CLINICAL PRESENTATION AND MANAGEMENT OF ...

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بسم اهللا الرحمن الرحيمUniversity of Khartoum

Faculty of Medicine

Postgraduates Medical Studies Board

CLINICAL PRESENTATION AND MANAGEMENT OF HEMOLYTIC DISEASE OF THE NEWBORN IN

KHARTOUM STATE

By

Dr. Khalid Yousif Ishag Ibrahim

M.B.B.S (U of K)

A thesis submitted in partial fulfillment for the requirements of the

Degree of Clinical M.D in Pediatrics and Child Health

May 2004

Supervisor

Prof. Zein A. Karrar

FRCP (L), FRCPCH (UK), MRCP

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1. Introduction and Literature Review 1.1. Definition:

The life span of erythrocytes obtained from term infants (60-80 days) is some

what shorter than that of the adult (110-120 days), where as the life span of

red cells obtained from premature infants (35-50 days) is considerably

shorter. The more immature infants, the greater the degree of reduction in

life span (1).

The hemolytic process is generally defined as pathological processes that

result in shortening of the normal red cell life span of 120 days in adult. A

different definition is employed for neonates since the normal red cell life

span of term infants is only 60-80 days and may be as short as 20-30 days

in infants born at 30-32 weeks of gestation( 1 ).

In most cases of significant hemolysis, some degree of hyperbilirubinemia

and reticulocytosis obviously must be interpreted in terms of values

appropriate for gestational and post gestational age(2, 3).

1.2. Hemolytic Disease of the Newborn (HDN):

Hemolytic disease of the newborn is a disorder in which the life span of fetal

and/or neonatal red cells is shortened due to the binding of transplacentally

transferred maternal IgG antibodies on fetal red cell antigens foreign to the

mother, inherited to the fetus from father(4).

1.2.1. Causes of hemolytic disease of the newborn (HND):

1.2.1.1. RH-hemolytic disease (Erythroblastosis Fetalis):

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The most important type of HDN in terms of clinical severity and frequency in

Caucasian populations is that due to anti-D antibodies developed in a Rh-D

negative woman(5) . Since the introduction of prophylaxis using maternally

administered anti-D immunoglobulin the number of babies affected by

severe HDN has fallen dramatically (5).

The proportion of HDN due to antibodies other than anti-D has risen, but the

severe cases with rare exceptions still result from anti-D antibodies. Access

to the fetal circulation by ultrasound-guided needling of the umbilical vein

has made direct investigation and in utero treatment a reality, but only if the

fetus at risk is recognized and the mother referred to a specialist fetal care

unit. The absolute reduction in numbers has led to a lack of experience in

managing an affected pregnancy at any one individual centre. Paradoxically,

optimum management of the sensitized woman has become more difficult to

achieve in recent years because of the success of anti-D prophylaxis (5).

1.2.1.2. ABO Incompatibility:

Although ABO incompatibility occurs in 20-25% of pregnancies, hemolytic

disease develops in only 10% of such offspring, and usually the infants are

of type A (6).

ABO hemolytic disease of the newborn is limited to mothers who are blood

group type 0 and whose babies are group A or B. Although ABO

incompatibility exists in 15 percent of 0 group pregnancies, ABO hemolytic

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disease is estimated to occur only in about 3 percent of all births. Since it is

more common than Rh hemolytic disease of the newborn (7-10).

There are many reasons for the low incidence and severity of ABO hemolytic

disease of the newborn despite considerable fetomaternal ABO

incompatibility. Most of anti-A and anti-B antibodies are of the 1gM type and

do not cross the placenta. A small number of group O women produce anti-A

and anti-B antibodies of the IgG type that can cross the placenta. The

severity of the disease in the infant may relate in part to the level of lgG anti-

A or anti-B in the mother and the IgG subclass. IgG2 constitutes a significant

component of anti-A and anti-B antibody; this subclass of lgG is transported

less readily across the placenta than are IgG1 or IgG3 and is a less efficient

mediator of macrophage-induced red cell clearance (11).

There are a small number of fully developed A or B antigen sites on fetal red

blood cells. IgG anti-A and anti-B are absorbed into other tissues bearing

these surface antigens, thereby diluting their effect, in addition, individuals of

the type O blood group have different lymphocyte precursor frequencies,

resulting in different titers of anti-A and anti-B than do individuals of A, B, or

AB blood groups(12).

Unlike Rh disease, ABO hemolytic disease of the newborn occurs with the

same frequency in the first as in subsequent pregnancies, since maternal

anti-A and anti-B antibodies are present normally secondary to sensitization

against A or B substances in food or bacteria. Anti-A and anti-B lgG

antibodies do not bind complement on the fetal red cell membrane,

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hemolysis occurs by non complement mediated phagocytosis of Ig-coated

red cells, similar to Rh hemolytic disease of the newborn (13).

ABO hemolytic disease is milder than Rhesus hemolytic disease, this is

because A and B antigens are present in many tissues beside RBC.

Consequently only a small fraction of anti A or anti B antibody that crosses

the placenta actually binds to erythrocytes and the remainder being

absorbed by other tissues.

1.2.1.3. Rh blood group C and E:

Within the Rh blood group system, the most immunogenic antigens after D

are c and E (14, 15). These antibodies are found in women who are Rh-D

positive and lack the c and E antigens, most usually those who have the

genotype CDe/CDe.

Isolated anti-E antibodies are the most frequently one found in antenatal

serology. They are sometimes naturally occurring and very rarely cause any

problems, either antenatally or post delivery. Occasionally a newborn may

require phototherapy or, very unusually, exchange transfusion. However, if

anti-c is found with anti-E, even in low concentration, the combination may

result in very severe HDN, necessitating fetal intervention (16).

1.2.1.4. Kell blood group system:

The Kell red cell blood group (17, 18) occasionally causes severe problems.

Ninety-two percent of the British populations are Kell negative (kk); the

remaining 8% are Kell positive and the majority is heterozygous Kk and only

one in 500 individuals are found to be homozygous KK positive. The

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antibody anti-K is usually found in patients who have had multiple

transfusions, either as a large number of donations to cover a single

traumatic incident, or as recurrent supportive therapy over a long period (19,

20, 21, 22).

When anti-K is found in antenatal sera the majority of patients have a history

of transfusion, but the partner’s blood should be tested to determine his Kell

status (18). There is no difficulty in finding blood for intrauterine or exchange

transfusion as over 90% of the populations are kk Kell negative. Kell

hemolytic disease can be very severe and rapidly fatal in utero at a relatively

early gestation (17, 23).

1.3. Historical Background:

1.3.1. ABO system:

Hemolytic disease due to ABO Incompatibility has been suspected almost

two decades before discovery of the involvement of the Rh-system in the

disease. In 1923 Ottenberg (24) was the first who gave the idea that

isoantibodies of the ABO system might some times be the cause of neonatal

jaundice.

1.3.2. Rh blood group system:

Is the most complex of the blood group systems that characterized by more

than 30 known antigens and a much larger number of complex alleles. The

Rh antigens are confined to the red-cell membrane. Landsteiner and Wiener

was the first described the system in 1940(25).

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The Wiener system proposed that the Rh phenotype be determined by a

single genetic locus with many alleles. The Fisher-Race system, on the other

hand, assumes that the inheritance of the Rh antigens is determined by

three pairs of allelic genes (C-c, D-d, and E-e) acting on three closely linked

loci. Despite expansion over the years, the Fisher-Race system does not

cover all the reactions that have been observed within the Rh system, but

because the CDE/cde nomenclature is easy to use and enables practical

visualization of how a given sample of cells will react with available antisera,

the World Health Organization (WHO) has recommended that the Fisher-

Race system to be adopted.

The role of the Rh-antibody in classical erythroblastosis fetalis was first

elucidated in 1941 by Levine & Katzin (26, 27). It is now recognized that the Rh-

antigen is a large protein molecule with several antigenic sites, and that each

of these antigens reflects specific chemical or structural protein

characteristic. There are several recognized Rh-antigens (C-c, D-d and E-e)

each of which is detected by specific antibodies. The most important of these

is the D-antigen, and RBCs processing this antigen are Rh-positive. Proteins

are produced under the direction of paired chromosomes, and this red blood

cell Rh-protein have two determinants of each antigen (CC or cc, Cc, DD,

dd, Dd) (25).

This classification follows the convention that the possession of a D gene

and antigen is termed Rh-D positive, whereas the absence of a D gene and

antigen is termed Rh-D negative.

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It follows that any Rh-D-positive offspring of a Rh-D negative mother has to

be heterozygous Dd Rh-D positive, having received a D- antigen from the

father but not from the mother. It also follows that if the father is homozygous

Rh-D positive then he can only have Rh-D-positive children, whereas if he is

heterozygous (Dd) Rh-D positive, and his wife is Rh-D negative, there is a

50:50 chance of his fathering an Rh-D negative baby who will not be affected

by maternal anti-D(28,29).

We know that the Rh blood group system consists of three homologous but

distinct Tran membrane proteins. Two have immunologically distinct

isoforms, Cc and Ee, but the principal protein D has no isoform d. The Rh

locus on chromosome 1 consists of two homologous structural genes, Cc,

Ee and D. The Rh-D gene encodes the major antigen, Rh-D, in ‘Rh-positive’

individuals. In Rh-negative individuals the Rh-D gene is absent and there is

no expression of D but normal Cc/Ee expression. This explains why anti-d

antibody has never been identified.

There is considerable racial variability in the prevalence of Rh-negativity.

About 15 percent of Caucasians are “Rh-negative,” compared to 7-8% of

American blacks, 5% of Asian Indians,(30) and 0.3 percent of the Chinese (31) and there still increase incidence of blood incompatibility in developing

countries(32,33, 34).

DD homozygous

Dd heterozygous

Rh-D positive dd Rh-D positive

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The Jamaican report of Lindo Haynes on the nature of ABO-HDN, showed

that ABO-HDN to be greater problem than Rh-HDN. This was partly

explained by the fact that over 50% of the mothers were group O, the most

likely group to have IgG anti-A and anti-B, and partly by low incidence of the

d gene, only 6.7% of mothers being Rh-negative(35).

The incidence of jaundice due to ABO hemolytic disease of the newborn was

studied in a mixed Arab population in Abu-Dhabi (36). It was found to be

higher in this population than among Northern American Whites but similar

to that in North American Blacks.

In Saudi Arabia, a study done for basic hematological value, of Hb

concentration, hematocrit ratio. RBCs count, MCV, MCH, MCHC, total and

differential leukocyte count and platelet, It was undertaken in a reference

Saudi population in the area of Jeddah from birth to adolescence (37). A total

number of 843 males and 830 females were investigated. Age groups were

allocated so as to include periods in development where physiological

variations are expected.

Regarding neonates, cord blood was obtained from clinically normal

consecutive Saudi babies born at the King A/AZIZ University Hospital

(KAUH) with a gestational age ranging from 38 to 42 weeks only those from

normal singleton pregnancy and delivery were included for those 1-3 days

venous blood was obtained from Saudi babies in the neonatal unit of KAUH.

The hemoglobin, Hematocrit and RBC count are higher at birth reach

maximum level during the first few days of life. This is followed by a

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precipitous fall to the lowest levels by the declined in the third month of life.

Various reasons are given for this such as hemolysis due to a reduced red

cell life span, expansion of the plasma volume and physiological depression

of erythropoiesis (37).

The mean cord Hb and MCV values 17.3 + 1.9 and 105 + 5.3 respectively

are lower than the corresponding values reported by Matoth from

Scandinavia 18.7 + 3.4 and 108 + 5.3(38). No sex differences could be

demonstrated in the mean hemoglobin, hematocrit and red cells count during

the first year of life.

In Sudan, a study done by Atieg from 1988 to 1989(39). to determine

reference values for glucose, bilirubin, total protein albumin, calcium,

phosphorous, hemoglobin, hematocrit, total and differential white blood cells

count, platelets and erythrocyte sedimentation rate in cord blood in

Sudanese normal infants of 37 to 40 weeks of gestation with no congenital

abnormality or trauma and with Apgar Score of 7 or more at one minute

delivered by normal vaginal delivery from healthy mother with an uneventful

pregnancy.

All socioeconomic classes and all ethnic groups in Khartoum city are

represented in his study and the blood samples were taken from the four

major hospitals in the city; namely; Soba Hospital, Khartoum Teaching

Hospital, Omdurman Hospital and St. Mary's Private Maternity Hospital.

A mean of 15.4 gm/dl, and 51% for hematocrit were obtained in his studies

which were lower than those ported in American by Vobecky (hemoglobin

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16.4 + 2.2 and hematocrit 45.3 + 4.7) and in Europeans and Americans, by

Willoughby (hemoglobin 19 + 2.2 gm/dl and hematocrit 54% + 100/0). A

study done by Forestier in France showed lower values (13.2 gm/dl) than

Ateig's result.

Atieg classified the newborns into two groups: Afro-Arab and pure Africans.

A mean of 15.4 gm/dl for Afro-Arab and a lower one of 13.9 for pure Africans

with statistically significant difference.

Causes of neonatal jaundice in K.T.H done by M.O.Swar (40), he found that

15.1 % ABO incompatibility, 8.1% Rhesus incompatibility, compared with

that done by Walyeldin.E.M, 9.2%, 7.7% ABO, Rh-incompatibility

respectively (41).

Another study in anemia in Sudanese newborn: etiology, risk factors and

clinical presentation done by Atifa M Abdalla showed that the common

causes of anemia were blood incompatibility (33.8%), blood loss (16.4%),

septicemia (14.4%), malaria (14.4%) and others(42).

1.4. Pathogenesis:

The binding of transplacentally transferred maternal anti-D IgG anti bodies to

D-antigens sites on the fetal red cell membrane is followed by adherence of

the coated red cells to Fc receptors of macrophages with rosette formation,

leading to extravascular non-complement-mediated phagocytosis and lyses,

predominantly in the spleen.

Although, Rh antigens are found on fetal cells as early as the seventh week

of gestation, the active transport of IgG across the placenta is slow until 24

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weeks of gestation. The degree of hemolysis may be, influenced by the

functional immaturity of the fetal reticuloendothelial system prior to 20 weeks

of gestation, maternal IgG levels, the IgG subclass, and the rate of

transplacental transfers Antibodies of the IgG1 and IgG3 subclasses, often

produced in Rh alloimmunization, have a high affinity for Fcy receptors and

are associated with severe disease, while maternal antibodies with

specificity for allogeneic monocytes, which block Fcy receptors on

mononuclear phagocytic cells, may result in unexpectedly mild hemolytic

disease of the newborn(27,28).

Isoimmune hemolytic disease from D-antigen is approximately three times

more frequent in white persons than in blacks. When Rh positive blood is

infused into Rh negative woman through error or when small quantities

(usually more than 1 ml) of Rh positive fetal blood containing D antigen

inherited from an Rh positive father enter the maternal circulation during

pregnancy, with spontaneous or induced abortion, or at delivery, antibody

formation against D may be induced in the unsensitized Rh negative

recipient mother. Once immunization has occurred, considerably smaller

doses of antigen can stimulate an increase in antibody titer. Initially, a rise of

antibody in the 19S gamma globulin fraction occurs, which later is replaced

by 7S (lgG) antibody; the latter readily crosses the placenta, causing

hemolytic manifestations (14).

Hemolytic disease rarely occurs during the first pregnancy, because

transfusions of Rh positive fetal blood into Rh negative mother tend to occur

near the time of delivery, too late for the mother to become sensitized and

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transmit antibody to her infant before delivery. The fact that 55% of Rh

positive fathers are heterozygous (D/d) and may have Rh negative offspring

and that only 50% of pregnancies have fetal to maternal transfusions

reduces the chance of sensitization, as does small family size, in which the

opportunities for its occurrence are fewer (43,44).

Finally, the capacity of Rh negative women to form antibodies is variable,

some producing low titers even after adequate antigenic challenge. Thus,

the overall incidence of isoimmunization of Rh negative mothers at risk is

low, with antibody to D detected in less than 10% of those studied, even

after five or more pregnancies; only about 5% ever have babies with

hemolytic disease (15).

When mother and fetus are also incompatible with respect to group A or B,

the mother is partially protected against sensitization by the rapid removal of

Rh positive cells from her circulation by her anti-A or anti-B, which are IgM

antibodies and do not cross the placenta(45).

Once a mother has been sensitized, her infant is likely to have hemolytic

disease. There is a tendency for the severity of Rh illness to worsen with

successive pregnancies. The possibility that the first affected infant after

sensitization may represent the end of the mother’s child bearing potential

for Rh positive infants argues urgently for the prevention of sensitization

when this is possible. Such prevention consists of injection of anti-D gamma

globulin (RhoGAM) in the mother immediately after the delivery of each Rh

positive infant (46, 47).

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The C-antigen is much less potent causing immunization in about 2% of

recipients under similar circumstances (48). Thus Giblett found that in 93%

of cases of hemolytic disease of the newborn, the disease resulted from the

presence of anti-D, while a further 6%were due to anti-C. The remaining 1 %

was caused by a wide variety of antibodies not only in the Rh-system, but in

most of the other known blood groups (45).

As a rough guide, about 15% of the endogenous populations of the U.K are

Rh-negative, whereas going east into Asia the population decrease so to

that hemolytic disease of the newborn is much rarer than in the U.K. On the

other hand in the Basque people of northern Spain, about 30% are Rh-

negative and this should make the disease more common. Increasing

movement of population, however, means that doctors should keep Rh-

hemolytic disease of the newborn in mind wherever they work (48,49).

Hemolysis associated with ABO incompatibility is similar to Rhesus

hemolytic disease in that maternal antibodies enter the fetal circulation and

react with A or B antigens on the erythrocytes surface, It can occur without

previous sensitization. In type A and B individual, naturally occurring anti B

and Anti A is isoantibodies IgM molecule that do not cross the placenta. In

contrast the isoantibodies present in type O individuals are predominantly

1gG molecule. For this significant reason, ABO incompatibility is largely

limited to type O mothers with type A or B fetus. Sensitization is such rarer

when the mother blood group is type A or B than when she has blood type O

as demonstrated by the antiglobulin test (50).

1.5. Pathophysiology:

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The pathophysiology of isoimmune hemolysis due to Rh-incompatibility

includes: a Rh-negative mother, a Rh-positive fetus, leakage of fetal RBCs

into maternal circulation, maternal sensitization to D-antigen on RBCs,

production and transplacental passage of maternal anti-D antibodies into

fetal circulation, then attachment of maternal antibodies to Rh-positive fetal

RBCs and lastly destruction of antibody coated fetal RBCs (51).

Rh-hemolytic disease is rare (1%) during the first pregnancy involving an Rh-

positive fetus but the likelihood of having an affected infant increases with

each subsequent pregnancy. The first pregnancy generally is characterized

by maternal sensitization to fetal RBCs. Small volume of fetal RBCs enter

the maternal circulation throughout gestation, although the major fetal

maternal bleeding responsible for sensitization occur during delivery(52).

In these cases in which significant hemolysis occurs during the first

pregnancy, it is thought that either isoimmunization may have occurred with

previous abortions, ruptured tubal pregnancy amniocentesis or transfusion

with Rh-positive blood(46,53). Recently, it has been suggested that the Rh-

negative girls born to Rh-positive mothers may be sensitized at birth as a

result of maternal fetal hemorrhage (14).

Regardless of the mechanism of initial sensitization, small amount of fetal

blood that enter the maternal circulation during subsequent pregnancies are

sufficient to elicit an immune response. The initial maternal response is

production of IgM anti-D and this subsequently is followed by the formation

of IgG anti-D. The titer of IgM anti-D, detected by agglutination with Coombs'

serum can be followed in maternal serum. Since IgM antibodies don't cross

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the placenta, however, only the concentration of IgG anti-D is important.

With elevated IgG antibody titers, there is an increase likelihood of neonatal

hemolytic disease (54).

1.6. Clinical features:

Anemia and hepatosplenomegaly are the hallmark of hemolytic disease of

the newborn, clinical spectrum of affected infants is highly variable. In Rh

hemolytic disease of the newborn, half of the infants have very mild disease

and do not require intervention. One-quarter of affected infants are born at

term with moderate anemia and develop severe jaundice. The remaining

one-quarter develops severe anemia and severe jaundice and without

intrauterine intervention becoming hydrops (48, 55).

In Kell hemolytic disease of the newborn the clinical spectrum of hemolytic

disease of the newborn is less predictable ranging from limited clinical

stigmata to frank hydrops (56). Anemia and hepatosplenomegaly are also

seen in ABO hemolytic of the newborn, but the disease is usually milder than

in Rh hemolytic disease of the newborn (55).

1.6.1. Jaundice:

May be absent at birth because of placental clearance of lipid-soluble

unconjugated bilirubin, but in severe cases bilirubin pigments stain the

amniotic fluid, cord, and vernix caseosa yellow. Icterus is generally evident

on the 1st day of life because the infant’s bilirubin-conjugating and excretory

systems are unable to cope with the load resulting from massive hemolysis.

Indirect-reacting bilirubin therefore accumulates postnatally and may rapidly

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reach extremely high levels, which represent a significant risk of bilirubin

encephalopathy.

There is a greater risk of developing kernictrus from hemolytic disease than

from comparable non-hemolytic hyperbilirubinemia, although the risk in an

individual patient may be due to the severity of illness (e.g., anoxia, acidosis) (57).

1.6.2. Anemia:

Infants with mild hemolytic disease of the newborn cord blood hemoglobin

concentrations slightly lower than the age-related normal range Hemoglobin

values usually begin to fall during the first 24 h of life, and hemolysis

continues until all incompatible red cells and/or circulating maternal

alloantibody is eliminated from the circulation. Since the alloantibodies are

IgG, the half-life is approximately 3 weeks. Physical examination in infants

with moderate to severe anemia will reveal pallor, tachypenia, and

tachycardia, hepatosplenomegaly. Signs of cardiovascular collapse and

tissue hypoxia-appear when anemia is severe (hemoglobin <4 g/dl,

hematocrit 15%) (2, 47, 58, 59).

1.6.3. Kernictrus:

The most common affected part of the brain is the basal ganglia and brain stem

nuclei. The cerebellum also can be affected

1.6.3.1. Clinical presentation of kernictrus:

1. Acute bilirubin encephalopathy:

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Phase I: Occurs in the first few days of life, there is decreased alertness,

hypotonia, and poor feeding,

Phase II: Variable in onset and duration, hypotonia of extensor muscles is a

typical sign.

Phase III: Infant aged more than one week: Hypotonia is a typical sign (57).

2. Chronic bilirubin encephalopathy (CBE):

Phase I: occurs in the first year of life consists of hypotonia, hyper-reflexia

and delay acquisition of milestones.

Phase II: in children older than one year, characterized by extrapyramidal

manifestation (Such as athetosis and chorea), the upper

extremities usually affected more than the lower, visual and

auditory systems,

3. Abnormalities of dentition:

For example dental enamel hypoplasia, green-stained teeth (57).

1.6.4. Hydrops fetalis:

When the compensatory capacity of the hematopoietic system is exceeded,

profound anemia results in pallor, signs of cardiac decompositions

(cardiomegaly, respiratory distress), massive anasarca, and circulatory

collapse. This clinical picture of excessive abnormal fluid in two or more fetal

compartments (skin, pleura, pericardium, placenta, peritoneum, amniotic

fluid), termed hydrops fetalis, frequently results in death in utero or shortly

after birth. With the use of RhoGAM to prevent Rh sensitization, non-

immune, non-hemolytic conditions are more frequent cause of hydrops.

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The severity of hydrops is related to the level of anemia and the degree of

reduction in serum albumin (oncotic pressure), which is due in part to hepatic

dysfunction. Alternatively, heart failure may increase right heart pressures,

with the development of edema and ascites. Failure to initiate spontaneous

effective ventilation because of pulmonary edema or bilateral pleural

effusions results in birth asphyxia; after successful resuscitation, severe

respiratory distress may develop.

1.6.5. disseminated intravascular coagulation:

Petechiae, purpura, and thrombocytopenia may also be present in severe

cases, reflecting decreased platelet production or the presence of concurrent

disseminated intravascular coagulation (60).

1.6.6. Hypoglycemia:

Occurs frequently in infants with severe isoimmune hemolytic disease and

may be related to hyperinsulinism and hypertrophy of the pancreatic islet

cells in these infants.

1.7. Clinical Course:

Clinical severity of Rh-erythroblastosis is variable but depends ultimately on

the quantity of maternal antibody that binds the fetal RBCs. The clinical

course is divided into mild, moderate or severe (48,61).

1.7.1. Mild hemolytic disease:

Approximately 50% of affected infants with a positive direct Coombs' test

(either Rhesus or ABO) have minimal hemolysis manifested by no anemia

(cord blood hemoglobin greater than 14 gm/dl) and minimal

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hyperbilirubinemia (cord blood bilirubin less than 4 mg/dl), while in the early

neonatal period mild anemia (Hb between >11<14 g/dl) and minimal

hyperbilirubinemia (total bilirubin less than 12 mg/dl) may be present. These

neonates generally do not require specific therapy unless the postnatal

bilirubin rise is greater than expected. In some of these infants, however,

the persistence of maternal antibody may result in exaggerated physiological

anemia at 2-3 months of age.

1.7.2. Moderate hemolytic disease:

In approximately 25% of affected infants, there is significant hemolysis, as

manifested by mild to moderate anemia (cord blood hemoglobin less than 14

gm/dl) and increased hyperbilirubinemia (cord blood bilirubin greater than

4mg/dl), regarding early neonatal period moderate anemia (Hb between 8-

11g/dl) and hyperbilirubinemia (total bilirubin 12-20 mg/dl).

The peripheral blood of moderately affected neonates may contain

numerous nucleated RBCs, decreased numbers of platelets and

occasionally a leukemoid reaction with marked numbers of immature

granulocytes. Infants with leukemoid reactions also may manifest marked

hepatosplenomegaly, a consequence of several factors: extramedullary

hematopoiesis, sequestration of antibody coated RBCs and

reticuloendothelial hyperplasia. This group of neonates will develop

kernictrus if not treated and thus early exchange transfusion with type

specific Rh-negative fresh RBCs are mandatory.

1.7.3. Severe hemolytic disease:

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A significant number of the remaining affected infants (25 %) have more

severe disease and are stillborn, hydropic or severely anemic. The etiology

of fetal death and hydrops is related to anemia induced cardiac failure. In

addition, there is usually some degree of hypo-proteinemia. Therapy for

these seriously affected fetuses is direct toward prevention of severe anemia

and death.

Concomitant ABO incompatibility protects against maternal Rh-sensitization

but it doesn't protect an Rh-positive fetus or neonate from hemolysis once

the mother is sensitized. ABO hemolytic disease of the newborn is usually

mild and rarely responsible for fetal deaths. A higher incidence and greater

severity is reported in South East Asians, Latin Americans, Arabs and South

African and American blacks (7-10), but even in these populations the clinical

phenomenon is early neonatal jaundice requiring phototherapy or exchange

transfusions. Severe fetal anemia and hydrops has been rarely reported (62,

63).

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1.8. Laboratory investigations:

1.8.1. Hematological investigations:

1.8.1.1. Blood type and Rhesus:

Blood type and Rhesus should be done in both mother and infant to prove or

exclude blood group or Rh-incompatibilities.

1.8.1.2. Coomb’s test:

It is usually positive in Rh-incompatibility. Occasionally, high titers of

maternal antibody may block Rh-antigenic sites on the neonatal red cells,

leading to false-negative Rh typing (64, 65). Antepartum RhoGAM given to the

mother may result in a weakly positive DAT result in the Infant at birth (66).

A presumptive diagnosis of ABO incompatibility is based on the presence of

ABO incompatible, a weakly to moderately positive direct Coombs test result,

and spherocytes in the blood smear, which may at times suggest the

presence of hereditary spherocytosis.

1.8.1.3. Complete blood count (CBC):

The cord blood hemoglobin varies, usually proportionally to the severity of

the disease; with hydrops fetalis it may be as low as 3-4 g/dl. The blood

smear usually shows polychromasia and a marked increase in nucleated

RBCs. The white blood cell count is usually normal but may be elevated;

there may be thrombocytopenia in severe cases (61). The reticulocyte count is

usually more than 6 percent and may approach 30 to 40 percent in severe

Rh disease (35).

1.8.1.4. Bilirubin:

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The cord bilirubin is usually between 3 and 5mg/dL (51-86 mmol/l) there may

be a substantial elevation of direct-reacting (conjugated) bilirubin. The

indirect-reacting bilirubin rises rapidly to high levels in the first 6 hr of life.

Transcutanous bilirubinometry can be used to detect the reflecting light from

bilirubin molecules (64, 65, and 66).

1.8.1.5. Serum albumin levels:

This may be useful in evaluating the risk of toxicity levels, since albumin bind

bilirubin in a ratio of 1:1 at the primary high affinity binding sites.

1.8.1.6. Arterial blood gas analysis:

May reveal metabolic acidosis and/or respiratory decompensation.

1.8.2. Radiological investigation:

Cardiomegaly and pleural and pericardial effusions may be evident on

radiological investigation Cardiac hypertrophy with disproportionate septal

hypertrophy has been noted in severely affected infants by echocardiography

(68).

24

1.9. Diagnosis:

1.9.1. Diagnosis of Rh- incompatibility:

1.9.1.1. Antenatal Diagnosis:

In Rh negative women, a history of previous transfusions, abortion, or

pregnancy should suggest the possibility of sensitization. Expectant parents’

blood types should be tested for potential incompatibility, and the maternal

titer of lgG antibodies to D should be assayed at 12-16, 28-32, and 36 wk.

The fetal Rh status may be determined by isolating fetal cells or fetal DNA

(plasma) from the maternal circulation or by amniocentesis and polymerase

chain reaction with primers to the Rh gene (69).

The presence of measurable antibody titer at the beginning of pregnancy, a

rapid rise in titer, or a titer of 1:64 or greater suggests significant hemolytic

disease, although the exact titer correlates poorly with the severity of

disease (69, 70, 71).

The severity of fetal disease should be monitored by amniocentesis,

percutaneous umbilical blood sampling (PUBS), and ultrasonography (U/S).

If there is a history of a previously affected infant or a stillbirth, a Rh positive

infant is usually equally or more severely affected than the previous infant,

and the severity of disease in the fetus should be followed.

Assessment of the fetus may require information obtained from

ultrasonography, amniocentesis, and PUBS. Real-time ultrasonography is

used to detect the progression of disease with hydrops defined as skin or

scalp edema, pleural or pericardial effusions, and ascites. Early

25

ultrasonographic signs of hydrops include organomegaly (liver, spleen,

heart), double bowel wall sign (bowel edema), and placental thickening.

Progression to polyhydramnios, ascites, pleural or pericardial effusions, and

skin or scalp edema may then follow. If pleural effusions precede ascites and

hydrops by a significant time, causes other than fetal anemia should be

suspected. Extramedullary hematopoiesis and, less so, hepatic congestion

compress the intrahepatic vessels, producing venous stasis with portal

hypertension, hepatocellular dysfunction, and decreased albumin synthesis (72).

Hydrops present when fetal hemoglobin is less than 5g/dI (Frequent when

under 7 g/dl and variable between 7 and 9 g/dl). Real time ultrasonography

predicts fetal well being by the biophysical profile, whereas Doppler

ultrasonography assesses fetal distress by demonstrating increased

vascular resistance. If there is ultrasonographic evidence of hemolysis

(hepatosplenomegaly), early or late hydrops, or fetal distress, amniocentesis

should be performed (72, 73, 74, 75).

Amniocentesis is used to assess fetal hemolysis. Hemolysis of fetal RBCs

produces hyperbilirubinemia before the onset of severe anemia. Bilirubin is

cleared by the placenta, but a significant proportion enters the amniotic fluid

and can be measured by spectrophotometer. Amniocentesis is performed if

there is evidence of maternal sensitization (titer >1:16), if the father is Rh

positive, or if there are ultrasonographic signs of hemolysis, hydrops, or

distress.

26

Ultrasonographically guided transabdominal aspiration of amniotic fluid may

be performed as early as 18-20 wk of gestation. Spectrophotometric

scanning of amniotic fluid wavelengths demonstrates a positive optical

density deviation of absorption for bilirubin from normal at 450 nm (76).

The Optic density 450 is a reflection of fetal bilirubin levels, and thus

hemolysis, and indicates the severity of anemia and the risk of intrauterine

death. With maturity, time level of amniotic fluid bilirubin normally declines;

thus, the fetal risk assessed during gestation in terms of three relative but

declining zones of OD 450, if hydrops or other signs suggesting fetal anemia

are present, PUBS should be performed to determine fetal hemoglobin

levels, and packed RBCs should be transfused if serious anemia exists

(hematocrit of 25-30%)(76).

27

1.9.1.2. Postnatal Diagnosis:

Immediately after the birth of any infant to Rh negative woman, blood from

the umbilical cord or from the infant should be examined for ABO blood

group, Rh type, haematocrit, hemoglobin, and reaction of the direct Coombs’

test. If the Coombs’ test result is positive, baseline serum bilirubin level

should be measured, and a commercially available RBC panel should be

used to identify RBC antibodies that are present in the mother’s serum. The

direct Coombs test result is usually strongly positive in clinically affected

newborn and may remain so for a few days up to several months (72).

1.9.2. Diagnosis of ABO-incompatibility:

A presumptive diagnosis is based on the presence of ABO incompatibility, a

weakly to moderately positive direct Coombs test result or even negative,

and spherocytes in the blood smear, which may at times suggest the

presence of hereditary spherocytosis. Hyperbiliruhinemia is often the only

other laboratory abnormality.

The hemoglobin level is usually normal but may be as low as 10-12 g/dl

(100-120 g/L). Reticulocytes may be increased to 10-15%, with extensive

polychromasia and increased numbers of nucleated RBCs. In 10-20% of

affected infants, the unconjugated serum bilirubin level may reach 20 mg/dL

or more.

1.9.1.3. Diagnosis of minor group incompatibility:

It is suggested by Coombs' positive hemolytic anemia in the absence of ABO

or Rh-incompatibility and a negative maternal indirect Coomb's test.

28

Definitive diagnosis requires identification of the specific antibody in neonatal

serum or RBCs and maternal serum should also contain elevated titer of that

antibody (49).

1.10. Treatment:

The main goals of therapy are to:

(1) Prevent intrauterine or extra uterine death from severe anemia and

hypoxia.

(2) Avoid neurotoxicity from hyperbilirubinemia.

1.10.1. Therapy during intrauterine:

Intrauterine Fetal Transfusion:

Intraperitoneal fetal transfusion has been largely replaced by direct

intravascular fetal transfusion (IVT) by venipuncture. Other techniques of

fetal transfusion reported include intrahepatic venous puncture,

combinations of intravascular with intraperitoneal transfusions, and even

intracardiac transfusion as a last resort, Hallak (77) and Chamber (78).

Intraperitoneal transfusions may be necessary when intravascular access is

difficult, as in early pregnancy when the umbilical vessels are narrow or later

when increased fetal size prevents access to the umbilical cord. The

intravascular technique offers precise diagnostic evaluation of the fetal

status and is effective even in hydropic fetuses by circumventing the problem

of erratic and often poor absorption of red blood cells from the peritoneal

cavity in such fetuses. The relative merits of direct simple intravascular

transfusion versus intravascular exchange transfusion have been debated,

29

but the shorter procedure time with direct simple IVT has made it the

procedure of choice at most centers (77, 78, and 79).

The first umbilical blood sampling with transfusion ideally should be

performed when the fetus is anemic but before hydrops has developed,

transfusions are perform at hematocrit levels of 25 to 30 percent or less.

Generally, the hematocrit drops by I to 2 percent per day in the transfused

hydropic fetus; the fall in hematocrit is rapid in fetuses with severe hemolytic

disease, necessitating a second transfusion within 7 to 14 days; the interval

between subsequent transfusions is usually 21 to 28 days. Very low pre-

transfusion fetal hematocrit levels, rapid large increases in post-transfusion

hematocrit level, and increases in umbilical venous pressure during IVT are

associated with fetal death post-transfusion(77,78).

Fresh ly packed O-negative red blood cells that are antigen negative for any

other identified antibody, cytomegalovirus (CMV) seronegative or leuko-

depleted, immediate, and cross-matched against the mother’s blood are

used (79). Fetuses are at risk for both post-transfusion cytomegalovirus and

graft-versus-host disease. Blood that is washed free of the anticoagulant

citrate and other additives and that has maximal in vivo survival is

advocated.

Acidosis is to be avoided so that the hemoglobin oxygen affinity is not

reduced due to a shift in the hemoglobin dissociation curve. Blood is

prepared to increase the fetal hematocrit to between 40 and 45 percent. The

blood should be as fresh as possible, warmed, and packed to a hematocrit of

30

70 to 85 percent in a volume calculated based on estimated fetal placental

blood volume, fetal hematocrit, and hematocrit of donor blood (78).

1.10.2. Therapy during delivery:

The decision as to when to deliver the fetus is based on gestational age,

fetal weight and lung maturity, fetal response to the transfusions, and the

ease of performing the transfusion combined with the antenatal ultrasound

and Doppler studies. Transfusions are provided up to 33 to 34 weeks, with

delivery as soon as lung maturity is achieved by antenatal steroid therapy.

Less severely affected fetuses may be allowed to proceed to term before

delivery.

Other treatments used in Rh-sensitized pregnancies include intravenous

IgG, plasmapheresis, plasmapheresis combined with intravenous

immunoglobulin, glucocorticoids, oral enteric-coated D-positive erythrocytes,

and promethazine hydrochloride. Each of these modalities attempts a

different kind of immune modulation or suppression to reduce antibody

response to antigen and may have an adjunctive role in the treatment of

severe isoimmunization (80, 81, and82).

1.10.3. Therapy extra-uterine:

Results of antenatal monitoring and obstetric interventions during pregnancy,

together with the history of the outcome of previous pregnancies, allows the

neonatal team to anticipate the needs of the infant born with hemolytic

disease. In infants with severe hemolytic disease, severe anemia and

hydrops are the immediate life-threatening concerns and are often

31

accompanied by perinatal asphyxia, surfactant deficiency, hypoglycemia,

acidosis, and thrombocytopenia. The prevention of kernictrus and

neurotoxicity due to severe unconjugated hyperbilirubinemia is the next

pressing problem. Phototherapy and exchange transfusion are the main

treatment modalities (83).

1.10.3.1. Phototherapy:

Discovered in England in 1950s by good nurse observer. The exposure of

bilirubin to light results in structural and configurational isomerization and

photo-oxidation of bilirubin to less toxic and less lipophilic Products that are

excreted efficiently without hepatic conjugation. Phototherapy is the prime

treatment for unconjugated hyperbilirubinemia, with the aim of treatment

being prevention of bilirubin neurotoxicity (83).

Intensive phototherapy has been found to effectively reduce bilirubin levels

and decrease the need for transfusions for hyperbilirubinemia in ABO and

Rh-hemolytic disease of the newborn, early and intensive phototherapy

should be indicated in infants with moderate or severe hemolysis or in

infants with rising bilirubin levels (>0.5mg/dl/h), phototherapy is indicated at

lower levels for pre-term or sick infant (84).

The action of phototherapy is to lower the total serum bilirubin and the other

is to form the water- soluble photo-isomer of bilirubin. So they should not be

able to cross the blood-barriers, these for phototherapy reduces the risk of

bilirubin-induced neurotoxicity as soon as the lights are turn on. At any given

total serum bilirubin the presence of 20-28% of photo-isomers means that

32

only 75-80% of total bilirubin is present in form that can cross blood-brain

barriers (85, 86, 86, 87, 88).

Green light penetrates skin better but clinically it is proved not more efficient

than white or blue fluorescent tubes which are widely used in phototherapy.

Narrow spectrum blue lamps appear to work best, while ordinary blue

fluorescent lamps are probably equivalent to standard lamps. Blue light may

cause discomfort to hospital staff members, which a meliorated by mixing

blue and white in the phototherapy units (84, 85, 89).

Fiberoptic light is used also in phototherapy. These units deliver high energy

levels, but to a limited surface area (90).This type of phototherapy in spite of

that it present worldwide, still not exist in Sudan. Studies show the

advantages of fiberoptic phototherapy units as follows:

1. Low risk of over heating the infant.

2. No need for eye shields

3. Ability to deliver phototherapy with the infant in a bassinet next to the

mother’s bed.

4. Simple deployment for home phototherapy.

5. When combined it with overhead phototherapy units large surface area

is irradiated

Tan K L in his study in Singapore concluded that for the efficacy of fiberoptic

phototherapy to be comparable to that of our conventional phototherapy, the

light dose of the standard mats needs to be doubled (90).

Indication of phototherapy:

33

This is an area of different opinions most of which are based on studies or

clinical observation, generally indications are:

1. When a newborn starts to develop kernictrus when serum bilirubin

reaches 350 µmol/L 20mg/dl at least in full term infant (during

preparation of blood for exchange transfusion).

2. Premature infants with jaundice.

3. Adjuvant to exchange transfusion when indicated.

4. Pathological unconjugated hyperbilirubinemia, serum bilirubin >12

mg/dl in term infant or less in pre-term.

As phototherapy is valuable and effective, but it’s not without risks,

followings are possible side effects:

1. Insensible water loss may occur but newer data suggest that this issue

is not as important as previously believed. So, fluid status should be

evaluated and supplementation may be needed.

2. Phototherapy may be associated with loose stools so, also fluid may

be needed.

3. Retinal damage has been observed therefore, covering of infants

undergoing phototherapy should be routine (83, 91).

4. The combination of phototherapy and hyperbilirubinemia can produce

more DNA-strand breakage and other effects on cellular genetic

materials.

5. Skin blood flow is increased during phototherapy in premature and this

increase the incidence of patent ductus arteriosus has been reported.

6. Hypoglycemia also appears to be more common in premature infants

under phototherapy lights. It has been suggested that this is mediated

by altered melanin metabolism.

34

7. Burn may result from failure to replace ultraviolet filters (83, 87, and91).

1.10.3.2 Exchange Transfusion:

Removes sensitized red blood cells, bilirubin, and free maternal antibody

from the plasma and corrects anemia.

Indications of early exchange transfusion (within 9-12 h after

birth):

1- Cord hemoglobin less than 11g/dl.

2- Cord bilirubin > 4.5 mg/dl.

3- Rapid raise in serum bilirubin level > 1 mg/dl/hr.

4- Moderate raise in serum bilirubin 0.5 mg/dl/hr with moderate

anemia.

Late exchange transfusions are performed when serum bilirubin levels

threaten to exceed 20 mg/dl in term infants, the level at which the risk of’

kernictrus is approximately 10%. Exchange transfusions performed at lower

bilirubin levels in premature infants, particularly those with hypoxemia,

acidosis, and hypothermia. Repeated exchange transfusions should be

carried out to keep the indirect fraction from exceeding 20 mg/dL. Symptoms

suggestive of kernictrus are mandatory indications for exchange transfusion

at any time.

There are no local guidelines for exchange transfusion in Sudan. The

standard international guidelines are mainly followed in addition to clinical

judgment by the treating consultant. Worldwide the number of exchange

transfusion was declined due to effective phototherapy and the serious

complications of exchange transfusion (83).

35

A double volume exchange should eliminate more than 50 percent of the

intravascular bilirubin. However, the amount of bilirubin is often less,

reflecting the equilibrating tissue-bound pool. The use of albumin prior to

exchange transfusion in an effort to mobilize tissue bilirubin is controversial.

Equilibration of extravascular and intravascular bilirubin and continued

breakdown of sensitized and newly formed red cells by persisting maternal

antibodies result in a rebound rise of bilirubin level following initial exchange

transfusion, often necessitating repeated exchange transfusions in severe

hemolytic disease. In infants with ABO hemolytic disease, single-volume

exchange transfusions have been shown to be comparable to double volume

exchange transfusions (92).

Using strict aseptic technique, the umbilical vein is cannulated with a

polyvinyl catheter to the distance not greater than 7 cm in a full term infant.

When free flow (blood is obtained, the catheter is usually in a large hepatic

vein or the inferior vena cava), alternatively the exchange may be performed

through placement of peripheral arterial (drawn out) and venous (infused)

lines or through femoral vein. The duration of the exchange is usually 1 to 2

hrs (92).

Acute complications:

Noted in 5-I0% of infants, include transient bradycardia with or without

calcium infusion, cyanosis, transient vasospasm, thrombosis, hypoglycemia,

apnea, bradycardia, Infections include CMV, HIV, and hepatitis, necrotizing

enterocolitis is a rare complication of exchange transfusion (93).

Late complications:

36

Infants who have hemolytic disease or who have had an exchange or an

intrauterine transfusion must be observed carefully for the development of

anemia and homeostasis. Late anemia may be hemolytic or hypo-

regenerative treatment with supplemental iron, erythropoietin, or blood

transfusion may be indicated (93, 94, and 95). A mild graft versus host reaction

may be manifested as diarrhea, rash, hepatitis and eosinophilia.

Inspissated bile syndrome refers to the rare occurrence of persistent icterus

in association with significant elevations of direct as well as indirect bilirubin

in infants with hemolytic disease.

Portal vein thrombosis and portal hypertension may occur among children

who have been subjected to exchange transfusion as newborn infants. It is

probably associated with prolonged, traumatic, or septic umbilical vein

catheterization (92).

1.10.3.3. Medications:

Medication usually is not administered in infant with physiological neonatal

jaundice. However, in certain instances, phenobarbitone, an enzyme inducer

of hepatic bilirubin metabolism, has been used to enhance bilirubin

metabolism, several studies have shown that phenobarbitone is effective in

reducing mean serum bilirubin values during the first week of life.

Phenobarbitone may be administered parentally in the mother or postnatally

in the infant (96).

In population in which incidence of neonatal jaundice or kernictrus is high,

this type of pharmacological treatment may warrant consideration. However,

concerns exist regarding the long-term effects of phenobarbitone on these

37

children. Therefore, this treatment is probably not justified in population with

a low incidence of neonatal jaundice. Other drugs can induce bilirubin

metabolism, but lack of adequate safety data present their use out side

research protocols (96,97).

Currently a new therapy is under development consisting of inhibition of

bilirubin production through blockage of heme oxygenase. This can be

achieved through the use of metal mesoporphyrins and protoporphyrins.

Apparently, heme can be excreted directly through the bile; thus, inhibition of

heme oxygenase does not result in accumulation of unprocessed heme. This

approach may virtually eliminate neonatal jaundice as a clinical problem.

However, before treatment can be applied on a wide scale (98).

Preliminary studies with high-dose intravenous immunoglobulin have shown

to reduced bilirubin levels and decrease the need for exchange transfusion

in infants with hemolytic disease (99,100). The decrease in bilirubin levels in

IVIG treated infants is attributed to reduction in hemolysis probably

secondary to blockade of reticuloendothelial Fc receptors.

1.11. Prevention of Rh-D immunization:

The development of successful prophylaxis programmes is an exciting and

sometimes bizarre story, which is eloquently recounted in a review article by

Clarke, one of the pioneers in the field (101). The observation that the

incidence of hemolytic disease of the newborn in Rh-D-negative women who

carried an ABO-incompatible fetus was less than expected, led to the

hypothesis that ABO-incompatible mating may have a protective effect

because the naturally occurring maternal anti-A or anti-B eliminated the fetal

38

Rh-D-positive red cells from the maternal circulation and so blocked the

production of Rh antibodies (17).

1.11.1. Immunoglobulin G- anti-D:

Clinical trials administering IgG anti-D, produced in male Rh-D-negative

volunteers, and to Rh-D-negative women in pregnancy were embarked upon

in the 1960s. By 1967 collective experience from the United States,

Germany and the United Kingdom clearly showed the protective effect of

giving IgG anti-D intravenously to the mother within 48 hours of delivery of

Rh-positive ABO-compatible fetus compared to non-treated matched

controls (102).

The risk of initial sensitization of Rh negative mothers has been reduced

from 10-20% to less than 1 % by intramuscular injection of 300 µg of human

anti-D globulin (1 mL of Rh0GAM) within 72 hr of delivery, and ectopic

pregnancy, abdominal trauma in pregnancy, amniocentesis, chorionic villus

biopsy, or abortion. This quantity is sufficient to eliminate approximately 10

ml of potentially antigenic fetal cells from the maternal circulation. Large

fetal-to-maternal transfers of blood may require proportionately more

RhoGAM. RhoGAM administered at 28-32 wk and again at birth (40 wk) is

more effective than a single dose.

The use of RhoGAM has dramatically decreased the incidence of hemolytic

disease of the fetus and newborn. The mechanism by which RhoGAM

prevents sensitization to the D antigen is not understood. One of the theories

proposed is that passively administered anti-D attaches to the D-antigen

sites on Rh-positive red blood cells in the circulation and interferes with the

39

host’s primary immune response to the foreign antigen. RhoGAM also may

inhibit antigen-induced B-cell responsiveness by stimulating an increase in

suppressor T-cell.

The postpartum administration of RhoGAM to non-sensitized Rh-negative

women who deliver an Rh-positive infant decreases the incidence of Rh-

isoimmunization from 12 to 13 % to approximately 2%. However about 1% of

Rh-negative women are apparent sensitized during pregnancy from small

asymptomatic transplacental hemorrhage. Further reduction in the incidence

of Rh-isoimmunization to 0.1% has been achieved by Antepartum RhoGAM

prophylaxis at 28 to 30 weeks gestation.

Although the cost effectiveness routine Antepartum prophylaxis is

questioned it has been recommended in the USA since 1981 and was

recently endorsed in the UK (102,103,104).

The standard dose in the United States 300 µg RhoGAM 1500 IU, affords

protections against a fetomaternal transfusion of 15 ml of Rh-positive red

blood cells or 30ml of Rh-positive blood.

Testing with Kleihouer-Betke test is recommended as a routine in the post-

partum period and antenatally if clinical circumstances suggest the possibility

of excessive fetomaternal hemorrhage, to determine if additional dose of

RhoGAM are indicated. The failure to implement current recommendations is

estimated to be responsible for almost 40% of recent cases of Rh-

isoimmunization (102,104).

Despite appropriate Rh-prophylaxis, about 0.1% of Rh-negative women may

be sensitized prior to 28 weeks gestation.

40

Monoclonal anti- RhoGAM currently in phase 1 trials (105) may replace

polyclonal RhoGAM derived from human plasma from immunized volunteer’s

donors in the future. Prophylaxis similar to RhoGAM does not yet exists for

aloimmunization to antigens other than D. Without prophylaxis about one in

six Rh-negative women who deliver a Rh-positive infant will develop anti-D

antibodies resulting from fetomaternal hemorrhage occurring either during

pregnancy or at delivery (106).

General recommendations for the administration of anti-D immunoglobulin to

a non-sensitized Rh-D-negative Woman in the UK should now include:

1. Post-delivery if she gives birth to a Rh-D positive infant.

2. Post-therapeutic abortion or identified spontaneous abortion.

3. To cover antenatal procedures such as amniocentesis, chorionic

Villus Sampling or external cephalic version.

4. If she threaten to abort or miscarry.

5. Antenatally at 28 and at again at birth particularly if she has no living

children.

Studies in Britain (107) and Canada (108) have shown that antenatal

prophylaxis could reduce sensitization to less than 0. 1%. Only a few

obstetric units in the UK offer routine antenatal prophylaxis to Rh-negative

women. This can no longer be justified by the shortage of anti-D

immunoglobulin that existed when postnatal prophylaxis was first introduced,

and we should now introduce routine antenatal prophylaxis at least for the

first at-risk pregnancy (107).

1.11.2. Development of synthetic anti-D human monoclonal antibody to

Rh-D antigen:

41

Monoclonal anti-D preparations are now widely used in blood transfusion

serology laboratories, but the development of the use of monoclonal anti-D

antibodies to replace polyclonal antibodies in prophylaxis of HDN is as yet in

its infancy (109,110,111)

1.11.3. Antenatal screening:

Routine serological testing of women is carried out to:

1. Identify pregnancies at risk of fetal and neonatal alloimmune

disease (HDN.

2. Identify Rh-D-negative women who require antenatal anti-D

prophylaxis.

3. Provide compatible blood safety in emergencies (112).

All women who have no antibodies at 10 -16 weeks at booking should be

tested once again between 28 and 36 weeks’ gestation. Some workers

believe that Rh-D negative women should have two tests, one at 28

weeks and one at 34-3 6 weeks, but sensitization late in pregnancy is

unlikely to result in HDN requiring treatment(71). If clinically significant

antibodies are present at booking, e.g. anti-D, Kell and c, either alone or

in combination, the partner’s phenotype should be determined and the

couple referred early to a specialist centre for assessment and further

investigation, and treatment if indicated.

1.12. Prognosis:

In Manitoba, Canada, perinatal mortality from hemolytic disease dropped

from 100 per year in the 1940s in a population of I million to I every 3 years

in the mid 1990s(117). Similar reductions have been described in the United

States and United Kingdom. There is little doubt that Rh immunoprophylaxis

42

played a critical role in the decline of perinatal mortality due to Rh-hemolytic

disease. Changes in birth order distribution and improvements in the quality,

of perinatal care have also been important factors (118).

Prior to the development of treatment measures in the 1940s, almost half of

all newborn infants with Rh-hemolytic disease died or were severely

handicapped. Perinatal, survival rates of over 90 percent have been

achieved with intrauterine transfusions in non-hydropic fetuses with severe

Rh hemolytic disease (119). The survival rate for hydropic fetuses is still low

(74%).

The neurodevelopmental outcome for infants saved by intrauterine

transfusion has generally been excellent, with more than 90 percent of

survivors being free of disability. Perinatal asphyxia and lower cord

hemoglobin level at birth have been associated with an increased risk of

neurological abnormalities. Neurological abnormality due to extreme indirect

hyperbilirubinemia secondary to alloimmune hemolytic disease has virtually

disappeared in the United States and Canada, but is still seen in countries

with more limited resources (120).

Even before the striking reduction in Rh-D HDN due to prophylaxis, the most

frequent cause of HDN was the hemolysis due to ABO incompatibility.

Although the incidence in the UK and the USA has been found to be

approximately 2% of all births, in only 1 in 3000 births does severe ABO

HDN occur. Mild cases not requiring exchange transfusion are identified as 1

in 150 births. Less than 5% of affected newborns require phototherapy, and

only in very rare cases is exchange transfusion required.

43

There is a one in three chance that there will be ABO incompatibility, but the

partner may be heterozygous in respect of the allele for the incompatible

antigen, for example AO rather than AA (homozygous), so that the chance of

ABO incompatibility between fetal red cells and maternal serum is one in

five(121,122).

There are distinct racial differences, and Asian and African babies, often

group B, may suffer more severe ABO HDN than Caucasian babies, usually

group A, born to group O mothers. Apart from the occasional case with a

history of other previously affected infants and present of IgG in the maternal

serum, screening of cord blood for ABO incompatibility is not usually

performed.

1.13. Further care after discharge:

1. Infants who are discharged earlier within the first forty-eight hours of

life need to be reassessed for jaundice within1-2 days.

2. Infants who have been treated for hemolytic jaundice require follow up

observation for several weeks because hemoglobin levels may fall

lower than seen in physiologic anemia. Transfusion may be required in

infants developing symptomatic anemia.

3. Follow-up for neurological examination is needed after several weeks

for the risk of kernictrus (101).

44

Justification

1. Clinical practice shows that hemolytic disease of the newborn is one of

the common causes of anemia in the newborn.

2. There is little published information about hemolytic disease of the

newborn in Sudan.

3. Hemolytic disease of the newborn is a common problem in Sudan and it

is a known cause of morbidity and mortality in newborn infants.

4. There are a lot of risk factors for Rh- incompatibility most of which are

preventable

45

Objectives

The study is designed to:

1. Determine the prevalence of hemolytic disease of the newborn among

jaundiced newborn admitted to hospital.

2. Study the clinical pattern of presentation of hemolytic disease of the

newborn.

3. Assess possible common causes & associated factors of hemolytic

disease of the newborn.

4. Evaluate short-term management & outcome of hemolytic disease of the

newborn.

46

22.. PPaattiieennttss aanndd MMeetthhooddss

22..11 SSttuuddyy ddeessiiggnn::

AA pprroossppeeccttiivvee lloonnggiittuuddiinnaall hhoossppiittaall bbaasseedd ssttuuddyy..

22..22 SSttuuddyy aarreeaa::

TThhee nneewwbboorrnnss iinncclluuddeedd iinn tthhee ssttuuddyy wweerree aaddmmiitttteedd iinn tthhee eemmeerrggeennccyy

ddeeppaarrttmmeennttss,, wwaarrddss aanndd nnuurrsseerriieess ooff tthhee ffoolllloowwiinngg hhoossppiittaallss::

11.. NNeeoonnaattaall SSppeecciiaall CCaarree UUnniittss && PPeeddiiaattrriicc WWaarrddss iinn SSoobbaa UUnniivveerrssiittyy

HHoossppiittaall..

22.. NNuurrsseerryy ooff KKhhaarrttoouumm TTeeaacchhiinngg HHoossppiittaall..

33.. KKhhaarrttoouumm EEmmeerrggeennccyy HHoossppiittaall ffoorr CChhiillddrreenn..

44.. OOmmdduurrmmaann PPeeddiiaattrriiccss &&MMaatteerrnniittyy TTeeaacchhiinngg HHoossppiittaallss..

55.. KKhhaarrttoouumm NNoorrtthh TTeeaacchhiinngg HHoossppiittaall..

66.. AAhhmmeedd GGaassiimm TTeeaacchhiinngg HHoossppiittaall..

These hospitals are the main neonatal and referral centers. They serve large

sectors of Khartoum state and near by areas.

47

22..33 SSttuuddyy dduurraattiioonn::

TThhee ssttuuddyy wwaass ccoonndduucctteedd oovveerr oonnee yyeeaarr ppeerriioodd,, ffrroomm tthhee 11sstt ooff JJaannuuaarryy

22000033 ttoo DDeecceemmbbeerr 22000033..

22..44 SSttuuddyy ppooppuullaattiioonn::

TThhee ssttuuddyy ggrroouupp wwaass 118833 ffuullll tteerrmm nneewwbboorrnnss ((ffrroomm bbiirrtthh ttoo 77 ddaayyss)) ooff

bbootthh sseexxeess tthhaatt wweerree cclliinniiccaallllyy jjaauunnddiicceedd.. TThhee ssaammppllee ssiizzee wwaass

ccaallccuullaatteedd aaccccoorrddiinngg ttoo tthhee eeqquuaattiioonn::

nn == ZZ22xxPPxxQQ xx ddeessiiggnn eeffffeecctt

dd22

nn == nnuummbbeerr ooff ssaammppllee ssiizzee

ZZ == ssttaattiissttiiccaall cceerrttaaiinnttyy == 11..9966

PP == pprroobbaabbiilliittyy == 00..0099

QQ == II –– pp == 00..9911..

dd == DDeessiirreedd mmaarrggiinn ooff eerrrroorr == 00..0022 -- 00.. 55

Design effect = 1 - 2

22..55 IInncclluussiioonn ccrriitteerriiaa::

48

All full term newborns admitted to the above mentioned hospitals who had

clinical jaundice (yellow discoloration of the skin and sclera) and their ages

ranging from 0 – 7 days.

49

22..66 EExxcclluussiioonn ccrriitteerriiaa::

11.. NNeewwbboorrnn wwiitthh mmaajjoorr ssuurrggiiccaall pprroobblleemm..

22.. PPrreetteerrmm nneewwbboorrnn..

33.. NNeewwbboorrnn wwhhoossee ppaarreennttss rreeffuusseedd ttoo ggiivvee ccoonnsseenntt..

22..77 EEtthhiiccaall ccoonnssiiddeerraattiioonn::

VVeerrbbaall ccoonnsseenntt wwaass oobbttaaiinneedd ffrroomm tthhee ppaarreennttss aanndd ttrreeaattiinngg ddooccttoorrss..

PPeerrmmiissssiioonn wwaass aallssoo oobbttaaiinneedd ffrroomm hhoossppiittaall aaddmmiinniissttrraattiioonnss..

22..88 RReesseeaarrcchh ttoooollss && tteecchhnniiqquuee::

22..88..11 RReesseeaarrcchh ttoooollss::

DDeettaaiilleedd qquueessttiioonnnnaaiirree wwaass ddeessiiggnneedd ccoonnttaaiinniinngg ddaattaa rreeggaarrddiinngg tthhee mmootthheerr

aaggee,, rreessiiddeennccee,, oorriiggiinn,, ppaasstt oobbsstteettrriiccaall hhiissttoorryy,, nneeoonnaattaall ddeeaatthhss,, aanndd ssppeecciiffiicc

qquueessttiioonnss aabboouutt ppaasstt hhiissttoorryy ooff nneeoonnaattaall jjaauunnddiiccee,, bblloooodd ggrroouuppiinngg aanndd

ccoooommbb’’ss tteesstt.. TThhee qquueessttiioonnnnaaiirree aallssoo iinncclluuddeedd tthhee aanntthhrrooppoommeettrriicc

mmeeaassuurreemmeennttss,, ggeessttaattiioonnaall aaggee,, ssyysstteemmiicc eexxaammiinnaattiioonnss aanndd iinnffoorrmmaattiioonn

aabboouutt mmaannaaggeemmeenntt aanndd ffoollllooww--uupp..

TThhee eexxaammiinnaattiioonn wwaass ddoonnee bbyy tthhee aauutthhoorr,, tthhee ssyymmppttoommss aanndd ssiiggnnss,, rreessuulltt ooff

iinnvveessttiiggaattiioonnss aanndd ffoollllooww uupp ffiinnddiinnggss wweerree rreeccoorrddeedd..

22..88..22 SSttuuddyy tteecchhnniiqquuee::

22..88..22..11 CCoonnsseenntt::

AAnn iinnffoorrmmeedd ccoonnsseenntt wwaass oobbttaaiinneedd ffrroomm tthhee ppaarreenntt bbeeffoorree iinncclluussiioonn ooff tthhee

50

nneewwbboorrnn iinn tthhee ssttuuddyy..

22..88..22..22 TThhee qquueessttiioonnnnaaiirree::

TThhee qquueessttiioonnnnaaiirreess wweerree ccoommpplleetteedd bbyy tthhee aauutthhoorr wwhhoo ddiirreeccttllyy iinntteerrvviieewweedd

tthhee mmootthheerrss..

22..88..22..33 CClliinniiccaall eexxaammiinnaattiioonn::

GGeessttaattiioonnaall aaggee ffoorr nneewwbboorrnnss wwaass aasssseesssseedd uussiinngg tthhee LLMMPP ((ssttaatteedd bbyy tthhee

mmootthheerr)),, tthhee eexxppeecctteedd ddaattee ooff ddeelliivveerryy &&tthhee ddaattee ooff ddeelliivveerryy ttooggeetthheerr wwiitthh tthhee

cclliinniiccaall aasssseessssmmeenntt uussiinngg tthhee DDuubboowwiittzz SSccoorriinngg SSyysstteemm..

MMeeaassuurreemmeenntt ooff tthhee hheeaadd cciirrccuummffeerreennccee wwaass ddoonnee uussiinngg fflleexxiibbllee nnoonn--

ssttrreettcchhaabbllee ttaappee aanndd tthhee rreeaaddiinngg wwaass ttaakkeenn ttoo tthhee nneeaarreesstt 00..11ccmm,, wwhhiillee tthhee

wweeiigghhtt ooff tthhee nneewwbboorrnn wwaass mmeeaassuurreedd uussiinngg WWHHOO wweeiigghhtt mmeeaassuurriinngg ssccaallee iinn

kkgg,, aanndd tthhee rreeaaddiinngg wwaass ttaakkeenn ttoo tthhee nneeaarreesstt 00..11 kkgg..

2.8.2.4 Methods of blood collection:

BBlloooodd wwaass ccoolllleecctteedd ffrroomm tthhee nneewwbboorrnn bbyy tthhee aauutthhoorr uunnddeerr aasseeppttiicc

ccoonnddiittiioonnss aass ppoossssiibbllee aass ccoouulldd bbee,, uussuuaallllyy ffrroomm ppeerriipphheerraall vveeiinn bbyy ddrrooppppiinngg

mmeetthhooddss ffrroomm tthhee ddoorrssuumm ooff tthhee hhaanndd,, iiff ffaaiilleedd hheeaall ppuunnccttuurreedd uussiinngg sstteerriillee

llaanncceett,, llaassttllyy ffeemmoorraall ssaammppllee iiff iinnddiiccaatteedd..

55mmll ooff bblloooodd wweerree ttaakkeenn iinniittiiaallllyy,, 22..55mmll ppuutt iinn EEDDTTAA ccoonnttaaiinneerr ffoorr

hheemmoogglloobbiinn,, rreettrriiccuullooccyytteess ccoouunntt,, PPCCVV aanndd ppeerriipphheerraall bblloooodd ppiiccttuurree.. 11 mmll ppuutt

iinn aa ddiissppoossaabbllee ssyyrriinnggee ffoorr eessttiimmaattiioonn ooff bblloooodd ggrroouupp aanndd ccoooommbb’’ss tteesstt aanndd

11..55 mmll ccoolllleecctteedd ssaammpplleess wwaass ppuutt iinn ddiissppoossaabbllee ssyyrriinnggee ffoorr eessttiimmaattiioonn ooff

51

sseerruumm bbiilliirruubbiinn.. IInn ssoommee ppaattiieennttss,, wwhheerree tthheerree iiss cclliinniiccaall ssuussppiicciioouuss ooff

ccoonnggeenniittaall iinnffeeccttiioonnss aannootthheerr bblloooodd ssaammppllee wwiillll bbee ttaakkeenn..

AAllssoo 11 mmll ooff bblloooodd wwaass ttaakkeenn ffrroomm tthhee mmootthheerr ffoorr eessttiimmaattiioonn ooff bblloooodd ggrroouupp

aanndd ccoooommbb’’ss tteesstt.. TThhee bblloooodd ssaammppllee wwaass sseenndd iimmmmeeddiiaatteellyy ttoo tthhee llaabb..

22..88..22..55 IInnvveessttiiggaattiioonnss::

TThhee ffoolllloowwiinngg iinnvveessttiiggaattiioonnss wweerree ddoonnee ffoorr aallll nneewwbboorrnnss::

HHeemmoogglloobbiinn ((gg//ddll))..

BBlloooodd ggrroouupp ffoorr tthhee nneewwbboorrnn &&tthhee mmootthheerr..

CCoommbb''ss tteesstt ddiirreecctt &&iinnddiirreecctt..

SSeerruumm bbiilliirruubbiinn ddiirreecctt &&iinnddiirreecctt..

RReettiiccuullooccyyttee ccoouunntt..

OOtthheerr iinnvveessttiiggaattiioonnss::

HHeemmaattooccrriitt ((PPCCVV))..

MMeeaann ccoorrppuussccuullaarr vvoolluummee ((MMCCVV))..

TToottaall wwhhiittee bblloooodd ccoouunntt ((TTWWBBCC)) aanndd ddiiffeerreennttiiaall++ BBaanndd cceellllss..

PPeerriipphheerraall bblloooodd ppiiccttuurree ((PPBBPP))..

BBFFFFMM ++ IICCTT..

TTOORRCCHH ssccrreeeenn..

22..88..22..66 EEvvaalluuaattee sshhoorrtt--tteerrmm mmaannaaggeemmeenntt &&ffoollllooww uupp::

AAfftteerr 66 wweeeekkss tthhee nneewwbboorrnnss wweerree eevvaalluuaatteedd cclliinniiccaallllyy aass wweellll aass uussiinngg

52

llaabboorraattoorryy iinnvveessttiiggaattiioonnss aass nneeeeddeedd ((tthhee lleevveell ooff sseerruumm bbiilliirruubbiinn aanndd HHbb))..

TThhee ttyyppee ooff mmaannaaggeemmeenntt ((hhoommee mmaannaaggeemmeenntt,, pphhoottootthheerraappyy,, eexxcchhaannggee

ttrraannssffuussiioonn aanndd ttoopp uupp ttrraannssffuussiioonn)) wwaass aallssoo eevvaalluuaatteedd..

22..88..33 LLaabboorraattoorryy pprroocceedduurree::

2.8.3.1 Serum bilirubin testing:

TToottaall sseerruumm bbiilliirruubbiinn wwaass eessttiimmaatteedd bbyy ddiiaazzoorreeaaggeenntt mmeetthhoodd.. IInn tthhiiss mmeetthhoodd,,

00..22 mmll ooff sseerruumm wwaass ppuutt iinn aa tteesstt ttuubbee,, aanndd tthheenn 00..55 mmll ooff ddiiaazzoorreeaaggeenntt wwaass

aaddddeedd.. DDiiaazzoorreeaaggeenntt iiss aa ssoolluuttiioonn ooff ssuullpphhaanniittiicc aacciidd aanndd ssooddiiuumm nniittrriittee.. TThhee

mmiixxttuurree wwaass iinnccuubbaatteedd ffoorr tthhiirrttyy mmiinnuutteess aatt rroooomm tteemmppeerraattuurree iinn ddaarrkk ppllaaccee

ttoo aavvooiidd uullttrraavviioolleett rraaddiiaattiioonn,, tthheenn ppuurrppllee ccoolloorr ddeevveellooppeedd aanndd tthhee sseerruumm

bbiilliirruubbiinn wwaass mmeeaassuurreedd bbyy ccaalloorriimmeetteerr aanndd ccoommppaarreedd wwiitthh ssttaannddaarrdd

aaccccoorrddiinngg ttoo tthhee eeqquuaattiioonn::

Total serum bilirubin =

Optical density of the test Concentration of the standard Optical density of the standard by milligrams per deciliter.

UUssuuaallllyy iinn tthhiiss tteesstt,, 22..55 mmll ooff mmeetthhaannooll iiss aaddddeedd ((aann aacccceelleerraattoorr)),, ttoo bbiilliirruubbiinn

ttoo rreeaacctt..

TToo eessttiimmaattee ddiirreecctt bbiilliirruubbiinn tthhee ssaammee mmeetthhoodd iiss rreeppeeaatteedd wwiitthhoouutt aaddddiinngg

mmeetthhaannooll.. TToo eessttiimmaattee iinnddiirreecctt bbiilliirruubbiinn wwee ssuubbttrraacctt tthhee ddiirreecctt ffrroomm tthhee ttoottaall..

2.8.3.2 Blood grouping and coomb’s test:

a) Blood grouping for ABO and Rhesus Factors:

X

53

BByy sslliiddee mmeetthhoodd iinn wwhhiicchh oonnee ddrroopp ooff ppeerriipphheerraall bblloooodd wwaass aaddddeedd ttoo oonnee

ddrroopp ooff aannttiisseerruumm,, aanndd tthheenn sshhaacckkeedd,, aafftteerr oonnee mmiinnuuttee,, wwee llooookk

mmaaccrroossccooppiiccaallllyy ttoo aagggglluuttiinnaattiioonn iiff tthheerree iiss aannyy ddoouubbtt wwee llooookk ttoo iitt uunnddeerr lliigghhtt

mmiiccrroossccooppee.. FFoorr aannttii--DD iinn ccaassee ooff ddoouubbtt,, ttwwoo ddrrooppss ooff bblloooodd wweerree aaddddeedd iinn

tthhee tteesstt ttuubbee,, tthheenn wwaasshheedd tthhrreeee ttiimmeess bbyy nnoorrmmaall ssaalliinnee ttoo rreemmoovvee aannyy

aannttiibbooddiieess,, tthheenn aannttii DD wwaass aaddddeedd ffoolllloowweedd bbyy cceennttrriiffuuggaattiioonn aanndd sseeeenn

mmaaccrroossccooppiiccaallllyy.. IIff nnoo cchhaannggee,, aannttiihhuummaann wwaass aaddddeedd ttoo ““bboovviinnee”” aannttiibbooddiieess

tthheenn,, iinnccuubbaatteedd iinn wwaatteerr--bbaatthh ffoorr ttwweennttyy mmiinnuutteess,, aanndd tthheenn rreeaadd

mmaaccrroossccooppiiccaallllyy oorr mmiiccrroossccooppiiccaallllyy..

b) Coomb’s test:

i- Direct:

00..55 mmll ooff wwhhoollee bblloooodd wwaass ttaakkeenn ffrroomm bbaabbyy iinn aa ssyyrriinnggee aanndd ppuutt iinn tteesstt ttuubbee

aanndd wwaasshheedd bbyy nnoorrmmaall ssaalliinnee tthhrreeee ttiimmeess ttoo wwaasshh aannttiibbooddiieess.. TThheenn,,

sseennssiittiizzeedd cceellllss wweerree aaddddeedd ttoo tthhee tteesstt ttuubbee aanndd iinnccuubbaatteedd ffoorr ttwwoo hhoouurrss aanndd

rreeaadd mmaaccrroossccooppiiccaallllyy,, iiff aagggglluuttiinnaattiioonn ooccccuurrrreedd iitt wwaass ssaaiidd ttoo bbee ppoossiittiivvee..

ii- Indirect:

BBlloooodd wwaass ttaakkeenn ffrroomm tthhee mmootthheerr iinn ssyyrriinnggee aanndd lleefftt ttoo cclloott,, tthheenn ffrreeee sseerruumm

wwaass iissoollaatteedd,, ppuutt iinn tteesstt ttuubbee aanndd tthheenn sseennssiittiizzeedd cceellllss wweerree aaddddeedd aanndd

iinnccuubbaatteedd ffoorr ttwwoo hhoouurrss aanndd llaatttteerr cceennttrriiffuuggeedd aanndd rreeaadd mmaaccrroossccooppiiccaallllyy aanndd

mmiiccrroossccooppiiccaallllyy..

2.8.3.3 Other investigations:

a) Hemoglobin “Hb”, packed cell volume “PCV”:

54

AA bblloooodd wwaass ttaakkeenn iinn aa ccoonnttaaiinneerr wwhhiicchh ccoonnttaaiinneedd eetthhyylleeddiimmeetthhyyllee tteettrraa

aacceettiicc aacciidd ““EEDDTTAA”” 00..22 mmll ooff bblloooodd wwaass aaddddeedd ttoo 55 mmll ooff ddrraabbiikkiinn

ssoolluuttiioonn((ddrraabbiikkiinn ssoolluuttiioonn ccoonnssiisstt ooff ppoottaassssiiuumm ffeerrrriicc ccyyaanniiddee,, ppoottaassssiiuumm

ccyyaanniiddee aanndd ppoottaassssiiuumm ddiihhyyddrrooggeenn pphhoosspphhaattee)) aanndd aafftteerr 55 mmiinnuutteess rreeaadd bbyy

ccaalloorriimmeetteerr iinn wwhhiicchh aa ffiilltteerr ooff 554400 nnaannoommeetteerr wwaass uusseedd..

b) Radiological investigations reported by expert radiologists.

c) Chemical investigations sent to specific laboratories.

2.8.4 Diagnosis:

2.8.4.1 Rhesus incompatibility:

The diagnosis based on the following:

1- Mother blood group is Rhesus “Rh” negative.

2- Newborn blood group is Rhesus positive.

3- Coomb’s test positive.

4- Reticulocytosis.

2.8.4.2 ABO incompatibility:

Diagnosed when:

1- The mother blood group is A, B, or O and the newborn blood group is

either B, A or AB respectively

2- Coomb’s test is positive.

3- Reticulocytosis

22..99 SSttaattiissttiiccaall mmeetthhooddss::

TThhee ddaattaa wwaass ccooddeedd aanndd ccoommppuutteedd uussiinngg aa ppeerrssoonnaall ccoommppuutteerr ((IIBBMM338866))..

55

DDaattaa wwaass vveetttteedd &&vveerriiffiieedd bbyy tthhee aauutthhoorr aafftteerr eenntteerreedd.. CChhii--ssqquuaarree wwaass

aapppplliieedd ttoo tteesstt ffoorr ssiiggnniiffiiccaanntt.. TThhee ccoolllleecctteedd ddaattaa wwaass aannaallyyzzeedd bbyy tthhee

ccoommppuutteerriizziinngg SSttaattiissttiiccaall PPaacckkaaggee ooff SSoocciiaall SSttuuddiieess ((SSPPSSSS)) aanndd aapppprroopprriiaattee

tteessttss ffoorr ssiiggnniiffiiccaannccee wweerree aapppplliieedd.. TThhee ssttaattiissttiiccaall ssiiggnniiffiiccaannccee wwaass sseett aatt PP <<

00..0055..

2.10 Research team:

OOtthheerr tthhaann tthhee aauutthhoorr;; ddooccttoorrss,, ssiisstteerrss,, nnuurrsseess aanndd qquuaalliiffiieedd LLaabboorraattoorryy

TTeecchhnniicciiaannss aassssiisstteedd iinn ddooiinngg tthhee rreesseeaarrcchh..

2.11 Role of the author:

TThhee aauutthhoorr rroollee wwaass ffiilllliinngg tthhee qquueessttiioonnnnaaiirree,, cclliinniiccaall eexxaammiinnaattiioonn,, aanndd mmoosstt

ooff tthhee ooccccaassiioonn bblloooodd ccoolllleeccttiioonnss wweerree ddoonnee bbyy tthhee aauutthhoorr..

56

3. Results

3.1. Socio-demographic characteristics of the study

Population:

3.1.1. Sex characteristics

A total of 183 newborns were studied in the pediatrics hospitals and

nurseries during one year study period. Regarding the sex characteristics of

the studied newborns, males were 105 (57.4%), while females were 78

(42.6%). The male to female ratio was 1.3: 1 as shown in figure 1.

3.1.2. Distribution of study population according to residence

and home origin:

Table 1 shows that the majority of the newborns were from Khartoum state

176 (96.2%), only seven are out of Khartoum (3.8%). From those who were

from Khartoum state 73 (39.9%) were from Khartoum city, 65 (35.5%) from

Omdurman and 38 (20.8%) were from Khartoum north.

Table 2 shows the home origin, 54 (29.5%) of the newborns were from the

North, 3 (1.6%) from East, 54 (29.5%) from West, 13 (7.1%) from South, 57

(31.2%) from central Sudan, and only 2 (1.1%) were non-Sudanese

57

F1, landscape

57.4%

42.6%

Male Female

Figure 1: Sex distribution of the study group (n = 183)

58

Table 1: Residence of the study group (n=183)

Residence No. %

Khartoum 73 39.9

Omdurman 65 35.5

Khartoum north 38 20.8

Out side Khartoum

state

7 3.8

Total 183 100.0

Table 2: Home origin of the study population (n=183)

Origin No. %

North 54 29.5

East 3 1.6

West 54 29.5

South 13 7.1

Central 57 31.2

Not Sudanese 2 1.1

Total 183 100.0

61

59

3.1.3 Age distribution of the study population:

Eleven newborns (6.0%) were only one day old, while 76(41.6%) of the

newborns had age between 2-3 days and 96 (52.4%) were between 4- 7

days, as illustrated in figure 2.

3.2 Clinical parameter that affect the study population:

3.2.1 Weight characteristics:

One hundred and twenty six (68.9%) of the newborns had normal birth

weight (between 2.5-3.5 kg), 34 (18.5%) had low birth weight(less than 2.5

kg) and 23 (12.6%) had large birth weight (more than 3.5 kg), as shown in

figure 3.

3.2.2 Date of onset of jaundice

Among the studied newborns 38 (20.8%) had jaundice that appeared in the

first day, 95 (51.9%) had jaundice in the second and third day, 50 (27.3%) in

the fourth to seventh day as shown in figure 4.

3.3 Serum bilirubin levels

As shown in figure 5 the values of total serum bilirubin were 37 (20.2%)

below 12 mg/dl, 112 (61.2%) between 12 to 20 mg/dl and 34 (18.6%) had

values of total serum bilirubin more than 20 mg/dl.

60

F2 landscape

Figure 2: Age distribution of the study population

96

76

11

0

10

20

30

40

50

60

1 day 2- 3 days 4-7 days

%

11(6.0%)

76(41.6%)

96(52.4%)

(n = 183)

61

F 3, (landscape)

Figure 3: Weight distribution of the study group

% 126 (68.9%)

0

1020304050

6070

< 2.5 2.5 - 3.5 >3.5

34 (18.5%)

23 (12.6%)

%

(n = 183)

Weight (kg)

66

62

F 4 (landscape)

Figure 4: Date of onset of jaundice in the study population

%

11(0.6%)

0

10

20

30

40

50

60

%

38(20.8%)%

95(51.9%)

50(27.3%)

1st day 2nd and 3rd day 4th – 7th day

(n = 183)

Date of onset of jaundice

67

63

F5(landscape)

Figure 5: Distribution of total serum bilirubin in the study group

%

37(20.2%)

0

10

20

30

40

50

60

70

<12 mg/dl 12-20 mg/dl >20 mg/dl

112(61.2%)

34(18.6%)

%

(n = 183)

(n = 183) Total serum bilirubin

68

64

3.4 Hemoglobin levels

Hemoglobin levels of the study group showed that 19 (10.4%) were below 8

g/dl, 28(15.3%) between 8 < 11 g/dl, 84(45.9%) between 11-14 g/dl and 52

(28.4%) were more than 14 g/dl, as shown in figure 6.

3.5 Blood group of the mothers and newborns

Forty three mothers, 53 newborns had blood group A+ve, while B+ve was

seen in 28, 38 in mothers and newborns respectively. Blood group O+ve

was the major one that detected in 79 mothers, 75 newborns. Five mothers

had blood group AB+ve, while only one newborn had blood group AB+ve.

Regarding negative blood groups, blood group A-ve was detected in 3

mothers and only one newborn, B - ve was discovered in 4 mothers, 2

newborns, about blood group O-ve was seen in19,13 in mothers and

newborns respectively, while AB-ve was detected in two mothers, no

newborn had blood group AB-ve in the study population this shown in figure

7.

3.6 Etiology of jaundice

Table 3, figure 8 shows that (14%) of the newborns had Rh incompatibility,

23 (12.6%) had ABO incompatibility, and 69 (37.7%) had neonatal sepsis.

Physiological jaundice and cephalohematoma were 27 (14.8%), 12 (6.6%)

respectively.

65

F6, (landscape)

Figure 6: Hemoglobin level of the study group

0

10

20

30

40

50

<8 g/dl 8-<11 g/dl 11-14 g/dl >14 g/dl.

%

19 (10.4%) 28 (15.3%)

84 (45.9%)

52 (28.4%)

(n = 183)

Hb level

70

66

F 7 (landscape)

Figure 7: Blood group of the mothers and the newborns

%

43

53

28

38

7975

51 3 1 4 2

1913

2 001020304050607080

A+ve B+ve O+ve AB+ve A-ve B-ve O-ve AB-ve

MothersNewborns

%

(n = 183)

(n = 183) Blood group

71

67

Table 3: Causes of neonatal jaundice in the study group

(n=183)

% No Cause

7.6 14 Rh incompatibility

12.6 23 ABO incompatibility

37.7 69 Neonatal sepsis

14.8 27 Physiological jaundice

6.6 12 Cephalohematoma

7.6 14 Infant of diabetic mother

1.1 2 Hepatitis B

2.7 5 Congenital infections

0.5 1 Down syndrome

1.1 2 Polycythemia

1.1 2 Congenital malaria

6.6 12 *Others

68

(landscape)

7.6

12.6

37.7

14.8

6.6 7.6

1.12.7

0.5 1.1 1.1

6.6

0

5

10

15

20

25

30

35

40

Rh inco

mpatib

ility

ABO inco

mpatib

ilityNeon

atal s

epsis

Physio

logica

l jaun

dice

Cephalo

hemato

ma

Infan

t of d

iabetic

moth

erHepa

titis B

Congen

ital in

fectio

nsDawns

syndro

mepo

lycyth

emia

Congen

ital m

alaria

*Othe

rs

Figure 8: Causes of neonatal jaundice in the study group

%

(n = 183)

73

69

Fourteen of newborns (7.6%) were infants of diabetic mothers. Of the

studied newborns 2 (1.1%) were positive for hepatitis B surface antigen, and

5 (2.7%) had congenital infection, two of them positive for cytomegalovirus

1gM, two positive for toxoplasmosis and one positive for rubella.

Only one (0.5%) was Down syndrome, two (1.1%) with polycythemia, two

(1.1%) had congenital malaria, and 12 (6.6%) of the studied newborns were

other causes, in these cases the cause may be a metabolic factor or

hypothyroidism or un determined that not included in this study.

3.7 Diagnosis and common causes of hemolytic disease of the

newborn

Figure 9 shows that, 37 (20.2%) of the newborn were diagnosed as

hemolytic disease of the newborn. 14 (7.6%) were Rh-incompatibility,

23(12.6%) were ABO-incompatibility. While the remaining 146 (79.8%) of the

newborn were diagnosed as non-hemolytic disease of the newborn.

70

0

10

20

30

40

50

60

70

80

F9 (landscape),

Figure 9: Diagnosis and common causes of hemolytic disease of the newborn

`

ABO Incompatibility Rh. Incompatibility Non-HDN

14 (7.6%)

146 (79.8%)

23 (12.6 %)

%

37 (20.2%)

(n = 183)

75

71

3.7.1 Date of onset of hemolytic diseases of the newborn. Table 4 shows that the majority of newborns presented with jaundice in the

first day 26 (70.3%), 9 (24.4%) were Rh-incompatibility and 17 (45.9%) were

ABO-incompatibility. While 9 (24.3%) of the newborn presented in the

second and third day, 4 (10.8%) were Rh-incompatibility and 5 (13.5%) were

ABO. two (5.4%) presented in the 4th –7th day, half of them was Rh-and half

was ABO incompatibility. P value <0.05.

3.7.2. Clinical presentation of hemolytic disease of the newborn

Table 5 shows that all of newborns presented with jaundice and pallor. While

5 (13.5%) presented with convulsions, one (5.4%) had fever, 12 (32.4%) had

Tachypenia, 17 (45.9%) had tachycardia, while 2 (5.4%) had

hepatosplenomegaly and 5 (13.5%) had sluggish reflexes, of whom 4 were

hypotonic and one was hypertonic

3.7.3 Factors associated with Rh-incompatibility: Table 6 shows that the risk factors of Rh incompatibility were family history of

jaundice newborn detected in 19(10.4%) mothers, past history of abortion in 2

(1.1%) mothers, while neonatal deaths in the family due to jaundice in 6 (3.6%)

mothers and Rh-negative in 19 (10.4%) mothers. They are statistically

significantly and their P value < 0.05.

About past history of blood transfusion 2 (1.1) mothers, multiparous and

grand multepara were 122 (66.6%) mothers, still birth 19 (10.4%) mothers,

mode of delivery and late clamping of the cord 2 (1.1). Not statistically

significant. P value > 0.05

72

3.7.4 Clinical pattern of presentation of hemolytic disease of the newborn

About newborns had pattern of HDN, 14 (37.8%) were mild (Hb between 11-

14g/dl, serum bilirubin < 12mg/dl.), 3(21.4%) of them were Rh-incompatibility

and 11(78.7%) were ABO-incompatibility. Regarding 15 (40.5%) newborns

had moderate pattern (Hb between 8-<11 g/dl, serum bilirubin between 12-

20mg/dl), 7 (46.7%) of them were Rh-incompatibility and 8 (53.3%) were

ABO. While 8 (21.6) had severe pattern (Hb < 8g/dl, serum bilirubin >

20mg/dl.), 4(50.0%) of them were Rh-incompatibility and 4 (50.0%) were.

ABO, it is statistically significant. P value <0.05, figure 10.

3.8 Methods Used in Treatment

One hundred thirty seven (74.9%) of the studied newborns received

phototherapy, 28 (15.3%) received exchange transfusion, 10 (5.5%) were

given home management, 143 (78.2%) of newborns received drugs

(antibiotics, phenobarbitone, IV fluids and electrolyte correction, this shown

in figure 11.

Twenty eight received exchange transfusion, 5 (2.7%) had serum bilirubin

between 12-20 mg/dl, 23(12.6%) were above 20mg/dl, no exchange

transfusion done bellow 12mg/dl. Regarding prescription of drugs, 143

(78.2%) received drugs, 25(13.7%) of them had serum bilirubin less than

12mg/d, 88(48.1%) had serum bilirubin between 12-20 mg/d, 30(16.4%)

were above 20mg/dl. The level of serum bilirubin is statistically significant.

P value <.05.

3.8.1 Phototherapy applied to the study group

73

Figure 12 shows that 137 (74.9%) put on phototherapy, 63 (34.5%) were

locally made, while 74 (40.4%) were standard one. The rest 46 (25.1%) did

not received phototherapy.

3.8.2 Exchange transfusion of the study population

Figure 13 shows that 28 (15.3%) received exchange transfusion, 24(85.7%)

received only one, while 4 (14.3%) of newborn needed second exchange

transfusion. Among those who received exchange transfusions 15 (53.6%)

needed top up transfusion.

74

T4 (landscape)

Table 4: Relation between date of onset of jaundice and

hemolytic disease of the newborn

(n =37)

Hemolytic disease

of the newborn

Date of onset of jaundice

1st day 2.nd and 3rd 4th-7th

Rh-incompatibility 9(24.4%) 4(10.8%) 1(2.7%)

ABO-incompatibility 17(45.9%) 5(13.5%) 1(2.7%)

Total 26(70.3%) 9(24.3%) 2(5.4%)

P. value < 0.05 X2 = 64.31

79

75

Table 5: Clinical presentation of hemolytic disease of the

newborn (n = 37)

% No. Clinical presentation

100% 37 Jaundice

5.4% 2 Fever

13.5% 5 Convulsions

100% 37 Pallor

32.4% 12 Tachypenia

45.9% 17 Tachycardia

5.4% 2 Hepatosplenomegaly

13.5% 5 Sluggish reflexes

10.8% 4 Hypotonia

2.7% 1 Hypertonia

76

Table 6: Factors associated with Rh-incompatibility

(n=183)

P. Value % No Risk factors

0.001 10.4 19 1. FH of jaundice newborn

0.682 1.1 2 2. PH of blood transfusion

0.002 14.8 12 3. PH of abortion

0.006 3.6 6 4. Neonatal death in the family due to

jaundice

0.653 66.6 122 5. Multiparous and grand multepara

0.238 10.4 19 6. Still birth

0.016 1.1 2 7. Given anti D before

0.719 75.4 138 8. Vaginal delivery

0.719 24.6 45 9. C/S delivery

0.615 1.1 2 10. Late clamping of the cord

0.000 10.4 19 11. Rh-ve mother

77

F10

Figure 10: Clinical pattern of presentation of hemolytic disease of the newborn

3 (21.4%)

11 78.7%)

7(46.7%

8(53.3%) 4(50%) 4(50%)

0

10

20

30

40

50

60

70

80

Mild Moderate Severe

Rh-incompatibility

ABO- incompatibility

%

3(21.4%)

11(78..7%)

7(46.7%)

8(53.3%)4(50.0%) 4(50.0%)

Clinical pattern

(n = 37)

82

78

f11(landscape)

Figure 11: Types of treatment used in the study population

%

5.10 (5.5%)

0

10

20

30

40

50

60

70

80

Home management phototherapy Exchange transfusion Drugs

137 (74.9%)

28 (15.3%)

143 (78.2%)

%

Types of treatment

83

(n = 183)

79

f12(landscape)

Figure 12: Phototherapy applied to the study group

74 (40.4%)

63 (34.56%)

46 (25.1%)

0

10

20

30

40

50

60

70

80

Phototherapy Did not received

63(34.5%)

74(40.4%)46(25.1%)

%

Standard . Locally made Didn't received

(n = 183)

84

80

f13(landscape)

24(85.7%)

4(14.3%)

15(53.6%)

n = 183

0

10

20

30

40

50

60

70

80

90

once twice top up transfusion

%

Exchange and top up transfusion

Figure 13: Exchange and top up transfusion in the study population (n = 28)

85

81

3.8.3 Exchange transfusion and values of serum bilirubin Tables 7 shows that twenty-eight (15.3%) who received exchange

transfusion, three (10.7%) of them had total serum bilirubin between 12- 20

mg/dl and no one received exchange transfusion if serum bilirubin less than

12 mg/dl.

Twenty-five (89.3%) newborns with total serum bilirubin above 20 mg/dl

received exchange transfusion. This shows that the need for exchange

transfusion is affected by the value of total serum bilirubin. P value <0.05.

3.8.4 Exchange transfusion and the causes of jaundice Table 8 shows that Twelve (42.9%) newborns with ABO isoimmnunization

received exchange transfusion, 11 (39.3%) of Rh-incompatibility, four

(14.3%) had sepsis and one (3.5%) of cephalohematoma received exchange

transfusion. The etiology of jaundice is significantly correlated with the need

of exchange transfusion, P value <0.05.

3.8.5 Treatment modalities and serum bilirubin Table 9 shows that 10 (5.9%) were managed at home, 9 (4.9%) of them had

serum bilirubin less than 12mg/dl and only one had serum bilirubin between

12-20 mg/dl. One hundred thirty seven (74.9%) put on phototherapy,

5(2.7%) of them had serum bilirubin less than 12mg/dl, 121(66.2%) had

serum bilirubin between 12-20 mg/dl, 11(6.0%) were above 20mg/dl. While

28(15.3%).

82

T7 (landscape)

Table 7: Relations between exchange transfusion and the

level of total serum bilirubin

(n = 28)

% No. of cases exchanged Serum bilirubin

0 0 < 12

10.7 3 12-20

89.3 25 >20

100 28 total

P value < 0.05 X2 = 83.41

87

83

Table 8: Exchange transfusion in relation to

causes of neonatal jaundice (n=

28)

% Received exchange

transfusion

Causes of jaundice

42.9 % 12 ABO incompatibility

39.3 % 11 Rh incompatibility

14.3 % 4 Neonatal sepsis

3.5 % 1 Cephalohematoma

0 0 Physiological jaundice

0 0 Congenital malaria

0 0 Congenital infection

0 0 Hepatitis B

0 0 Infant of diabetic mother

0 0 Polycythemia

0 0 Dawn syndrome

0 0 *Others

P value <0.05 X2 =83.26

84

T9 landscape

Table 9: Relation between treatment modalities and

serum bilirubin (n = 183 )

Treatment

Serum

bilirubin

Home

management

phototherapy Exchange

transfusion

Drugs

< 12 9 (4.9%) 5 (2.7 %) 0 25 (13.7%)

12 -20 1 (0.5 %) 121 (66.2%) 5 (2.7%) 88 (48.1%)

>20 0 11 (6.0 %) 23 (12.6%) 30 (16.4%)

Total 10 (5.4%) 137 (74.9%) 28 (15.3 %) 143 (78.2%)

P.value < 0.05 X2 = 56.81

89

85

3.8.6 Treatment modalities and hemolytic disease of the newborn

Table 10 shows that all Rh incompatibility put on phototherapy, 11 of them

received exchange transfusion and 12 were given drugs. Regarding ABO

incompatibility all of them put on phototherapy, 12 of them received

exchange transfusion and 13 were given drugs. The modalities of treatment

are statistically significant. P value < 0.05.

3.9 Outcome at Time of Discharge

Regarding the outcome, 169 (92.3%) were discharged from the hospital well,

9 (4.9%) had some neurological deficit and 5 (2.8%) died in the hospital.

This is shown in figure 14.

3.9.1 Outcome at time of discharge compared with the values of total serum bilirubin Table 11 shows that among those who had values of total serum bilirubin

below 12 mg/dl, 36 (19.7%) discharged from hospital well, and only one

(0.5%) died. Out of 112 (61.2%) newborns who had total serum bilirubin

values between 12 to 20 mg/dl, about 108 (59.0%) of them were discharged

from hospital well, 2 (1.1%) had some neurological deficit and 2 (1.1%) died.

While thirty-four (18.6%) newborns had total serum bilirubin more than 20

mg/dl, 25 (13.7%) of them were discharged well, 7 (3.8%) had some

neurological deficit and two (1.1%) died. These differences are statistically

significant P value < 0.05

86

T10(landscape),

Table 10: Treatment modalities and Hemolytic disease of the

newborn (n = 37)

Treatment Haemolytic

disease of the

newborn Home

management

Phototherapy

Exchange

transfusion

Drug Total (%)

Rhesus

Incompatibility

0 14 11 12 14 (37.8%)

ABO

Incompatibility

0 23 12 13 23 (62.2%)

Total 10 37 23 25 37 (100%)

P. value < 0.05 X2 = 53.64

91

87

f14(landscape),

Figure 14: Outcome of the study group at time of discharge

0

10

20

30

40

50

60

70

80

90

100

Well Some neurological deficit Died

169 (92.3%)

9 (4.9%) 5 (2.8%)

%

(n = 183)

Outcome 92

88

t11(landscape) Table 11: Relation between outcome at time of discharge and serum bilirubin level

(n =183)

Serum bilirubin Outcome at time of discharge %

Mg/dL Well Some neurological deficit Died

< 12 36(19.7%) 0 1 (0.5%) 37 (20.2 %)

12 – 20 108(59.0% ) 2(1.1% ) 2(1.1 ) 112(61.2%)

> 20 25(13.7% ) 7 (3.8 %) 2 (1.1 %) 34(18.6 %)

Total 169 (92.4%) 9 (4.9 %) 5 (2.7 %) 183 (100.0%)

P value < 0.05 x2 = 64.51

93

89

3.9.2 Outcome at time of discharge and the causes of jaundice Table 12 shows the outcome at time of discharge in relation to the cause of

jaundice. Deaths occurred in 2 newborns with Rhesus incompatibility, 2 had

sepsis and one had hepatitis B. Regarding the 2 newborns with Rhesus

incompatibility that died, this was found to be statistically significant. P value

< 0.05.

About neurological deficit, 3 were Rh-incompatibility, 2 were ABO-

incompatibility, 3 had neonatal sepsis an only one had cephalohematoma.

The rest of the studied group discharged well from hospital.

3.9.3 Outcome at time of discharge and methods used in treatment: Table 13 shows that one hundred thirty seven (74.9%) newborns in this

study received phototherapy, out of them 133 (97.1%) were discharged from

hospital well, 3 (2.2%) had some neurological deficit and 1 (0.5%) died.

In those who received exchange transfusion, 19 (67.9%) were discharged

from hospital well, 6 (21.4%) had some neurological deficit and 3 (10.7%)

died.

90

Table 12: Comparison between the outcome at time of discharge and the

cause of jaundice (n=183)

Outcome

Total DiedSome

neurological

deficit

Well Causes

14 (7.6%) 2 3 9 Rh incompatibility

23 (12.6%) 0 2 21 ABO incompatibility

69 (37.7%) 2 3 64 Neonatal sepsis

27 (14.8%) 0 0 27 Physiological

jaundice

12 (6.6%) 0 1 11 Cephalohematoma

14 (7.6%) 0 0 14 Infant of diabetic

mother

2 (1.1%) 1 0 1 Hepatitis B

5 (2.7%) 0 0 5 Congenital infections

1(0.5%) 0 0 1 Dawns syndrome

2 (1.1%) 0 0 2 Polycythemia

2 (1.1%) 0 0 2 Congenital malaria

12 (6.6%) 0 0 12 *Others

91

t13 landscape

Table 13: Relation between treatment modalities and outcome

at time of discharge

(n = 183)

Treatment Outcome at time discharge

Home

management

Phototherapy Exchange

transfusion

Drugs

Well 10 (100%) 133 (97.1%) 19 (67.9%) 132(92.3%)

Some neurological deficit 0 3 (2.2%) 6 (21.4%) 6 (4.2%)

Died 0 1(0.5%) 3 (10.7%) 5 (3.5%)

Total 10 (4.4%) 137 (74.9%) 28 (15.3%) 143 (78.2%)

P. value > 0.05 X2 = 17.84

96

92

All newborns that had home management were discharged well from

hospital. The majority of the newborns received drugs 143 (78.2%), 132

(92.3%) were discharged from hospital well, 6 (4.2%) had some neurological

deficit and 5 (3.5%) died. The outcome at time of discharge was not affected

by methods of treatment, P value > 0.05.

3.10 Follow up

Regarding follow up one hundred seventy six (96.2%) of the newborns came

for follow up, while 7 (3.8%) didn't come for the follow up, as shown on figure

15.

93

F15 landscape

96.2%

3.8%

Come for follow upNot come for follow up

Figure 15: Follow up in the study population

(n = 183)

98

(n = 183)

94

4- Discussion

Males with neonatal jaundice were predominate (57.4%), this is comparable

to the study done by M. Jeffery (123), Maisels and Kring E (132).

Most of the study newborns were from Khartoum and Omdurman this may

be explained by the fact that central hospitals which serve children were

found in Khartoum, in addition to active nursery in Omdurman maternal

hospital. The majority of people live in Khartoum and Omdurman provinces.

Most of the Sudanese tribes included in the study population were

predominant tribes that originated from North, South, West, East and Centre

of the Sudan. This is because all tribes are represented in the capital. A

small percentage (3.8%) was originally non Sudanese.

In this study, (41.6%) of the age of newborns lies between 2-3 days which is

comparable to studies done in Alain (43,8%) (124,125).

Regarding the clinical factors, most of the study populations had normal birth

weight (NBW) (68.9%), but a significant numbers of them had low birth

weight (18.5%). This is consistent with a study done by S. Linn et al in 1985

which showed the relation between low birth weight and neonatal jaundice

(125).

Among the studied newborns 95 (51.9%) had jaundice in the second and

third days, this is comparable to several studies (46-59%)(40,41,124,125).

Over sixty percent of newborns in the study had total serum bilirubin levels

between 12 to 20 mg/dl. While (18.6%) had total serum bilirubin levels more

than 20 mg/dl, this shows that hyperbilirubinemia in this studied newborns is

95

mainly between 12 to 20 mg/dl, which is in line with previous studies (41,126).

Most of the study group had Hb between 11-14 g/dl (45.9%) but in a

significant number (10.4%) the Hb is below 8 g/dl. Thus, anemia due to

hemolysis is a feature of neonatal jaundice in this group, which is similar to

study done in Sudan in 1997 (42).

Blood group distribution in U K is about 48% group O, 29.5% group A, 22%

group B and 5% group AB, a similar incidence was reported in U.S.A (17,29,49).

Our results were relatively comparable where the most predominant is O

positive.

About one third (37.7%) of newborn with jaundiced had sepsis, this is

comparable to study done by S. Linn, et al (37.4%) (124) and Guaran et al

(37.1%) (127), but higher than in study done by M. Jeffirey et al (24.6%) (123)

and Adekunle Dawodu et al (23.1%) (125) in United Arab Emirates.

ABO incompatibility was a cause of neonatal jaundice in (12.6%) newborn,

which is comparable to a study done in Australia (10%) (127), but lower when

compared with studies from Asia (16.1%) (128,129) Middle East (15.1%) (125)

and Africa (14.1%) (9,130). Rhesus incompatibility is very high if compared with

all these studies which mentioned above but lower if compared to study

done in Sudan (8.1%) and this may reflects a fact that some social factors

like illiteracy, health education, financial and availability of health services

may contribute. Infants of diabetic mothers who developed jaundice were

(7.6%) which agrees with some study done in Middle East (125).

Newborns with jaundice of other etiology comprise (6.6%) of the study

96

population which is lower than reports from similar studies from Middle East

(9.7%) (125), but very low when compared with studies from western countries

(11.6%) (127). In the study done in 1979 in Khartoum (40), ABO incompatibility

and Rhesus incompatibility were causes of jaundice in 15. 1% and 8.1%

respectively which is higher than this study. It also showed infection as a

cause of jaundice in 9.1% of cases which is lower than that seen in this

study. Physiological jaundice in Swar study (40) was (52.5%) which is much

higher than in this study. Undetermined causes for the etiology of jaundice

were 14.1% in Swar study, comparable to only 6.6% in this study (40). A

decrease in the incidence of ABO and Rhesus incompatibility as causes of

jaundice in the last twenty years may be due to awareness and health

education.

Hemolytic disease of the newborn caused either by ABO or Rhesus

incompatibility was the major factor of neonatal jaundice (20.2%). In our

study group, ABO incompatibility was common than Rhesus incompatibility,

this is consistent with lindo Haynes(35) and al Jawad in Abu Dhabi (36). Our

result is in contrast to a study done in Saudi Arabia where Rh-incompatibility

was the commonest cause (133).

The majority of newborns presented in the first day, this is comparable

with study done in Sudan (40), Middle East (125) and Africa (9,130). The most

common presenting symptom was jaundice, which is due to the fact that

jaundice is more readily noticed by the family and mothers tend to regard it

as a serious disease. Fever was the presenting complains in (5.4%) and the

newborns had either septicemia or malaria. Pallor was a major signs in

97

newborn with jaundice.

Hepatosplenomegaly was detected in (5.4%) of the jaundiced newborns and

was associated with severe anemia due to Rh incompatibility or sepsis.

Tachypenia and tachycardia were detected in (32.4%), (45.9%) respectively

and reflect hyperdynamic circulation caused by anemia (61,72).

In Rh negative mothers, the risk factors were mainly, history of neonatal

jaundice, neonatal deaths in the family due to jaundice, past history of

abortion, which are similar to other studies (52,54).

Past history of blood transfusion, multiple pregnancies, still birth, mode of

delivery and late clamping of the cord were not risk factors of developing Rh-

incompatibility, unlike other studies (52,54).

The pattern of HDN were mild 14 (37.8%) or moderate 15 (40.5%) or severe

8 (21.7%), and ABO was commoner than Rh incompatibility but fortunately

less severe, the same as Swar study (40).

One hundred thirty seven (74.9%) newborns received phototherapy. There

was no specific level of serum bilirubin for indication of phototherapy. It

depends mainly on the decision of the treating consultant. The locally made

phototherapy was of value in reducing bilirubin level. Twenty eight (15.3%)

of studied newborns received exchange transfusion. Twenty-five (89.3%) of

them had total serum bilirubin more than 20 mg/dl, which is much lower than

in study done by Gartner et al (131). Most of the newborns who received

exchange transfusion were those with ABO (42.9%) and Rhesus

incompatibility (39.3%) and this is comparable to studies done in Middle East (125) and Australia (127).

98

Some newborn with Rh incompatibility or neonatal sepsis received exchange

transfusion more than once. Of those who received exchange transfusion,

(53.6%) had top up transfusion, this explain the fact that anemia is a feature.

In our study exchange transfusion depends mainly on the level of serum

bilirubin as well as clinical examination, this goes with study done in Middle

East (125) and Australia (127). No newborn developed complications associated

with exchange transfusion unlike study from America (93).

All newborns with sepsis and those who received exchange transfusion were

given antibiotics. Prescription of drugs to (78.2%) of the studied population

was difficult to be justified.

In this study the majority (92.3%) were well at time of discharge, (4.9%)

discharged with some neurological deficit and (2.8%) died. These results

were acceptable and comparable to Maisels and Kring study 132). Deaths

occurred mainly in those with serum bilirubin more than 20 mg/dl and

seemed to be related to hyperbilirubinemia. This hypothesis is agreed by

other studies (93).

Seven (3.8%) of newborn did not come for follow up after initial treatment.

This could be due to the fact that their mothers ignored the need for

reporting babies after they became well or due to financial problem of

transport, since the majority of them were from low socio-economic status.

99

Conclusion

Jaundice in Sudanese newborn is common during the first three days of life

and is commoner in males. The common presenting symptoms were

jaundice, fever, while the common presenting signs were pallor, tachypenia

and tachycardia.

The prevalence of hemolytic disease of the newborn among jaundiced

newborn was 37(20.2%), ABO incompatibility is more common than Rh

incompatibility and less severe.

Different etiologies contributing in the causation of neonatal jaundice, most

of them are sepsis, ABO and Rhesus incompatibility were important causes

of jaundice.

Risk factors for Rh incompatibility in Rh negative mothers were mainly

history of neonatal jaundice, neonatal deaths due to jaundice and past

history of abortion.

In newborns with jaundice, different methods were used in treatment,

phototherapy (74.9%), exchange transfusion (15.3%) and drugs (78.2%).

The study showed that most of the newborns with jaundice were discharged

from hospital in good condition (92.3%), some with neurological deficit

(4.9%) and (2.8%) died. Patients who developed neurological deficit or died

had Rhesus incompatibility or septicemia.

100

Recommendations

1. Mothers should be encouraged to have regular antenatal care, which

include blood grouping and rhesus status.

2. Early detection and referral of rhesus negative mothers to a central

hospital so as to be manage properly.

3. Training of midwives and primary health workers to identify jaundice in

newborns and refer them for assessment and management.

4. A newborn with jaundice need careful evaluation to determine the

etiology of jaundice, and also a national standard guidelines for their

management.

5. Incidence of rhesus-incompatibility can be reduced by giving anti-D to

high risk rhesus negative mothers; this policy should be adopted in all

obstetric units to be offered in a cheap price.

6. Prevention of Kernictrus is better than to treat it, so more emphasis on

training doctors to recognize and treat a jaundice newborn.

7. Providing of standard phototherapy units in all neonatal units, nursery

units and pediatrics ward.

8. Prescriptions of antibiotics in newborns should follow a national

standard guidelines.

101

References

1. Zipursky A. Erythrocyte morphology in newborn infants. A new look.

Pediatr Res 1987; 11: 483-87.

2. Moe PJ. Umbilical cord blood and capillary blood in the evaluation of

anemia in erythroblastosis fetalis. Acta Pediatr Scand 1997; 56: 391-

93.

3. Weiner CP. Human fetal bilirubin levels and fetal hemolytic disease. Am

J Obstet Gynecol 1992; 166: 1449-55.

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بسم اهللا الرحمن الرحيم

UNIVERSITY OF KHARTOUM FACULTY OF MEDICINE

DPOSTGRADUATE MEDICAL STUDIES BOAR Questionnaire

HEMOLYTIC DISEASE OF THE NEWBORN IN KHARTOUM STATE

Serial No. □□□ A- Mother: 1. Name:…………………………………………………………

2. Age: □□YEARS 3. Residence:……………………………………………………. 4. Origin:………………………………………………………… 5. Tribe:………………………………………………………..… 6. Address/ Telephone:……………………………………. 7. Education:

a) Illiterate □ b) primary□ c) secondary□ d) graduated□

8. Past history of jaundice newborn: YES □ NO□

If yes, i-age of onset □□days

ii-Maximum bilirubin level: □□mg/dl

iii-Diagnosis HDN □ Not HDN □

iv-Treatment: a)Home management□ b)Phototherapy□ c)Exchange

transfusion□ d)Top up transfusion□

9. Past history of blood transfusion: a) YES□ b) NO□

10. Past history of abortion or D&C: a) YES□ b) NO□

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11. Given anti-D before: a) YES□ b) NO□

12. External cephalic version: a) YES□ b) NO□

13. No. of live birth: □□

14. No. of stillbirth: □□ 15. No. of neonatal deaths: □□ 16. Cause of neonatal death:………………………………..

17. Drugs during pregnancy: a) YES□ b) NO□ If yes, specify...................................................................

18. Drugs during delivery: a) YES□ b) NO□ If yes, specify...................................................................

19. Mode of delivery: a) Vaginal Delivery □ b) C/S □

20. Delivery place: a) Hospital □ b) Home□

21. Cord clamped a) Early □ b) Delay □

22. Blood group: a) A+ve□ b) B+ve□ c) O+ve□ d) AB+ve□

e) A-ve□ f) B-ve□ g) O-ve□ d) AB+ve□

23. Coomb's test: a) +ve□ b) -ve□ 24. Father education:

a)Illiterate□ b)primary□ c) secondary□ d)graduated□ 25. Father occupation:……………………………………… …

:Neonate-B

122

1. Age: □□Days

2. Sex: a- Male□ b- Female□

3. General look: a-Pale □ b-Jaundice□

c- Cyanosed□ d- Febrile□

4. Weight (grams): □□□□grams

5. GA (weeks): □□WK

6. Date of onset of jaundice: □□ day

7. Respiratory rate: □□/min

8. Heart rate: □□□/min

9. Cephalohematoma: a) YES□ b) NO□

10. Hepatosplenomegaly: a) YES□ b) NO□

11. CNS: a) Convulsion□ b) Hypotonia□

d) Hypertonia□ e) Primitive reflexes□ C- Investigations:

1. Hb (g/dl): □□g/dl

2. Retics: □□% 3. Peripheral blood picture:…………………………………………….

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4. PCV: □□

5. MCV: □□

6. Blood group: a) A+ve□ b) B+ve□ c) O+ve□ d) AB+ve□

e) A-ve□ f) B-ve□ g) O-ve□ d) AB-ve□

7. Coombs test: a) +ve□ b) -ve□

8. Total serum bilirubin: a) Direct□ b) Indirect□

9. TWBCs: □□□□□

10. Band cells: a) +ve□ b) -ve□

11. BFFM: a) +ve□ b) -ve□ D- Treatment and out come:

1. Drugs: a) YES□ b) NO□

2. Phototherapy: a) YES□ b) NO□ If yes, specify………………………………………

If yes, a) standard□ b) locally made□

3. Exchange transfusion: a) YES□ b) NO□

If yes, a) once□ b) twice □ c) >two□

3. Top up transfusion: a) YES□ b) NO□

4. Home advice: a) YES□ b) NO□

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E. Outcome at time of discharge:

a) Well□ b) some neurological deficit□ c) Died□ F. Follow up:

I) Weight: □□□□grams

II) Hepatosplenomegaly: a) YES□ b) NO□ III) CNS: a) Convulsion□ b) Hypotonia□

c) Hypertonia□ d) Primitive reflexes□

IV) Hb (g/dl) □□g/d

V) Total serum bilirubin: a) Direct□ b) Indirect□ G. Diagnosis: