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1. Hemolytic Disease of the Newborn Dr. Ayman Asfour,
Director of Transfusion Medicine
University of Mississippi Medical Center
2. Names for HDN Hydrops fetalis
Icterus gravis neonatorum
Kernicterus (outcome)
Erythroblastosis fetalis
3. HDN Destruction of RBC
Neonates and infants
Intrinsic (membrane defect, enzymes)
Acquired (infection, alloimmunization)
Platelets and Granulocytes G-6-phosphate dehydrogenas, pyruvate kinase
eliptocytosis, spherocytosis, , pyropoikilocytosis
congenital syphilis, toxoplasmosis, CMV, rubella, coxackie and E-coli
Rh, ABO maternal autoimmune hemolytic anemiaG-6-phosphate dehydrogenas, pyruvate kinase
eliptocytosis, spherocytosis, , pyropoikilocytosis
congenital syphilis, toxoplasmosis, CMV, rubella, coxackie and E-coli
Rh, ABO maternal autoimmune hemolytic anemia
12. The DAT will detect antibodies coating the fetal cells
15. History 1609 Diamond and colleagues
Landsteiner and weiner
Coomb, Mourant and Fischer
levine discovered the anti(D) in anemic infants
Mrs. Kell French midwife Hydrops fetalis, jaundice and anemia
Guinea pigs injected with Rhesus monkey RBCs developed an antibody that reacted with 85% of human RBCsFrench midwife Hydrops fetalis, jaundice and anemia
Guinea pigs injected with Rhesus monkey RBCs developed an antibody that reacted with 85% of human RBCs
16. Frequency ABO HDN 65%
Rh HDN 33%
Others 2%
17. Serology Maternal Antibody
Fetal antigen
Cross the placental barrier
IgG1 and IgG3
High and low responders
Primary and secondary response
Anamnestic response
18. Basics Mom lacks an antigen
Baby has an antigen
Mom produces Antibody (IgG)
19. Fetal-maternal hemorrhage Placental membrane rupture
Trauma
Amniocentesis
Abortion
Delivery
20. RBC antigens RBCs are formed by 2-3 weeks gestational age
Most antigens are well developed by 10-12 weeks
Except ABO, P1, Lewis and Cartwright
21. Clinical Erythroblastosis
Extramedullary hematopoiesis
Portal hypertension
Hypoproteinemia and edema
Hydrops
Mother protects against high bilirubin Anemia leads to erythropoiesis expansion, extrameduullary hematopeiesis
Hydrops, scalp edema, ascites, pleural effusion
Portal hypertension, liver function deteriorates, hypoalbuminemia and hydrops
indirect hemoglobinAnemia leads to erythropoiesis expansion, extrameduullary hematopeiesis
Hydrops, scalp edema, ascites, pleural effusion
Portal hypertension, liver function deteriorates, hypoalbuminemia and hydrops
indirect hemoglobin
22. RES removes Ab labeled RBCs (Fc receptors on macrophages)
Indirect bilirubin, maternal circulation
Direct soluble, Indirect insoluble
Mom protects baby
23. Anemia, more cells produced, erythroblastosis fetalis.
Extramedullary erythropoiesis
Hepatosplenomegaly
Portal hypertension
Edema
24. Basal ganglia and kernicterus
25. ABO Disease 31% Whites, 50% Asians
Mild
ABO antigens weak expression
Anti-A, anti-B (IgM doesnt cross placenta)
Anti-A,B in group O (IgG crosses placenta)
ABO substance in fetal plasma
Only 10% require therapy
Mother O
ABO substance neutralize antibodies
10% with ABO incompatibility require therapyMother O
ABO substance neutralize antibodies
10% with ABO incompatibility require therapy
26. ABO HDN Firstborn is at risk
DAT positive in 20-40%
Only 10% developed hemolysis
Careful assessment of the newborn is the key
Protects against Rh immunization Study by Dea-jardins
80% of those with hemolysis have positive DATStudy by Dea-jardins
80% of those with hemolysis have positive DAT
27. Non-ABO Disease Rh(D) most immunogenic
48-65% before RhIg prophylaxis
18.7% after RhIg
History of previous transfusion
K1, c, E
28. Prophylaxis 0.1 ml Rh(D) pos cells
Expressed at 4 weeks of gestation
Anti-D is formed by 6 months after the first pegnancy
Rhogam (RhIg) 20 m g/ml RBCs
Hypothetical mechanisms
Steric changes in conformation
29. Anti-idiotype feed-back inhibition
Alloimmunization dropped from 14% to 2%
Antepartum RhIg, 0.2%
At 28-32 weeks gestation
1 m g/ml=5 IU
IM 300 mg dose, IV available more expensive
1968 Rhig has been licenced in USA
plasma pools , HCV non-lipid coated virus are not inactivated (parvo B19)
nucleic acid testing and filteration1968 Rhig has been licenced in USA
plasma pools , HCV non-lipid coated virus are not inactivated (parvo B19)
nucleic acid testing and filteration
30. Indications for RhIg All Rh-D neg women at 28 weeks gestation
Amnio, abortion, trauma, ITP and transfusion
Partial D not Du
Given within 72 hours after delivery
300 mg == 1500 IU for 15 ml RBCs
Weak-D or Du no need for RhIg CAP and American college of ob and gyn
2 reports of fatal HDN due to partial D
weak D express the complete antigen, but partial D with gene rearrangement (n 22)and point mutations (n 9)
Studies showed that it is ok up to 13 days after exposure to Rh-D positive cellsWeak-D or Du no need for RhIg CAP and American college of ob and gyn
2 reports of fatal HDN due to partial D
weak D express the complete antigen, but partial D with gene rearrangement (n 22)and point mutations (n 9)
Studies showed that it is ok up to 13 days after exposure to Rh-D positive cells
31. Testing Conversion from neg to pos Rh typing
Rosette test
Weak-D antiglobulin-based phenotype study
Kleihauer-Betke* (KNOW the calculations!)
Adult cells (HbA) lose hemoglobin and look pale
Fetal cells (HbF) retain hemoglobin during staining process and look bright pink
Flow cytometry Rosette screening with Rh-D positive indicator cells coated with anti-D
K B test, HbF and HbA differential solubility
Tx of Rh pos blood;20 micro gram/ml of RBCs IM and 18 IV
<12 weeks gestation 50 micro gram
others 300 micro grams
KB 5/1000
5/1000 X maternal blood volume (85 ml/kg)=25
vials=25/30=.83 doses
round up to 1 + 1=2 vialsRosette screening with Rh-D positive indicator cells coated with anti-D
K B test, HbF and HbA differential solubility
Tx of Rh pos blood;20 micro gram/ml of RBCs IM and 18 IV
<12 weeks gestation 50 micro gram
others 300 micro grams
KB 5/1000
5/1000 X maternal blood volume (85 ml/kg)=25
vials=25/30=.83 doses
round up to 1 + 1=2 vials
32. Maternal Assays ABO, Rh including weak D(Du)
IAT and titer
A titer of 8-32 for anti-Rh-D
8 for anti-K1
Rhogam mimics anti-D
Ultrasonography
Age, hydrops, liver, blood velocity
and placental thickness Area opaca vasculosa, blood islands of the yolk sac, hemangioblasts, peripheral angioblasts and central hemoblasts
erythropoietin reaches the coelomic caviyt by decidualization of the endometrium.
RhD antigen is is expressed as early as 38 dayintrauterine.
K1 and Jkb 6-8 weeks
K2, Fya, Fyb at 6-8 weeks of gestation
Maternal serum + hetrozygous Rh-D positive cells + donor monocytes.
Maternal IAT test replaced MMAArea opaca vasculosa, blood islands of the yolk sac, hemangioblasts, peripheral angioblasts and central hemoblasts
erythropoietin reaches the coelomic caviyt by decidualization of the endometrium.
RhD antigen is is expressed as early as 38 dayintrauterine.
K1 and Jkb 6-8 weeks
K2, Fya, Fyb at 6-8 weeks of gestation
Maternal serum + hetrozygous Rh-D positive cells + donor monocytes.
Maternal IAT test replaced MMA
33. Amniocentesis
Bilirubin OD450
Spectral absorption curve
Liley curve, useful after 27 weeks
Queenan curve
Transplacental puncture, can lead to fetomaterna hemorrhage, ultrasonographic guidance
L/S ratio >2 lng maturity, surfactant. Lecithin/sphingomyelin
Testing paternal blood with the same primers used to test fetal blood to determine the Rh-D status , PCR, to avoid the false positive results due to rearrangements in the RhD gene, if father not available a 4 fold increase in antibody titer is diagnostic
Transplacental puncture, can lead to fetomaterna hemorrhage, ultrasonographic guidance
L/S ratio >2 lng maturity, surfactant. Lecithin/sphingomyelin
Testing paternal blood with the same primers used to test fetal blood to determine the Rh-D status , PCR, to avoid the false positive results due to rearrangements in the RhD gene, if father not available a 4 fold increase in antibody titer is diagnostic
34. Fetal Assays Blood type
Hematocrit (30% indicates anemia)
DAT
Reticulocyte count
Total bilirubin
Middle cerebral artery blood velocity Cord insertion site should be avoided to avoid bradycardia, because vagal nerve distribution
The vein should be sampled rather than the arteryCord insertion site should be avoided to avoid bradycardia, because vagal nerve distribution
The vein should be sampled rather than the artery
35. Clinical Management IAT, antiglobulin phase
Titer if positive every 2-4 weeks
32 critical value
Amniocentesis, every 2 weeks
Paternal typing
If positive, fetal typing
If positive, serial OD Hct ,30% IUT
last OD at 37 weeks, then L/S ratio, induce labor if ok at 39 weeks.Hct ,30% IUT
last OD at 37 weeks, then L/S ratio, induce labor if ok at 39 weeks.
36. 2nd pregnancy, titers are not helpful
Queenan curve, doppler at 18 weeks
Hematocrit <30%
IUT
37. Marsh score Grade Score
4+ 12
3+ 10
2+ 8
1+ 5
+W 3
38. 1 2 4 8 16 32 64
3+ 3+ 3+ 2+ 2+ 2+ 1+
10 10 10 8 8 8 5
Titer (64)
Score 59
39. IUT 1963 intraperitoneal transfusion (IPT)
1981 intravenous transfusion (IVT)
1982 in Denmark, ultrasonographic guidance
1986 Yale and Mt.Sinai
1963 Liley
1981 Rodeck1963 Liley
1981 Rodeck
40. IVT
less frequent transfusions
shorter stay in ICU
IPT
(weeks - 20) X 10 = volume to transfuse
41. CMV negative
Irradiated
Fresh (to avoid ?Ca++)
Maternal blood if possible
Leukoreduced What type of blood to give fetus:
42. How much to transfuse Mandelbrot
Vfetoplacental X (Hctfinal - Hctinitial) X Hcttransfused blood
Giannina
weight in grams X 0.04
will raise Hct by 20% Hct final 35-40%
Hct initia <30
Hct unit 70-80%
fetopalcental volume = (weight in grams + 1.046) X 0.14 Hct final 35-40%
Hct initia <30
Hct unit 70-80%
fetopalcental volume = (weight in grams + 1.046) X 0.14
43. IUT indications Hematocrit < 30%
> 0.5 mg/dl/h bilirubin in Rh
> 1.0 mg/dl/h bilirubin in ABO
Serum bilirubin > 20 mg/dl
Serum bilirubin > 15 for > 36 h
kernicterus, basal ganglia, indirect bilirubin Survival 84%
92% in nonhydropic
70% in hydropic
increased umbilical venous pressure and decreased heart rate
acidic pH of transfused blood
low fetal hemoglobin in transfused blood
increased 2-3 DPG in transfused blood, increases release of O2
iron overload
Kernicterus, basal ganglia, indirect bilirubin, deafness mental retardation, brain damage severe, extrapyramidal, gaze disturbance may appear after the first year of lifeSurvival 84%
92% in nonhydropic
70% in hydropic
increased umbilical venous pressure and decreased heart rate
acidic pH of transfused blood
low fetal hemoglobin in transfused blood
increased 2-3 DPG in transfused blood, increases release of O2
iron overload
Kernicterus, basal ganglia, indirect bilirubin, deafness mental retardation, brain damage severe, extrapyramidal, gaze disturbance may appear after the first year of life
44. Phototherapy UV light, photooxidation
10-14 mg/dl bilirubin
Exchange transfusion if failed
2 volumes
Rh, ABO-compatible Rh-D negative
ABO incompatibility, O negative washed
reconstituted with AB plasma
45. Donor compatible with mother AHG phase
Sickle negative blood
Target hematocrit of 50%
Fetal blood = 85 ml / kg Fetal blood volume 85 ml/kg
50% Hct of transfused bloodFetal blood volume 85 ml/kg
50% Hct of transfused blood
46. Conclusion IgG cross the placenta
Rh-D, ABO, Kell
RhIg, used as a prevention
Can be fatal
Maternal assays, fetal assays
Amniocentesis, ultrasonography
IPT, IVT, phototherapy and exchange Tx