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Hemolytic disea se of newbor n due to ABO incompa tibility

Hemolytic disease of newborn due to ABO incompatibility

Faris B. AL-Swaf* , Rekan S. Jumaa** , Isam S. Saeed***


*Dept. of pediatrics, Ninava College of Medicine, Mousl University .
**Department of pediatrics, College of Medicine, Tikrit University .
***Specialist pediatrician, Ninava health directorate

Abstract
Hemolytic disease of newborn due to ABO-incompatibility is the most common cause of
hemolytic diseases of newborns, its occur due to ABO blood group incompatibility between the
mother and infant. The aim of study is to identify the incidence and severity of jaundice in
patients with ABO incompatibility. Fifty four babies with ABO incompatibility admitted to Al-
Khansah maternity and children teaching hospital (in Mosul were studied between the first of
January and end of May 2005). Thirty five were males (68.8%), and 19 cases were females
(35.2%), their age was 1-10 days, the majority were fullterms 44 cases (81.5%) .and in most of
them the weight was> 2.5kg. Family history of jaundice or treatment was negative in (59.2%).
Twenty three cases presented during the second and third day of life and jaundice was the
hallmark of the disease found in 100% followed by poor feeding, pallor, opisthotonos and
hepatosplenomegaly. Serum bilirubin level more than 323 pmol/L (> 19 mg/dl) was in (40.8%)
hemoglobin level between 100-140 g/L was found in (53.7%) reticulocyte count between (5-9%)
was found in (63%) and direct Coomb’s test was positive in (5.5%) of the patients. Thirty two
patients (59.2%’) treated with phototherapy and in most of them 18 patients (56.2%) the duration
of phototherapy was 24-48 hr, while 22 cases (40.8%) were treated by exchange transfusion and in
most of them 16 cases the exchange transfusion was done once. Total serum bilirubin was lowered
by 25-50% immediately after the exchange transfusion in 13 cases (59%). The prognosis was good
for the most of the patients 46 cases (85.3%) and they were discharged well from the hospital.

Introduction In mother with type A and B


Hemolytic disease of newborn blood, naturally occurring antibodies are
due to ABO-incompatibility (HDNABO) of 1gM class, which do not cross the
is the most common cause of hemolytic placenta, where as in type O mother the
diseases of the newborns(1). Hemolytic antibodies are predominantly IgG in
Disease of Newborn (HDN) also called nature (cross the placenta)(1). Because A
Icterus gravis Neonatorum which was and B antigens are widely expressed in a
first described by Morgagni in 1761 but variety of tissues besides RBCs, only
only in the last 35 years has it’s origin in small portion of antibodies crossing the
the blood group incompatibilities placenta is available to bind to fetal
between fetus and mother been known (2). RBCs, in addition, fetal RBCs appear to
A French midwife was the first to report have less surface expression of A or B
hemolytic disease of the newborn in a set antigen, resulting in few reactive sites-
of twins in 1609(3).HDN-ABO is a form hence the low incidence of significant
of Isoimmune hemolytic disease of the hemolysis in affected neonates(5).
newborn due to ABO blood group The infants of type A blood group
incompatibility between the mother and are generally type Al which is more
infant. The anti-A or anti-B antibodies of antigenic than A2. Low antigenicity of
a mother of blood group O, B or A may the ABO factors in the fetus and newborn
cross the placenta and sensitize the RBCs infant may account for the low incidence
of an A, B, or AB infant(4). of severe ABO hemolytic disease relative

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Hemolytic disea se of newbor n due to ABO incompa tibility

to the incidence of incompatibility an ectopic pregnancy, amniocentesis, or


between the blood group of the mother even a normal pregnancy. The risk of
and child. Although antibodies against A feto-maternal transfusion is increased by
and B factors occur without previous manual extraction of the placenta and by
immunization (natural antibodies), they version (external or internal) procedures
(9)
are ordinarily present in the 1gM fraction . The aim of study is to identify the
of gamma globulin, which does not cross incidence and severity of jaundice in
the placenta. patients with ABO incompatibility.
However, univalent, incomplete
(albumin active) antibodies to A antigen Patients and Methods
may be present in the IgG fraction, which Fifty four babies with
does cross the placenta, so O-A hyperbilirubinemia and blood groups
isoimmune hemolytic disease may be A,B and AB Rh +ve whom there mothers
found in first born infants. were blood group O (45 are Rh +ve and 9
Mothers who become immunized against Rh -ve) admitted to the Al -Khansah
A or B factors from a previous Maternity and Children Teaching
incompatible pregnancy also exhibit IgG hospital in Mosul were studied between
antibody. These immune antibodies are the first of January and the end of May
the primary mediators in ABO 2005).
isoimmune disease(1) . Clinical information were taken
HDN-ABO may affect a first including age, sex, gestational age, birth
pregnancy as frequently as a subsequent weight, previous family history of
one and it’s not possible to predict ABO neonatal jaundice, the onset of the
hemolytic disease antenatally, even if the jaundice, Feeding of the baby, activity of
blood group set-up is correct. HDN-ABO the baby, fever and any other symptoms .
protects against Rh immunization as Complete and full examination
naturally occurring anti A and anti B was done to all the babies looking for the
antibodies in the A,B or AB mother presence of pallor, jaundice,
destroy incompatible fetal red cells hepatosplenomegaly and any
immediately on entering to the maternal neurological signs like opisthotonos.
circulation(6) . Blood sample was taken for all the babies
For reasons that are unclear B-O and send for blood group and Rh,
incompatibility (mother type O, Baby complete blood picture including
type B) seems to be in general more reticulocyte count, total serum bilirubin
severe than A-O incompatibility(7). and direct Coomb’s test.
HDN-ABO can occur if: Blood sample was taken from
their mothers and send for identification
• The mother is O and the fetus is B or A of blood group and Rh factor, and
or AB (most common). indirect Coomb’s test. All the babies
were treated by phototherapy and/or
• The mother is A and the fetus is B or exchange transfusion and most of them
AB (uncommon). did well and discharged in good
condition.
• The mother is B and the fetus is A or
AB (uncommon)(8).Sensitization of the
Results
mother to fetal antigens may have
A total 54 patients admitted to
occurred by previous transfusion, or by
hospital and included in present study.
conditions of pregnancy that results in
Table (1) Shows the age of onset of
transfer of fetal erythrocytes into the
jaundice in patient with ABO-
maternal, such as first trimester abortion,
incompatibility, the most common age

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Hemolytic disea se of newbor n due to ABO incompa tibility

presented with jaundice 1-3 days 23 Discussion


cases (42.5%) followed by 1st 24 hours, Twenty three babies presented
19 cases ,and then >3days 12 cases. with jaundice during the second and
Table (2) Shows the sex distribution of third day of life, whereas, (35.2 %) of
patient, 35, were males while 19, were them presented in the first day of life and
females. 12 cases (22.3%) presented after the
Gestational age of our patients 44 third day of life, similar finding was
babies were >38weeks while 10 were reported previously (1,2,4,6,10)

<38weeks. The weight of patient Thirty five were males (64.8%) and
39cases were more than 2.5kg, while 15 nineteen were females (3 5.1%) , male
cases less than 2.5kg. Table(3) shows infants have consistently higher level of
family history of jaundice and treatment, bilirubin than females(11,12). Forty four
number of patients with jaundice not patients (81.5%) were fullterms and 10
required treatment were 10(18.5%), patients (18.5%) were premature, this is
jaundice with phototherapy in contrast to the fact that the jaundice is
8cases,jaundice with phototherapy, and observed in approximately 60% of term
exchange transfusion 4cases, and without infants and 80% of preterm infants was
previous history were 32 cases. reported previously(1). In 15 patients
Table (4) shows clinical features (27.8%), the body weight was less than
at admission to hospital, all patients had 2.5 kg while in 39 (72.2%) patient, while
jaundice, patients with jaundice and poor (62.9%) was > 2.5. This stands against
feeding were 9 cases. Twenty five the fact that small for gestational age
patients treated by phototherapy while 20 babies developed polycythemia (due to
cases treated by exchange transfusion as fetal hypoxia) which lead to
shown in table (5). Patients treated by hyperbilirubinemia and this was reported
phototherapy were 32 ,most of them 18 by Robert M. Kliegman(9).
patients the duration of phototherapy Most of the patients 32 cases had
was 24-48hr as shown in table (6). Six no previous history of jaundice and/or
babies required more than one exchange phototherapy and/or exchange
transfusion, two of them had Rh-ve transfusion and this result is proved by
mother, one of them underwent the fact that ABO-incompatibility is
exchange transfusion twice and the other presented in approximately 12% of
underwent three times as showen in table pregnancies, with evidence of fetal
(7). sensitization in 3% of live births and
Table (8) shows the outcome fewer than 1% of births are associated
three patients died ;one had Rh- with significant hemolysis and ,this was
incompatibility in addition to ABO- reported by Mentzer WC, Glader
incompatibility, the others two had BE,1998(10).
proved neonatal sepsis, 46 patients All the patients (54) cases had the
discharged well.Table (9) shows the jaundice as the hallmark of the disease
main investigations done to the patients and some patients (7) cases(12.9%)
with ABO-incompatibility in present developed pallor with jaundice and two
study includes, Total serum bilirubin patients developed neurological signs
>19mg/dl in 22 cases (40.8%), like poor feeding (9)cases(16.7%) and
Hemoglobin level ranged from 100- opisthotonos 3 cases, Barbara J. Stoll and
140g/l in 29 cases, regarding Robert M. Kliegman said that ABO-
Reticulocyte percentage the majority of incompatibility is the most common
patients (34 cases) between 5-9.Direct cause of hemolytic disease of
coombs test negative in 51 cases. newborns(1).The blood group of (59.2%)
was A +ve and it was B +ve in (34.5%)of

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Hemolytic disea se of newbor n due to ABO incompa tibility

the babies and this is consistent with the These results indicate that
studies of john a. Ozolek, Jon F. phototherapy is an important and
Watchko and Francis Mimouni in effective measure in the treatment of
1993(10), and supported by the fact found hyperbilirubinemia and also the exchange
by Dean Edell(10). transfusion was effective for reducing the
The hemoglobin level was 100- neonatal jaundice and these results are
140g/l in 53.7% of the patients at supported by the fact that the need for
admission, while the reticulocyte count exchange transfusion decreases due to
was (5-9%)in 63% of the patients and, so phototherapy, but when there is an
this means that ABO-compatibility is a indication for exchange transfusion,
mild disease and this is supported by the phototherapy should not be used as a
fact that hemolysis develops in only 10% substitute, however, phototherapy may
of ABO-compatibility and this was found reduce the need for repeated exchange
by Barbara J. Stoll and Robert M. transfusion in infants with hemolysis and
Kliegman(1). Total serum bilirubin was this was reported by previous
more than (19 mg/dl) in 40.8% of the study(1) and this results was also found
patients. So that ABO-incompatibility is by Maurer H.M. et. al in his study on
an important cause of efficacy of phototherapy as a substitute
hyperbilirubinemia, this is consistent for exchange transfusion particularly in
with the study done by Tariq Al-Shujairi severe hemolysis.
in 2001(14). Barbara J. Stoll and Robert They were nine babies with Rh-
M. Kliegman(1) concluded that Jaundice ve mothers, seven babies has been treated
is the only clinical manifestation of with phototherapy alone and just two
ABO-incompatibility. required exchange transfusion and this
Direct combs test was positive in means that ABO-incompatibility is
three patients only and this test is a protective against Rhesus hemolytic
qualitative one so, a positive results does disease of newborn and this is supported
not suggest the amount of antibody or the by the fact that ABO incompatibility
degree of hemolysis, Maisels MJ(13), but between the mother and fetus protects
Barbara J. Stoll and Robert M. against Rh immunization as naturally
Kliegman(1) said that direct Coomb’s test occurring anti A and anti B antibodies in
is weakly to moderately positive in ABO A, B or AB mother destroy incompatible
incompatibility. Indirect Coomb’ s test fetal red cells immediately on entering to
was negative in all the mothers of the the maternal circulation, and this fact was
patients and this means that this test is a found by Mclntosh N.(6).
weak marker for hemolysis, this was Also Bowman J. M. in 1986
proved by Swinhoe D,J. et. al. In found that ABO-incompatibility should
1990(15). not be taken into account when making a
Thirty two patients (59.2%) decision for management of Rhesus
treated with phototherapy and in most of hemolytic disease for newborn and ABO
them ,18 patients(56.2%) the duration of incompatibility does not ameliorate the
phototherapy was 24-48 hr, while 22 severity of erythroblastosis fetalis after
cases (40.8%) were treated by exchange Rhesus immunization has developed(16).
transfusion and in most of them 16 cases We recommend to educate people
(72.2%) the exchange transfusion was through mass media about jaundice in
done just once and the total serum newborn baby in order to seek early
bilirubin was lowered by 25-50% medical advice so that diagnosis and
immediately after the exchange prompt treatment can be instituted to
transfusion in 13 cases out of 22. prevent dangerous sequelae .

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Hemolytic disea se of newbor n due to ABO incompa tibility

References 9. Robert M. Kliegman. Fetal and


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Neonatal
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Infant. In: Behrman RE, Kliegman
Erythrocyte disorders in infancy. In:
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Taeusch HW, Ballard RA, eds.
Textbook of Pediatrics. 17th ed.
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2. Vulliamy D.G. Haemorrhage and
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lack of clinical significance of blood
stone 1977; 156-157
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12. Shelley C. Springer, MD, MBA,
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of pediatrics. And south Carolina
professor, Department of
Medical Association. . Kernicterus
pediatrics, Division of Neonatology.
last updated. Feb. 14, 2003.
University of Mississippi
13. Maisels MJ. Jaundice In: Avery,
Medical center, Prashant G
Fletcher, eds. Neonatology,
Deshpande, MD. Consulting staff,
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Last updated. March, 14, 2003.
of management of indirect - reacting
6. Mclntosh N. The newborn. In: Forfar
neonatal hyperbilirubinemia Iraq,
and Arneil’s Textbook of pediatrics.
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livingstone, London; 1998; 232- 233.
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6.

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Hemolytic disea se of newbor n due to ABO incompa tibility

Table (1): The age of onset of jaundice in patient with ABO-incompatibility .

Age Case %
1st 24 hr 19 35.2
1-3 days 23 42.5
>3 days 12 22.3
Total 54 100%

Table (2): Sex, Gestational age, Birth weight distribution of patients with ABO-
incompatibility ..

No. %

Male 35 64.8%

Female 19 35.2%

>38 wk* 44 81.5%

<38 wks* 10 18.5%

<2.5** 15 27.8%

>2.5** 39 72.2%

* Gestational age ** Birth weight

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Hemolytic disea se of newbor n due to ABO incompa tibility

Table(3): Family history of jaundice and its treatment.

Family history of jaundice No. %


Jaundice not required treatment 10 18.5
Jaundice +Phototherapy 8 14.8
Jaundice + Phototherapy + Exchange
4 7.4
transfusion
non 32 59.3 -
Total 54 100

Table(4): General condition of neonate at admission time

Clinical Features No. =54 %


Jaundice 54 100
Jaundice + poor feeding 9 16.7
Jaundice + pallor 7 12.9
Jaundice + Opisthotonos 3 5.5
Jaundice + Hepato-
2 3.7
splenomegaly

Table(5): Treatment methods to the patient with ABO-incompatibility

Phototherapy Exchange transfusion

No. (%) No. (%)

Rh +ve mother 25 20
(46.2) (37)
Rh –ve mother 7 2
(12.9) (3.7)
Total No. 32 22
(59.2) (40.8)

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Hemolytic disea se of newbor n due to ABO incompa tibility

Table(6): Duration of phototherapy in hours.


Hour No (%)
24-48 18 56.2
49-72 11 34.3
>72 3 9.5
Total 32 100

Table(7): Frequency of exchange transfusions.


frequency No. %
once 16 72.7
Twice 5 22.7
Trice 1 4.6
Total 22 100%

Table(8): Outcome (condition on discharge).

No. %
Well 46 85.3
Kernicturous 5 9.2
Death 3 5.5
Total 54 100

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Hemolytic disea se of newbor n due to ABO incompa tibility

Table(9): Investigations to the patients with ABO-incompatibility

No. %

<170(<10mg)* 16 29.6%
170-323 (10-19)* 16 29.6%
>323 (>19)* 22 40.8%
<100** 2 3.7%
100-140** 29 53.7%
141-200** 23 42.6%
5-9*** 34 63.2%
10-14*** 17 31.5%
>14*** 3 5.5%
Positive**** 3 5.5
Negative**** 51 94.5

* TSB levels in µmol/L (mg/dl)

** Hb.(g/L)

*** Reticulocyte%

**** Direct coombs test

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