CASE REPORT

Hiperbilirubinemia
Pembimbing:
dr. Nurifah, Sp. A
Oleh:
Felicia Cynthiadewi Y. (202006010046)

KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS KATOLIK INDONESIA ATMA JAYA
RUMAH SAKIT UMUM BHAYANGKARA TK.1. PUSDOKKES POLRI
PERIODE 2 JANUARI - 11 MARET 2023
01 CASE ILLUSTRATION
IDENTITY
NAME By. Ny. M

GENDER Female

AGE 3 days old

RELIGION Moslem

ADDRESS Jl. RS Polri 006/005

DATE OF BIRTH 9 January 2023

EXAMINATION
12 January 2023 at 12.00
DATE
ANAMNESIS

CHIEF COMPLAINT ADDITIONAL COMPLAINT

The patient’s body turned
None
yellow since yesterday
afternoon
HISTORY OF PRESENT DISEASE
9-11 January ‘23
Still being treated in Bougenville, because of
TTN and GDS 53 mg/dL

1 2 3
9 January ‘23 11 January ‘23
Day of birth The body turned
yellow (head, upper &
lower abdomen, thighs)
HISTORY
MEDICAL HISTORY
01 ● CPAP FiO2 25%, PEEP 8, flow 8 → for 3 days
(9 January - 11 January 2023)
● IVFD D10% 80 cc/kgBB/jam
● IVFD Aminosteril 6% 40 cc/hari
● IVFD N5 + KCl + Ca gluconas 13 cc/jam
● Ampicillin Sulbactam 2 x 250 mg IV
HISTORY PREGNANCY & DELIVERY HISTORY

02 2nd child
Birth age 38 weeks, sectio caesarea (BSC 1x)
ANC is routinely checked with healthy results

IMMUNIZATION HISTORY
03 1st Hepatitis B immunization 4 hours after birth

FAMILY MEDICAL HISTORY

04 N/A

PERSONAL & SOCIAL HISTORY

05 N/A
HISTORY GROWTH & DEVELOPMENTAL HISTORY

Ballard’s Score : 35 → Appropriate for gestational age (AGA)

Primitive Reflexes (+), consisting of:

● Glabellar Reflex
● Snout Reflex
● Rooting Reflex
● Sucking Reflex
● Palmomental Reflex
● Grasp Reflex
● Moro Reflex
● Galant Reflex
● Asymmetrical Tonic Neck Reflex
● Babinski Reflex
● Placing Reflex
● Walking Reflex
PHYSICAL EXAMINATION

General Appearance : Spontaneously crying, active movement

Level of Consciousness : Compos Mentis (E4V5M6)
Vital Signs :
● HR : 132 x/min
● RR : 45 x/min
● T : 36,9 oC
● SpO2 : 100% on NC ½ lpm
 Anthropometry Data

Age : 3 days old

BW/A =124/6%
Weight : 4.360 gram
BH/A = 104%
Height : 52 cm BW/BH = 114,7% (overweight)
HC : 38 cm
CC : 36 cm
AC : 32 cm
 General Status
HEAD Normocephali, black hair, deformity (-), Jaundice (+)

EYES Pale conjunctiva -/-, icteric sclera +/+

ENT Normotia, discharge (-), deformity (-), nostril breathing (-), tonsil T1/T1

MOUTH Moist oral mucosa

NECK Lymph node enlargement (-), Jaundice (+)

Symmetrical shape and movement of the chest, intercostal retraction (-), Jaundice
THORAX
(+)

PULMO Symetrical vocal fremitus, Vesicular, rhonci (-), wheezing (-)

Ictus cordis not visible nor palpable, normal heart border, regular I & II sounds,
HEART
murmur (-), gallops (-)
 General Status

● Flat, Jaundice (+)

● Bowel sound (+) 4x/min
ABDOMEN ● Liver is palpable 1 cm below the rib cage, sharp border
● Spleen not palpable
● Palpation pain (-)

● The minor labia is enclosed by major labia

ANOGENITALIA
● Urethra (+), Vagina (+), Anus (+), fistula (-)

● Warm, CRT < 2 s, edema (-/-/-/-), normal skin turgor

EXTREMITIES ● Sianosis (-)
● Jaundice (+) in upper extremities
 PHYSICAL EXAMINATION

● Icteric skin (+)

● Kramer 3
 LABORATORY EXAMINATION
12/1/2023
Pemeriksaan Hasil Nilai Rujukan Unit

HEMATOLOGI
Darah Rutin 13.1 15.0-24.6 g/dL
Hemoglobin 39 45-75 %
Hematokrit 11.650 5.000-21.000 /uL
Leukosit 209 229-553 ribu/uL
Trombosit
Bilirubin 0.28 <0.5 mg/dL
Bilirubin direk 11.02 <1.0 mg/dL
Bilirubin indirek 11.30 <12 ,g/dL
Bilirubin total 1.63 <0.5
Pro-Calcitonin
 Babygram
9/1/2023
● Heart is not enlarged
● The superior mediastinum is not dilated
● The bronchovascular pattern of both lungs is good,
reticulogranular infiltrates in the perihiler and right
paracardial areas of both costophrenic sinuses and
hemidiaphragm are good
● Intestinal gas distribution reaches the minor pelvis
● No dilatation or intestinal wall thickening is seen
Impression: TTN (transient tachypnea of the
newborn)
 Resume

A patient, 3 days old, was born at Bhayangkara Tk. I R. Said Sukanto Hospital in 9
January 2023 and was being observed at Bougenville ward with complaints of the body
turned yellow since yesterday afternoon (day-3). There were no additional complaints.
From physical examination, patient had icteric sclera (+/+), hepatomegaly 1 cm
below the rib cage, jaundice Kramer 3.
From the laboratorium test, total bilirubin 11.30 mg/dL, Direct bilirubin 0.28
mg/dL, Indirect Billirubin 11.02 mg/dL, Pro-Calcitonin 1.63. Babygram radiology with
impression TTN.
Diagnosis
● Hyperbilirubinemia
● Transient tachypnea of the newborn with
improvement
● Full-term neonatus
● Large for gestational age (LGA)
 MANAGEMENT

Pediatrician Co-Assistant
● Blue light ● Educate the parents about
● Oxygen NC ½ lpm hyperbilirubinemia in newborns
● Ampicillin sulbactam 2 x 250 mg ● Blue light
IV (H3) ● Oxygen NC ½ lpm
● ASI (continue) ● Ampicillin sulbactam 2 x 250 mg
IV (H3)
● ASI (continue)
PROGNOSIS

● Quo ad vitam: bonam

● Quo ad functionam: bonam
● Quo ad sanationam: bonam
 FOLLOW UP
13 January 2023 (day 5, day of sick 3)

Subjective Objective Assessment Planning

Tend to sleep a lot, Moderately ill ● Hyperbilirubine ● Blue light

spontaneously Compos Mentis mia ● Oxygen NC ½ lpm
crying, yellow on RR: 46x/min, ● Transient ● Ampicillin
tachypnea of the sulbactam 2 x 250
the body started to HR: 135x/min, newborn with mg IV (H4)
disappear T: 36.8 oC improvement ● ASI (continue)
-Head: normocephalic ● Full-term
-Eyes: Icteric Sclera (+/+) neonatus
-ENT: no deformity, Tonsil T1/T1 ● Large for
-Mouth: Wet lips (+), wet oral mucosa gestational age
(LGA)
 FOLLOW UP
13 January 2023 (day 5, day of sick 3)
Subjective Objective Assessment Planning

-Neck: Lymph node enlargement (-)

-Pulmo: Vesicular +/+, rhonchi -/-, wheezing -/-
-CV: Regular I & II heart sound, murmur (-),
gallop (-)
-Abdomen: Flat, Bowel sound (+) 4x/min, liver
and spleen are not palpable
-Genitalia: Normal
-Extremity: Warm, CRT <2s, edema (-/-/-/-)
-Integument : Jaundice, Kramer 1
 FOLLOW UP
14 January 2023 (day 6, day of sick 4)

Subjective Objective Assessment Planning

Tend to sleep a lot, Moderately ill ● Hyperbilirubine ● Blue light

spontaneously Compos Mentis mia ● Ampicillin
crying, yellow on RR: 22x/min, ● Full-term sulbactam 2 x 250
neonatus mg IV (H4)
the body has HR: 105x/min, ● Large for ● ASI (continue)
disappeared T: 36.8 oC gestational age
-Head: normocephalic (LGA) Patient allowed to go
-Eyes: Icteric Sclera (-/-) home
-ENT: no deformity, Tonsil T1/T1
-Mouth: Wet lips (+), wet oral mucosa
 FOLLOW UP
14 January 2023 (day 6, day of sick 4)
Subjective Objective Assessment Planning

-Neck: Lymph node enlargement (-)

-Pulmo: Vesicular +/+, rhonchi -/-, wheezing -/-
-CV: Regular I & II heart sound, murmur (-),
gallop (-)
-Abdomen: Flat, Bowel sound (+) 4x/min, liver
and spleen are not palpable
-Genitalia: Normal
-Extremity: Warm, CRT <2s, edema (-/-/-/-)
-Integument : Jaundice (-)
Lab (14/2/2023)
Pro-calcitonin: 0.28
Literature
Review
 Definition of Hyperbilirubinemia

A transient condition which is often found in full-term newborn (50-70%) and

preterm newborn (80-90%) with serum level of total bilirubin ≥5 mg/dL (86
μmol/L)
-IDAI-

Excessive accumulation of bilirubin in the blood that is characterized by

jaundice, discoloration of the skin, sklera, and nails into yellow.
Hyperbilirubinemia also can be seen clearly if the serum level of total bilirubin
5-7 mg/dL
-Ministry of Health RI-
 more common in low- and middle-income countries
EPIDEMIOLOGY such as: sub-Saharan Africa and East Asia

1 week old
newborn

Pre-term newborn
60-80%
Mostly physiological jaundice

1.1 million infants

Severe hyperbilirubinemia with or
without bilirubin encephalopathy
ETIOLOGY
2 types of newborn hyperbilirubinemia

Indirect Direct
Hyperbilirubinemia Hyperbilirubinemia
● Increase production of bilirubin ● Obstruction of biliary flow
● Decrease in clearance of bilirubin ● Infeksi
● Other causes ● Genetic
● Other causes
 Indirect Hyperbilirubinemia
(Increase production of bilirubin)

Immune-mediated hemolysis

01 02
ABO incompatibility Rhesus incompatibility

Nonimmune-mediated hemolysis

01 02 03
RBC membrane defects RBC enzyme defects sequestration (cephalohematoma,
● G6PD deficiency subgaleal hemorrhage, ICH,
● pyruvate kinase polycythemia,sepsis)
deficiency
Indirect Hyperbilirubinemia
Decrease in clearance bilirubin

01 02
Crigler-Najjar type 1 & 2 Gilbert Syndrome

Other causes

01 02 03
Breast milk jaundice Breast feeding jaundice Infant of a mother with diabetes,
congenital hypothyroidism, drugs,
intestinal obstruction, pyloric
stenosis
Direct Hyperbilirubinemia
Neonatal Cholestasis → direct bilirubin level >1 mg/dL

01 02
Obstruction of biliary flow Infection
● Biliary atresia CMV, Hepatitis, sifilis, rubella,
● Choledocal cyst toxo, herpes
● Neonatal cholelitiasis
● Neonatal sclerosing cholangitis

03 04
Genetic Other causes
● Alagille syndrome ● Idiopathic neonatal hepatitis
● Aagenaes syndrome ● Hypotension
● Cystic fibrosis
Risk Factor
PATOPHYSIOLOGY
DIAGNOSIS
ANAMNESIS

● Family history of jaundice, anemia, splenectomy, spherocytosis, G6PD

deficiency, liver disease
● Relative history of jaundice or anemia
● History of illness during pregnancy
● History of drug use during pregnancy
● History of traumatic birth
● Administration of total parenteral nutrition
● Breastfeeding
DIAGNOSIS
PHYSICAL EXAMINATION

● Signs of prematurity
● Small for gestational age
● Signs of intrauterine infection (microcephaly, small gestation)
● Extravascular bleeding
● Paleness
● Petechiae
● Hepatosplenomegaly Omphalitis
● Chorioretinitis
● Hypothyroid sign
● Change in stool color to pale
DIAGNOSIS
PHYSICAL EXAMINATION
Kramer scoring
DIAGNOSIS
LABORATORY EXAMINATION

● Total, direct, and indirect serum bilirubin

● Complete peripheral blood, peripheral blood smear, reticulocyte counT
● Blood type, Rhesus, and direct Coombs' test of mother and baby to look for
hemolytic disease
● G6PD enzyme levels in erythrocytes
● Liver function tests, urine tests
● If sepsis is clinically suspected → blood culture examination, CRP and Pro-
Calcitonin
 Nomogram for Hyperbilirubinemia

Total serum bilirubin (TSB) nomogram:

● Delivered at ≥ 36 weeks’ gestation
with birth weight of at least 2,000 g
● Delivered at ≥ 35 weeks’ gestation
with birth weight of at least 2,500 g
Treatment
Blue light phototerapy

Blue-green spectrum with wave

length 430-490 nm and minimum
strength 30 uW/cm2
Treatment
Exchange transfusion
The act of exchanging a baby's blood with donor blood by removing and replacing a large amount of blood
repeatedly over a short period of time
Treatment
Breast-feeding jaundice
● Monitor the amount of breast milk given, whether it is sufficient or not
● Breastfeeding from birth at least 8 times a day
● Provision of water, sugar water, and replacement formula is not needed.
● Monitor weight gain and frequency of urination and bowel movements
● If the bilirubin level reaches 15 mg/dL, it is necessary to increase the fluid volume and
stimulate milk production by expressing the breasts.
● Examination of the components of breast milk is carried out if hyperbilirubinemia
persists >6 days, bilirubin levels >20 mg/dL, or a history of previous breastfeeding
jaundice in children
Treatment
Breast-milk jaundice
● The American Academy of Pediatrics → does not recommend stopping
breastfeeding and recommends continuing breastfeeding
● Gartner and Aurbach → temporarily stopping breastfeeding to allow the liver
to conjugate excess indirect bilirubin
CASE
ANALYSIS
 CASE ANALYSIS
Case Literature
Definition
Hyperbilirubinemia in neonates can be seen Full-term Newborn with serum level of total
when the blood bilirubin level is 5-7 mg/dL bilirubin of 11.30 mg/dL

Epidemiology
st Newborn, 3 days old, jaundice (+)
Often found in the 1 week of life of 8-11%
newborns
 CASE ANALYSIS

Case Literature
Risk Factor

● Major risk factor Patient with gestational age of 38 weeks,

birth weight of 4,450 grams (macrosomic
● Minor risk factor
baby), female, with mother's age of 32 years.
● Decreased risk
Patients are categorized in the minor/low risk
category
 CASE ANALYSIS

Case
Etiology
2 types of newborn hyperbilirubinemia:
● Direct hyperbilirubinemia / Conjugated
hyperbilirubinemia
● Indirect hyperbilirubinemia /
Unconjugated hyperbilirubinemia
In physiological hyperbilirubinemia,
unconjugated bilirubin is the predominant
product and usually the serum level is less than
15 mg/dl.
Literature
Serum level :
● Total bilirubin: 11.30 mg/dL
● Direct bilirubin: 0.28 mg/dL
● Indirect Billirubin: 11.02 mg/dL
Classified as Indirect Physiologic
Hyperbilirubinemia
 CASE ANALYSIS

Case Literature
Diagnosis

Anamnesis Family history was denied

● Family history of jaundice, anemia, splenectomy,
spherocytosis, G6PD deficiency, liver disease Patient was born by sectio caesarea
● Relative history of jaundice or anemia
because history of SC 1x
● History of illness during pregnancy
● History of drug use during pregnancy
● History of traumatic birth
● Administration of total parenteral nutrition
● Breastfeeding
 CASE ANALYSIS

Case Literature
Diagnosis

Physical Examination ● Jaundice, Kramer III

● Signs of prematurity ● Hepatosplenomegali (+)
● Small for gestational age ● No other abnormalities
● Signs of intrauterine infection
● Extravascular bleeding
● Paleness, Petechiae
● Hepatosplenomegaly, Omphalitis
● Chorioretinitis, Hypothyroid sign
● Change in stool color to pale
● Kramer score
 CASE ANALYSIS
Case Literature
Diagnosis

Lab Examination Patient only be tested for the serum

● Total, direct, and indirect serum bilirubin bilirubin and Pro-calcitonin :
● Complete peripheral blood, peripheral blood ● Total bilirubin: 11.30 mg/dL
smear, reticulocyte count ● Direct bilirubin: 0.28 mg/dL
● Blood type, Rhesus, and direct Coombs' test of ● Indirect Billirubin: 11.02 mg/dL
mother and baby ● Pro-calcitonin: 1.63
● G6PD enzyme levels in erythrocytes
● Liver function tests, urine tests
● Blood culture examination, CRP and Pro-
Calcitonin
 CASE ANALYSIS

Case
Therapy
● Blue light phototherapy
● Exchange transfusion
● Breast milk
Literature
● The patient was given phototherapy
treatment with blue light for 3 days and
given the antibiotic Ampicillin Sulbactam 2
x 250 mg IV
● Once found there is no jaundice in the
patient and the patient can breathe
spontaneously. The patient is allowed to go
home
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 BIBLIOGRAPHY
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