Asynchronous SGD

Dr. Becina

PRIME 2
November 29 , 2022

Submitted by:

PRIME 2 JUNIOR INTERNS

 Fule, Sofia Gabrielle B.

Animas, Archie J.
Gabriel, Mark Joseph D.
Aquino, Janjer Bon M. *

Gaceta, Chelsea Denise T. *

Aquino, Trisha Mae V.

Arzaga, John Joel C. Gaite, Summer Marionne *

Ascano, John Christian Gamilde, Lourdes Gayle R.

Garcia, Jan Rossana S.

Aslam, Areej D. *

Garcia, Marc Wilhelm M.

Asprer, Calman Jan M.

Garong, Maria Ana Therese D.

Atienza, Marielle M.

Gille, Genree Ann B.

Bartolome, Nimrod Ramil II C. *
Gonzales, Jan Chloe C.

Fortes, Hannah Selina V.

Francisco, Jenica Vianca Loren

G.

Francisco, Krizza Mae A.

*F2F Duty
X= DONE
JI Animas, Archie J
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

SALIENT FEATURES
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

DIFFERENTIAL DIAGNOSES

SEPSIS INDUCED CHOLESTASIS

RULE IN RULE OUT

14 days old (-) fever

(+) generalized jaundice for (-) cough, cold
15 days (-) diarrhea, vomiting
(+) yellowish palpebral (-) Distress
conjunctivae, yellowish sclera (-)pallor,
(+) CBC: thrombocytosis (-) neurologic symptoms
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
(+) Maternal History of UTI

VITAMIN K DEFICIENCY BLEEDING

RULE IN RULE OUT

(-) Vitamin K prophylaxis at -More common in preterm infants

 birth -No maternal intake of anticonvulsant and
(+) Bruise at the left ankle anti-TB medications
Breast-fed
Jaundice

ABO HEMOLYTIC DISEASE

RULE IN RULE OUT

14 days old, Filipino Cannot completely rule out need ABO

(+) jaundice within 24 hours compatibility test
from birth
(+)generalized jaundice for 15
days
(+) yellowish palpebral
conjunctivae, yellowish sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

MAIN DIAGNOSIS:

To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out

sepsis

CASE DISCUSSION

● Jaundice- accumulation of bilirubin in the skin, sclera and mucosa and is the most
common transitional finding in the newborn period.
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile on
Bhutani chart

PHYSIOLOGIC VS. PATHOLOGIC JAUNDICE

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - Present within 24th-36th

ONSET
3rd day of life hour of life
 INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2
BILIRUBIN mg/dL/hr or >5mg/day

PEAK TOTAL 12 mg/dL >12 mg/dL (full term)

BILIRUBIN 10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

CASE MANAGEMENT

● Plan
○ Admit the patient
○ Secure consent for admission and management
● Diet
○ Encourage breastfeeding
● Diagnostics
○ CBC with Platelet Count
○ Peripheral Blood Smear
○ Bilirubin levels
○ Blood culture and sensitivity prior to antibiotics
○ Direct Coombs Test
● Disposition
○ Phototherapy
○ Weigh patient daily then record
○ Monitor vital signs and record
○ Monitor intake and output every shift and record
○ Refer accordingly
JI Aquino, Trisha Mae V.
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

I. SALIENT FEATURES
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

II. DIFFERENTIAL DIAGNOSES

RULE IN RULE OUT

SEPSIS INDUCED 14 days old (-) fever

CHOLESTASIS (+) generalized jaundice for (-) cough, cold
15 days (-) diarrhea, vomiting
(+) yellowish palpebral (-) Distress
conjunctivae, yellowish sclera (-)pallor,
(+) CBC: thrombocytosis (-) neurologic symptoms
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
(+) Maternal History of UTI

VITAMIN K (-) Vitamin K prophylaxis at -More common in

DEFICIENCY birth preterm infants
BLEEDING (+) Bruise at the left ankle -No maternal intake of
Breast-fed anticonvulsant and
Jaundice anti-TB medications
 ABO HEMOLYTIC 14 days old, Filipino Cannot completely rule
DISEASE (+) jaundice within 24 hours out need ABO
from birth compatibility test
(+)generalized jaundice for 15
days
(+) yellowish palpebral
conjunctivae, yellowish sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

III. MAIN DIAGNOSIS:

To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out

sepsis

IV. CASE DISCUSSION

● Jaundice- accumulation of bilirubin in the skin, sclera and mucosa and is the most
common transitional finding in the newborn period.
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile on
Bhutani chart

PHYSIOLOGIC VS. PATHOLOGIC JAUNDICE

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - Present within 24th-36th

ONSET
3rd day of life hour of life

INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2

BILIRUBIN mg/dL/hr or >5mg/day

PEAK TOTAL 12 mg/dL >12 mg/dL (full term)

BILIRUBIN 10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

 ETIOLOGY

● Unconjugated Hyperbilirubinemia / Indirect Hyperbilirubinemia

- Increased Bilirubin Production
- Immune-mediated hemolysis - induces blood group incompatibilities such
as ABO and Rhesus incompatibility
- Decreased Bilirubin Clearance
- Miscellaneous Causes
● Conjugated Hyperbilirubinemia / Direct Hyperbilirubinemia
- Obstruction of biliary flow
- Infections
- Genetic causes
- Miscellaneous

ABO INCOMPATIBILITY

● Most common cause of hemolytic disease in the newborn, Mother is type O and
baby is either type A or B
● Clinical Manifestation:
○ Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
○ No pallor and hepatosplenomegaly
○ Kernicterus and Hydrops fetalis is rare

DIAGNOSIS
● Blood Typing - ABO incompatibility
● Direct Antigen Test - (+) DAT
● Bilirubin levels - Hyperbilirubinemia
● CBC with Platelet Count - mild anemia, reticulocytosis
● Peripheral Blood Smear - Polychromasia, nRBCs, Spherocytes

TREATMENT
● Phototherapy - mainstay treatment
○ 20 cm distance between infant and light source
○ Converts bilirubin into byproducts that are less toxic and more easily
excreted (photoisomerization)
● Intravenous Immunoglobulin
○ Recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and RH hemolytic disease
● Transfusion
○ Simple Transfusion
- Moderate to severe anemia without severe hyperbilirubinemia
- 10-20 ml/kg over 2-4 hours
 ○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
- Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
decline despite 4-6 hrs of intensive phototherapy
- Rate of increase in TB indicates that level will reach 25 mg/dL
within 48 hrs
- Early signs of bilirubin encephalopathy
- There is hemolysis causing anemia and hydrops fetalis
● Post-discharge monitoring of hematocrit
V. CASE MANAGEMENT
● Plan
○ Admit the patient
○ Secure consent for admission and management
● Diet
○ Encourage breastfeeding
● Diagnostics
○ CBC with Platelet Count
○ Peripheral Blood Smear
○ Bilirubin levels
○ Blood culture and sensitivity prior to antibiotics
○ Direct Coombs Test
● Drugs
○ Ampicillin
○ Gentamicin
● Disposition
○ Phototherapy
○ Weigh patient daily then record
○ Monitor vital signs and record
○ Monitor intake and output every shift and record
○ Refer accordingly
JI Arzaga, John Joel C.
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

Salient features
14 day old, female
CC: Yellowish discoloration of skin for 15 days
Maternal history
G4P4 (4004); failure of descent
History of UTI (6 months of pregnancy)
Delivered full term, via elective low segment cesarean section
CBC: thrombocytosis
Blood type: B+
Hyperbilirubinemia
Physical examination
Yellowish palpebral conjunctiva
Yellowish sclera
Generalized jaundice
Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnoses

Rule in Rule out

Sepsis Induced 14 days old (-) fever

Cholestasis (+) generalized jaundice (-) cough, cold
for 15 days (-) diarrhea, vomiting
(+)yellowish palpebral (-) Distress
conjunctivae, yellowish (-)pallor,
sclera (-) neurologic symptoms
(+)CBC: thrombocytosis To complete rule out base
(+) Elevated levels of total on laboratory findings
bilirubin, direct bilirubinand
indirect bilirubin
(+) Maternal History of UTI
Vit K Deficiency bleeding No Vitamin K prophylaxis
at birth
Bruise at the left ankle
Breast-fed
Jaundice
More common in preterm
infants
No maternal intake of
anticonvulsant and anti-TB
medications
Coagulation studies

ABO Hemolytic Disease
14 days old, Filipino Cannot completely rule out
(+) jaundice within 24 need ABO compatibility
hours from birth test
(+)generalized jaundice for
15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

Initial Diagnosis
To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out sepsis

Management
Plan
Admit the patient

Secure consent for admission and management

Diet
Encourage breastfeeding

Diagnostics
CBC with Platelet Count
Peripheral Blood Smear
Bilirubin levels
Blood culture and sensitivity prior to antibiotics
Direct Coombs Test
 Disposition
Phototherapy
Weigh patient daily then record
Monitor vital signs and record
Monitor intake and output every shift and record
Refer accordingly

Jaundice and Hyperbilirubinemia

Jaundice: accumulation of bilirubin in the skin, sclera, mucosa
Most common transitional finding in the newborn period
>5 mg/dL: level at which it becomes clinically apparent
Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile on
Bhutani chart

Physiologic vs Pathologic Jaundice

FORM PHYSIOLOGIC PATHOLOGIC

ONSET Visible on the 2nd - 3rd Present within 24th-36th hour
day of life of life
INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr or
BILIRUBIN >5mg/day
PEAK TOTAL 12 mg/dL >12 mg/dL (full term)
BILIRUBIN 10-14 mg/dL (preterm)
DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

Etiology
Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
Increased Bilirubin Production
Immune-mediated hemolysis - Includes blood group incompatibilities such
as ABO and Rhesus incompatibility
Decreased Bilirubin Clearance
Miscellaneous Causes

Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia

Obstruction of biliary flow
 Infections
Genetic causes
Miscellaneous

ABO Incompatibility
The most common cause of hemolytic disease in the newborn
Mother is type O, baby is either type A or B
Clinical Manifestation:
Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
No pallor and hepatosplenomegaly
Kernicterus and hydrops fetalis are rare

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description ● Most common cause of
hemolytic disease of the
newborn
● Mother is type O and baby
is either A or B
Presentation ● Most cases are mild
Jaundice usually during the first
24 hours of life
MIld hepatosplenomegaly
● Occurs when Rh(+)
blood is infused to a
Rh(-) woman
● Rarely occurs in first
pregnancy
● Mild hemolysis to
severe anemia
● Jaundice is usually
evident on the 1st day
of life
JI Ascaño, John Christian V.
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

I. SALIENT FEATURES
➔ 14 day old, Female
➔ Yellowish discoloration of skin for 15 days
➔ Maternal History - G4P4 (4004); failure of descent, History of UTI (6
months of pregnancy)
➔ Delivered full term, via elective low segment cesarean section
➔ CBC - revealed thrombocytosis
➔ Blood type - B+
➔ Hyperbilirubinemia
➔ Physical examination:
◆ Yellowish palpebral conjunctiva
◆ Yellowish sclera
◆ Generalized jaundice
◆ Flat, 3x3 cm bluish gray discoloration on the left ankle
II. DIFFERENTIAL DIAGNOSIS

RULE IN RULE OUT

Sepsis induced ● 14 days old ● (-) fever, cough,

Cholestasis ● Generalized colds
jaundice for 15 ● (-) diarrhea,
days vomiting
● Yellowish ● (-) distress
palpebral ● (-) pallor
conjunctiva, ● (-) neurologic
yellowish sclera symptoms
● Thrombocytosis
● Elevated levels of
total bilirubin,
direct bilirubin,
and indirect
bilirubin
● Maternal history
of UTI
 Vitamin K Deficiency ● No Vitamin K ● More common in
Bleeding prophylaxis at preterm infants
birth ● No maternal
● Bruise at the left intake of
ankle anticonvulsant
● Breastfed and anti-TB
● Jaundice medications

ABO Hemolytic ● 14 days old ● Cannot

Disease ● Filipino completely rule
● Jaundice within out; needs ABO
24 hours from compatibility test.
birth
● Generalized
jaundice for 15
days
● Yellowish
palpebral
conjunctiva,
yellow sclera
● Elevated levels of
total bilirubin,
direct bilirubin,
and indirect
bilirubin
● Unknown blood
type of parents

III. MAIN DIAGNOSIS

➔ T/C Hyperbilirubinemia secondary to ABO incompatibility; Rule out Sepsis
IV. CASE DISCUSSION
Jaundice with Hyperbilirubinemia
● Jaundice: accumulation of bilirubin in the skin, sclera, mucosa. Most
common transitional finding in the newborn period
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th
percentile on Bhutani chart
 FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - 3rd day of Present within 24th-36th hour

ONSET
life of life

INCREASE <5 mg./dL/day Increases by >0.2 mg/dL/hr or

IN TOTAL >5mg/day
BILIRUBIN

PEAK 12 mg/dL >12 mg/dL (full term)

TOTAL 10-14 mg/dL (preterm)
BILIRUBIN

DIRECT <2 mg/dL >2 mg/dL

BILIRUBIN

DURATION < 10-14 days >10-14 days after birth

Etiology
➔ Unconjugated Hyperbilirubinemia/Indirect Hyperbilirubinemia
◆ Increased bilirubin production - immune mediated hemolysis -
includes blood group incompatibilities such as ABO and Rhesus
incompatibility
◆ Decreased Bilirubin Clearance
◆ Miscellaneous Causes
➔ Conjugated Hyperbilirubinemia/Direct Hyperbilirubinemia
◆ Obstruction of biliary flow
◆ Infections
◆ Genetic causes
◆ Miscellaneous
ABO Incompatibility
➔ Most common cause of hemolytic disease in the newborn, Mother is type
O and baby is either type A or B
➔ Clinical Manifestation:
◆ Mild, jaundice occurs during the first 24 hours of life and is the only
clinical manifestation
◆ No pallor and hepatosplenomegaly
◆ Kernicterus and Hydrops fetalis is rare
Diagnosis
➔ Blood Typing - ABO incompatibility
➔ Direct Antigen Test - (+) DAT
➔ Bilirubin levels - Hyperbilirubinemia
 ➔ CBC with Platelet Count - mild anemia, reticulocytosis
➔ Peripheral Blood Smear - Polychromasia, nRBCs, Spherocytes
Treatment
➔ Phototherapy - mainstay treatment
◆ 20 cm distance between infant and light source
◆ Converts bilirubin into byproducts that are less toxic and more
easily excreted (photoisomerization)
➔ Intravenous Immunoglobulin
◆ Recommended when serum bilirubin is approaching exchange
levels despite maximal interventions including phototherapy.
◆ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr)
reduces the need for exchange transfusion in both ABO and RH
hemolytic disease

V. CASE MANAGEMENT
Plan
➔ Admit the patient
➔ Secure consent for admission and management
Diet
➔ Encourage breastfeeding
Diagnostics
➔ Complete Blood Count with Platelet Count
➔ Peripheral Blood Smear
➔ Bilirubin levels
➔ Blood culture and sensitivity prior to antibiotics
➔ Direct Coombs Test
Disposition
➔ Phototherapy
➔ Weigh patient daily then record
➔ Monitor vital sign and record
➔ Monitor intake and output every shift and record
➔ Refer accordingly
JI Asprer, Calman Jan M.
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022
Salient Features:
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnosis
● Sepsis Induced Cholestasis - This was ruled in since the patient presented with
Jaundice beyond the 1st 24 hr of life as presented by the yellowish palpebral
conjunctivae and yellowish sclera. Laboratory results also showed
thrombocytosis on complete blood count, Elevated levels of total bilirubin, direct
bilirubin and indirect bilirubin and a maternal history of urinary tract infection
which can all lead to developing sepsis. However, this could be ruled out since
there were no noted symptoms such as fever, cough, cold, diarrhea, vomiting,
cardio respiratory distress, pallor, presence of neurologic symptoms which are
common presentation of sepsis but to completely rule out base on laboratory
findings

● Vitamin K Deficiency Bleeding - This was ruled in since in the history, the
patient did not receive Vit K prophylaxis at birth, there was also a bruise noted on
the left ankle upon PE. In addition, it is common in breast-fed patients and may
manifest as jaundice. However, it was ruled out since it is more common in
preterm infants and in those with maternal history of intake of anticonvulsants
 and anti-TB drugs. In addition, coagulation studies is needed to rule this out
which (usually reveals prolonged PT, PTT and decreased Vit-K dependent
coagulation factors)

● ABO Hemolytic disease - Hemolytic disease of the fetus and newborn (HDFN)
is an immune-mediated red blood cell (RBC) disorder in which maternal
antibodies attack fetal or newborn RBCs. This was ruled in since the patient
presented with jaundice beyond the 1st 24 hr of life as presented by the yellowish
palpebral conjunctivae and yellowish sclera. Laboratory results also showed
thrombocytosis on complete blood count, Elevated levels of total bilirubin, direct
bilirubin and indirect bilirubin and unknown blood type of the parent. To rule this
out we need to perform ABO compatibility test.

Main Diagnosis: To consider Hyperbilirubinemia secondary to ABO

incompatibility; Rule out sepsis

Initial Management
Plan
● Admit the patient
● Secure consent for admission and management
Diet
● Encourage breastfeeding
Diagnostics
● CBC with Platelet Count
● Peripheral Blood Smear
● Bilirubin levels
● Blood culture and sensitivity prior to antibiotics
● Direct Coombs Test
Drugs
● Ampicillin
● Gentamicin
Disposition
● Phototherapy
● Weigh patient daily then record
● Monitor vital signs and record
● Monitor intake and output every shift and record
● Refer accordingly
Discussion:
Jaundice is defined as the accumulation of bilirubin in the skin, sclera and mucosa and
is the most common transitional finding in the newborn period.
Jaundice during the 1st 24 hr of life warrants diagnostic evaluation and should be
considered pathologic until proved otherwise. It becomes clinically apparent at a level
>5 mg/dL.

Physiologic VS. Pathologic Jaundice

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - 3rd day Present within 24th-36th hour of life
ONSET
of life

INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr or

BILIRUBIN >5mg/day

PEAK TOTAL 12 mg/dL >12 mg/dL (full term)

BILIRUBIN 10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

Etiology
Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
● Increased Bilirubin Production
○ Immune-mediated hemolysis - Includes blood group incompatibilities such
as ABO and Rhesus incompatibility
● Decreased Bilirubin Clearance
● Miscellaneous Causes

Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia

● Obstruction of biliary flow
● Infections
● Genetic causes
● Miscellaneous
ABO Incompatibility
● Most common cause of hemolytic disease in the newborn
● Mother is type O, baby is either type A or B
● Clinical Manifestation:
○ Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
○ No pallor and hepatosplenomegaly
○ Kernicterus and hydrops fetalis is rare

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description ● Most common cause of hemolytic ● Occurs when Rh(+) blood is

disease of the newborn
● Mother is type O and baby is
either A or B
Presentation ● Most cases are mild
● Jaundice usually during the first
24 hours of life
● MIld hepatosplenomegaly
infused to a Rh(-) woman
● Rarely occurs in first pregnancy
● Mild hemolysis to severe anemia
● Jaundice is usually evident on the
1st day of life

Diagnosis
● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

Management
● Phototherapy
 ○ 20 cm distance between infant and light source
● Complications of Phototherapy:
○ Loose stools
○ Erythematous macular/ purpuric rash
○ Overheating
○ Dehydration
○ Hypothermia from exposure
○ Bronze baby syndrome
○ Corneal damage
● Intravenous Immunoglobulin
○ Recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
● Transfusion
○ Simple Transfusion
■ Moderate to severe anemia without severe hyperbilirubinemia
■ 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
○ Evidence of on-going hemolysis and Total Bilirubin (TB) fails to decline
despite 4-6 hrs of intensive phototherapy
○ Rate of increase in TB indicates that level will reach 25 mg/dL within 48
hrs
○ Early signs of bilirubin encephalopathy
○ There is hemolysis causing anemia and hydrops fetalis
● Post-discharge monitoring of hematocrit
JI Atienza, Marielle M.
Prime 2 (Written Output under Dr Becina)
Small Group Discussion
November 29, 2022

Salient Features
14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnosis:

Rule In Rule Out

Sepsis induced 14 days old (-) fever

Cholestasis (+) generalized jaundice
for 15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) CBC: thrombocytosis
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
(+) Maternal History of UTI
(-) cough, cold
(-) diarrhea, vomiting
(-) Distress
(-) pallor,
(-) neurologic symptoms
To complete rule out base
on laboratory findings

Vitamin K Deficiency No Vitamin K prophylaxis More common in preterm

 Bleeding at birth infants
Bruise at the left ankle No maternal intake of
Breast-fed anticonvulsant and anti-TB
Jaundice medications

Coagulation studies**

ABO Hemolytic Disease
14 days old, Filipino Cannot completely rule out
(+) jaundice within 24 need ABO compatibility
hours from birth test
(+)generalized jaundice for
15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

Initial Diagnosis:
➔ To consider Hyperbilirubinemia secondary to ABO incompatibility; rule out sepsis

Initial Management:
Plan
- Admit the patient
- Secure consent for admission and management
Diet
- Encourage breastfeeding
Diagnostics
- CBC with Platelet Count
- Peripheral Blood Smear
- Bilirubin levels
- Blood culture and sensitivity prior to antibiotics
- Direct Coombs Test
 Disposition

- Phototherapy
- Weigh patient daily then record
- Monitor vital signs and record
- Monitor intake and output every shift and record
- Refer accordingly

Case Discussion

Jaundice: accumulation of bilirubin in the skin, sclera, mucosa

● Most common transitional finding in the newborn period

● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile
on Bhutani chart

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - Present within 24th-36th hour of

ONSET
3rd day of life life

INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr or

BILIRUBIN >5mg/day

PEAK TOTAL 12 mg/dL >12 mg/dL (full term)

BILIRUBIN 10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

ABO Incompatibility - Most common cause of hemolytic disease in the newborn

● Mother is type O, baby is either type A or B
● Clinical Manifestation:
○ Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
 ○ No pallor and hepatosplenomegaly
○ Kernicterus and hydrops fetalis is rare

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of - Occurs when Rh(+) blood is

hemolytic disease of the infused to a Rh(-) woman
newborn - Rarely occurs in first
- Mother is type O and pregnancy
baby is either A or B

Presentation - Most cases are mild - Mild hemolysis to severe

- Jaundice usually during anemia
the first 24 hours of life - Jaundice is usually evident
- MIld on the 1st day of life
hepatosplenomegaly

Diagnosis:
● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

Management:

● Phototherapy
○ 20 cm distance between infant and light source
○ Complications of Phototherapy:
 ■ Loose stools
■ Erythematous macular/ purpuric rash
■ Overheating
■ Dehydration
■ Hypothermia from exposure
■ Bronze baby syndrome
■ Corneal damage
● Intravenous Immunoglobulin
○ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
● Transfusion
○ Simple Transfusion
● Moderate to severe anemia without severe hyperbilirubinemia
● 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
● Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
decline despite 4-6 hrs of intensive phototherapy
● Rate of increase in TB indicates that level will reach 25 mg/dL
within 48 hrs
● Early signs of bilirubin encephalopathy
● There is hemolysis causing anemia and hydrops fetalis
● Post-discharge monitoring of hematocrit
JI Fortes, Hannah Selina V.
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

Salient Features
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle
Differential Diagnosis
Sepsis induced Cholestasis

Rule In Rule Out

14 days old (-) fever

(+) generalized jaundice for 15 days (-) cough, cold
(+) yellowish palpebral conjunctivae, (-) diarrhea, vomiting
yellowish sclera (-) Distress
(+) CBC: thrombocytosis (-)pallor,
(+) Elevated levels of total bilirubin, (-) neurologic symptoms
direct bilirubin and indirect bilirubin To complete rule out base on
(+) Maternal History of UTI laboratory findings

Vitamin K Deficiency Bleeding

Rule In Rule Out

 No Vitamin K prophylaxis at birth More common in preterm infants
Bruise at the left ankle No maternal intake of anticonvulsant
Breast-fed and anti-TB medications
Jaundice
Coagulation studies**

ABO hemolytic disease

Rule In Rule Out

14 days old, Filipino Cannot completely rule out need ABO

(+) jaundice within 24 hours from birth compatibility test
(+)generalized jaundice for 15 days
(+) yellowish palpebral conjunctivae,
yellowish sclera
(+) Elevated levels of total bilirubin,
direct bilirubin and indirect bilirubin
Unknown blood type of parents

Initial Diagnosis
● To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out
sepsis

Initial Management
Plan
- Admit the patient
- Secure consent for admission and management
Diet
- Encourage breastfeeding
Diagnostics
- CBC with Platelet Count
- Peripheral Blood Smear
- Bilirubin levels
- Blood culture and sensitivity prior to antibiotics
- Direct Coombs Test
Disposition
- Phototherapy
- Weigh patient daily then record
- Monitor vital signs and record
 - Monitor intake and output every shift and record
- Refer accordingly

Case Discussion
Jaundice and Hyperbilirubinemia
● Jaundice: accumulation of bilirubin in the skin, sclera, mucosa
● Most common transitional finding in the newborn period
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile
on Bhutani chart

Bhutani Chart
● On the X axis - age of the patient starting from birth up to the 7th DOL
● While on the Y axis - total serum bilirubin
● Risk factors = isoimmune hemolytic disease, G6PD deficiency, asphyxia,
significant lethargy, temperature instability, sepsis, acidosis, or albumin
<3g/dL
● For well infants 35 - 37 6/7 wk, can adjust TSB levels for intervention around the
medium risk line. It is an option to intervene at lower TSB levels for infants closer
to 35 wks and at higher TSB levels for those closer to 37 6/7 wks.
● It is an option to provide conventional phototherapy in hospital or at home at TSB
levels 2 - 3 mg/dL below those shown, but home phototherapy should not be
used in any infant with risk factors
 - Hour-specific thresholds for phototherapy in newborns ≥35 weeks
gestation with unconjugated hyperbilirubinemia and one or more
neurotoxicity risk factors
- This figure summarizes the AAP's recommended hour-specific TSB
thresholds for initiating phototherapy according to GA (completed weeks)
in newborns with one or more risk factor for neurotoxicity. In addition to
GA, other risk factors for neurotoxicity include hemolytic conditions,
clinical instability in the previous 24 hours, sepsis, and hypoalbuminemia.
These thresholds are based on expert opinion as to when the benefits of
phototherapy likely exceed its potential harms. Decisions to start
phototherapy should be based upon TSB values; do not subtract direct
(conjugated) bilirubin from the total value. In rare cases of severe
hyperbilirubinemia in which direct (conjugated) bilirubin is >50% of the
TSB, consult an expert. If bilirubin testing is performed with TcB, the value
should be confirmed with TSB if the TcB value is >15 mg/dL (257
micromol/L) or within 3 mg/dL (51 micromol/L) of the phototherapy
threshold. However, if the TcB level is at or above the treatment threshold,
phototherapy should be initiated while awaiting TSB confirmation. Note
that infants <24 hours old with a TSB at or above the phototherapy
threshold are likely to have a hemolytic process and should have
additional laboratory evaluation.

Physiologic vs Pathologic Jaundice

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - Present within 24th-36th

ONSET
3rd day of life hour of life

INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2

 BILIRUBIN mg/dL/hr or >5mg/day

PEAK TOTAL 12 mg/dL >12 mg/dL (full term)

BILIRUBIN 10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

Etiology
● Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
○ Increased Bilirubin Production
■ Immune-mediated hemolysis - Includes blood group
incompatibilities such as ABO and Rhesus incompatibility
○ Decreased Bilirubin Clearance
○ Miscellaneous Causes
● Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia
○ Obstruction of biliary flow
○ Infections
○ Genetic causes
○ Miscellaneous

ABO Incompatibility
● Most common cause of hemolytic disease in the newborn
● Mother is type O, baby is either type A or B
● Clinical Manifestation:
○ Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
○ No pallor and hepatosplenomegaly
○ Kernicterus and hydrops fetalis is rare

ABO Incompatibility vs Rh Incompatibility

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of hemolytic - Occurs when Rh(+) blood is

disease of the newborn infused to a Rh(-) woman
- Mother is type O and baby is - Rarely occurs in first
either A or B pregnancy

Presentation - Most cases are mild - Mild hemolysis to severe

 - Jaundice usually during the first anemia
24 hours of life - Jaundice is usually evident on
- MIld hepatosplenomegaly the 1st day of life

Diagnosis
● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

Management
● Phototherapy
○ 20 cm distance between infant and light source
● Complications of Phototherapy:
○ Loose stools
○ Erythematous macular/ purpuric rash
○ Overheating
○ Dehydration
○ Hypothermia from exposure
○ Bronze baby syndrome
○ Corneal damage
● Intravenous Immunoglobulin
○ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
● Transfusion
○ Simple Transfusion
- Moderate to severe anemia without severe hyperbilirubinemia
- 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
- Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
decline despite 4-6 hrs of intensive phototherapy
- Rate of increase in TB indicates that level will reach 25 mg/dL
 within 48 hrs
- Early signs of bilirubin encephalopathy
- There is hemolysis causing anemia and hydrops fetalis
● Post-discharge monitoring of hematocrit
JI Francisco, Jenica Vianca Loren G.
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

SALIENT FEATURES
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

DIFFERENTIAL DIAGNOSIS

Sepsis induced Cholestasis

Rule In Rule Out

14 days old (-) fever

(+) generalized jaundice for 15 days (-) cough, cold
(+) yellowish palpebral conjunctivae, (-) diarrhea, vomiting
yellowish sclera (-) Distress
(+) CBC: thrombocytosis (-)pallor,
(+) Elevated levels of total bilirubin, (-) neurologic symptoms
direct bilirubin and indirect bilirubin To complete rule out base on
(+) Maternal History of UTI laboratory findings

Vitamin K Deficiency Bleeding

Rule In Rule Out

 No Vitamin K prophylaxis at birth More common in preterm infants
Bruise at the left ankle No maternal intake of anticonvulsant
Breast-fed and anti-TB medications
Jaundice
Coagulation studies**

ABO hemolytic disease

Rule In Rule Out

14 days old, Filipino Cannot completely rule out need ABO

(+) jaundice within 24 hours from birth compatibility test
(+)generalized jaundice for 15 days
(+) yellowish palpebral conjunctivae,
yellowish sclera
(+) Elevated levels of total bilirubin,
direct bilirubin and indirect bilirubin
Unknown blood type of parents

INITIAL DIAGNOSIS
→ To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out sepsis

INITIAL MANAGEMENT
● Plan
○ Admit the patient
○ Secure consent for admission and management
● Diet
○ Encourage breastfeeding
● Diagnostics
○ CBC with Platelet Count
○ Peripheral Blood Smear
○ Bilirubin levels
○ Blood culture and sensitivity prior to antibiotics
○ Direct Coombs Test
● Disposition
○ Phototherapy
○ Weigh patient daily then record
○ Monitor vital signs and record
 ○ Monitor intake and output every shift and record
○ Refer accordingly

CASE DISCUSSION

Jaundice and Hyperbilirubinemia

● Jaundice: accumulation of bilirubin in the skin, sclera, mucosa
● Most common transitional finding in the newborn period
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile
on Bhutani chart

BHUTANI CHART
● On the X axis - age of the patient starting from birth up to the 7th DOL
● While on the Y axis - total serum bilirubin
● Risk factors = isoimmune hemolytic disease, G6PD deficiency, asphyxia,
significant lethargy, temperature instability, sepsis, acidosis, or albumin
<3g/dL
● For well infants 35 - 37 6/7 wk, can adjust TSB levels for intervention around the
medium risk line. It is an option to intervene at lower TSB levels for infants closer
to 35 wks and at higher TSB levels for those closer to 37 6/7 wks.
● It is an option to provide conventional phototherapy in hospital or at home at TSB
levels 2 - 3 mg/dL below those shown, but home phototherapy should not be
used in any infant with risk factors
 - Hour-specific thresholds for phototherapy in newborns ≥35 weeks
gestation with unconjugated hyperbilirubinemia and one or more
neurotoxicity risk factors
- This figure summarizes the AAP's recommended hour-specific TSB
thresholds for initiating phototherapy according to GA (completed weeks)
in newborns with one or more risk factor for neurotoxicity. In addition to
GA, other risk factors for neurotoxicity include hemolytic conditions,
clinical instability in the previous 24 hours, sepsis, and hypoalbuminemia.
These thresholds are based on expert opinion as to when the benefits of
phototherapy likely exceed its potential harms. Decisions to start
phototherapy should be based upon TSB values; do not subtract direct
(conjugated) bilirubin from the total value. In rare cases of severe
hyperbilirubinemia in which direct (conjugated) bilirubin is >50% of the
TSB, consult an expert. If bilirubin testing is performed with TcB, the value
should be confirmed with TSB if the TcB value is >15 mg/dL (257
micromol/L) or within 3 mg/dL (51 micromol/L) of the phototherapy
threshold. However, if the TcB level is at or above the treatment threshold,
phototherapy should be initiated while awaiting TSB confirmation. Note
that infants <24 hours old with a TSB at or above the phototherapy
threshold are likely to have a hemolytic process and should have
additional laboratory evaluation.

Physiologic vs Pathologic Jaundice

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - 3rd Present within 24th-36th hour

ONSET
day of life of life

INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr or

BILIRUBIN >5mg/day
 12 mg/dL >12 mg/dL (full term)
PEAK TOTAL BILIRUBIN
10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

ETIOLOGY
● Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
○ Increased Bilirubin Production
■ Immune-mediated hemolysis - Includes blood group
incompatibilities such as ABO and Rhesus incompatibility
○ Decreased Bilirubin Clearance
○ Miscellaneous Causes
● Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia
○ Obstruction of biliary flow
○ Infections
○ Genetic causes
○ Miscellaneous

ABO Incompatibility
● Most common cause of hemolytic disease in the newborn
● Mother is type O, baby is either type A or B
● Clinical Manifestation:
○ Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
○ No pallor and hepatosplenomegaly
○ Kernicterus and hydrops fetalis is rare

ABO Incompatibility vs Rh Incompatibility

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of hemolytic - Occurs when Rh(+) blood is

disease of the newborn infused to a Rh(-) woman
- Mother is type O and baby is - Rarely occurs in first
either A or B pregnancy

Presentation - Most cases are mild - Mild hemolysis to severe

- Jaundice usually during the first anemia
 24 hours of life - Jaundice is usually evident on
- MIld hepatosplenomegaly the 1st day of life

DIAGNOSIS
● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

MANAGEMENT:
● Phototherapy
○ 20 cm distance between infant and light source
● Complications of Phototherapy:
○ Loose stools
○ Erythematous macular/ purpuric rash
○ Overheating
○ Dehydration
○ Hypothermia from exposure
○ Bronze baby syndrome
○ Corneal damage
● Intravenous Immunoglobulin
○ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
● Transfusion
○ Simple Transfusion
- Moderate to severe anemia without severe hyperbilirubinemia
- 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
- Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
decline despite 4-6 hrs of intensive phototherapy
- Rate of increase in TB indicates that level will reach 25 mg/dL
 within 48 hrs
- Early signs of bilirubin encephalopathy
- There is hemolysis causing anemia and hydrops fetalis
● Post-discharge monitoring of hematocrit
JI Francisco, Krizza Mae
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

Salient Features
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnosis

Sepsis induced Cholestasis

Rule In Rule Out

14 days old (-) fever

(+) generalized jaundice for 15 days (-) cough, cold
(+) yellowish palpebral conjunctivae, (-) diarrhea, vomiting
yellowish sclera (-) Distress
(+) CBC: thrombocytosis (-)pallor,
(+) Elevated levels of total bilirubin, (-) neurologic symptoms
direct bilirubin and indirect bilirubin To complete rule out base on
(+) Maternal History of UTI laboratory findings

Vitamin K Deficiency Bleeding

Rule In Rule Out

 No Vitamin K prophylaxis at birth More common in preterm infants
Bruise at the left ankle No maternal intake of anticonvulsant
Breast-fed and anti-TB medications
Jaundice
Coagulation studies**

ABO hemolytic disease

Rule In Rule Out

14 days old, Filipino Cannot completely rule out need ABO

(+) jaundice within 24 hours from birth compatibility test
(+)generalized jaundice for 15 days
(+) yellowish palpebral conjunctivae,
yellowish sclera
(+) Elevated levels of total bilirubin,
direct bilirubin and indirect bilirubin
Unknown blood type of parents

INITIAL DIAGNOSIS
→ To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out sepsis

INITIAL MANAGEMENT

Plan
- Admit the patient
- Secure consent for admission and management
Diet
- Encourage breastfeeding
Diagnostics
- CBC with Platelet Count
- Peripheral Blood Smear
- Bilirubin levels
- Blood culture and sensitivity prior to antibiotics
- Direct Coombs Test
Disposition

- Phototherapy
 - Weigh patient daily then record
- Monitor vital signs and record
- Monitor intake and output every shift and record
- Refer accordingly

CASE DISCUSSION

Jaundice and Hyperbilirubinemia

● Jaundice: accumulation of bilirubin in the skin, sclera, mucosa
● Most common transitional finding in the newborn period
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile
on Bhutani chart

BHUTANI CHART

● On the X axis - age of the patient starting from birth up to the 7th DOL
● While on the Y axis - total serum bilirubin
● Risk factors = isoimmune hemolytic disease, G6PD deficiency, asphyxia,
significant lethargy, temperature instability, sepsis, acidosis, or albumin
<3g/dL
● For well infants 35 - 37 6/7 wk, can adjust TSB levels for intervention around the
medium risk line. It is an option to intervene at lower TSB levels for infants closer
to 35 wks and at higher TSB levels for those closer to 37 6/7 wks.
● It is an option to provide conventional phototherapy in hospital or at home at TSB
levels 2 - 3 mg/dL below those shown, but home phototherapy should not be
used in any infant with risk factors
 - Hour-specific thresholds for phototherapy in newborns ≥35 weeks
gestation with unconjugated hyperbilirubinemia and one or more
neurotoxicity risk factors
- This figure summarizes the AAP's recommended hour-specific TSB
thresholds for initiating phototherapy according to GA (completed weeks)
in newborns with one or more risk factor for neurotoxicity. In addition to
GA, other risk factors for neurotoxicity include hemolytic conditions,
clinical instability in the previous 24 hours, sepsis, and hypoalbuminemia.
These thresholds are based on expert opinion as to when the benefits of
phototherapy likely exceed its potential harms. Decisions to start
phototherapy should be based upon TSB values; do not subtract direct
(conjugated) bilirubin from the total value. In rare cases of severe
hyperbilirubinemia in which direct (conjugated) bilirubin is >50% of the
TSB, consult an expert. If bilirubin testing is performed with TcB, the value
should be confirmed with TSB if the TcB value is >15 mg/dL (257
micromol/L) or within 3 mg/dL (51 micromol/L) of the phototherapy
threshold. However, if the TcB level is at or above the treatment threshold,
phototherapy should be initiated while awaiting TSB confirmation. Note
that infants <24 hours old with a TSB at or above the phototherapy
threshold are likely to have a hemolytic process and should have
additional laboratory evaluation.

Physiologic vs Pathologic Jaundice

FORM PHYSIOLOGIC PATHOLOGIC

 Visible on the 2nd - Present within 24th-36th
ONSET 3rd day of life hour of life

<5 mg./dL/day Increases by >0.2

INCREASE IN TOTAL
mg/dL/hr or >5mg/day
BILIRUBIN

12 mg/dL >12 mg/dL (full term)

PEAK TOTAL
10-14 mg/dL (preterm)
BILIRUBIN

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

ETIOLOGY
● Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
○ Increased Bilirubin Production
■ Immune-mediated hemolysis - Includes blood group
incompatibilities such as ABO and Rhesus incompatibility
○ Decreased Bilirubin Clearance
○ Miscellaneous Causes
● Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia
○ Obstruction of biliary flow
○ Infections
○ Genetic causes
○ Miscellaneous

ABO Incompatibility vs Rh Incompatibility

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of hemolytic - Occurs when Rh(+) blood is

disease of the newborn infused to a Rh(-) woman
- Mother is type O and baby is - Rarely occurs in first
either A or B pregnancy
Presentation - Most cases are mild - Mild hemolysis to severe
- Jaundice usually during the first anemia
24 hours of life - Jaundice is usually evident on
- MIld hepatosplenomegaly the 1st day of life

DIAGNOSIS
● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

MANAGEMENT
● Phototherapy
○ 20 cm distance between infant and light source
● Complications of Phototherapy:
○ Loose stools
○ Erythematous macular/ purpuric rash
○ Overheating
○ Dehydration
○ Hypothermia from exposure
○ Bronze baby syndrome
○ Corneal damage
● Intravenous Immunoglobulin
○ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
● Transfusion
○ Simple Transfusion
- Moderate to severe anemia without severe hyperbilirubinemia
- 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
- Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
 decline despite 4-6 hrs of intensive phototherapy
- Rate of increase in TB indicates that level will reach 25 mg/dL
within 48 hrs
- Early signs of bilirubin encephalopathy
- There is hemolysis causing anemia and hydrops fetalis
● Post-discharge monitoring of hematocrit
JI Fule, Sofia Gabrielle B.
Prime 2 (Written Output under Dr. Becina)
SGD - Asynchronous
November 29, 2022

Salient features
14 day old, female
CC: Yellowish discoloration of skin for 15 days
Maternal history
G4P4 (4004); failure of descent
History of UTI (6 months of pregnancy)
Delivered full term, via elective low segment cesarean section
CBC: thrombocytosis
Blood type: B+
Hyperbilirubinemia
Physical examination
Yellowish palpebral conjunctiva
Yellowish sclera
Generalized jaundice
Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnosis
Rule In Rule Out
Sepsis Induced 14 days old
Cholestasis (+) generalized jaundice (-) fever
for 15 days (-) cough, cold
(+) yellowish palpebral (-) diarrhea, vomiting
conjunctivae, yellowish (-) Distress
sclera (-)pallor,
(+) CBC: thrombocytosis (-) neurologic symptoms
(+) Elevated levels of total To complete rule out base
bilirubin, direct bilirubin and on laboratory findings
indirect bilirubin
(+) Maternal History of UTI

Vitamin K Deficiency No Vitamin K prophylaxis More common in preterm

Bleeding at birth infants
Bruise at the left ankle No maternal intake of
Breast-fed anticonvulsant and anti-TB
Jaundice medications

Coagulation studies**

ABO Hemolytic Anemia 14 days old, Filipino Cannot completely rule out
(+) jaundice within 24 need ABO compatibility
hours from birth test
(+)generalized jaundice for
15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents
Initial Diagnosis
To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out sepsis

Management
Plan
Admit the patient

Secure consent for admission and management

Diet
Encourage breastfeeding

Diagnostics
CBC with Platelet Count
Peripheral Blood Smear
Bilirubin levels
Blood culture and sensitivity prior to antibiotics
Direct Coombs Test

Disposition
Phototherapy
Weigh patient daily then record
Monitor vital signs and record
Monitor intake and output every shift and record
Refer accordingly

Jaundice and Hyperbilirubinemia

Jaundice: accumulation of bilirubin in the skin, sclera, mucosa
Most common transitional finding in the newborn period
>5 mg/dL: level at which it becomes clinically apparent
Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile on
Bhutani chart

Physiologic vs Pathologic Jaundice

FORM PHYSIOLOGIC PATHOLOGIC

 ONSET Visible on the 2nd - 3rd Present within 24th-36th hour
day of life of life
INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr or
BILIRUBIN >5mg/day
PEAK TOTAL 12 mg/dL >12 mg/dL (full term)
BILIRUBIN 10-14 mg/dL (preterm)
DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

Etiology
Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
Increased Bilirubin Production
Immune-mediated hemolysis - Includes blood group incompatibilities such
as ABO and Rhesus incompatibility
Decreased Bilirubin Clearance
Miscellaneous Causes

Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia

Obstruction of biliary flow
Infections
Genetic causes
Miscellaneous

ABO Incompatibility
The most common cause of hemolytic disease in the newborn
Mother is type O, baby is either type A or B
Clinical Manifestation:
Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
No pallor and hepatosplenomegaly
Kernicterus and hydrops fetalis are rare

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description • Most common cause of • Occurs when Rh(+)
hemolytic disease of the newborn blood is infused to a Rh(-)
• Mother is type O woman
and baby is either A or B • Rarely occurs in
first pregnancy
Presentation • Most cases are mild • Mild hemolysis to
• Jaundice usually severe anemia
during the first 24 hours of life • Jaundice is
• MIld usually evident on the 1st day
hepatosplenomegaly of life

JI Gabriel, Mark Joseph D.

Prime 2 (Written Output under Dr. Becina)
Topic: SGD
Date: Nov 29, 2022

Salient features:
● 14 years old
● CC: yellowish discoloration of skin for 15 days
● Previous LTCS
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
❖ Yellowish palpebral conjunctiva
❖ Yellowish sclera
❖ Generalized jaundice
❖ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential diagnosis:

● Sepsis-induced cholestasis
● ABO hemolytic anemia
● Vitamin K deficiency bleeding

Initial Diagnosis
To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out sepsis
Management
DIET ● Encourage breastfeeding

DIAGNOSTICS ● Complete blood count with platelet count

● Peripheral blood smear
● Total bilirubin, B1 and B2
● Blood GS/CS
● Direct Coombs test

DRUGS ● Intravenous immunoglobulin

DISPOSITION ● Admit the patient

● Secure consent for admission and management
● For phototherapy
● Weigh patient daily and record
● Monitor VS every 4 hours and record
● Monitor I and O every shift and record
● Refer accordingly

JI Gamilde, Lourdes Gayle R.

Prime 2 (Written Output)
Topic: SGD under Dr. Becina
November 29 2022
Salient features:
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnoses

Rule in Rule out

Sepsis Induced 14 days old (-) fever

Cholestasis (+) generalized jaundice (-) cough, cold
for 15 days (-) diarrhea, vomiting
(+)yellowish palpebral (-) Distress
conjunctivae, yellowish (-)pallor,
sclera (-) neurologic symptoms
(+)CBC: thrombocytosis To complete rule out base
(+) Elevated levels of total on laboratory findings
bilirubin, direct bilirubinand
indirect bilirubin
(+) Maternal History of UTI

Vit K Deficiency bleeding No Vitamin K prophylaxis More common in preterm

at birth infants
Bruise at the left ankle No maternal intake of
Breast-fed anticonvulsant and anti-TB
Jaundice medications
Coagulation studies**
 ABO Hemolytic Disease 14 days old, Filipino Cannot completely rule out
(+) jaundice within 24 need ABO compatibility
hours from birth test
(+)generalized jaundice for
15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

Initial Diagnosis: To consider Hyperbilirubinemia secondary to ABO incompatibility;

Rule out sepsis

Initial Management

Plan
- Admit the patient
- Secure consent for admission and management

Diet
- Encourage breastfeeding

Diagnostics
- CBC with Platelet Count
- Peripheral Blood Smear
- Bilirubin levels
- Blood culture and sensitivity prior to antibiotics
- Direct Coombs Test

Disposition

- Phototherapy
- Weigh patient daily then record
- Monitor vital signs and record
- Monitor intake and output every shift and record
- Refer accordingly
Case Discussion

● Jaundice: accumulation of bilirubin in the skin, sclera, mucosa

● Most common transitional finding in the newborn period
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile
on Bhutani chart

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - 3rd Present within 24th-36th hour of life

ONSET day of life

<5 mg./dL/day Increases by >0.2 mg/dL/hr or >5mg/day

INCREASE IN TOTAL
BILIRUBIN

12 mg/dL >12 mg/dL (full term)

PEAK TOTAL 10-14 mg/dL (preterm)
BILIRUBIN

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

Etiology
Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
- Increased Bilirubin Production
- Immune-mediated hemolysis - Includes blood group incompatibilities such
as ABO and Rhesus incompatibility
- Decreased Bilirubin Clearance
- Miscellaneous Causes
Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia
- Obstruction of biliary flow
- Infections
- Genetic causes
 - Miscellaneous

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of - Occurs when Rh(+) blood is

hemolytic disease of the infused to a Rh(-) woman
newborn - Rarely occurs in first pregnancy
- Mother is type O and baby is
either A or B

Presentation - Most cases are mild - Mild hemolysis to severe anemia

- Jaundice usually during the - Jaundice is usually evident on
first 24 hours of life the 1st day of life
- MIld hepatosplenomegaly

Diagnosis:

● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

Case Management:

★ Phototherapy
○ 20 cm distance between infant and light source
★ Complications of Phototherapy:
○ Loose stools
○ Erythematous macular/ purpuric rash
○ Overheating
○ Dehydration
○ Hypothermia from exposure
 ○ Bronze baby syndrome
○ Corneal damage
★ Intravenous Immunoglobulin
○ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
★ Transfusion
○ Simple Transfusion
- Moderate to severe anemia without severe hyperbilirubinemia
- 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
- Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
decline despite 4-6 hrs of intensive phototherapy
- Rate of increase in TB indicates that level will reach 25 mg/dL
within 48 hrs
- Early signs of bilirubin encephalopathy
- There is hemolysis causing anemia and hydrops fetalis
★ Post-discharge monitoring of hematocrit

JI Garcia, Jan Rossanna S.

Prime 2 (Written Output under)
Topic: SGD under Dr. Becina
Date: November 29, 2022

SALIENT FEATURES
 ➔ 14 day-old, female who came in at our institution with a chief complaint of yellowish
discoloration of skin for 15 days.
➔ She was born to a G4p4 (4004) mother after a pregnancy complicated by failure of
descent.
➔ During the 6th month of pregnancy, mother was diagnosed with UTI and was prescribed
with cefuroxime 250 mg BID for 7 days
➔ Patient was delivered full term via elective repeat low segment cesarean section due to
prev cs.
➔ Jaundice was noticed 14 days PTA (patient was still in BGH), seen by a pediatrician,
daily sun exposure for 30 mins was advised and was sent home a day after
➔ The jaundice persisted despite daily sun exposure
➔ 1 day PTA there was thrombocytosis on CBC, and hyperbilirubinemia (↑↑ Total, Direct
and Indirect Bilirubin levels)
➔ Patient’s blood type is B+, maternal blood type unknown
➔ On PE, the patient had yellow palpebral conjunctiva and sclera,generalized jaundice,
and a flat, 3x3 cm bluish gray discoloration on the left ankle

DIFFERENTIAL DIAGNOSES

1) Sepsis-induced Cholestasis
● Rule in
○ 14 days old
○ (+) generalized jaundice for 15 days
○ (+) yellowish palpebral conjunctivae, yellowish sclera
○ (+) CBC: thrombocytosis
○ (+) Elevated levels of total bilirubin, direct bilirubin and indirect bilirubin
○ (+) Maternal History of UTI
● Rule out:
○ (-) fever
○ (-) cough, cold
○ (-) diarrhea, vomiting
○ (-) Distress
○ (-)pallor,
○ (-) neurologic symptoms
○ To complete rule out base on laboratory findings
2) Vitamin-K Deficiency Bleeding
● Rule in
○ No Vitamin K prophylaxis at birth
○ Bruise at the left ankle
○ Breast-fed
○ Jaundice
● Rule out
○ More common in preterm infants
○ No maternal intake of anticonvulsant and anti-TB medications
○ Coagulation studies needed to fully rule out**

3) ABO Hemolytic Disease

 ● Rule in
○ 14 days old, Filipino
○ (+) jaundice within 24 hours from birth
○ (+)generalized jaundice for 15 days
○ (+) yellowish palpebral conjunctivae, yellowish sclera
○ (+) Elevated levels of total bilirubin, direct bilirubin and indirect bilirubin
○ Unknown blood type of parents
● Rule out:
○ Cannot be totally ruled out

WORKING DIAGNOSIS

★ To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out sepsis

CASE DISCUSSION

JAUNDICE & HYPERBILIRUBINEMIA

★ Jaundice: accumulation of bilirubin in the skin, sclera, mucosa
★ Most common transitional finding in the newborn period
★ >5 mg/dL: level at which it becomes clinically apparent
★ Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile on
Bhutani chart
★ Bhutani Chart

★ Hour-specific thresholds for phototherapy in newborns ≥35 weeks gestation with

unconjugated hyperbilirubinemia and one or more neurotoxicity risk factors
★ Physiologic vs Pathologic Jaundice
The distinction between physiologic and pathologic jaundice relates to the timing,
rate of rise, and extent of hyperbilirubinemia, because some of the same causes of
physiologic jaundice (e.g., large RBC mass, decreased capacity for bilirubin conjugation,
increased enterohepatic circulation) can also result in pathologic jaundice. Evaluation
should be determined on the basis of risk factors, clinical appearance, and severity of
the hyperbilirubinemia.

Physiological jaundice accounts for 75% of neonatal hyperbilirubinemia and

results from a physiological alteration in neonatal bilirubin metabolism. Physiological
jaundice typically appears after 24 hours of age, peaks at around 48-96 hours, and
resolves by two to three weeks in full-term infants.

Jaundice is considered pathological if it presents on the first day of life, TSB is

more than the 95th centile for age based on age-specific bilirubin nomograms, levels rise
by more than 5 mg/dL/day or more than 0.2 mg/dL/hour, or jaundice persists beyond 2 to
3 weeks in full-term infants.

★ ABO Incompatibility
As mentioned, exaggerated hemolysis, either immune or non-immune mediated,
is the most common cause of pathological hyperbilirubinemia in newborns.
Immune-mediated hemolysis is seen with blood group incompatibility such as ABO/RH
incompatibility and leads to hemolytic disease of newborns (HDN). ABO incompatibility is
the most common cause of HDFN, this form is usually much milder than Rh disease and
rarely requires aggressive clinical management or therapeutic intervention.
Approximately 20% of live births are at theoretical risk for immune-mediated hemolysis
based on ABO mismatch, most often the mother being group O and the infant either
group A or B. Less often, the mother will be group A and the infant group B, or vice
versa.
Most cases of ABO incompatibility are mild, with jaundice as the only clinical
manifestation. The infant is not generally affected at birth but will develop jaundice in the
1st 24 hr, which is always abnormal. Pallor and hepatosplenomegaly are not present,
and the development of hydrops fetalis or kernicterus is extremely rare.
 ★ ABO vs Rh Incompatibility

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of hemolytic - Occurs when Rh(+)

disease of the newborn blood is infused to a
- Mother is type O and baby is Rh(-) woman
either A or B - Rarely occurs in first
pregnancy

Presentation - Most cases are mild Mild hemolysis to severe

- Jaundice usually during the first anemia
24 hours of life Jaundice is usually
- MIld hepatosplenomegaly evident on the 1st
day of life

★ Diagnosis
A presumptive diagnosis is based on the presence of serologic ABO incompatibility
between the mother and infant, plus positive DAT. In the DAT, agglutination of red blood cells
(RBCs) from the neonate, when suspended with serum that contains antibodies to
immunoglobulin G (IgG), indicates the presence of maternal antibody on the RBC surface. A
positive DAT demonstrates the presence of maternal antibody on the neonate's RBCs and in the
setting of blood type incompatibility, and evidence of hemolysis (hyperbilirubinemia, anemia,
reticulocytosis) is consistent with HDFN.

★ Management
○ Phototherapy
■ 20 cm distance between infant and light source
■ Complications of Phototherapy:
● Loose stools, Erythematous macular/ purpuric rash, Overheating,
Dehydration, Hypothermia from exposure, Bronze baby syndrome,
Corneal damage

○ Intravenous Immunoglobulin
■ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
■ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic
disease.
○ Transfusion
■ Simple RBC transfusion may be required in patients with anemia that is
moderate to severe (hematocrit between 25 and 35 percent and/or
 symptoms attributable to anemia) without severe hyperbilirubinemia (ie,
not requiring exchange transfusion). In addition, simple transfusion may
be used in infants with more severe anemia and/or hyperbilirubinemia if
exchange transfusion is not readily available.
■ RBC transfusions generally are given in aliquots of 10 to 20 mL/kg, over
two to four hours.
■ Exchange transfusion is used to treat severe anemia and severe
hyperbilirubinemia. Exchange transfusion removes serum bilirubin and
decreases hemolysis by the removal of antibody-coated neonatal RBCs
and unbound maternal antibody. Immediate exchange transfusion is
recommended if
- Evidence of on-going hemolysis and Total Bilirubin (TB) fails to decline
despite 4-6 hrs of intensive phototherapy
- Rate of increase in TB indicates that level will reach 25 mg/dL within 48
hrs
- If there are early signs of bilirubin encephalopathy
- There is hemolysis causing anemia and hydrops fetalis
■ Postdischarge monitoring of hemoglobin or hematocrit is essential in
newborns with ABO hemolytic disease.

CASE MANAGEMENT

PLAN
● Admit the patient
● Secure consent for admission and management

DIET
● Encourage breastfeeding

DIAGNOSTICS
● CBC with Platelet Count
● Peripheral Blood Smear
● Bilirubin levels
● Blood culture and sensitivity prior to antibiotics
● Direct Coombs Test

DISPOSITION
● Phototherapy - mainstay in management. This converts bilirubin into byproducts that are
less toxic and more easily excreted. Recommended distance is 20 cm between infant
and light source
● Weigh patient daily then record
● Monitor vital signs and record
● Monitor intake and output every shift and record
● Refer accordingly
 JI Garcia, Marc Wilhelm M.
Prime 2 (Written Output under)
Topic: SGD under Dr. Becina
Date: November 29, 2022

Salient Features:
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
● H istory of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnosis Rule in Rule out

Sepsis induced Cholestatsis 14 days old (-) fever

(+) generalized jaundice for 15 days (-) cough, cold
(+) yellowish palpebral conjunctivae, (-) diarrhea, vomiting
yellowish sclera (-) Distress
(+) CBC: thrombocytosis (-)pallor,
(+) Elevated levels of total bilirubin, (-) neurologic symptoms
direct bilirubin and indirect bilirubin To complete rule out base on laboratory
(+) Maternal History of UTI findings

Vitamin K Deficiency Bleeding
No Vitamin K prophylaxis at birth More common in preterm infants
Bruise at the left ankle No maternal intake of anticonvulsant and
Breast-fed anti-TB medications
Jaundice
Coagulation studies

ABO hemolytic diease
14 days old, Filipino Cannot completely rule out need ABO
(+) jaundice within 24 hours from birth compatibility test
(+)generalized jaundice for 15 days
(+) yellowish palpebral conjunctivae,
yellowish sclera
(+) Elevated levels of total bilirubin,
 direct bilirubin and indirect bilirubin
Unknown blood type of parents

Initial Diagnosis: To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out

sepsis

Initial Management:
● Plan
○ Admit the patient
○ Secure consent for admission and management
● Diet
○ Encourage breastfeeding
● Diagnostics
○ CBC with Platelet Count
○ Peripheral Blood Smear
○ Bilirubin levels
○ Blood culture and sensitivity prior to antibiotics
○ Direct Coombs Test
● Disposition
○ Phototherapy
○ Weigh patient daily then record
○ Monitor vital signs and record
○ Monitor intake and output every shift and record
○ Refer accordingly

Case Discussion:
Jaundice is defined as the accumulation of bilirubin in the skin, sclera and mucosa and is
the most common transitional finding in the newborn period.
Jaundice during the 1st 24 hr of life warrants diagnostic evaluation and should be considered
pathologic until proved otherwise. It becomes clinically apparent at a level >5 mg/dL.

This s is the Bhutani chart, on the X axis - age

of the patient starting from birth up to the 7th
DOL, while on the Y axis - total serum bilirubin
Risk factors = isoimmune hemolytic disease,
G6PD deficiency, asphyxia, significant lethargy,
temperature instability, sepsis, acidosis, or
albumin <3g/dL
For well infants 35 - 37 6/7 wk, can adjust TSB
levels for intervention around the medium risk
line. It is an option to intervene at lower TSB levels for infants closer to 35 wks and at higher
TSB levels for those closer to 37 6/7 wks.
It is an option to provide conventional phototherapy in hospital or at home at TSB levels 2 - 3
mg/dL below those shown, but home phototherapy should not be used in any infant with risk
factors.

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - 3rd day Present within 24th-36th

ONSET
of life hour of life

INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr

BILIRUBIN or >5mg/day

12 mg/dL >12 mg/dL (full term)

PEAK TOTAL BILIRUBIN
10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

There are two distinct types of Neonatal hyperbilirubinemia namely the Unconjugated
Hyperbilirubinemia(UHB) or Indirect Hyperbilirubinemia.

Unconjugated hyperbilirubinemia is the more common type and is either physiological or

pathological. Based on the mechanism of bilirubin elevation, the etiology of unconjugated
hyperbilirubinemia can be subdivided into the following three categories:
● Increased Bilirubin Production
○ Immune-mediated hemolysis - Includes blood group incompatibilities such as
ABO incompatibility (such as in our case) and Rhesus incompatibility
○ Non-immune mediated hemolysis - includes RBC membrane defects like
hereditary spherocytosis and elliptocytosis; RBC enzyme defects like
glucose-6-phosphate dehydrogenase (G6PD) deficiency; pyruvate kinase
deficiency; sequestration like cephalohematoma, subgaleal hemorrhage,
Intracranial hemorrhage; polycythemia, and sepsis.
● Decreased Bilirubin Clearance
○ Crigler-Najjar type I & II, and Gilbert syndrome.
● Miscellaneous Causes
○ Other miscellaneous etiologies include the infant of a mother with diabetes,
congenital hypothyroidism, drugs like sulfa drugs, ceftriaxone, and penicillins,
 Intestinal obstruction, pyloric stenosis, breast milk jaundice, breastfeeding
jaundice.

Conjugated hyperbilirubinemia, also referred to as neonatal cholestasis, is characterized by

elevation of serum conjugated/direct) bilirubin (> 1.0 mg/dL) and is due to impaired hepatobiliary
function. Distinguishing CHB from UHB is critical because cholestatic jaundice/CHB is almost
always pathologic and warrants prompt evaluation and treatment. The causes of neonatal
cholestasis/CHB are extensive and can be classified into the following categories:
● Obstruction of biliary flow: Biliary atresia, choledochal cysts, neonatal sclerosing
cholangitis, neonatal cholelithiasis
● Infections: CMV, HIV, rubella, herpes virus, syphilis, toxoplasmosis, urinary tract infection
(UTI), septicemia
● Genetic causes: Alagille syndrome, alpha-1 anti-trypsin deficiency, galactosemia,
fructosemia, Tyrosinemia type 1, cystic fibrosis, progressive familial intrahepatic
cholestasis (PFIC), Aagenaes syndrome, Dubin-Johnson syndrome, Bile acid synthesis
disorders(BSAD)
● Miscellaneous: Idiopathic neonatal hepatitis, parenteral nutrition induced cholestasis,
gestational alloimmune liver disease/neonatal hemochromatosis, hypotension

ABO Incompatibility
● Most common cause of hemolytic disease in the newborn
● Mother is type O, baby is either type A or B
● Clinical Manifestation:
○ Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
○ No pallor and hepatosplenomegaly
○ Kernicterus and hydrops fetalis is rare

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of hemolytic - Occurs when Rh(+) blood is infused to a
disease of the newborn Rh(-) woman
- Mother is type O and baby is either A or - Rarely occurs in first pregnancy
B

Presentation - Most cases are mild - Mild hemolysis to severe anemia

- Jaundice usually during the first 24 - Jaundice is usually evident on the 1st
hours of life day of life
- MIld hepatosplenomegaly
Diagnostics:
● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

Management:
● Phototherapy
○ 20 cm distance between infant and light source
● Complications of Phototherapy:
○ Loose stools
○ Erythematous macular/ purpuric rash
○ Overheating
○ Dehydration
○ Hypothermia from exposure
○ Bronze baby syndrome
○ Corneal damage
● Intravenous Immunoglobulin
○ Recommended when serum bilirubin is approaching exchange levels despite
maximal interventions including phototherapy.
○ Mechanism: inhibition of hemolysis by blocking antibody receptors on RBCs.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces the
need for exchange transfusion in both ABO and Rh hemolytic disease.
● Transfusion
○ Simple Transfusion
■ Moderate to severe anemia without severe hyperbilirubinemia
■ 10-20 ml/kg over 2-4 hours
● Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
○ Evidence of on-going hemolysis and Total Bilirubin (TB) fails to decline despite
4-6 hrs of intensive phototherapy
○ Rate of increase in TB indicates that level will reach 25 mg/dL within 48 hrs
○ Early signs of bilirubin encephalopathy
○ There is hemolysis causing anemia and hydrops fetalis
● Postdischarge monitoring of hemoglobin or hematocrit is essential in newborns with ABO
hemolytic disease.
JI Garong, Maria Ana Therese D.R.
Prime 2 (Written Output under)
Topic: SGD under Dr. Becina
Date: November 29, 2022

Salient Features
14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnosis:

Rule In Rule Out

Sepsis induced 14 days old (-) fever

Cholestasis (+) generalized jaundice
for 15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) CBC: thrombocytosis
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
(+) Maternal History of UTI
(-) cough, cold
(-) diarrhea, vomiting
(-) Distress
(-) pallor,
(-) neurologic symptoms
To complete rule out base
on laboratory findings

Vitamin K Deficiency No Vitamin K prophylaxis More common in preterm

Bleeding at birth infants
Bruise at the left ankle No maternal intake of
Breast-fed anticonvulsant and anti-TB
Jaundice medications
 Coagulation studies**

ABO Hemolytic Disease
14 days old, Filipino Cannot completely rule out
(+) jaundice within 24 need ABO compatibility
hours from birth test
(+)generalized jaundice for
15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

Initial Diagnosis:
To consider Hyperbilirubinemia secondary to ABO incompatibility; rule out sepsis

Initial Management:
Plan
- Admit the patient
- Secure consent for admission and management
Diet
- Encourage breastfeeding
Diagnostics
- CBC with Platelet Count
- Peripheral Blood Smear
- Bilirubin levels
- Blood culture and sensitivity prior to antibiotics
- Direct Coombs Test
Disposition

- Phototherapy
- Weigh patient daily then record
- Monitor vital signs and record
- Monitor intake and output every shift and record
- Refer accordingly

Case Discussion

Jaundice: accumulation of bilirubin in the skin, sclera, mucosa

● Most common transitional finding in the newborn period

 ● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile
on Bhutani chart

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - Present within 24th-36th hour of

ONSET
3rd day of life life

INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr or

BILIRUBIN >5mg/day

PEAK TOTAL 12 mg/dL >12 mg/dL (full term)

BILIRUBIN 10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

ABO Incompatibility - Most common cause of hemolytic disease in the newborn

● Mother is type O, baby is either type A or B
● Clinical Manifestation:
○ Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
○ No pallor and hepatosplenomegaly
○ Kernicterus and hydrops fetalis is rare

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of - Occurs when Rh(+) blood is

hemolytic disease of the infused to a Rh(-) woman
newborn - Rarely occurs in first
- Mother is type O and pregnancy
baby is either A or B

Presentation - Most cases are mild - Mild hemolysis to severe

- Jaundice usually during anemia
the first 24 hours of life - Jaundice is usually evident
 - MIld on the 1st day of life
hepatosplenomegaly

Diagnosis:
● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

Management:

● Phototherapy
○ 20 cm distance between infant and light source
○ Complications of Phototherapy:
■ Loose stools
■ Erythematous macular/ purpuric rash
■ Overheating
■ Dehydration
■ Hypothermia from exposure
■ Bronze baby syndrome
■ Corneal damage
● Intravenous Immunoglobulin
○ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
● Transfusion
○ Simple Transfusion
● Moderate to severe anemia without severe hyperbilirubinemia
● 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
● Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
decline despite 4-6 hrs of intensive phototherapy
● Rate of increase in TB indicates that level will reach 25 mg/dL
 within 48 hrs
● Early signs of bilirubin encephalopathy
● There is hemolysis causing anemia and hydrops fetalis
● Post-discharge monitoring of hematocrit
JI Gille, Genree Ann B.
Prime 2 (Written Output under Dr Becina)
Small Group Discussion
November 29, 2022

Salient features
14 day old, female
CC: Yellowish discoloration of skin for 15 days
Maternal history
G4P4 (4004); failure of descent
History of UTI (6 months of pregnancy)
Delivered full term, via elective low segment cesarean section
CBC: thrombocytosis
Blood type: B+
Hyperbilirubinemia
Physical examination
Yellowish palpebral conjunctiva
Yellowish sclera
Generalized jaundice
Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnoses

Rule in Rule out

Sepsis Induced 14 days old (-) fever

Cholestasis (+) generalized jaundice (-) cough, cold
for 15 days (-) diarrhea, vomiting
(+)yellowish palpebral (-) Distress
conjunctivae, yellowish (-)pallor,
sclera (-) neurologic symptoms
(+)CBC: thrombocytosis To complete rule out base
(+) Elevated levels of total on laboratory findings
bilirubin, direct bilirubinand
indirect bilirubin
(+) Maternal History of UTI
Vit K Deficiency bleeding No Vitamin K prophylaxis
at birth
Bruise at the left ankle
Breast-fed
Jaundice
More common in preterm
infants
No maternal intake of
anticonvulsant and anti-TB
medications
Coagulation studies

ABO Hemolytic Disease
14 days old, Filipino Cannot completely rule out
(+) jaundice within 24 need ABO compatibility
hours from birth test
(+)generalized jaundice for
15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

Initial Diagnosis
To consider Hyperbilirubinemia secondary to ABO incompatibility; Rule out sepsis

Management
Plan
Admit the patient

Secure consent for admission and management

Diet
Encourage breastfeeding

Diagnostics
CBC with Platelet Count
Peripheral Blood Smear
Bilirubin levels
Blood culture and sensitivity prior to antibiotics
Direct Coombs Test
 Disposition
Phototherapy
Weigh patient daily then record
Monitor vital signs and record
Monitor intake and output every shift and record
Refer accordingly

Jaundice and Hyperbilirubinemia

Jaundice: accumulation of bilirubin in the skin, sclera, mucosa
Most common transitional finding in the newborn period
>5 mg/dL: level at which it becomes clinically apparent
Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile on
Bhutani chart

Physiologic vs Pathologic Jaundice

FORM PHYSIOLOGIC PATHOLOGIC

ONSET Visible on the 2nd - 3rd Present within 24th-36th hour
day of life of life
INCREASE IN TOTAL <5 mg./dL/day Increases by >0.2 mg/dL/hr or
BILIRUBIN >5mg/day
PEAK TOTAL 12 mg/dL >12 mg/dL (full term)
BILIRUBIN 10-14 mg/dL (preterm)
DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

Etiology
Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:
Increased Bilirubin Production
Immune-mediated hemolysis - Includes blood group incompatibilities such
as ABO and Rhesus incompatibility
Decreased Bilirubin Clearance
Miscellaneous Causes

Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia

Obstruction of biliary flow
 Infections
Genetic causes
Miscellaneous

ABO Incompatibility
The most common cause of hemolytic disease in the newborn
Mother is type O, baby is either type A or B
Clinical Manifestation:
Mild, jaundice occurs during the first 24 hours of life and is the only clinical
manifestation
No pallor and hepatosplenomegaly
Kernicterus and hydrops fetalis are rare

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description ● Most common cause of
hemolytic disease of the
newborn
● Mother is type O and baby
is either A or B
Presentation ● Most cases are mild
Jaundice usually during the first
24 hours of life
MIld hepatosplenomegaly
● Occurs when Rh(+)
blood is infused to a
Rh(-) woman
● Rarely occurs in first
pregnancy
● Mild hemolysis to
severe anemia
● Jaundice is usually
evident on the 1st day
of life
JI Gonzales, Jan Chloe C.
Prime 2 (Written Output Dr. Becina)
Topic
Date Nov 29, 2022

Salient features:
● 14 day old, female
● CC: Yellowish discoloration of skin for 15 days
● Maternal history
○ G4P4 (4004); failure of descent
○ History of UTI (6 months of pregnancy)
● Delivered full term, via elective low segment cesarean section
● CBC: thrombocytosis
● Blood type: B+
● Hyperbilirubinemia
● Physical examination
○ Yellowish palpebral conjunctiva
○ Yellowish sclera
○ Generalized jaundice
○ Flat, 3x3 cm bluish gray discoloration on the left ankle

Differential Diagnoses
 Rule in Rule out

Sepsis Induced 14 days old (-) fever

Cholestasis (+) generalized jaundice (-) cough, cold
for 15 days (-) diarrhea, vomiting
(+)yellowish palpebral (-) Distress
conjunctivae, yellowish (-)pallor,
sclera (-) neurologic symptoms
(+)CBC: thrombocytosis To complete rule out base
(+) Elevated levels of total on laboratory findings
bilirubin, direct bilirubinand
indirect bilirubin
(+) Maternal History of UTI

Vit K Deficiency bleeding No Vitamin K prophylaxis More common in preterm

at birth infants
Bruise at the left ankle No maternal intake of
Breast-fed anticonvulsant and anti-TB
Jaundice medications
Coagulation studies**

ABO Hemolytic Disease 14 days old, Filipino Cannot completely rule out
(+) jaundice within 24 need ABO compatibility
hours from birth test
(+)generalized jaundice for
15 days
(+) yellowish palpebral
conjunctivae, yellowish
sclera
(+) Elevated levels of total
bilirubin, direct bilirubin and
indirect bilirubin
Unknown blood type of
parents

Initial Diagnosis: To consider Hyperbilirubinemia secondary to ABO incompatibility;

Rule out sepsis
Initial Management

Plan
- Admit the patient
- Secure consent for admission and management

Diet
- Encourage breastfeeding

Diagnostics
- CBC with Platelet Count
- Peripheral Blood Smear
- Bilirubin levels
- Blood culture and sensitivity prior to antibiotics
- Direct Coombs Test

Disposition

- Phototherapy
- Weigh patient daily then record
- Monitor vital signs and record
- Monitor intake and output every shift and record
- Refer accordingly

Case Discussion

● Jaundice: accumulation of bilirubin in the skin, sclera, mucosa

● Most common transitional finding in the newborn period
● >5 mg/dL: level at which it becomes clinically apparent
● Neonatal Hyperbilirubinemia: total serum or plasma bilirubin >95th percentile
on Bhutani chart

FORM PHYSIOLOGIC PATHOLOGIC

Visible on the 2nd - 3rd day of Present within 24th-36th hour

ONSET life of life

<5 mg./dL/day Increases by >0.2 mg/dL/hr or

INCREASE IN TOTAL
>5mg/day
BILIRUBIN
 12 mg/dL >12 mg/dL (full term)
PEAK TOTAL BILIRUBIN 10-14 mg/dL (preterm)

DIRECT BILIRUBIN <2 mg/dL >2 mg/dL

DURATION < 10-14 days >10-14 days after birth

Etiology

Unconjugated Hyperbilirubinemia/ Indirect Hyperbilirubinemia:

- Increased Bilirubin Production

- Immune-mediated hemolysis - Includes blood group incompatibilities such
as ABO and Rhesus incompatibility
- Decreased Bilirubin Clearance
- Miscellaneous Causes
Conjugated Hyperbilirubinemia/ Direct Hyperbilirubinemia

- Obstruction of biliary flow

- Infections
- Genetic causes
- Miscellaneous

ABO INCOMPATIBILITY Rh INCOMPATIBILITY

Description - Most common cause of - Occurs when Rh(+) blood is

hemolytic disease of the infused to a Rh(-) woman
newborn - Rarely occurs in first pregnancy
- Mother is type O and baby is
either A or B

Presentation - Most cases are mild - Mild hemolysis to severe anemia

- Jaundice usually during the - Jaundice is usually evident on
first 24 hours of life the 1st day of life
- MIld hepatosplenomegaly
Diagnosis:

● Blood Typing
○ ABO Incompatibility
● Direct Antigen Test
○ (+) DAT
● Bilirubin levels (Total, Direct. Indirect
○ Hyperbilirubinemia
● Complete Blood Count with Platelet Count
○ Mild anemia
○ Reticulocytosis
● Peripheral Blood Smear
○ Polychromasia
○ nRBCs
○ Spherocytes

Management:

★ Phototherapy
○ 20 cm distance between infant and light source
★ Complications of Phototherapy:
○ Loose stools
○ Erythematous macular/ purpuric rash
○ Overheating
○ Dehydration
○ Hypothermia from exposure
○ Bronze baby syndrome
○ Corneal damage
★ Intravenous Immunoglobulin
○ recommended when serum bilirubin is approaching exchange levels
despite maximal interventions including phototherapy.
○ Intravenous immunoglobulin (0.5-1.0 g/kg/dose; repeat in 12 hr) reduces
the need for exchange transfusion in both ABO and Rh hemolytic disease.
★ Transfusion
○ Simple Transfusion
- Moderate to severe anemia without severe hyperbilirubinemia
- 10-20 ml/kg over 2-4 hours
○ Exchange Transfusion: For severe anemia with severe hyperbilirubinemia
- Evidence of on-going hemolysis and Total Bilirubin (TB) fails to
decline despite 4-6 hrs of intensive phototherapy
- Rate of increase in TB indicates that level will reach 25 mg/dL
within 48 hrs
 - Early signs of bilirubin encephalopathy
- There is hemolysis causing anemia and hydrops fetalis
★ Post-discharge monitoring of hematocrit