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Hemolytic Disease of The New Born (HDN)

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Miftah Yasin
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99 views24 pages

Hemolytic Disease of The New Born (HDN)

Uploaded by

Miftah Yasin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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HEMOLYTIC DISEASE OF THE NEW

BORN(HDN)
Outlines
o ABO vs Rh hemolytic disease of the newborn
• Definition
• Pathogenesis
• Incidence
• Clinical feature
• Diagnosis
• Management
• Prevention
What is HDN?
• Destruction of the RBCs of the fetus and newborn
by antibodies produced by the mother

Y Fetal cti on
+ = tr u
RBC De s
Mother’s
antibodies
Pathogenesis

Fetomaternal Hemorrhage

Maternal Antibodies formed against Paternally derived


antigens

During subsequent pregnancy, placental passage of maternal


IgG antibodies

Maternal antibody attaches to fetal red blood cells

Fetal red blood cell hemolysis


Incidence
• ABO HDN___________65%
• Rh HDN_____________33%
• Others______________2%
ABO Disease
• About 1 in 5 pregnancies are ABO-incompatible, but only
10% develop HDN
• Mild-ABO antigens weak expression
• Anti-A, anti-B (IgM – doesn’t cross placenta)
• Anti-A,B in group O (IgG – crosses placenta)
• First born is at risk
• Protects against Rh immunization
Diagnosis
 Clinical features
 Mostly Jaundice is the only feature
 Not generally affected at birth
 Liver & spleen is not enlarged
 Laboratory findings
• ABO incompatibility
• Microspherocytes are characteristic of ABO- HDN
• Hyperbilirubinemia
• Hemoglobin level (10-12 g/dl)
• Positive direct Coombs test
Treatment of ABO HDN
• Only about 10% require therapy
• Supportive & Phototherapy is sufficient
• Rarely is exchange transfusion needed

• Phototherapy is exposure to artificial or sunlight to


reduce jaundice
• Exchange transfusion involves removing newborn’s
RBCs and replacing them with normal fresh donor
cells
Phototherapy

Fluorescent Blue Light in the 420-475 nm range


Indication of phototherapy
Complications of phototherapy
1. Increased insensible water loss
2. Retinal damage
3. Erythematous skin rash
4. Bronze baby syndrome
5. Hypo or hyperthermia
6. Sterility if tests not well covered
Exchange transfusion
Indications for exchange trasfusion
• Hydrops fetalis
• History of previous sibiling requiring an exchange transfusion because of Rh
isoimmunization in a baby born with palor HSM and +ve direct coombs test
• Cord Hgb < 11gm%
• Cord TSB 5 mg%
• Rate of rise of TSB > 1mg % Despite phototherapy
• Rate of rise of TSB > 0.5mg % Despite phototherapy if Hgb is between 11 to 13
gm%
• Any TSB > 12 mg% in the 1st 24 hrs
• Any TSB >20 mg% in the Neonatal period
What type of blood to give ?
• Maternal blood if possible
• CMV negative
• Irradiated
• Fresh Whole Blood (to avoid k), <7 days old
• Intrauterine transfusion: RBCs
• Group O, D-negative (Maternal blood if possible)
• Leukoreduced
The exchange
• Should be carried out over a 45-60 min period,
• Usually volume taken out and given will be 20 ml at a time but
smaller aliquots (5-10 mL) may be indicated for sick and premature
infants.
• The goal should be an isovolumetric exchange of approximately two
blood volumes of the infant (2 x85 mL/kg).
• Exchange should start with removal of blood
• If child anemic (Hb < 15) give an extra aliquot volume of blood at the
end, leaving a positive balance).
• Place back under phototherapy lights after the procedure
• Feed after 3 hours.
Post exchange
• Give Vitamin K 1mg/IM
• Repeat all medications which the baby was receiving
• Monitor VS ½ hrly for the first 2hrs
• Watch for bleeding from umbilical stump
• Continue photo therapy
• Check for blood sugar, TSB and HCT after two hrs
• Start feeding after 2 to 3 hrs if baby is well and stable
Complications of ET

• Infection
• Haemorrhage
• Portal and splenic vein thrombosis
1. Catheter related • Air embolism

• Overload cardiac failure


• Hypovolaemic shock
• Arrhythmia (Catheter tip
2. Hemodynamic near sinus-node in Rt Atria)
• Electrolyte imbalance
problems
Rh HDN
• Mother is D negative (d/d) and child is D positive (D/d)
• Most severe form of HDN
• Sensitization usually occurs very late in pregnancy, so the first
Rh-positive child is not affected
• Chances of F.M.H. are only 5% in 1st trimester but 47% in 3rd
trimester, many conditions can increase the risk.
• Chances of primary sensitization during 1st pregnancy is only 1-2%,
but 10 to 15% of patients may become sensitized after delivery.
• ABO incompatibility and Rh non-responder status may protect
Pathogenesis Of Rh Iso-immunisation
Rh Negative Women Man Rh positive (Homo/Hetero)
 
Rh Neg Fetus
No problem
  Fetus    Rh positive Fetus

Mother previously sensitized Rh+ve R.B.C.s enter
 
Secondary immune response Maternal circulation


Non sensitized Mother
? Iso-antibody (IgG)     ?  Primary immune response


Fetus
Fetus  unaffected, 1st
 Baby usually escapes.
Haemolysis Mother gets sensitised? 

 19
Pathology Of Iso-immunisation
AFTER BIRTH  HAEMOLYSIS  IN UTERO
  
Jaundice ANAEMIA BILLIRUBIN
Kernicterus
 
Hepatic Failure
 HEPATIC MAT. LIV NO
  ERYTHROPOESIS EFFECT
 DEATH IUD & DYSFUNCTION 
   
ERYTHROBLASTOSIS PORTAL & UMBILICAL VEIN 
  HYPERTNSION, HEART FAILURE
FETALIS 

  
BIRTH OF AN AFFECTED INFANT - Wide spectrum of presentations. Rapid
deterioration of the infant after birth. May contiune for few days to few months.
Chance of delayed anaemia at 6-8 weeks probably due to persistance of anti Rh
antibodies.
20
Clinical feature

 When erythroblasts are used up in the bone marrow,


erythropoiesis in the spleen and liver are increased
– Hepatosplenomegaly (enlarged liver & spleen)
– Hypoproteinemia (from decreased liver function) leads to cardiac
failure edema, etc called “Hydrops fetalis”
Diagnosis & Management
• Serologic Testing (mother &
newborn)
• Real time u/s
• Amniocentesis & Cordocentesis
• Percutaneous umbilical blood
sampling

• Intrauterine
Transfusion(Hct<30%)
• Early Delivery
• Supportive therapy
• Phototherapy & Newborn
Transfusions
Prevention
Rh Ig (RhoGAM®) is given to the mother to prevent
immunization to the D antigen
RhIg (1 dose) is given at 28 weeks’ gestation
Another dose of Rh Ig should be given to the
mother within 72 hours of delivery (even if stillborn)
– Mother should be D negative
– Newborn should be D positive or weak D
– About 10% of the original dose will be present at birth,
so it’s important to give another dose to prevent
immunization
THANK YOU
24

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