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Haemolytic Disease of The Newborn

hemolytic anemia

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20 views23 pages

Haemolytic Disease of The Newborn

hemolytic anemia

Uploaded by

raghdashrweed5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Haemolytic

disease of
the newborn
5th July 2021
Dr Julia Arthur
Neonatal Consultant
Addenbrookes Hospital Cambridge
• History
• Pathophysiology
Contents • Diagnosis
• Management
History of HDN
• HDN used to be a major cause of fetal loss and death among newborn babies

• 1609 French midwife – twins.


• One baby being swollen and died soon after birth, the other baby developed jaundice and died several days later.

• 1950 the underlying cause was defined


• Newborn's red blood cells (RBCs) are being attacked by antibodies from the mother.

• 1960s, trials in the US and the UK


• Showed that giving therapeutic antibodies to women during their pregnancy largely prevented HDN from developing

• 1970s, routine antenatal care included screening of all expectant mothers to find those whose pregnancy may be at risk of HDN and giving
preventative treatment.

• Currently, dramatic decrease in the incidence of HDN, particularly severe cases that were responsible for stillbirth and neonatal death.
Pathophysiology of HDN
Maternal
Maternalredred
cellcell
antibodies (IgG) IgG
antibodies:

Haemolysis Anaemia

Bilirubin Heart Failure

Jaundice Hydrop
Causes of HDN –
Rhesus incompatibility
• Incompatibility of the Rh blood group between the
mother and fetus.
• D antigen on rbc surface
• Other Rh antigens as c, C, E, and e

Rh D-negative mother and an Rh D-positive child

• Mother is exposed to babies blood and produces anti-D


antibodies (sensitization)
• Antibodies cross the placenta > haemolysis of foetal rbc
• HDN worsens in subsequent pregnancies
• Anti-D antibody injection after sensitization event
Causes of HDN –
ABO incompatibility
• Mother O type blood, foetus AB, A or B type (A most
common)
• O type serum contains naturally occurring
anti-A and anti-B antibodies

• HDN due to ABO incompatibility is usually less


severe than Rh incompatibility.
• foetal RBCs express less of the ABO blood group
antigens compared with adult levels.
• The ABO blood group antigens are expressed by a
variety of fetal tissues, reducing chance of anti-A
and anti-B binding their target antigens on the
fetal RBCs.
Diagnosis of HDN
• Antenatal - Positive maternal antenatal antibody screening and/or anaemic/hydropic
foetus

• Postnatal - Rapidly developing or significant hyperbilirubinaemia not predicted by


maternal antenatal antibody screening

• Laboratory findings- Positive direct anti-globulin test (DAT), Haemolysis on blood film
Rh antigens: anti-D (1 in 1,200), anti-c,
Antenatal- anti-E

maternal anti-Kell

antibody anti-Kidd (Jk)


screening
anti-Duffy (Fy)

anti-MNS antigens
Antenatal scan - Hydrops
Postnatal - • Jaundice – physiological / pathological
• Jaundice is always pathological if develops in first
Jaundice in 24 hrs of life
• THINK SEPSIS
first 24 hrs • LOOK FOR EVIDENCE HAEMOLYSIS
When is it significant jaundice at 38+ weeks?
Why are we worried
about jaundice
• Unconjugated Bilirubin (water insoluable)
• Crosses blood brain barrier
• Toxic to brain at high levels
• Bilirubin encephalopathy (Kinicterus)

• Kernicterus is now very rare in


the UK, affecting less than 1 in every
100,000 babies.
Postnatal -
Laboratory tests
Cord gas – known high risk pregnancies (Rh –ve
mother)

Or Infants blood
• Hb
• Blood film (spherocytes ABO incompatibility)
• Bilirubin
• Direct coombs test (DCT) / Direct antibody test
(DAT)
DAT - weakly 1+/ strongly positive 4+
(degree of haemolysis)

• 23% of DAT+ required phototherapy

• 100% of DAT 4+ required phototherapy

• 15% DAT+ from prophylactic anti-D

• 94% DAT+ in ABO-incompatible mother/baby


Other
• Red blood cell membrane defect
causes of
• Red blood cell enzyme defect
haemolytic
disease • Haemoglobinopathy: α-thalassaemia major
Treatments
• Phototherapy
• Exchange Transfusion
• IV immunoglobulin
Phototherapy
Exchange transfusion
• Removing the infant's blood in small aliquots
and it replacing with donor blood

• Physically removing bilirubin & antibodies

Risks:
Cardiovascular and respiratory instability
Electrolyte imbalance
NEC
Mortality

IV immunoglobulin
Attached to antigen on babies rbc to prevent the maternal antibodies
attaching and causing the rbc to break down
Summary HDN
• History
• Pathophysiology – Rhesus / ABO incompatibility
• ABO more common and less severe
• Maternal IgG antibodies crossing placenta and causing breakdon of infants rbc
• Diagnosis – antenatal, postnatal, laboratory
• Jaundice in first 24 hrs pathological
• Treatments – phototherapy, exchange transfusion, IV IG
Any
Questions

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