CASE STUDIES: HYPERBILIRUBINAEMIA BY: NICOLE STEVENS

Case Study 1 Maternal history: Gravida 5, Para 4 (after birth of Eric) Blood group O+ve; anti-c, anti-e antibodies pos GBS neg, Hep B/syph/HIV neg Hep C pos Smoker (15 day) Normal morphology scan; 32/40 scan showing asymmetrical growth restriction

Case Study 1 Induction of labour for IUGR & polyhydramnios 1225hrs, Normal vaginal birth Live born male, Apgars 36.6wks, Birth weight: 2600gs Transferred to postnatal ward for ongoing care Mother planning to breastfeed

Case Study 1 17/5 On examination by midwife at 33hrs of age, noted to be jaundiced. Had been feeding 2-3/24; had not passed mec since birth SBR taken: 228 micromol/L (in exchange range); paediatric team notified Seen by paed, admitted to SCN, quadruple phototherapy lights commenced

Case Study 1 Plan (17/5): Feed to maintain TFI at 80mL/kg; EBM/formula 3x8 Bloods to be taken in 4hrs (Blood group, coombs and repeat SBR) Monitor abdomen, notify paeds of distention or feed intolerance. Note: large mec stool passed shortly after admission to SCN

Case Study 1 SBR 4 hrs later (37hrs): 212 (out of exchange range); passing concentrated urine Plan: Continue quadruple lights, remain in isolette Repeat SBR in 6hrs: 178 (out of phototherapy range) Plan (18/5): Feeds increased to 100mL/kg Reduce to double phototherapy Note results back from group and coombs: O Pos, pos coombs, anti-IgG pos, anti-C3 neg

Case Study 1 Plan 19/5 – 20/5 (day 4 – 5): Increased TFI to 120mLs/kg Out of isolette for feeds Mum suppressed lactation, bottle feeding on NanHa Daily blood tests continuing Baby examining well, alert vigorous, fully suck feeding. Normal weight loss post birth

Case Study 1 Day 6 down to single lights. Continue daily bloods, regular feeds Day 10 back up to triple lights. Day 11 back to birth weight. Day 12 decrease to double lights

Case Study 1 Day 13 continuing decrease in Hb, pale, slightly lethargic, but haemodynamically stable Given blood transfusion. IV bung inserted and given 50mLs PRBC (19mL/kg), expected to raise Hb by 4.7g/dL 6 grams intragram P also given, IV, over several hours

Case Study 1 Day 14 reduced to single lights Day 15 phototherapy ceased Home day 18 with paediatric clinic follow up with repeat Hb and retics prior to this appointment Discharge wt: 2790g, 39.3wks CA Discharge medications: Folate and ferrous suphate daily.

10. Pathology summary DateTimeSBR Hbother 17/ /6 18/ / Hct 48.8%, plat / /6 Opos, coombs pos, anti-C3:neg, anti-IgG: pos 19/ /12 20/ /8 21/ /7 22/ /7 23/ /7 24/ / / /29 26/ /

11. Pathology summary DateTimeSBR Hb other 27/ /8 28/ / / / PRBC transfusion 30/ / / / / / DISCHARGED HOME 19/6 (outpt f/up) 8.4 retics 3.1% 6/7 8.6 retics 2.6% 25/ /9 13.5

12. Considerations Communication from antenatal care providers to paediatric team regarding maternal anti-e, anti-c antibodies Early screening of SBR (cord blood) Closer monitoring and awareness in first 24 hrs Physiological v’s Pathological jaundice Early onset jaundice can be a neonatal emergency Haemolytic disease of the newborn Action of phototherapy

Case study 2 Multipara G3P2, 39+2wks gestation Repeat elective caesarean section booked O+ve, antibodies neg, rubella immune GBS –ve, well through pregnancy No other history of note

Case Study 2 Date of birth 29/7/11 Time of birth 0930hrs Live female infant Born via EL LUSCS Apgars To postnatal ward for routine care Weight 3590g

Case Study 2 Noted to be jaundiced at 26 hrs of age SBR taken: 188/ hrs) Just at treatment line Double phototherapy commenced Breast feeds + 90mL/kg topups Further bloods taken at 2020hrs (35hrs old):SBR: 186/12. Going away from treatment line (below) Blood group: A+ve, DAT: positive, Hb: 12.9, WCC: 25.5, Platelets: 267

Case Study 2 Double lights continued Bloods repeated 0615hrs (45hrs old): SBR: 158/9 Phothotherapy ceased Bloods repeated 12 hrs later: SBR 168/11 Remained out of lights Bloods repeated 24 hrs later (69hrs old): SBR: 171/12, Hb: 12.7 Minimal rise, unconcerning

Case Study 2 Mum suppressed lactation Discharged home Day 4, bottle feeding Followed up by DOM service No further issues NICE guidelines currently the tool in use in SCN at BHS, other places will have different tools which will slightly alter the ranges. (National Institute for Health and Clinical Excellence: treatment threshold graphs for babies with neonatal jaundice).

ABO incompatability A common and generally mild type of haemolytic disease in babies Occurs, usually, with an O group mum and an A or B group baby Prem babies will be more severely affected than healthy term babies. Does not become more severe in future pregnancies (such as with the negative blood group mothers)

ABO incompatability Review of blood types: The genes you inherit from your parents determine your blood group; there are 4 (major) types:A, B, AB & O Each type has an individual collection of chemicals on the blood cell surface, known as antigens A has A antigen, B has B antigen, AB has both and O has none If different blood types mix, an immune response occurs and antibodies will be produced to attack the foreign antigen

ABO incompatability Generally during pregnancy mother and fetus’ blood doesn’t mix, but it can (miscarriage, trauma, birth and sometimes for unknown reasons) The O group mum may produce antibodies against an A, B or AB group baby, these antibodies can cross the placental membrane and increase the rate of haemolysis (red blood cell destruction), hence increasing the production of bilirubin – a waste product

Jaundice and length of stay Readmit from home, dehydrated, no underlying haemolytic disease – if treated and fed usually only 24 – 48 hrs stay required. Increase education to parents, if breastfeeding, provide lactation support Premature baby, may be a reoccurring problem over first 1 – 2 weeks of life, usually resolved by the time baby otherwise ready for home Pathological/haemolytic cause: can be protracted length of treatment over 1 – 2 wks (sometimes longer), with rebounds. Long term anaemia may result in need for top up transfusions. Breast milk jaundice: months, low levels persisting over prolonged period of time, not usually requiring treatment beyond the first 1 – 2 weeks. Diagnosed by exclusion after several weeks.

Nursing Care Educate parents Maximise time under lights and surface area exposed (lights above and below in more severe cases). Big nappies covering half the body need to be folded down/minimised; don’t over nest and reduce exposure to lights. Consider nappy off & staying in incubator to feed in pathological cases (in early days if levels high) If coming out for feeds, keep it brief. Eye care Skin care Feeding support/establishment of lactation

CASE STUDY 3 Multipara G3P2, 39.2wks gestation Repeat elective caesarean section booked O+ve blood group, antibodies neg, rubella immune, GBS –ve Well through pregnancy No other history of note

CASE STUDY 3 Time of birth 0930hrs (day 1) Live female infant Born via EL LUSCS Apgars To postnatal ward for routine care Weight 3590g

CASE STUDY 3 Noted to be jaundiced at 26hrs of age SBR taken: 1130hrs (day 2) Double phototherapy lights commenced Breast feeds and 90mL/kg topups given Further bloods taken at 2020hrs (35hrs of age): SBR: 186/12; blood group: A +ve, DAT positive; Hb: 12.9, WCC: 25.5, Platelets: 267

CASE STUDY 3 Double lights continued Bloods 0615hrs (45hrs old, day 3), SBR: 158/9 Phototherapy ceased Bloods repeated 12 hrs later, SBR: 168/11 Remained out of lights Bloods repeated 24hrs later (69hrs old), SBR: 171/12, Hb: 12.7

CASE STUDY 3 Mum suppressed lactation Discharged home day 4, bottle feeding Followed up by DOM service No further issues

Questions Would you call this a physiological or a pathological jaundice? What is your diagnosis? Are there any ‘warning bells’ in the maternal history?

Questions Would you take this baby out of the isolette for breastfeeds? Nappy on or off? Why would bloods be repeated again the same day? There was minimal change in the SBR after several hours of treatment, would that be expected in this case?

QUESTIONS What are some other causes for pathological jaundice? What is the common factor no matter the cause? Hint, regularly monitor the babies FBE as well as their SBR Parent education – how do we explain jaundice and phototherapy to parents?

G6pd What is that an abbreviation for? Why is it significant when we talk about jaundice in newborns? What are some of the triggers that exaccerbate this condition?

G6pd Does it affect men or women more? Which nationalities are more commonly affected? Is it hereditary?

CASE STUDY 4 G1P1, PPROM (4 days prior to birth), 33wks, received oral then IV antibiotics O+ve blood group, GBS+ve, normal USS Hospitalised after ROM’s Unexpected, precipitate, breech vaginal birth in ward Obstetric response called Paed team arrived as male infant born

CASE STUDY 4 Required IPPV with air and then oxygen for over first 5 mins of life, CPAP for several more minutes, weaned to air, off and managed well. Extensive bruising noted to upper legs, buttocks and scrotum Apgars and Admitted to SCN; BW: 2230g

CASE STUDY 4 IV bung inserted, bloods taken for CRP, cultures & FBE, surface swabs taken and gastric aspirate taken Significant malodour noted from baby Moved to isolette commenced on IV 10% 60mL/kg Antibiotics continued for 5 days, fluids increased daily, enteral feeds increased and IV fluids decreased accordingly Baby remained well respiratory wise

CASE STUDY 4 Baby B +ve, DAT neg Hb: 16.9 Other bloods NAD, gastric aspirate grew ureaplasma urealyticum (associated with PROM’s) SBR 47hrs of age 219/8; phototherapy commenced SBR 73hrs of age; ptx ceased SBR 97hrs of age; remained out of ptx

QUESTIONS Is this a pathological or physiological jaundice? What are this babies risks factors for elevated SBR levels? Nursing considerations – in or out for feeds? Nappies on or off? Eye care? BA’s – what to expect and what to explain to parents? Documentation, funding etc