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1.

Expain blood group and mechanism of incompability

 There are 2 systems in blood grouping
o ABO system
o Rhesus system
 Important to know blood group
o Since it is important during blood transfusion
o To prevent blood clumping @ agglutination when incompability blood mixed

ABO blood grouping system
o There are 4 type of blood types:
 A, B, O, AB
Rhesus system
o There are rhesus(+) and rhesus (-)

 Incompabilty
o Definition of compability: capable of being mixed without undergoing destructive chemical changes
 COOMBS’ Test used to identify whether the blood that need to use compable with the recipient blood.
o Direct test: used to detect antibody attached to red blood cell membrane
o Indiredt test: used to detect “free” serum antibodies against blood group antigen
 ABO incompability
o Occurs usually in infant that has blood type others than O with mother that blood type O



O blood
group
mother
pregnant
with baby
blood type
others than
O.
Blood of the
mother and
baby mixed
Mother's
body
produce
antibodies
as the baby
known as
foreign
substance
One of the
antibody:
IgG can
cross
placental
barrier and
enter baby
body
Baby body
immunizatio
n still weak,
IgG attack
baby blood
causing
hemolysis
occurs
baby
become
jaundice

2. Explain metabolism of bilirubin



3. Neonatal hyperbilirubinemia
 Hyperbilirubinemia
o is where excessive bilirubin in the blood that cause jaundice.
o Etiology:
 Production of high level of bilirubin in liver.
 Failure of Damaged liver
 Obstruction of excretory ducts in liver and kidney
 Neonatal Hyperbilirubinemia
 Physiology:
o is normal during 1
st
week of life where 60% in term infants and 80% in preterm infants
o Yellow color result from accumuation of unconjugated, nonpolar, lipid soluble bilirubin pigment in
skin where it is the end of product of heme-globin catabolism
o Risk factors:
 Blood group incompatibility
 Previous sibling receive phototherapy
 Cephalohematoma @ significant bruising
 Maternal age
 Diabetic mother

 Pathologic
o Occur when time of appearance, duration and pattern varies from physiologic jaundice
o Serum bilirubin rise at rate faster than 5mg/dL/24H
o Serum bilirubin is >12mg/dL in full term and 10-14mg/dL in preterm
 Risk factors:
o Premature
o Breastfeeding
o Weight loss
normal level of indirect bilirubin in
umbilical cord serum is 1-3 mg/dL
rise at a rate <4mg/dL/24H
jaundice become visible on 2nd ,
3rd day
Peak on the 2nd-4th day at 5-
6mg/dL
drop <2mg/dL on 5th-7th day
o Blood group incompatibility
 Sign and Symptoms:
o Skin become yellow
o Tends to be longer in breastfeeded baby
o Start from head & face then spread to whole body
 Management:
o Phototherapy
 Blue fluorescent lamp (420-480 nm) are used.
 Table 1. AAP recommendations for the management of hyperbilirubinemia in healthy term newborns
infants
Age
(hour)
Total serum bilirubin (mg/dL)
Consider
phototherapy
Phototherapy Exchange transfusion if
phototherapy fails
Exchange
transfusion
< 24
25-48
49-72
> 71

> 12
> 15
> 17

> 15
> 18
> 20

> 20
> 25
> 25

> 25
> 30
> 30
 Table 2. Recommendations for the management of hyperbilirubinemia in preterm infants (sick and well)
and sick term infants
Weight (gram) Total serum bilirubin level (mg/dL)
Well infant Sick infant
Phototherapy Exchange
transfusion
Phototherapy Exchange
transfusion
< 1500
1500-2000
2000-2500
> 2500
5-8
8-12
12-15
13-15
16-18
18-20
4-7
7-10
10-12
13-15
10-14
14-16
16-18
17-22

 The infant’s eye should be covered with opaque patches for overhead lamp phototherapy.
To maximize exposure, infants should be naked in servocontrolled incubators.
Phototherapy does increase insensible fluid losses. For infants weighing < 1500 g,
increase fluids by 0,5 mL/kg/hour; for those weighing > 1500 g, increase by 1
mL/kg/hour. Over hydration does not increase bilirubin elimination.
 Complication:
 The retinal effects of phototherapy on the exposed infant’s eyes are unknown.
However, animal studies suggest that retinal degeneration may occur. Thus, eye
shields must be used.
 Increased insensible fluid loss increases fluid requirements by 25%. In addition,
stools may become looser and more frequent. Use of fiber optic phototherapy
results in lower insensible loss.
 Bronze baby syndrome. With conjugated hyperbiirubinemia, phototherapy
causes photodestruction of copper porphyrins, causing urine and skin become
bronze.
 Congenital erythropoietic porphyria is a rare syndromes in which phototherapy
is contraindicated. Exposure to visible light of moderate to high intensity will
produce severe bullous lessions on exposed skin and may lead to death.
 Termination of phototherapy
 Phototherapy is stopped when the following criteria are met:
o the bilirubin level is low enough to eliminate the risk of kernicterus
o the infant is old enough to handle the bilirubin level
o EXCHANGE TRANFUSION
 Exchange transfusion is used when the risk of kernicterus for a particular infant is
significant. A double-volume exchange replaces 85% of the circulating red blood cells
and decreases the bilirubin level to about half of the preexchange value. Besides
removing bilirubin, an exchange transfusion can be used to correct severe anemia.
 Albumin transfusions may be useful if bilirubin levels are > 20 mg/dL and serum albumin
levels are < 3 mg/dL. Infusion of 1 g of albumin 1 hour before exchange transfusion may
improve the yield of bilirubin removal. Fluid volume and cardiovascular status must be
carefully considered before giving albumin.
 It is only used when PHOTOTHERAPY is FAIL.
 In hemolytic disease, immediate exchange transfusion is usually indicated if:
 the cord bilirubin level is over 4,5 mg/dL and the cord hemoglobin level is under
11 mg/dL
 the bilirubin level is rising over 1 mg/dL per hour despite phototherapy
 the hemoglobin level is between 11 and 13 mg/dL and the bilirubin level is
rising over 0,5 mg/dL per hour despite phototherapy
 the bilirubin level is 20 mg/dL, or it appears that it will reach 20 mg/dL at the
rate it is rising
 there is progression of anemia in the face of adequate control of bilirubin by
other methods
 The complication of exchange transfusion?
 hypocalcemia and hypomagnesemia
 hypoglycemia
 acid-base balance
 hyperkalemia
 cardiovascular
 bleeding
 infections
 hemolysis
 miscellaneous (hypothermia, hyperthermia, necrotizing enterocolitis
o Complication of hyperbilirubinemia(bilirubin encephalopathy)
 clinical presentation of acute bilirubin encephalopathy can be divided into three phases:
 hypotonia, lethargy, high-pitched cry and poor suck
 hypertonia of extensor muscles (with opistotonus, rigidity, oculogyric crisis, and
retrocollis), fever and seizures. Many infants die in this phase. All infants who
survive this phase develop chronic bliirubin encephalopathy
 hypotonia replaces hypertonia after about 1 week of age
o BHP- Informed consent on therapy given to the baby(phototherapy)
o Phop- Education on breast milk role in jaundice for baby
o CRP- 60% of aterm and 80% of preterm baby will having jaundice