1. Case Presentation A 20hr-old newborn with icteric skin
Huang, ChengMin
4C Conference Room

2. Identification 20 hr-old, female 蔡X雯之女 Chart No:1235040X
Date of Admission: 96/11/16
Chief Complain
Icteric skin noted within 24 hours after birth

3. Present illness
This female infant, who weighted 3316g, was born by vaginal delivery at 39+2 weeks' gestation to a healthy 32-year-old mother after an uncomplicated pregnancy.
However, yellowish skin color with jaundice extending to lower legs was found by our staff on the next day (20hrs after birth). The infant did not have high pitch crying nor abnormal reflex. The TcB level was 18.5 and SB showed 26.3.
Therefore, she was transferred to our NICU promptly.

4. Birth and Family History
Birth History:
G2P2, GA: 39+2 weeks, BBW:3316g, DOIC(-),
PROM(-) Apgar score:9-->10　　
Vaccination: Nil
Feeding: Breast milk
Growth and Development:
BW:3316g (50-75th%), BL:49cm (25-50th%),
HC:33cm (25-50th%)
Family History:
1. Father: type O, Mother: type O, Rh: (+)
2. No G6PD deficiency history
Prenatal screening revealed that the mother had type A Rh-positive blood.

5. Physical Examination General appearance: normal term Vital sign:
BT:36.8C, P:138/min,
R:40/min, BP:66/43 mmHg
Color: yellowish
Perfusion: good
Head: no cephalohematoma
Eyes: icteric sclera
Ears: normally set, formed
Mouth: n.p.
Neck: n.p
Chest expansion: good
Chest retraction:
normal breathing sound
Heart: normal splitting
Abdomen: flat, soft
Liver: 2cm below costal margin
Spleen: impalpable
Umbilicus: n,p,
Genitalia: normal
Anus: normal
Reflexes: normal
Muscle tone: good

6. Laboratory Examinations
WBC H 27.0 K/cmm | RBC L 3.20 M/cmm
Hb g/dl | Hct %
MCV H fl | MCH H 37.4 pg
MCHC g/dl | RDW H 18.5 %
Pl H 400 K/cmm | Reti H 15.2 %
Blast / % | Pro %
Myelo % | Meta %
Band % | Seg H 67.5 %
Eos / % | Baso %
Mono % | Lymph L 6 %
Aty-lym / % | NRBC %
Remarks / |
<緊急血液檢驗報告> 醫師: 陳永榮 採檢:96/11/16 全血 8262L42026
PT secs | PT(NP) secs
APTT secs | APTT(NP) secs

7. Laboratory Examinations
GLU.A.C. L 49 mg/dL | CREA H 1.3 mg/dL
BIL-T H 21.9 mg/dL | BIL-D mg/dL
AST H 102 U/L | BUN mg/dL
LD H 778 U/L | CA L 8.0 mg/dL
P H 5.7 mg/dL | NA mmol/L
K mmol/L | CL mmol/L
ALT U/L | CRP mg/L
ALBUMIN g/dL |
<緊急尿液，糞便檢驗報> 醫師: 陳永榮 採檢:96/11/16 尿液 8263K98739
SG <= | PH
LEU NEGATIVE /UL | NIT POSITIVE
PRO mg/dL | GLU NEGATIVE mg/d 0-30
KET NEGATIVE mg/d | UBG E.U. mg/d 0-1
BIL mg/dL | ERY NEGATIVE /UL
WBC /HPF | RBC /HPF
Epith /HPF | Cast / /LPF
Crystal / /HPF | Bacteria +
Remark / |

8. RBC Morphology
<一般血液檢查報告> 醫師: 陳永榮 採檢:96/11/17 全血 8221K95438
RBCmo |
COMMENT : RBC morphology:
Size: ANISOCYTOSIS(++)
Color: NORMOCHROMIC, POLYCHROMASIA(++)
Shape: TEAR DROP CELLS(+), BURR CELL(+)

10. Tentative Diagnosis
Neonatal hyperbilirubinemia
Hemolytic anemia

11. Diagnostic Test
HDN Investigation:
Baby Blood Typing:
ABO Type: O
Rh Typing D:+
Direct Coombs Test:3+(strong) reaction
Antibody Screening Test: positive
Mother Blood Typing:
Direct Coombs Test: negative reaction
Antibody Identification Report:
ABO Type: O+
Direct Coombs Test:2+(strong) reaction
Coombs C3d Monospecific Test: negative reaction
Coombs IgG Monospecific Test: 2+(strong) reaction
Antibody identification: Anti-c
Mother’s serum: anti-c and anti-E antibody

12. Management Exchange blood transfusion.
Prepare compound blood ( type O RBC Hct:45%, and type AB FFP)
Intensive phototherapy
IVF hydration: 140ml/kg/day.
Arrange Auditory brainstem response (ABR) test.

13. Procedures of Exchange Transfusion
Reserved for dangerously high indirect bil. Level
Remove sensitized RBC and circulating Abs
Lower serum bilirubin
repeated until twice the blood volume has been replaced.
BW:3.3kg
15ml per cycle, 30 cycles, weight (kg) x 80ml/kg x 2
21.9(16:43)14.8(10hr)14.3(13hr)
Complications
Infection, NEC, thrombus, thrombocytopenia
Arrhythmia, electrolyte imbalance
Hypoglycemia

14. Indications for Exchange Transfusion
Evidence of acute bilirubin encephalopathy
Hypertonia, hyperextension of neck, arching of back (opisthotonos), high pitched cry, fever.
Full Term Babies (>38 weeks)
Hemolysis (due to any cause) or other risk factors
total bilirubin level exceeds 22.5 mg/dl after 6 hours of intensive phototherapy.
Bilirubin : Albumin Ratio.

15. AAP Guidelines for Exchange Transfusion
Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114:

16. Novel Therapy
IVIG mg/kg reduce the need for ET with hemolytic disease (Rh or ABO)
Acta Paediatr 1999; 88:216
J Int Med Res 1995; 23:264
Phenobarbital increases the conjugation and excretion of bilirubin
Dev Pharmacol Ther 1990; 15:215
Metalloporphyrins reduce bilirubin production by competitive inhibition of heme oxygenase
Pediatrics 1995; 95:468
Pediatrics 1999; 103:1

17. RhD haemolytic disease of the fetus and the newborn.
Blood Rev Mar;14