anemia , rhesus and blood group incompatibility in

8/12/2019 Anemia , Rhesus and Blood Group Incompatibility In

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Dr. Dina Garniasih, SpA, Mkes.


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Hematologic physiology of the

newbornNormal development: The physiologic anemia

of infancy

In utero the fetal aortic O2 saturation is45%; erythropoietin levels are high, RBC

production is rapid, and reticulocyte valuesare 3 to 7%.

After birththe O2 saturation is 95%, anderythropoietin is undetectable.

RBC production by day 7 is < 1/10 the levelin utero. Reticulocyte counts are low, andthe Hb level falls.


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normal development: The

physiologic anemia of infancy

At 8 to 12 weeksHb nadir

O2 delivery to the tissue is impaired,

erythropoietin production is stimulated,

and RBC production increases.

Active erythropoiesisiron stores are

rapidly utilized.

The reticuloendothelial system hasadequate iron for 15 to 20 weeks in term

infants.


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Anemia of prematurity

RBC mass is decreased at birth.

The Hb nadir is reach earlier, because:

RBC survival is decreased.

There is a relatively more rapid rate of

growth.

Vit E deficiency is common.


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anemia of prematurity

Erythropoietin is produced by: Term infant at a Hb level of 10-11 g/dL

Premature infant at a Hb level of 7 to 9 g/dL.

Iron administration before the age of 10-14weeks does not increase the nadir of thehemoglobin level or diminish its rate ofreduction.

Once the nadir is reached RBCproduction is stimulated an iron storesare rapidly depleted because less iron isstored in premature infant.


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Etiology of anemia in the

neonateBLOOD LOSS:

/normal Ht

/normal reticulocyte count

Normal bilirubin level

Obstetric cause of blood loss, includingmalformations of plasenta and cord

Occult blood loss: Fetomaternal bleeding Fetoplacental bleeding

Twin-to-twin transfusion


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etiology of anemia in the

neonateHEMOLYSIS

Ht

reticulocyte

bilirubin level

Immune hemolysis: Rh incompatibility

ABO incompatibility Minor blood group incompatibility

Maternal disease


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neonate

Bleeding in the neonatal period:

Intracranial bleeding

Massive cephalhematoma

Retroperitoneal bleeding

Ruptured liver or spleen

Adrenal or renal hemorrhage

Gastrointestinal bleeding Bleeding fromumbilicus

Iatrogenic cause


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neonate

Hereditary RBC disorders:

RBC membran defects

Metabolic defect

Hemoglobinopathies

Acquired hemolysis:

Infectionbacterial or virus

DIC Vit E deficiency or other nutritional anemias

Microangiopathic hemolytic anemia


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neonateDIMINISHED RBC PRODUCTION

Ht

reticulocyte

normal bilirubin level

Diamond-Blackfan syndrome

Congenital leukemia or other tumor

Infections, especially rubella and parvovirus

Osteopetrosis, leading to inadequateerythropoiesis

Physiologic anemia or anemia of prematurity


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Diagnostic approach to anemia

in the newborn

The family history

The obstetric history

The physical examination:

Acute blood loss Chronic blood loss

Chronic hemolysis

Complete blood count Reticulocyte count

Blood smear


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Diagnostic approach to anemia

in the newborn

Coombs test and bilirubin level

Apt test on gastrointestinal blood ofuncertain origin

Kleihauer-Betke preparation of themothers blood.

Ultrasound of abdomen and head

Test on parents Studies for infection

Bone marrow (rarely used)


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Therapy

TRANSFUSION

Indications for transfusion: Infants with significant respiratory disease or

CHD

Healthy, asymptomatic newborns will self-correct a mild anemia

Infants with ABO incompatibility who do nothave an exchange transfusion may haveprotracted hemolysis

Premature babies may have be quitecomfortable with hemoglobin levels of 6.5 to 7.0mg/dL


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therapy

Blood products and methods of

transfusion

Packed RBCs

Whole blood

Exchange transfusion with packed RBCs

Irradiated or frozen RBCs

Direct-donor transfusion Transfusing stored red blood cells from a

single unit reserved for an infant.


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therapy

PROPHYLAXIS

Term infant should be sent home from

hospital on iron-fortified formula (2

mg/kg per day) if they are notbreastfeeding.

Premature infants (preventing or

ameliorating the anemia of prematurity). Iron supplementation in the preterm infant

prevents late iron deficiency.


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therapy

Mothers milk or formulas similar to mothers

milk

Vitamin E (15 to 25 IU of water-soluble form)

is given daily until the baby is 38 to 40weeks postconceptional age

These infants should be followed carefully

Recombinant human erythropoietin (REPO)


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RHESUS

ISOIMMUNIZATIONClinical Features

Anemia, mild to severe

Jaundice (indirect hyperbilirubinemia)

Presents during first 24 hours. May cause kernicterus

(1) Exchange transfusion

(2) Factors that predispose to the development

of kernicterus at lower levels of bilirubin

prematurity, hypoproteinemia, metabolicacidosis, drugs (sulfonamides, caffeine, sodiumbenzoate), and hypoglycemia.


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rhesus isoimmunization

Hepatosplenomegaly; varies with

severity.

Petechiae (only in severely affected

infants).

Severe illness with birth of infant with

hydrops fetalis, stillbirth, or death in

utero and delivery of a macerated fetus. Late hyporegenerative anemia with

absent reticulocytes.


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rhesus isoimmunization

Laboratory Findings Serologic abnormalities (incompatibility

between blood group of infant and mother;direct Coombs test positive in infant;

mothers serum has the presence ofimmune antibodies detected by the indirectCoombs test)

Hb level, reticulocyte count, smear-

increased nucleated red cells, markedpolychromasia, and anisocytosis

indirect bilirubin level.


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Determine zygosity of the father

Examination of the amniotic fluid for

spectrophotometric analysis of bilirubin.

The following are indications for amniocentesis:

a. History of previous Rh disease severe

enough to require an exchange transfusion or to

cause stillbirth.

b. Maternal titer of anti-D, anti-c, or anti-Kell (or

other irregular antibodies) of 1:8 to 1:64 or

greater by indirect Coombs test or albumin

titration and depending on previous history.


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PostnatalHyperbilirubinemia exchange transfusion.

phototherapy

In hydropic infant at birth: Adequate ventilation.

Partial exchange transfusion.

Double-volume exchange transfusion.

Clinical signs suggesting kernicterus at anytime at any bilirubin level are an indication forexchange transfusion.


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Prevention of Rh Hemolytic

DiseaseRh hemolytic disease can be prevented by the use of Rh Ig at a dose of

300 mg, which is indicated in the following circumstances:

For all Rh-negative, Rh0 (Du)-negative mothers who are

unimmunized to the Rh factor.

For all unimmunized Rh-negative mothers who have undergone

spontaneous or induced abortion. After ruptured tubal pregnancies in unimmunized Rh-negative

mothers

Following any event during pregnancy that may lead to

transplacental hemorrhage or antepartum hemorrhage in

unimmunized Rh-negative women

Following tubal ligation or hysterotomy after the birth of an Rh-

positive child in unimmunized Rh-negative women.

Following chorionic villus sampling at 1012 weeks gestation. In

these patients 50 mg of Rh immunoglobulin should be given.


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ABO Isoimmunization

Clinical Features

Jaundice (indirect hyperbilirubinemia)

usually within first 24 hours; may be of

sufficient severity to cause kernicterus

Anemia

Hepatosplenomegaly.


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ABO Isoimmunization

Diagnosis Hemoglobin decreased

Smear: spherocytosis in 80% of infants,reticulocytosis, marked polychromasia

Elevated indirect bilirubin level Demonstration of incompatible blood group

Group O mother may have an infant who is group Aor B.

Rarely, mother may be A and baby B or AB or

mother may be B and baby A or AB. Direct Coombs test on infants red cells

usually positive


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ABO Isoimmunization

Demonstration of antibody in infantsserum These antibodies can be demonstrated by

the indirect Coombs test in the infantsserum using adult erythrocytes possessingthe corresponding A or B antigen.

Antibody can be eluted from the infants redcells and identified.

Demonstration of antibodies in maternalserum.


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ABO Isoimmunization

Treatment

Antenatal management or premature

delivery is not required.

After deliverycontrolling the

hyperbilirubinemia by frequent

determination of unconjugated bilirubin

levels, with a view to the need forphototherapy or exchange transfusion.

Whole blood.


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anemia , rhesus and blood group incompatibility in

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