Hemolytic Disease of The Newborn: (Erythroblastosis Fetalis)

hemolytic
Disease of the
Newborn
(erythroblastosis fetalis)
• 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.
• It was not until the 1950s that the underlying
cause of HDN was clarified; namely, the
newborn's red blood cells (RBCs) are being
attacked by antibodies from the mother. The
attack begins while the baby is still in the
womb and is caused by an incompatibility
between the mother's and baby's blood.
Hemolytic Disease of the Newborn
• is an alloimmune condition that develops in a fetus, when the IgG

molecules produced by the mother pass through the placenta
• Among these antibodies are some which attack the red blood cells in the
fetal circulation
• the red cells are broken down and the fetus can develop reticulocytosis
and anemia
• This fetal disease ranges from mild to very severe, and fetal death from
heart failure (hydrops fetalis) can occur
• When the disease is moderate or severe, many erythroblasts are present

in the fetal blood and so these forms of the disease can be called
erythroblastosis fetalis (or erythroblastosis foetalis)
Pathophysiology
This disorder occurs when the fetus has a blood group antigen that the mother does not
posses. The mother’s body forms an antibody against that particular blood group
antigen, and hemolysis begins. The process of antibody formation is called maternal
sensitization.
The fetus has resulting anemia from the hemolysis of blood cells. The fetus compensates
by producing large numbers of immature erythrocytes, a condition known as
erythroblastosis fetalis, hemolytic disease of the newborn, or hydrops fetalis. Hydrops
refers to the edema and fetalis refers to the lethal state of the infant.
In Rh incompatibility, the hemolysis usually begins in utero. It may not affect the first
pregnancy but all pregnancies that follow will experience this problem. In ABO
incompatibility, the hemolysis does not usually begin until the birth of the newborn.
• Hemolytic disease occurs most
frequently when the mother does
Etiology not have the Rh factor present in
her blood but the fetus has this
factor.
• Another common cause of

hemolytic disease is ABO
incompatibility. In most cases of
ABO incompatibility, the mother
has blood type O and the fetus has
blood type A. It may also occur
when the fetus has blood type B or
AB.
• Hemolysis is occasionally caused by

maternal anemias, such as
thalassemia or from other blood
group antigens (anti-D).
Symptoms
• Hemolysis leads to elevated bilirubin levels.
• After delivery bilirubin is no longer cleared (via

the placenta) from the neonate's blood and the
symptoms of jaundice (yellowish skin and yellow
discoloration of the whites of the eyes) increase
within 24 hours after birth.
• Like any other severe neonatal jaundice, there is

the possibility of acute or chronic kernicterus.
• Profound anemia can cause:
• high-output heart failure, with pallor,
• enlarged liver and/or spleen,
• generalized swelling, and
• respiratory distress.
• The prenatal manifestations are known as:

• hydrops fetalis;
• in severe forms this can include petechiae and purpura.
• The infant may be stillborn or die shortly after birth.
Diagnosis
The diagnosis of HDN is based on history and
laboratory findings:
• Blood tests done on the newborn baby

• Biochemistry tests for jaundice
• Peripheral blood morphology shows increased reticulocytes.
Erythroblasts (also known as nucleated red blood cells)
occur in moderate and severe disease.
• Positive direct Coombs test (might be negative after fetal
interuterine blood transfusion)
• Blood tests done on the mother

• Positive indirect Coombs test
The Coombs test detects Rh incompatibility
between mother and fetus
This test uses antibodies that bind to anti-

D antibodies. The test is named for Robin
Coombs, who first developed the technique of
using antibodies that are targeted against
other antibodies.
Coombs test
Direct Coombs test: diagnoses Indirect Coombs test: used in the
HDN prevention of HDN
• The indirect Coombs test finds anti-D antibodies in
• The direct Coombs test detects the mother's serum. If these were to come into
contact with fetal RBCs they would hemolyse them
maternal anti-D antibodies that
and hence cause HDN. By finding maternal anti-D
have already bound to fetal RBCs. before fetal RBCs have been attacked, treatment can
be given to prevent or limit the severity of HDN.
• First, a sample of fetal RBCs is
washed to remove any unbound • For this test, the mother's serum is incubated with
antibody (Ig). When the test Rh D-positive RBCs. If any anti-D is present in the
antibodies (anti-Ig) are mother's serum, they will bind to the cells. The cells
added, they agglutinate any fetal are then washed to remove all free antibodies. When
RBCs to which maternal anti-Ig antibodies are added, they will agglutinate
antibodies are already bound. any RBCs to which maternal antibodies are bound.
• This is called the indirect Coombs test because the

• This is called the direct Coombs
anti-Ig finds "indirect" evidence of harmful maternal
test because the anti-Ig binds antibodies, requiring the addition of fetal RBCs to
"directly" to the maternal anti-D show the capacity of maternal anti-D to bind to fetal
Ig that coats fetal RBCs in HDN. RBCs.
Management
• Before birth, options for treatment
include:
• intrauterine transfusion or early induction of
labor when pulmonary maturity has been
attained, fetal distress is present, or 35 to 37
weeks of gestation have passed.
• The mother may also undergo plasma exchange

to reduce the circulating levels of antibody by
as much as 75%.
• After birth, treatment depends on the severity
of the condition, but could include:
• temperature stabilization and monitoring,
• phototherapy,
• transfusion with compatible packed red blood,
• exchange transfusion with a blood type
compatible with both the infant and the
mother,
• sodium bicarbonate for correction of acidosis
and/or assisted ventilation.
• Rhesus-negative mothers who have had a
pregnancy with/are pregnant with a rhesus-
positive infant are given Rh immune globulin
(RhIG) at 28 weeks during pregnancy, at 34
weeks, and within 72 hours after delivery to
prevent sensitization to the D antigen.
Nursing Management
•
1. Administer RhoGAm to the unsensitized Rh-negative
client as appropriate
• Administer RhoGAM at 28 weeks’ gestation, even when titers
are negative, or after any invasive procedure, such as
amniocentesis. RhoGAM protects against the effects of early
transplacental hemorrhage (as recommended by the
American College of Gynecologists).
• When the Rh-negative mother is in labor, crossmatch for

RhoGAM, which must given within 72 hours of delivery of the
newborn.
• 2. Provide management for the sensitized Rh-negative

mother and Rh-positive fetus.
• Focus management of the sensitized Rh-negative mother
on close monitoring of fetal well-being, as reflected by Rh
titers, amniocentesis results, and sonography.
• If there is evidence of erythroblastosis, notify the
perineal team of the possibility for delivery of a
compromised newborn.
3. Provide management for ABO incompatibility.

• Phototherapy usually can resolve the newborn jaundice
associated with ABO incompatibility.
• In addition, initiation of early feeding and exchange blood
transfusions may be immediate measures required to reduce
indirect bilirubin levels.
• Provide client and family teaching.
Preventing HDN
• Determine Rh status of the mother

• If the mother is not sensitized, reduce the
risk of future sensitization
• If the mother is sensitized, determine
whether the fetus is at risk and monitor
accordingly

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hemolytic

• is an alloimmune condition that develops in a fetus, when the IgG

• When the disease is moderate or severe, many erythroblasts are present

• Another common cause of

• Hemolysis is occasionally caused by

• After delivery bilirubin is no longer cleared (via

• Like any other severe neonatal jaundice, there is

• The prenatal manifestations are known as:

• Blood tests done on the newborn baby

• Blood tests done on the mother

This test uses antibodies that bind to anti-

• This is called the indirect Coombs test because the

• The mother may also undergo plasma exchange

• When the Rh-negative mother is in labor, crossmatch for

• 2. Provide management for the sensitized Rh-negative

3. Provide management for ABO incompatibility.

• Determine Rh status of the mother

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