO Blood Group System (Dennis O'Neil 2011)
Genotype
The ABO locus encodes specific glycosyltransferases that synthesize A and B antigens on RBCs. For A/B antigen synthesis to occur, a precursor called the H antigen must be present. In RBCs, the enzyme that synthesizes the H antigen is encoded by the H locus. (Dean L. Bethesda., 2005)
Non-antigen biology
41
The carbohydrate molecules on the surfaces of red blood cells have roles in cell
membrane integrity, cell adhesion, membrane transportation of molecules, and
acting as receptors for extracellular ligands, and enzymes. ABO antigens are
found having similar roles on epithelial cells as well as red blood cells.
(Mohandas et al.; 2005)
The possible ABO alleles for one
parent are in the top row and the
alleles of the other are in the left
column. Offspring genotypes
are shown in black. Phenotypes
are red.
Parent
Alleles
A B O
AAA
(A)
AB
(AB)
AO
(A)
BAB
(AB)
BB
(B)
BO
(B)
OAO
(A)
BO
(B)
OO
(O)
Table (10): inheritance of ABO Blood Group
Inheritance
ABO blood types are inherited through genes on chromosome 9, and they do
not change as a result of environmental influences during life. An individual's ABO
type is determined by the inheritance of 1 of 3 alleles (A, B, or O) from each
parent. The possible outcomes are shown below:
Association with von
Willebrand factor
The ABO antigen is also expressed
on the von Willebrand
42
factor (vWF) glycoprotein, (Sarode, R., 2000) which participates
in haemostasis (control of bleeding). In fact, having type O blood predisposes to
bleeding, (O'Donnell, 2001) as 30% of the total genetic variation observed in
plasma vWF is explained by the effect of the ABO blood group, and individuals
with group O blood normally have significantly lower plasma levels of vWF
(and Factor VIII) than do non-O individuals. (Shima. M., 1995)
In addition, vWF is degraded more rapidly due to the higher prevalence of blood
group O with the Cys1584 variant of vWF (an amino acid polymorphism in VWF).
(Bowen, DJ. & Collins PW., 2005).
Subgroups
A1 and A2
The A blood type contains about twenty subgroups, of which A1 and A2 are the most common (over 99%). A1 makes up about 80% of all A-type blood, with A2 making up the rest. These two subgroups are interchangeable as far as transfusion is concerned, but complications can sometimes arise in rare cases when typing the blood. (The Owen Foundation., 2008)
Bombay phenotype
Figure (7): Bombay phenotype inheritance
The H antigen is a precursor to the A and B antigens. For instance, the B allele must be present to produce the B enzyme that modifies the H antigen to become the B antigen. It is the same for the A allele. However, if only recessive alleles for the H antigen are inherited (hh), as in the case above, the H antigen will not produced. Subsequently, the A and B antigens also will not be produced. The result is an O phenotype by default since a lack of A and B antigens is the O type. This seemingly impossible phenotype result has been referred to as a Bombay phenotype because it was first described in that Indian city. The ABO blood
43
system is further complicated by the fact that there are two subtypes of type A and two of AB. These are referred to as A1, A2, A1B, and A2B.(Dennis O'Neil., 2011)
Chapter (3): Hemolytic disease of the newborn
(ABO)
HISTORICAL BACKGROUND
Haemolytic disease of the newborn (HDN) used to be a major cause of fetal
loss and death among newborn babies. The first description of HDN is thought to
be in 1609 by a French midwife who delivered twins—one baby was swollen and
died soon after birth, the other baby developed jaundice and died several days
later. For the next 300 years, many similar cases were described in which
newborns failed to survive. (Dean L. Bethesda., 2005)
Incidence and prevalence
ABO incompatibility between the mother and the baby occurs in 15-20% of all
pregnancies, which produces HDN in 10% of these cases The fact prevealed
ABO incompatibility is not always a benign condition and should be considered in
all babies who have haemolysis and whose mothers are group O, even in the
presence of a negative DAT. Asians and blacks have a higher prevalence of DAT-
positive ABO HDN than Caucasians.(Neelam Marwaha & Hari Krishan
Dhawan, 2009) Thirty-eight per cent mothers were ABO incompatible with their
babies, whereas 62% mothers were compatible.(Bashiru S. et al.; 2011)
In a study conducted to Michael sgro, douglas Campbell and vibhuti shah
2006 showed that the percentage of ABO incompatibility as a cause of severe
neonatal hyperbilirubinemia is about 51% followed by G6PD about 21.5% other
antibody incompatibility about 13% and other causes about 14.5% ABO hemolytic
disease of newborn occurring in about 15% of infants with A or B blood type born
44
to blood type O mothers and, unlike non- hemolytic disease of newborn. ABO
incompatibility is usually a problem of the neonate rather than of the fetus, A and B
antigens are only weakly expressed on neonatal RBCs. ABO hemolytic disease of
newborn therefore usually mild and characterized by negative or weakly positive
Coombs' test. ABO hemolytic disease of newborn rarely requires whole blood
exchange transfusion, in contrast to hemolytic disease of newborn due to anti-D or
other antibodies. (Kathryn Drabik-Clary et al; 2006)
MECHANISM
Haemolysis associated with ABO incompatibility exclusively occurs in type-O
mothers with foetuses who/ have type A or type B blood, although it has rarely
been documented in type-A mothers with type-B infants with a high titre of anti-B
IgG. In mothers with type A or type B, naturally occurring antibodies are of the IgM
class and do not cross the placenta, whereas 1% of type-O mothers have a high
titre of the antibodies of IgG class against both A and B. They cross the placenta
and cause haemolyses in foetus. Haemolysis due to anti-A is more common than
haemolyses due to anti-B, and affected neonates usually have positive direct
Coombs test results. However, haemolyses due to anti-B IgG can be severe and
can lead to exchange transfusion. Because A and B antigens are widely
expressed in various tissues besides RBCs, only a small portion of antibodies
crossing the placenta are available to bind to foetal RBCs.
(Luchtman-Jones L. & Schwartz AL. 2006)
The reasons for the mildness of ABO erythroblastosis are that the foetal RBC
membrane has fewer A and B antigenic sites; most anti-A and anti-B is IgM and
does not cross into the foetal circulation; the small amount of anti-A or anti-B that
is IgG and does cross into the foetal circulation has many antigenic sites in tissue
and secretions other than on the RBCs to which it can bind. Because only a small
amount of antibody is fixed to each RBC membrane, the direct antiglobulin test is
only weakly positive when cord RBCs are tested and may be negative when
capillary blood is tested at 1 or 2 days of age. (Bowman J., 2011)
45
Moderating factors
In about a third of all ABO incompatible pregnancies maternal IgG anti-A or
IgG anti-B antibodies pass through the placenta to the foetal circulation leading to
a weakly positive direct Coombs test for the neonate's blood. However, ABO HDN
is generally mild and short-lived and only occasionally severe because:
IgG anti-A (or IgG anti-B) antibodies that enter the fetal circulation from the
mother find A (or B) antigens on many different fetal cell types, leaving
fewer antibodies available for binding onto fetal red blood cells.
Fetal RBC surface A and B antigens are not fully developed during
gestation and so there are a smaller number of antigenic sites on fetal
RBCs.
(Wang, M. et al.; 2005)
Diagnosis
ABO incompatibility occurs in 20-25% of pregnancies, but laboratory evidence of haemolytic disease occurs only in 1 of 10 such infants, and the haemolytic disease is severe enough to require treatment in only 1 in 200 cases. There are a number of reasons why ABO incompatibility is rarely serious:1. Most anti-A and anti-B antibodies are IgM (hence they don’t cross the placenta).2. Neonatal RBCs express A and B poorly (the expression of A and B antigens increases as the baby grows).3. Many cells other than red cells express A and B antigens and thus sop up some of the transferred antibody. (Kristine Krafts., 2009)
ABO haemolytic disease occurs almost exclusively in infants of A or B type born of group O mothers. Normal anti-A and anti-B antibodies are IgM and therefore don’t cross the placenta. For reasons not understood, however, some group O women have IgG anti-A and anti-B even without prior sensitization! In this situation, a firstborn child may be affected. Fortunately, even with transplacentally acquired antibodies, lysis of infant red cells is minimal. ABO incompatibility is diagnosed with same tests as Rh incompatibility (DAT, IAT, Kleihauer-Betke test). There’s no effective protection against ABO incompatibility reactions! Good thing they’re not very common. (Kristine Krafts., 2009)
46
Clinical picture
The typical diagnostic findings are jaundice, pallor, hepatosplenomegaly, and
foetal hydrops in severe cases. The jaundice typically manifests at birth or in the
first 24 hours after birth with rapidly rising unconjugated bilirubin level. Anaemia is
most often due to destruction of antibody-coated RBCs by the reticuloendothelial
system, and, in some infants, anaemia is due to intravascular destruction. The
suppression of erythropoiesis by intravascular transfusion (IVT) of adult Hb to an
anaemic foetus can also cause anaemia. Extra medullary haematopoiesis can
lead to hepatosplenomegaly, portal hypertension, and ascites.
(Moise KJ. ., 2008)
Postnatal problems also include: Asphyxia Pulmonary hypertension Pallor (due to anemia) Edema (hydrops, due to low serum albumin) Respiratory distress Coagulopathies (↓ platelets & clotting factors) Jaundice Kernicterus (from hyperbilirubinemia): explained previously. Hypoglycemia (due to hyperinsulinemnia from islet cell hyperplasia)
(William H. Tooley., 2004)
Complications
Complications of hemolytic disease of the newborn during pregnancy:
Mild anemia: When the baby’s red blood cell count is deficient, his blood
cannot carry enough oxygen from the lungs to all parts of his body, causing
his organs and tissues to struggle.
47
Hyperbilirubinemia and jaundice: The breakdown of red blood cells
produces bilirubin, a brownish yellow substance that is difficult for a baby to
discharge and can build up in his blood (hyperbilirubinemia) and make his
skin appear yellow.
Severe anemia with enlargement of the liver and spleen: The baby’s body
tries to compensate for the breakdown of red blood cells by making more of
them very quickly in the liver and spleen, which causes the organs to get
bigger. These new red blood cells are often immature and unable to function
completely, leading to severe anemia.
Hydrops fetalis: When the baby’s body cannot cope with the anemia, his
heart begins to fail and large amounts of fluid build up in his tissues and
organs. (Louis Diamond., 2010)
Complications of hemolytic disease of the newborn after birth:
Severe hyperbilirubinemia and jaundice: Excessive buildup of bilirubin in
the baby’s blood causes his liver to become enlarged.
Kernicterus: Buildup of bilirubin in the blood is so high that it spills over into
the brain, which can lead to permanent brain damage.
(Louis Diamond., 2010)
LABORATORY FINDINGS
a) CBC count findings
i. Anaemia
ii. Increased nucleated RBCs, reticulocytosis, polychromasia,
anisocytosis, spherocytosis, and cell fragmentation
iii. Neutropenia
iv. Thrombocytopenia
(Christensen RD, Henry E., 2010)
48
v. Hypoglycaemia is common and is due to islet cell hyperplasia and
hyperinsulinism. The abnormality is thought to be secondary to release
of metabolic by-products such as glutathione from lysed RBCs.
Hypokalaemia, hyperkalaemia, and hypocalcaemia are commonly
observed during and after exchange transfusion
(Vidnes., 1977)
b) Serologic test findings
Indirect Coombs test and direct antibody test results are positive in the mother
and affected newborn. Unlike Rh alloimmunization, direct antibody test results are
positive in only 20-40% of infants with ABO incompatibility.
(Romano EL et al.; 1973)
In a recent study, positive direct antibody test findings have a positive predictive
value of only 23% and a sensitivity of only 86% in predicting significant haemolysis
and need for phototherapy, unless the findings are strongly positive (4+).
(Murray NA., 2007)
This is because foetal RBCs have less surface expression of type-specific
antigen compared with adult cells. Although the indirect Coombs test result
(neonate's serum with adult A or B RBCs) is more commonly positive in neonates
with ABO incompatibility, it also has poor predictive value for haemolysis. This is
because of the differences in binding of IgG subtypes to the Fc receptor of
phagocytic cells and, in turn, in their ability to cause haemolysis.
(Bakkeheim E. & Bergerud U., 2009)
49
Treatment of ABO HDN
1. Phototherapy is sufficient. Discussed previously.
2. Exchange transfusion may be needed. Discussed previously.
(Karen L. Dallas., 2012)
3. New trends in therapy for HDN :
Improved phototherapy
The changing clinical practice surrounding HDN is, in no small way, the result of
improvements in both the understanding and delivery phototherapy. Since then
considerable advances have been made and it is now appreciated more fully that
the efficacy of phototherapy in reducing neonatal hyperbilirubinaemia is dependent
on a number of factors: (Verman HU. Et al.; 2004)
The spectral qualities of the delivered light (optimal wave length range 400–
520 nm, with peak emissions of 460 nm)
• Irradiance (intensity of light)
• Body surface area receiving phototherapy
• Skin pigmentation
• Total serum bilirubin concentration at commencement of phototherapy
• Duration of exposure. (Hart G. et al.; 2005)
Modern phototherapy devices are designed to maximise the efficacy of
phototherapy to the neonate and clinicians are more appreciative of the importance
of ensuring such devices are employed correctly (i.e. ensuring correct distance
between device and patient, proper maintenance and servicing of phototherapy
units). Phototherapy units are now smaller, easier to use around the cot, more
efficient - particularly high-intensity gallium nitride light-emitting diodes (LEDs), and
50
more powerful- the total irradiance that can be applied to an individual neonate has
vastly increased. In short phototherapy is now a viable alternative to the planned
use of exchange transfusion in the therapy of even moderate to severe HDN, and
as devices continue to develop and improve phototherapy is likely to play an even
greater role in the therapy of HDN. For a fuller description of developments in
neonatal phototherapy since its first use the reader is referred to recent reviews.
(Irene A.G. Roberts., 2008)
High dose intravenous immunoglobulin
In the last 10–15 years a number of studies of high dose intravenous
immunoglobulin (IVIG) as adjuvant treatment for HDN have been published and two
systematic reviews have been carried out.
In 2004 Miqdad et al., reported the use of IVIG in a study of 112 well term
neonates with hyperbilirubinaemia resulting from DATpositive ABO HDN. In addition
to phototherapy the intervention group (n=56) received 500 mg/kg IVIG over 4 h if
the serum bilirubin was rising by 8.5 mmol/L per hour or greater. Exchange
transfusion was carried out in all neonates if the serum bilirubin exceeded 340
mmol/L, or was rising by greater than 8.5 mmol/L per hour in the phototherapy only
group. In the phototherapy only group 16 neonates were treated with exchange
transfusion whereas only 4 neonates in the IVIG group required exchange
transfusion. The duration of phototherapy was also reduced in the IVIG group. No
side-effects of IVIG were seen.
Also Alpay et al. in 1999 studied 116 neonates with hyperbilirubinaemia
resulting from DAT-positive ABO or Rh HDN of whom 58 received IVIG 1 g/kg over
4 h when the serum bilirubin exceeded 204 mmol/L. Exchange transfusion was
performed if the serum bilirubin exceeded 290 mmol/L or was rising by more than
51
17 mmol/L per hour. In the phototherapy only group 22 neonates were treated with
exchange transfusion whereas only 8 neonates in the IVIG group required
exchange transfusion. Again the duration of phototherapy and hospital stay were
significantly reduced in the IVIG group. No adverse effects of IVIG were reported.
Similar results have been found in previous smaller studies assessing the use of
IVIG in the treatment of HDN. Despite the positive benefits of IVIG suggested by
these studies there are methodological difficulties and questions about the safety of
IVIG that potentially limit the size of the role IVIG may have in the treatment of
HDN. The preponderance of ABO HDN in the larger studies suggests that the
neonates assessed are relatively well and the vast majority would be expected to
respond to intensive phototherapy alone unless low thresholds for exchange
transfusion (bilirubin — 290–340 mmol/L) are employed. There is also variation in
the timing of administration and dose of IVIG between studies. Late anaemia may
be more prevalent in those treated with IVIG, presumably because fewer neonates
have exchange transfusion and therefore removal of maternal antibody. No major
side effects have been reported in the neonates treated with IVIG but since IVIG is
a pooled blood product the potential for transmission of blood borne infections
remains. (Hayakawa F. et al.; 2002) (Quinti I. et al.; 2002)
Given these facts how should neonatal paediatricians approach the use of IVIG
in patients with HDN. The current trial evidence clearly points to positive benefits,
particularly the reduction in the need for exchange transfusion.
Paediatricians are less experienced with this technique due to the reduction of ABO
disease and so morbidity associated with this procedure may increase in the future.
Therefore the use of a more straightforward but effective therapy should be
considered in the limited number of patients where the likelihood of exchange
transfusion is greatest. These would include neonates with red cell alloimmunisation
unmodified by antenatal therapy or neonates with potential ABO HDN where a
previous sibling has suffered from severe disease requiring exchange transfusion.
52
Also the neonate with severe DAT-positive hyperbilirubinaemia readmitted from the
community, where the serum bilirubin already exceeds local guidelines for
exchange transfusion, but where initial therapy with IVIG is liable to be available
more quickly than exchange transfusion. In these relatively rare circumstances
adjuvant therapy with IVIG seems justified. A single dose of IVIG of 500 mg/kg
appears to be as effective as any other regimen.
(Irene A.G. Roberts., 2008)
Metalloporphyrins
Metalloporphyrins are heme analogs that competitively inhibit the activity of
heme oxygenase, the rate-limiting enzyme in heme catabolism. This action reduces
the formation of bilirubin and makes them potential agents for both the prophylactic
and therapeutic reduction of hyperbilirubinaemia in the newborn. Tin (Sn)
mesoporphyrins are the most fully studied compounds in this context.
In 1988 Kappas et al. reported the prophylactic use of Sn-Protoporphyrin
(SnPP) in 122 term infants with DAT-positive ABO incompatability. At doses up to
2.25 mg/kg body weight, administered by 2 or 3 intramuscular injections, they
demonstrated a significant reduction in the rate of rise of plasma bilirubin levels
beginning at 48 h post SnPP administration that continued until 96 h. The only
reported side effect in SnPP treated neonates was transient erythema during the
concurrent use of phototherapy in two neonates.
In 1994 Valaes et al., reported the results of 5 sequential studies of the
prophylactic use of Sn-Mesoporphyrin (SnMp) in preterm neonates between 30 and
36 weeks gestational age. SnMp was administered at doses up to 6 mg/ kg body
weight by intramuscular injection beginning within the first 24 h of life. 517 neonates
were studied over 4 years between 1988 and 1992. As the study population were 53
preterm newborns prophylactic phototherapy was commenced at predetermined
low levels and the main outcome of the study was a reduction in the requirement for
phototherapy in SnMp treated neonates. This was most marked in those neonates
receiving the highest dose of Sn- Mp (6 mg/kg) where mean peak incremental
plasma bilirubin concentration was reduced by 41% and phototherapy requirements
by 76%, compared to control neonates. Transient erythema was again noted in
conjunction with phototherapy in SnMp treated neonates but no other adverse
effects were noted during the study or at follow-up at 3 and 18 months.
More recently Martinez et al., have looked at the therapeutic effect of SnMp in
healthy term neonates (without haemolytic disease) with moderate
hyperbilirubinaemia (plasma bilirubin 256–308 mmol/L) developing between 48– 96
h of age. Despite being a population of relatively uncomplicated neonates a
significant number of these would be expected to go on to be treated with
phototherapy, often causing maternal anxiety and lengthening hospital stay. The
study enrolled a total of 84 neonates, 40 of who received a single intramuscular
dose of SnMp at 6 mg/kg body weight. In the control neonates 12 (27%) required
phototherapy at a predetermined level of 333 mmol/L, whereas none of the SnMp
treated neonates required phototherapy. SnMp treated neonates also required a
shorter period of plasma bilirubin monitoring and a reduced number of plasma
bilirubin measurements. No adverse effects of SnMp use were observed. Positive
effects of SnMP in reducing peak plasma bilirubin concentrations have also been
observed in neonates with glucose-6-phosphate dehydrogenase deficiency. In
addition neonates of Jehovah's Witness parents have been given SnMP to reduce
the likelihood of jaundiced neonates requiring therapy with exchange transfusion.
(Kappas A. et al.; 2001)
Given these data there is good evidence to suggest that a single dose of SnMP in
uncomplicated neonates reduces peak plasma bilirubin concentrations and reduces
54
the need for phototherapy. As these are outcomes that themselves are not likely to
result in harm it can be argued that SnMP therapy presents an unknown risk as the
long-term consequences of such therapy are not yet fully known. However,
phototherapy in relatively well neonates often provokes a high degree of maternal
concern and prolongs hospital stay, both of which are unwanted outcomes in
modern hospital-based medical practice. Further studies are underway to more fully
assess the efficacy and safety of SnMP but the use of metalloporphyrins to reduce
the medical burden of neonatal hyperbilirubinaemia may well find a role in the future
as models of health care become increasingly community centred.
(Irene A.G. Roberts., 2008)
Chapter (4): Coombs test
History of the Coombs test
The Coombs test was first described in 1945 by Cambridge immunologists
55
Robin Coombs (after whom it is named), Arthur Mourant and Rob
Race. Historically, it was done in test tubes. Today, it is commonly done
using microarray and gel technology. (Coombs RRA.,1945)
Mechanism
The two Coombs tests are based on the fact that anti-humanantibodies, which are
produced by immunizing non-human species with human serum, will bind to
human antibodies, commonly IgG orIgM. Animal anti-human antibodies will also
bind to human antibodies that may be fixed onto antigens on the surface of red
blood cells (also referred to as RBCs), and in the appropriate test tube conditions
this can lead to agglutination of RBCs. The phenomenon of agglutination
of RBCs is important here, because the resulting clumping of RBCs can be
visualised; when clumping is seen the test is positive and when clumping is not
seen the test is negative.
Common clinical uses of the Coombs test include the preparation of blood
for transfusion in cross-matching, screening for atypical antibodies in the blood
plasma of pregnant women as part ofantenatal care, and detection of antibodies
for the diagnosis of immune-mediated haemolytic anemias.
Coombs tests are done on serum from venous blood samples which are taken
from patients by venepuncture. The venous blood is taken to a laboratory (or
blood bank), where trained scientific technical staff do the Coombs tests. The
clinical significance of the result is assessed by the physician who requested the
Coombs test, perhaps with assistance from a laboratory-based hematologist.
(Geha R., et al 2008)
Direct Coombs test
The direct Coombs test finds antibodies attached to your red blood cells. The
antibodies may be those your body made because of disease or those you get in a
56
blood transfusion. The direct Coombs test also may be done on a newborn baby
with Rh-positive blood whose mother has Rh-negative blood. The test shows
whether the mother has made antibodies and if the antibodies have moved
through the placenta to her baby.
(Pagana KD. et al.; 2010)
Figure (8 ) Direct Coombs test
Indirect Coombs test
The indirect Coombs test finds certain antibodies that are in the liquid part of
your blood (serum). These antibodies can attack red blood cells but are not
57
attached to your red blood cells. The indirect Coombs test is commonly done to
find antibodies in a recipient's or donor's blood before a transfusion.
A test to determine whether a woman has Rh-positive or Rh-negative blood (Rh
antibody titer) is done early in pregnancy. If she is Rh-negative, steps can be
taken to protect the baby.
(Pagana KD. et al.; 2010)
Figure (9):
The indirect Coombs test
Laboratory method
First stage
58
Washed test red blood cells (RBCs) are incubated with a test serum. If the
serum contains antibodies to antigens on the RBC surface, the antibodies will bind
onto the surface of the RBCs.
Second stage
The RBCs are washed three or four times with isotonic saline and then
incubated with antihuman globulin. If antibodies have bound to RBC surface
antigens in the first stage, RBCs will agglutinate when incubated with
the antihuman globulin (also known Coombs reagent) in this stage, and the
indirect Coombs test will be positive.
Titrations
By diluting a serum containing antibodies the quantity of the antibody in the
serum can be gauged. This is done by using doubling dilutions of the serum and
finding the maximum dilution of test serum that is able to produce agglutination of
relevant RBCs.
(Geha R. et al.; 2008)
Results
No clumping of cells (agglutination), indicating that there are no antibodies to
red blood cells, is normal. Normal value ranges may vary slightly among
laboratories. Talk to your doctor about the meaning of your specific test results.
59
An abnormal (positive) direct Coombs' test means you have antibodies that act
against your red blood cells. This may be due to:
1. Autoimmune hemolytic anemia without another cause
2. Chronic lymphocytic leukemia or other lymphoproliferative disorder
3. Drug-induced hemolytic anemia (many drugs have been associated with this
complication)
4. Erythroblastosis fetalis (hemolytic disease of the newborn)
5. Infectious mononucleosis
6. Mycoplasmal infection
7. Syphilis
8. Systemic lupus erythematosus or another rheumatologic condition
9. Transfusion reaction, such as one due to improperly matched units of blood
10. The test is also abnormal in some people without any clear cause,
especially among the elderly. Up to 3% of people who are in the hospital
without a known blood disorder will have an abnormal direct Coombs' test.
An abnormal (positive) indirect Coombs' test means you have antibodies that
will act against red blood cells your body views as foreign. This may suggest:
1. Autoimmune or drug-induced hemolytic anemia
2. Erythroblastosis fetalis hemolytic disease
3. Incompatible blood match (when used in blood banks)
(Schrier SL. Et al.; 2010)
60
Practical work
Patients and method
61
This prospective study took place on full term healthy newborns
admitted to neonatal intensive care unit at Menouf hospital and Benha university hospital started from January 2012 to September 2012 including about 106 babies of different gender [males and females].
Inclusion criteria:
1- Newborns with gestation ages ranged from (37 weeks-42 weeks)2- Newborns whose weights greater than 2500 g.3- Infant of blood group A or B was born to mother of blood group O
4- Jaundice observed clinically with in 1st 48 hours of birth (serum indirect bilirubin levels as follow :> 5 mg/dL at 12 hr,> 8mg/dL at 24 hr and>12.5 mg/dL at 48hr).
5-Patients who need exchange transfusion (serum indirect bilirubin concentration increasing by 0.5-1 mg/dL/hr or exceeding 20mg/dL).
Exclusion criteria:
1-Newborns<37 weeks
2- Newborns<2.5 Kg
3-Newborns with Rh incompatibility
4-Sick Newborns:
- Newborns with respiratory distress. - Newborns with perinatal asphyxia. - Newborns with congenital anomalies. - Newborns with neonatal sepsis. - Newborns with history or manifestations of congenital infections.
- All patients were divided into two groups:62
Group I: jaundice in ABO-incompatibility HDN cases presented in newborns with blood group A born to mothers with blood group O
Group II: jaundice in ABO-incompatibility HDN cases presented in newborns with blood group B born to mothers with blood group O
- All patients were submitted to:
1-Full history
I. Present history Onset of jaundice Type of feeding, sufficient or not - vomiting or not Time of passage of meconium and frequency of stooling Drug intake in NICU
II. Family history Sibling of jaundice and G6PD on maternal side
III. Maternal history Gravidity – parity – previous blood transfusion – maternal disease –
previous pregnancies outcome – maternal drug intake
IV. Perinatal history Gestational age – onset and duration of labor – oxytocin to the mother
– instrumental delivery – delayed 1st cryV. History of treatment
Phototherapy ( time and levels needed) (single – double – triple) Exchange transfusion (How many times? – When? – type and volume
of blood – complications)
2- Full clinical examination of newborn done to detect:63
Gender Reflexes (moro and suckling reflexes) Assessment of gestational age General ex. (pallor – petichea – extensive bruising – dark urine – clay
stool – dehydration - ecchymosis – hematoma) Head ex. (cephalehematoma – subgleal hematoma) Extremities ex. (bruises – ecchymosis – petichea – hematoma) Chest ex. (tachypnea – retraction – air entry – adventitious sounds) Heart ex. (tachycardia – adventitious sounds) Abdominal ex. (omphalities – hematoma – bruises –
hepatosplenomegally – tenderness)
3-The following laboratory investigations were done:
- Blood group of the mothers and their babies.
- Serum Total and Direct bilirubin levels at 6, 12, 24, 36 and 48 hours of baby age.
- Other tests for evaluating the condition as indicated:
Complete blood countLiver enzymesSerum albumin levelReticulocytic countIndirect Combs’ testC-reactive protein and blood culture
Statistical method64
Using Microsoft Excel 2003 and SPSS v18.0 for Microsoft Windows 7 the clinical and
laboratory data were statistically analyzed. Categorical variables were analyzed by chi-square,
student t-tests or Mann-Whitney test.
Hypothesis
In our study, we conjectured that severity of jaundice in O-B infants more than that of O-A
infants in ABO incompatibility HDN.
The null hypothesis: There is no difference is tested.
The alternative hypothesis: There is a difference between O-A infants and O_B infants in
the severity of the disease.
However, the data give rise to rejection of the null hypothesis and accept of the alternative
hypothesis falsely suggesting that there is higher severity of ABO incompatibility HDN in O-B
infant than O-A infants.
NB:
1- P value less than 0.05 (P < 0.05) was considered significant.2- P Value less than 0.01 (p < 0.01) was considered highly significant.3- P value more than 0.05 (p > 0.05) was considered insignificant
)Bland, 2000 and Kirkwood, 2003(
Obstacles and constrains
Some of data may appear incomplete due to defective registrations in some of the files.
Results and analysis of data
A total 106 patients admitted to hospital and included in present study. These patients divided into O-A and O-B groups.
65
Table (1): distribution of cases of both groups (O-A and O-B groups) in our study
Groups A B Total test P value
No. % No. % No. %
A+ve 65 100.0 0 0.0 65 61.3 207.8 0.001 HS
B+ve 0 0.0 41 100.0 41 38.7
Table (1) shows that patients in our study divided into 2 groups O-A group 65 cases (61.3%) and O-B group 41 cases (38.7%).
Table (2): Distribution of ABO jaundice according to gender in study group
Group
Gender
A B Total X2 test P value
No % No % No %
Male 41 63.1 23 56.1 64 60.4 0.512 0.474 NSFemale 24 36.9 18 43.9 42 39.6
Total 65 100 41 100 106 100
Table (2) shows the sex distribution of patients. In group A, 41cases (63.1%) were male patients while 24 cases (36.9%) were female patients. In group B, 23 cases (56.1%) were male patients while 18 cases (43.9%) were female patients.
Table (3): Comparison between O-A and O-B patients regarding maternal risk factors in study group
Group
Maternal Risk
A(n=65) B(n=41) Total x2 test P value
No % No % No %
66
factors
Mode of delivery
NVD 33 50.7 18 44 51 48.1
CS 32 49.3 23 56 55 51.9
Gravidity 1 15 23 8 19.5 23 21.7
2 16 24.6 11 26.8 27 25.4
3 19 29.2 5 12.2 24 22.7
4 8 12.3 7 17.1 15 14.2
5 4 6.2 10 24.4 14 13.2
6 3 4.7 0 0 3 2.8
Previous blood transfusion
No 62 95.4 41 100 103 97.2 1.947 0.282 NS
Yes 3 4.6 0 0 3 2.8
Spontaneous abortion
No 49 75.4 29 70.7 78 73.6 0.28 0.597 NS
Yes 16 24.6 12 29.3 28 27.4
Maternal drug intake nitrofurantoin
No 45 69.2 28 68.3 73 86.9 0.01 0.919 NS
Yes 20 30.8 13 31.7 33 31.1
Salicylates No 61 93.8 40 97.6 101 95.3 0.772 0.647 NS
Yes 4 6.2 1 2.4 5 4.7
Sulfonamide No 64 98.5 41 100.0 105 99.1 0.637 1.0 NS
Yes 1 1.5 0 0.0 1 0.9
Group A(n=65) B(n=41) Total x2 test P value
No. % No. % No. %
Oxytocin intake in delivery
No 33 50.8 23 56.1 56 52.8 0.286 0.593 NS
Yes 32 49.2 18 43.9 50 47.2
Instrumental No 62 95.4 41 100.0 103 97.2 1.947 0.282 NS
67
delivery
Yes 3 4.6 0 0.0 3 2.8
Table (3) shows maternal risk factors in group A and group B patients. Firstly patients delivered by normal vaginal delivery (NVD) 51 patients (48.1%) while 55 patients (51.9%) delivered by caesarian section (CS). Maternal gravida 1 were 23cases (21.7%), gravida 2 were 27 cases (25.4%), gravida 3 were 24 cases (22.7%), gravida 4 were 15 cases (14.2%), gravida 5 were 13 cases (13.2%) and gravida 6 were 3 cases (2.8%). Mothers with previous blood transfusion were 3 cases (2.8%). Mothers with spontaneous abortions were 28 cases (27.4%). The study showed 5 cases with maternal intake of salicylates (4.7%), 1 case with maternal intake of sulfonamide (0.9%), and 33 cases with maternal intake of nitrofurantoin (31.1%). Mothers with oxytocin intake in delivery were 50 cases (47.2%). Mothers with instrumental delivery were 3 cases (2.8%).
Table )4(: Risk factors affecting ABO incompatibility neonatal jaundice in study group
Variable Groups Mean S. bilirubin at admission
± SD Student t test
P value
Family historyPositive 25.98 3.31
0.463 0.65 NSNegative 21.4 0.0
OxytocinPositive 26.68 4.03
1.174 0.257 NSNegative 24.9 1.57
Gravidity
2 23.0 0.0
F=1.68 0.214 NS3 23.77 0.78
4 23.93 2.39
5 25.65 1.06
6 27.62 3.59
Variable Groups Mean S. bilirubin at admission
± SD Student t test
P value
Mode of deliveryNVD 26.71 3.82
1.39 0.185 NSCS 24.6 1.42
Poor feeding Positive 26.05 3.26 0.849 0.408 NS
Negative 23.2 0.0
68
Sequestrated bloodYes 27.6 0.0 0.533 0.601 NS
No 25.79 3.3
Hypoalbuminemia Yes
No
Table (4) shows that higher mean serum bilirubin in positive cases with previous family history, oxytocin intake in delivery, poor feeding, sequestrated blood and hypoalbuminemia. It shows also higher mean serum bilirubin in NVD than in CS cases. As well as mean serum bilirubin level increases proportionally with gravidity.
Table )5(: Comparison between O-A and O-B groups regarding onset of jaundice in hours noted by mothers in study group
Variable Groups Mean ± SD Range Student t-test P value
Onset of jaundice
A 36.6 8.362.202 0.03 S
B 32.78 9.22
Table (5) shows the age of onset of jaundice in patient noted by mother with ABO incompatibility, the most common age presented with jaundice (36.6) hours in group A patients (61%) while in group B patients (39%) presented with jaundice earlier at (32.7) hours with P value (0.03) which is significant .
Table )6(: Comparison between O-A & O-B according to family history in study group
Group
Family history
A(n=65) B(n=41) Total test P value
No % No % No %
Sibling No 18 27.7 10 24.4 28 26.4 0.141 0.707 NS
69
with jaundice
Yes 47 72.3 31 75.6 78 73.6
Treatment of previous siblings with jaundice(78 cases)
Photo-therapy
44 94 27 87 71 91
Photo-therapy plus Ex. transfusion
3 6 4 13 7 9
G6PD on maternal side
No 62 95.4 40 97.6 102 96.2 0.328 1.0 NS
Yes 3 4.6 1 2.4 4 3.8
Table (6) shows family history of jaundice in patients with Abo incompatibility. There were 47 cases of group A patients (72.3%) presented with previous family history of jaundice, about 44 cases (94%) treated with phototherapy only while 3 cases only (6%) treated with phototherapy plus exchange transfusion. There were 31 cases of group B patients (75.6%) presented with previous family history of jaundice, about 27 cases 87% treated with phototherapy while 4 cases (13%) treated with phototherapy plus exchange transfusion. There were 28 cases (26.4%) without family history of jaundice. Only 3 cases of group A and 1 case of group B presented with history of G6PD on maternal side.
Table )7(: Comparison between O-A & O-B according to neonatal history and Physical examination in study group
Group A(n=65) B(n=41) Total test P value
70
Physical exam.
No % No % No %
Need for resuscitation
No 58 89.2 34 82.9 92 86.8 0.872 0.351 NS
Yes 7 10.8 7 17.1 14 13.2
Delayed 1st cry
No 58 89.2 35 85.4 93 87.7
Yes 7 10.8 6 14.6 13 13.3
Pallor No 42 64.6 22 53.7 64 60.4 1.262 0.261 NS
Yes 23 35.4 19 46.3 42 39.6
Dark urine No 63 96.9 41 100.0
104 98.1 1.286 0.521 NS
Yes 2 3.1 0 0.0 2 1.9
Moro reflex Normal 57 87.7 29 70.7 86 81.1 4.73 0.03 S
Weak 8 12.3 12 29.3 20 18.9
Suckling reflex
Normal 57 87.7 28 68.3 85 80.2 5.96 0.015 S
Weak 8 12.3 13 31.7 21 19.8
Vomiting No 45 69.2 27 65.9 72 67.9 0.135 0.935 NS
Once 17 26.2 12 29.3 29 27.4
Twice 3 4.6 2 4.9 5 4.7
Group
Physical exam.
A(n=65) B(n=41) Total test P value
No. % No. % No. %
Generalized ecchymosis
No 65 100.0 40 97.6 105 99.1 1.6 0.387 NS
71
Yes 0 0.0 1 2.4 1 0.9
Cephalhemato-ma
No 65 100.0 40 97.6 105 99.1 1.6 0.387 NS
Yes 0 0.0 1 2.4 1 0.9
Extremities ecchymosis
No 65 100.0 39 95.1 104 98.1 3.232 0.147 NS
Yes 0 0.0 2 4.9 2 1.9
Extremities bruises
No 65 100.0 38 92.7 103 97.2 4.895 0.055 NS
Yes 0 0.0 3 7.3 3 2.8
Extremities hematoma
No 64 98.5 41 100.0 105 99.1 0.637 1.0 NS
Yes 1 1.5 0 0.0 1 0.9
Abdominal hematoma
No 64 98.5 41 100.0 105 99.1 0.637 1.0 NS
Yes 1 1.5 0 0.0 1 0.9
Abdominal bruises
No 65 100. 0
40 97.6 105 99.1 1.6 0.387 NS
Yes 0 0.0 1 2.4 1 0.9
Table (7) shows 13 patients (12.3%) with delayed 1st cry after delivery. These cases needed resuscitation after birth. In group A patients 8 cases (12.8%) with weak moro and suckling reflexes while in group B patients 12 cases (29.3%) presented with weak moro reflex and 13 cases (31.7%) presented with weak suckling reflex sequentially P value shows significant deference between A and B groups in moro and suckling reflexes. 20 cases (18.9%) presented with weak moro reflex at admission, while 21 cases (19.8%) presented with weak suckling at admission. 42 cases (39.6%) presented with pallor on examination and 2 cases (1.9%) presented with dark urine. 29 cases ( 27.4%) had once vomiting at admission while 5 cases only (4.7%) had twice vomiting at admission. There were 10 cases of sequestrated blood which include generalized ecchymosis, cephalhematoma, extremities hematoma, extremities bruises, extremities ecchymosis, abdominal hematoma and abdominal bruises.
Table )8(: Comparison between O-A & O-B according to level of serum bilirubin )total & direct( at admission at 6, 12, 24, 36 & 48 hours of admission in study group
Variable Groups Mean ± SD Student t test P value
Tsb at admissionA 18.08 3.23
4.073 0.001 HSB 21.03 4.13
72
Dsb at admissionA 1.22 0.47
*1.84 0.065 NSB 1.65 1.74
Tsb at 6 h. after admission
A 17.16 2.393.94 0.001 HS
B 19.66 4.03
Dsb at 6 h. after admission
A 1.27 0.460.863 0.39 NS
B 1.35 0.45
Tsb at 12 h. after admission
A 16.15 2.28 3.9 0.001 HS
B 18.33 3.43
Dsb at 12 h. after admission
A 1.46 1.77 *0.152 0.879 NS
B 1.32 0.59
Tsb at 24 h. after admission
A 14.89 2.33 3.98 0.001 HS
B 17.26 3.77
Dsb at 24 h. after admission
A 1.22 0.35 0.80 0.426 NS
B 1.31 0.79
Tsb at 36 h. after admission
A 13.45 2.7 4.718 0.001 HS
B 16.19 3.22
Dsb at 36 h. after admission
A 1.19 0.41 0.876 0.383 NS
B 1.29 0.66
Tsb at 48 h. after admission
A 12.45 2.31 4.198 0.001 HS
B 14.75 3.29
Dsb at 48 h. after admission
A 1.08 0.39 1.287 0.201 NS
B 1.2 0.596
Tsb = total serum bilirubin Dsb = direct serum bilirubin *= Mann-Whitney testTable (8) shows high significant difference statistically between O-A and O-B groups in
total serum bilirubin level at admission at 6, 12, 24, 36 & 48 hours of admission, while there is no significant difference between O-A and O-B groups in direct serum bilirubin level at admission at 6, 12, 24, 36 & 48 hours of admission.
Table )9(: Comparison between O-A & O-B according to mean number of hours for extensive phototherapy )double & triple( in study group
Variable Groups Mean no. of hrs.
± SD Student t test
P value
Extensive A 34.06 26.57 2.23 0.028 S
73
phototherapy D plus T
B 45.66 25.2
Table (9) shows there is significant difference between O-A and O-B groups in their need for extensive phototherapy.
N.B: unit of phototherapy was suggested by authors in order to make a standard that describe the total amount of phototherapy received by patients for easier comparing.
Table )10(: Comparison between O-A & O-B according to mean number of time units of phototherapy )one unit of phototherapy = one hour of four lamps of valid potency, about 50 cm distance from patient(
Variable Groups Mean ± SD Student t test
P value
Extensive phototherapyD2 plus T3
A 75.8 62.022.49 0.015 S
B 107.12 64.98
D2 = Double phototherapy for one hour T3 = triple phototherapy for one hour
Table (10) shows significant difference between O-A and O-B groups in time units needed for extensive phototherapy. We calculated the units for every patient with B & A groups to compare number of them for each group.
Table )11(: Comparison between O-A & O-B according to Duration of admission in study group
Variable Groups Mean no. of hrs.
± SD Student t test
P value
Duration of admissionS+D+T
A 93.42 21.061.303 0.195 NS
B 98.93 21.43
S+D+T = Single + Double + Triple phototherapy
Table (11) shows no statistical significant difference between O-A and O-B groups in the duration of admission.
74
Table )12(: Comparison between O-A & O-B according to number of exchange transfusion in study group
Group
TTT (Ex transfusion)
A(n=65) B(n=41) Total test P value
No
% No % No %
NO of transfusion
No 59
90.8 28 68.3 87 82.1 9.57 0.008 HS
Once 6 9.2 11 26.8 17 16.0
Twice 0 0.0 2 4.9 2 1.9
Table (12) shows highly significant difference statistically between O-A and O-B groups in need for exchange transfusion.
Table )13(: Comparison between O-A & O-B according to results of Indirect coomb’s test in study group
Group
Variable
A(n=65) B(n=41) Total test P value
No % No % No %
Indirect coomb’s
Positive 27 41.5 24 58.5 51 48.1 5.18 0.088 NS
Negative 38 58.5 17 41.5 55 51.9
75
Table (13) shows no significant difference between O-A and O-B groups in results of indirect comb’s test.
Table )14(: Comparison between O-A & O-B according to CRP in study group
Group
Variable
A(n=65) B(n=41) Total test P value
No % No % No %
CRP Positive 7 10.8 8 19.5 15 14.2 1.58 0.208 NS
Negative 58 89.2 33 80.5 91 85.8
Table (14) shows no significant difference between O-A and O-B groups in results of CRP.
Table )15(: Comparison between O-A & O-B according to level of serum bilirubin )total & direct( at admission at 6, 12, 24, 36 &48 hours in response to treatment with phototherapy in study group
Groups Mean ± SD Student t test P value
Tsb for group A
Admission 18.08 3.23
45.182 0.001 HS
6h 17.16 2.39
12h 16.15 2.28
24h 14.89 2.33
36h 13.45 2.7
48h 12.45 2.31
Dsb for group A
Admission 1.22 0.47
1.649 0.146 NS
6h 1.27 0.4612h 1.46 1.77
24h 1.22 0.35
36h 1.19 0.41
48h 1.08 0.39
Admission 21.03 4.13 16.34 0.001 HS
76
Tsb for group B
6h 19.66 4.0312h 18.33 3.4324h 17.26 3.7736h 16.19 3.2248h 14.75 3.29
Dsb for group B
Admission 1.65 1.74
1.278 0.274 NS
6h 1.35 0.45
12h 1.32 0.59
24h 1.31 0.79
36h 1.29 0.66
48h 1.2 0.596
Tsb = total serum bilirubin Dsb = direct serum bilirubin
Table (15) shows highly significant statistically in response to treatment in both A and B groups.
Table )16(: comparison between O-A and O-B regarding albumin level in study group
Group
Variable
A(n=65) B(n=41) Total test P value
No
% No % No %
Albumin level
>3.5 mg/dl
9 75 11 64.7 20 69
<3.5 mg/dl
3 25 6 35.3 9 31
Table (17):
77
Variable Groups Mean Serum bilirubin level at admission
± SD Student t-test
P value
Gravidity
1A
B
2A
B
3AB
4AB
5AB
6A
B
Table )18(: Comparison between O-A & O-B according to blood picture in study group
Variable Groups Mean ± SD Student t test
P value
Hemoglobin level
A 12.59 1.0982.35 0.021 S
B 12.0 1.45
Hematocrit value
A 34.62 5.564.092 0.001 HS
B 30.35 4.66
PlateletsA 297.45 73.66
0.592 0.56 NSB 289.1 65.59
WBCsA 14.89 4.48
1.038 0.302 NSB 15.83 4.61
Serum Albumin level
A 3.98 0.1852.66 0.013 S
B 3.72 0.296
78
ReticulocytesA 6.88 2.56
3.72 0.001 HSB 9.3 4.16
Table (18) shows that there are highly statistically significant differences about values of reticulocytes and hematocrit and statistically significant differences about values of hemoglobin and serum albumin between O-A & O-B groups.
79
Discussion
Discussion
Jaundice is a common clinical problem in the neonatal period. Many neonates develop
hyperbilirubinemia that requires intervention. It can progress to severe hyperbilirubinemia, resulting in kernicterus (Bhutani et al., 2004).
In a study conducted to Michael sgro, Douglas Campbell and vibhuti shah 2006 showed
that the percentage of ABO incompatibility as a cause of severe neonatal hyperbilirubinemia is
about (51%) followed by G6PD about (21.5%) other antibody incompatibility about (13%) and
other causes about (14.5%).
In the present study we documented 106 cases of hyperbilirubinemia due to ABO
incompatibility between mothers and their babies randomly found that O-A group were about
65 cases (61.3%) and O-B group were about 41 cases (39.7%). Bhat YR and Kumar CG 2012
also made study including 878 deliveries, 151 (17.3%) neonates were ABO incompatible with
their mothers. The proportions who were O-A and O-B incompatible were (50.4%) and
(49.6%), respectively.
Table (2) illustrated that male patients were 1.5 times as like female patients, Numan N.
Hameed et al; 2011 made study about 100 cases of ABO HDN with age range from 1-12 days.
Fifty three percent were males and (47%) were females but Mohammad Irshad et al; 2011
80
studied about 45 cases of ABO incompatibility there were 33 (72%) males and 12 (28%)
females.
Table (3) showed maternal risk factors in group A and group B patients. Firstly, patients
delivered by normal vaginal delivery (NVD) 51 patients (48.1%) while 55 patients (51.9%)
delivered by caesarian section (CS). Secondly, Mothers with oxytocin intake in delivery were
50 cases (47.2%). In addition, table (4) showed that there are higher mean total serum bilirubin
at admission in NVD babies and whose mothers took oxytocin in labor but without significance.
This was in agreement with Oral et al., 2003 who reflected that there is no significant effect of
oxytocin infusion on the incidence of neonatal hyberbilirubinemia, disagreeing with keren et
al., 2005 and El-Shafie et al.,2003 who included that the oxytocin exposure as risk factor for
hyperbilirubinemia.
D'souza et al, 1979 stated that raised plasma bilirubin levels in cord blood, probably
enhanced by breakdown of fetal red cells, appeared to be a dose dependent effect of oxytocin.
Also, Buchan, 1979 stated that the vasopressin – like action of oxytocin causes osmotic
swelling of erythrocytes leading to decreased deformability and hence more rapid destruction
with resultant hyperbilirubinemia in the neonates, these studies were done on venous cord blood
of 95 healthy newborn infants, 15 were delivered by elective cesarean section, 40 after
spontaneous labor and 40 after oxytocin use. There was no significant difference between the
first two groups while infants born after oxytocin-induced labor showed clear evidence of
increased hemolysis with resultant hyperbilirubinemia.
Maisels (1999) stated that there was an association between the use of oxytocin to induce
or augment labor and an increased incidence of neonatal hyperbilirubinemia, although the
mechanism for this is unclear.
Our findings were in accordance with Burgoes et al., 2008 stating that one of the factors
associated with decreased likelihood of readmission for jaundice was cesarean section delivery,
he found that bilirubin on days 1 and 2 were found to be higher in newborns delivered vaginally
than caesarian section. As has been suggested neonates are stressed prior to birth and induce
conjugative enzymes prior to vaginal delivery. Further newborns delivered by cesarean section
81
are breast-fed relatively infrequently during 1st 48 hours of life than those born by vaginal
delivery.
In addition, our findings were in accordance with El-Shafie et al., 2003 stating that
normal vaginal delivery was increased risk of hyperbilirubinemia this could be explained by
the increased use of oxytocin infusion and the increased incidence of traumatic delivery with in
normal delivery than cesarean section delivery. However Olcay et al., 2004 stated that mode of
delivery did not influence levels of bilirubin.
Zarrinkoub F. & Beigi A, 2007 found that there were no statistically significant
relationships between jaundice and maternal age, parity, mode of delivery, neonatal gender or
previous siblings with jaundice (p>0.05).
Table (3) illustrated risk factors of ABO HDN severity, Firstly maternal gravida 1 were 23
cases (21.7%), gravida 2 were 27 cases (25.4%), gravida 3 were 24 cases (22.7%), gravida 4
were 15 cases (14.2%), gravida 5 were 13 cases (13.2%) and gravida 6 were 3 cases (2.8%) and
table (15) appeared higher mean serum bilirubin on paragravida. Gitesh Dubal and Varsha
Joshi; 2012 indicated strong influence of paragravida on neonatal jaundice and its TSB level.
Secondly, Mothers with previous blood transfusion were three cases (2.8%). Mothers with
spontaneous abortions were 28 cases (27.4%). Valentin I. and Govallo, M.D; 1993 had a study
about 85 women with ABO-sensitization but only 31 cases had ABO-HDN. Nine of the women
only (29%) had previous spontaneous abortions.
The study showed 5 cases with maternal intake of salicylates (4.7%), 1 case with maternal
intake of sulfonamide (0.9%), and 33 cases with maternal intake of nitrofurantoin (31.1%).
Merck 2009 in his manual of pediatric stated certain drugs and agents in neonates with G6PD
deficiency (e.g., acetaminophen, alcohol, antimalarial, aspirin, bupivacaine, oxytocin,
corticosteroids, nitrofurantoin , penicillin, phenothiazine, sulfonamides) are oxidizing agents
that lead to overproduction of bilirubin due to hemolytic anemia.
82
Table (5) appeared that commonly our patients presented within the 2nd day of life (86%)
compared with patients presented within the 1st day of life (14%) that disagree with Pavan
Kumar in an Indian study 2012 but has been stated in many studies like Barbara J. et al;
2004 . Our study shows that 9 cases of O-B group (22%) in contrast with 6 cases of O-A group
(9%) presented in the 1st 24 hours of life which stated by Michael Kaplan etal.2010 whose
results demonstrated that more O-B than O-A newborns developed hyperbilirubinemia at <24
hours (93.9%) vs. (48.1%) and showed highly significance. (P-value <0.0001)
Also, table (5) showed family history of jaundice in patients with Abo incompatibility.
78 cases of 106 cases (73.6%) presented with previous family history of jaundice and history of
jaundice's treatment, Numan N. Hameed et al; 2011 illustrated that family history of neonatal
jaundice, history of jaundice's treatment is negative in (54%). Our result is disagreeing with that
ABO-incompatibility is presented in approximately 12% of pregnancies, with evidence of fetal
sensitization in 3% of live births and less than 1% of births are associated with significant
hemolysis and, Mentzer WC & Glader BE, 1998 reported this. This conflict may be due to low
birth control in our society. Wennberg et al.; 2006 stated that family history of previously
jaundiced baby as a child whose sibling needed phototherapy is 12 times more likely to also
have significant jaundice.
Table (6) showed that 42 patients (39.6%) cases developed pallor with jaundice, 21
patients (19.8%) developed neurological signs like poor feeding, KJ Barrington; 2005 stated
that acute encephalopathy which defined as (a clinical syndrome, in the presence of severe
hyperbilirubinemia, of lethargy, hypotonia and poor suck, which may progress to hypertonia
with a high-pitched cry and fever, and eventually to seizures and coma) does not occur in full-
term infants whose peak TSB concentration remains below 340 µmol/L and is very rare unless
the peak TSB concentration exceeds 425 µmol/L. Above this level, the risk for toxicity
progressively increases. Even with concentrations greater than 500 µmol/L, there are still some
infants who will escape encephalopathy. All of the reasons for the variable susceptibility of
infants are not known; however, dehydration, hyperosmolarity, respiratory distress, hydrops,
83
prematurity, acidosis, hypoalbuminemia, hypoxia and seizures are said to increase the risk of
acute encephalopathy in the presence of severe hyperbilirubinemia.
In our study table (6) illustrated that there are 8 cases only of O-A group (12.3%) had
weak moro and suckling reflexes but nearly 12 cases (29%) of O-B group had weak moro and
suckling reflexes. This showed statistically significant difference between both groups that
weak moro and suckling reflexes occur more in O-B group.
In our study table (6) illustrated that there are 10 cases only with sequestrated blood,
which there is no statistical significant difference between these and others without sequestrated
blood regarding mean serum bilirubin level at admission. So as we detected that mean serum
hemoglobin in O-A group equal that of O-B group (mean Hg= 11.8). KJ Barrington; 2005 is in
accordance with our study in that sequestrated blood as cephalhematoma, bruises, hematomas,
ecchymosis has no statistical significance in ABO hemolytic disease of newborn.
Table (8) showed high significant difference statistically between O-A and O-B groups in
total serum bilirubin level at admission and at 6, 12, 24, 36 & 48 hours of admission, while
there is no significant difference between O-A and O-B groups in direct serum bilirubin level at
admission at 6, 12, 24, 36 & 48 hours of admission. Koura, H.M et al; 2009 stated that There
was no significant statistical difference between (Group I treated cases) and (Group II untreated
cases) in (TSB) level on admission (p>0.05); while after 24 and 48 hours of therapy the (TSB)
level was significantly lower in the treated group (Group I) than the untreated group (Group II)
where the p value was 0.000 and 0.001 respectively.
84
Table (9) showed there is significant difference between O-A and O-B groups in their need
for extensive phototherapy. Table (10) shows significant difference between O-A and O-B
groups in time units needed for extensive phototherapy. We calculated the units for every
patient with B & A groups to compare number of them for each group. Sunita Bhandari, 2011
stated that extensive phototherapy used in maximizing energy delivery and maximizing the
available surface area. Thus, O-B cases had more severe jaundice than O-A cases so that they
need more extensive phototherapy.
Table (11) showed no statistical significant difference between O-A and O-B groups in the
duration of admission. In accordance with our study, Koura, H.M et al; 2009 also stated that
the duration of phototherapy the difference was not statistically significant (p>0.05) where in
the patient group the mean duration was (85.07 ± 24.33 hours) and in the treated group the
mean duration was (96.33 ± 20.48 hours).
Table (12) showed highly significant difference statistically between O-A and O-B
groups in need for exchange transfusion. In accordance of us, Bakkeheim et al; 2009 found a
significantly increased rate of invasive treatments, including intravenous immune globulin
therapy and exchange transfusion, in O-B infants compared with O-A. Two studies documented
a higher need for exchange transfusion in O-B neonates than in O-A.
BRINK et al. 1969 stated that jaundice occurred in the O-B group it tended to be slightly
more ever than in the O-A group. This was indicated by the observation that an exchange blood
transfusion was required in 12 out of the 36 jaundiced cases in the O-B group, whereas it was
needed in only 24 of the 80 O-A jaundiced cases which agree with our study.
Table (13) showed no significant difference between O-A and O-B groups in results of
indirect comb’s test. (48.1%) of cases presented with +ve indirect coomb’s test but it showed
more positive results in O-B cases, so that indicates more antigenicity in B grouped infants
than in A grouped infants. Sameer Wagle 2011 stated that indirect coomb’s test is usually
positive in ABO HDN patients. Although in 1990 Swinhoe D.J. proved that indirect Coomb’ s
test was negative in all the mothers of the patients and this means that this test is a weak
marker for hemolysis.
85
Table (14) showed only 15 (14.2 %) positive cases of CRP which shows no significant
difference between O-A and O-B groups in results of CRP. Can Vet J. 2005 stated that
increased bilirubin concentrations caused a significant decrease in CRP values as we
concluded.
Table (18) showed that there are highly statistically significant differences about values
of reticulocytes and hematocrit and statistically significant differences about values of
hemoglobin and serum albumin between O-A & O-B groups. Faris B. alswaf et al; 2009 made
study about 55 cases and stated that main investigations done to the patients with ABO-
incompatibility includes, Total serum bilirubin >19mg/dl in 22 cases (40.8%), Hemoglobin
level ranged from 100- 140g/l in 29 cases, regarding Reticulocyte percentage the majority of
patients (34 cases) between 5-9 %. Our study showed that O-A group reticulocytes was about
6.88% but in O-B group was about 9.3% which is highly statistically significant.
Michael Kaplan, et al; 2010 stated that Hb values were somewhat lower for the O-B
neonates, the difference between these and the O-A group was not significant (17.0 ± 3.1 g/dl
vs. 17.7 ± 2.8 g/dl, p=0.2), in spite of our study showed significant difference between O-A and
O-B group regarding hemoglobin level.
In accordance with our study, Shu-Huey et al; 2012 stated that Mean Hb and RBC for the
AO group were higher and nucleated RBC ratios were lower than for the BO group; however,
these differences were also not statistically significant. Interestingly, the mean Hct value of the
BO group was significantly lower than that of the AO group (p = 0.04).
Faris B. alswaf et al; 2009 made study about 55 cases and stated that main
investigations done to the patients with ABO-incompatibility includes, Total serum bilirubin
>19mg/dl in 22 cases (40.8%), Hemoglobin level ranged from 100- 140g/l in 29 cases,
regarding Reticulocyte percentage the majority of patients (34 cases) between 5-9 %. Our study
showed that O-A group reticulocytes was about 6.88% but in O-B group was about 9.3% which
is highly statistically significant.
86
A slight increase in reticulocytes is a common feature in HDN due to ABO
incompatibility according to Rosenfield 1955. In the series of fairly severe cases collected by
Crawford and co-workers 1953, the reticulocyte count exceeded 15% in 6 out of 11 cases.
Michael Kaplan et al; 2010 showed that Several investigators were unable to show any
difference in clinical severity between O-A and O-B hemolytic disease of the newborn,
although in the former report there was a trend towards performing exchange transfusion during
the first 24 hours more frequently in O-B compared with O-A infants. Similarly, a retrospective
analysis of ABO hemolytic disease did not find significant relationships between the infants’
blood type and clinical outcome. Sisson and Kaplan 1972 reported no significant differences in
severity or response to therapy between the two blood types. An infant whose blood group was
A was as likely to be affected by ABO hemolytic disease as a blood group B infant .
87
Summary and Conclusion
Conclusion and recommendation
88
Summary
89
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Arabic summary
العربى الملخصحديثى لالطفال حدوثا المشاكل اكثر من الوريدى اليرقان يعتبر
مستوى ارتفاع عن ناتجة وهى المبتسرين وخصوصا الوالدةفى , حميدة مشكلة انها من الرغم وعلى الدم فى البيليروبين
الجانبية االعراض االعتبار فى نضع ان يجب لكن االحيان معظمارتفاع من البيليروبين.المحتملة
) االم دم زمرة ووليدها االم بين الدم زمر تنافر دم Oيعتبر وزمرةالحمراء) A or Bالطفل الدم كرات تكسر عنها ينتج والتى
اليومين فى حدوثة سباب اهم من اليرقان حدوث الى والمؤديةالبيليروبين مستوى ارتفاع اسباب اهم ومن الطفل لعمر االولين
95
على تاثيرة لتفادى الطفل دم لتغيير معه نحتاج لمستوى بالدم. للطفل المركزى العصبى الجهاز
بين كثيرة تباينات وجود واالبحاث الدراسات بعض اثبتت ولقدالزمرتين (( و A-Oتنافر
)B- O (مستوى ارتفاع ومعدل منهما كل حدوث معدل حيث من. منهما كل فى البيليروبين
: البحث من الهدف
عن -1 الناتج الوليدى اليرقان حدوث الى المؤدية العوامل معرفة. ووليدها االم دم تنافرزمر
الزمرتين (-2 تنافر بين (A,Bالمقارنة االم) زمرة حيث) Oمع من. البيليروبين ارتفاع ومعدل منهما كال حدوث معدل
البحث طرق
باليرقان المصابين المواليد على البحث هذا اجراء يتم سوفالوالدة حديثى لالطفال المركزة العناية وحدة فى والموجودين
رسالة وجمعية الجامعى بنها ومستشفى العام منوف بمستشفىيناير شهر من ابتداء ببنها من 106وعددهم 2012الخيرية وليد
النوعين.
: الدراسة هذة وتشمل
مابين- (1 الرحمية اعمارهم تتراوح الذين .42-37المواليد اسبوع)
عن 2- اوزانهم تزيد الذين .2.5المواليد كجم
دمهم ( (-3 زمرة الذين جميعا AorBالمواليد امهاتهم تكون بحيثدمهن :Oزمرة
اليومين- فى بالدم البيليروبين مستوى ارتفاع من ويعانونالطفل عمر من االولين
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البيليروبين- مستوى ارتفاع نتيجة لهم الدم لتغيير يحتاجون. الدم زمر تنافر وهو السبب لنفس بالدم
باليرقان المصابون المواليد من كال الدراسة هذة من ويستبعدمن ويعانون
الدم -1 تسممالوالدة -2 اثناء اختناقالتنفس -3 فى صعوبةخلقية -4 عيوبوراثية -5 عدوىالدم -6 زمر Rhتنافر
: الى يخضعون سوف الوالدة حديثى االطفال وكل
العوامل -1 وجود عدم او وجود لمعرفة االم من كامل بيان اخذ. اليرقان حدوث الى المؤدية
لمعرفة -2 الوالدة حديثى االطفال على كامل اكلينيكى كشف. اليرقان لحدوث خطر عوامل وجود عدم او وجود
3-: االتية المعملية والفحوصاتوامهاتهم/ 1 المرضى دم زمرة تحديدبالدم/ 2 الكلى البيليروبين مستوىبالدم/ 3 مباشر والغير المباشر البيليروبين مستوى تحديد
. الطفل عمر من والرابع والثانى االول اليوم وخصوصاالدم/ 4 فى البيليروبين الية يصل مستوى اعلى تحديد5: اخرى/ معملية فحوصات
للدم - كاملة صورةالدم - فى االلبومين مستوىالشبكية - الخاليا عدد
االحصائى التحليل
يتم سوف تجميعها يتم سوف التى والبيانات المعلومات ان. المناسبة االحصائية بالطرق وتحليلها جداول فى وضعها
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