Hemolytic Disease of the Newborn

HDN - Definition
A condition in which the life span of the fetal or newborn RBC is shortened due to maternal Allo-antibodies against paternal Antigens on fetal red cells. It was first reported by a french midwife in 1609 in a set of twins, but its pathogenesis not known until mid twentieth century.

Allo-antibodies implicated
Anti-D Anti-D+C Anti-D+E Anti-C Anti-E Anti-c Anti-e Anti-K. Others

Pathogenesis of HDN
Feto-maternal Haemorrhage Maternal Antibody Placental passage of Antibody from mother to fetus Attachment of maternal Antibody to fetal red cells Destruction of fetal red cells

Rhesus Hemolytic Disease of the Newborn

Factors effecting immunization & severity of HDN

1. Antigenic exposure : Feto-maternal Hage occurs usually in late pregnancy and delivery Amount is < 0.1 ml in 75% (Risk of sens. 3%) Amount is > 0.1 ml in 25% (Risk of sens. 22%) Amount is > 15 ml in 0.3% when mother is first sensitized this called the primary response, while a repeat exposure to Ag in as little as 0.03 ml could induce the secondary response.

Factors effecting immunization & severity of HDN

2. Host factors :
Individual variability. ~70% of RhD-ve will produce Anti-D, if transfused RhD +ve blood. ~10% of Rh D negative ladies will not be immunized by an Rh D positive pregnancy.

Factors effecting immunization & severity of HDN

3. Immunoglobulin Class :
Only IgG passes the placenta. Passage occurs starting at the 2nd trimester and until birth.

4. Antibody specificity:

Factors effecting immunization & severity of HDN

5. ABO Group of the Mother :
Risk of immunization to D Antigen in ABO incompatible first pregnancies is ~ 3% , compared to 15% if ABO compatible.

Why???

Rhesus HDN
IgG antibody in mother passes to circulation of Fetus Destroy fetal RBC in spleen Anemia Stimulation of fetal marrow to produce RBC Appearance of NRC in fetal blood (erythroblastosis fetalis) Both liver and spleen called in (hepatosplenomegaly) EMH leads to Portal hypertension & liver damage lead to hypoproteinaemia. Edema+effusion+Ascites Hydropes fetalis.

When will hemolysis stops ?

It will continue after birth, Why? Maternal antibodies are still present in fetal circulation (half life 25 days) Bilirubin will accumulate beyond ability of liver to handle, because of liver immaturity, but why will it be more

apparent after birth??

Prediction of possible HDN

Women at risk of alloimmunization should undergo indirect coombs test and titres at their first prenatal visit. If positive obtain a paternal blood type and genotype. If father is homozygous for Ag, then do serial titres for antibody in mother. If father heterozygous, then determine fetal blood type by PCR, by testing fetal cells in Amniotic fluid or maternal circulation or by performing cordocentesis.

Prediction of possible HDN

Indicators of severe HDN are :
Previous children with hemolytic disease. Rising maternal antibody titre. Rising amniotic fluid bilirubin concentration. U/S evidence of Hydrops.

Clinically HDN presents with :

Jaundice, Pallor, hepatosplenomegaly, Hydrops in severe cases. The jaundice typically starts at birth or in first 24 hours and increased rapidly due usually to unconjugated bilirubin.

Severity varies :

Neonatal Hemolytic anemia. Icterus gravidus Neonatorum Intrauterine Death (Hydropes Fetalis). First child is classically spared , unless?!!! Once immunized all future Rh(D) positives will be affected.

Why does Hydrops occur in HDN :

Anemia is not the only cause. Excessive hepatic extramedullary hemopoiesis leads to portal and umbilical venous obstruction and diminished placental perfusion because of oedema. Increased placental weight and oedema of the chorionic villi interfer with placental transport. Hydrops results from fetal hypoxia, anemia, congestive heart failure, hypoproteinemia secondary to hepatic dysfunction. Hydrops does not occur unless Hb is <4 g/dl (PCV <15%).

Workup in HDN :
Complete blood Picture shows :
Anaemia. Increased NRC (erythroblastosis fetalis) High retics counts. Neutropenia maybe observed, although after IUT neutrophilia is more likely. Thrombocytopenia : common after exchange or IUT.

Workup in HDN :
Metabolic abnormalities : - Hypoglycemia is common. - Hyperkalemia and hypocalcemia are common after exchange transfusion. Serological tests : - In mother Indirect coombs positive. - In newborn direct coombs test is positive.

Workup in HDN :
Imaging studies : High resolution US has great impact in detecting early hydrops. Also this US could be used to direct needles in fetal transfusion.

Rh Isoimmunization
Prevention
of Rh isoimmunization: Mainstay is Anti-D Immunoglobulin, developed and used since the seventies.

The main question is not whether women should receive such prophylaxis, but :
Which ones should do so..? At what time they should do so? And in what doses?

Prevention of Rh isoimmunization
Which women should do so..?
An Rh (D) negative women giving birth to an Rh (D) positive fetus. An Rh (D) negative woman having an abortion, chorionic villus biopsy, and external version of a breech presentation Consider it in those pregnant Rh(D) negative with abdominal trauma, Placenta previa, abruptio placenta,uterine bleeding from any source.

Prevention of Rh isoimmunization
At what time they should do so?
As soon as possible after birth of Rh D positive newborn, but up to 72 hrs postpartum is acceptable. Because of the presence of some risk of Rh isoimmunization during pregnancy, though small (1.5%), Anti-D maybe given at 28-32 weeks gestation, in Rh D ve mother.

Prevention of Rh isoimmunization
And in what doses? Different experiences : In UK : 100 g (500IU) In Australia : 125 g In US and some Parts of Europe: 200-300 g (1000-1500 IU). In principle 20 g (100IU) of Anti-D is sufficient to neutralize antigenecity of 2 ml Rh D positive whole blood

Prevention of Rh isoimmunization
To Determine dose exactly we could do Kleihauer-Betke test, which is a test designed to determine the proportion of fetal cells in maternal blood (i.e.FM Hage)

Because of the length taken in doing the above test, some physicians resort to Indirect Coombs test in the mother to assess the adequancy of Anti-D in a women with significant FMH; the test should become positive in a previously negative lady indicating the presence of an excess antibody.

Diagnosis of Rh isoimmunization
All pregnant women should have their Rh phenotype determined early in pregnancy. Women negative for D or other antigens in Rh system should be further screened for their antibodies. The presence of antibodies indicates that the fetus maybe affected.

Some important notes on Iso-immunization

The Antibody titre does predict the

presence or severity of fetal disease, except in first affected pregnancy. In subsequent pregnancies, the most powerful predictor of severity , is its severity in previous pregnancies. Rising serial antibody levels is another important predictor of severity.

Treatment of Iso-immunization
Early delivery before the baby is too severely affected, remains the mainstay of established isoimmunization. IU transfusion should be considered, until the fetus is mature enough for delivery. Plasmapharesis to reduce antibody levels during pregnancy. IV IG with or without plasmapharesis . Immunosuppression by promethazine!!!

What to do if you have a sensitized mother with detectable antibodies ??

If titre is < 16, repeat at monthly intervals in 2nd trimester and biweekly in 3rd. If titre is > 32, repeat at 18-20 w if persistent or increasing, do amni ocentesis or umbilical blood sampling between 20-24 weeks. If however mother has severely affected previous children then aminocentesis is done earlier (18-20 wks).

What to do if you have a sensitized mother with detectable antibodies ??

Aminocentesis : is basically used to determine the degree of fetal affection indirectly by assessing the bilirubin level by measuring the change in OD at 450 nm, then using liley graph to determine severity.

Zone III

Liley Graph Severely affected : IUT/ Early delivery/ ET

Zone II

moderately affected : IUT/ Early delivery/ ET

Zone I

Not or mildly affected, repeat aminocentesis every 2-4 wks, to 34-36 wks

 In 50% the hemolytic disease is mild, with positive DAT. Most have no anemia (HB>14 g/dl) and minimal hemolysis (cord bilirubin < 4 mg/dl). They require early phototherapy, no transfusions. Indication for Phototherapy are generally based on Bilirubin level correlated with age, so that it is indicated for
- bilirubin >4 mg/dl at birth, and bili>10 if <12 hrs, and bili>14 if less than 24hrs.

Management of sensitized newborn

Management of sensitized newborn

In 25% the hemolytic disease is moderate, with positive DAT. Most have ,moderate anemia, and although they may not be clinically jaundiced at birth they rapidly become so in the first 24 hrs. They are at risk of encephalopathy without proper treatment. They require early exchange transfusions (O negative fresh) and intensive phototherapy, They require monitoring for delayed anemia with low retics at 6 wks of life.

Management of sensitized newborn

1. 2. 3. 4. Exchange Transfusion Aim : Remove bilirubin. Remove sensitized red cells. Remove incompatible antibodies. Replacement of incompatible red cells by compatible ones. 5. Suppression of fetal erythopoiesis.
Indications for exchange : Severe Anaemia < 10 g/dl; marked
hyperbilirubinaemia (related to weight, the less the weight, the less the cut-off bilirubin for ET, rapidly rising bilrubin despite adequate phototherapy)

Management of sensitized newborn

In 25% the hemolytic disease is severe, who are either stillborn or have hydrops fetalis at birth This consequence indicate the inadequacy of our maternal management scheme and maybe preventable.

ABO Hemolytic Disease of the Newborn

ABO HDN
ABO incompatibility between the mother and newborn infant can cause HDN. In 20% of all births, there is incompatibility between the mother and the fetus. Maternal anti-A and Anti-B (of IgG type) cross the placenta to attach and cause destruction of fetal RBC with corresponding Antigens.

ABO HDN
Hemolysis associated with ABO HDN is mainly limited to O mothers with A or B blood.

Why?

Hemolysis is ABO HDN is classically mild

Why?

ABO HDN
The history of previous transfusions or pregnancy is unrelated to severity or occurrence of ABO HDN. Why? ABO HDN may occur in first or subsequent pregnancies, but not necessarily all of them.

ABO HDN
What do you expect the clinical picture to be?
Most often the presentation is with jaundice within 12-48 hrs of birth with mild anemia. Hb maybe normal and increased bilirubin maybe mild (as seen in physiological Jaundice). Rarely there is severe HDN requiring exchange transfusion.

ABO HDN
What do you expect to find on blood picture?
Mild anemia. Spherocytes and microspherocytes. Polychromasia.

Direct Coombs Test :

Usually positive, but negative results does not exclude a diagnosis. The severity of the disease is independent of the strength of DCT. Direct Coombs maybe positive in absence of anemia.

Comparison between ABO & RH HDN

Characteristic
First pregnancy

ABO
Yes
Yes (Anti-A,B)

Rh
Rare
Yes (Anti-D,etc)

Antibody IgG
Bilirubin at birth
Anemia at birth

Phototherapy
ExchangeTransfusion

Normal No Yes Rare

none yes

elevated Yes Yes common

sometimes rare

IUT spherocytes

Making a Diagnosis of ABO HDN

When a newborn develops anemia in the first 12-48 hrs, then ABO HDN is among the DD. Direct Coombs test is the most important diagnostic test. In all cases of ABO HDN requiring transfusion therapy Direct Coombs was positive

Making a Diagnosis of ABO HDN

On useful policy is to collect cord blood samples by venipuncture from all delivered infants. If the infant will thereafter develop jaundice, then ABO, Rh and Direct Coombs should be done. It is estimated that 90% of ABO HDN

complicated by Jaundice will have a positive Coombs. If coombs is negative, other cause of jaundice
should be excluded. If all other possible cause excluded, then an eluate of the cord RBC will always reveal ABO antibodies in ABO HDN>

Other HDNs and Main DD

Anti-K Any Immune IgG Blood system antibody may theoratically be implicated. Other causes of Hemolysis in newborn are: Hereditary Spherocytosis. G6PD deficiency (esp. in Iraq)

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