1. PREDICTION OF OUTCOME IN ABO INCOMPATIBLE NEONATES WITH RESPECT TO MATERNAL IgG ANTI-A AND ANTI-B TITRE IN O GROUP MOTHERS Govt T.D Medical College, Alappuzha Dr Shahida, Dr Meena D, Dr Sasikala N, Dr Mayadevi S

2. BACKGROUND
The fetus may inherit father’s blood group whose antigen on red cells has corresponding antibodies in the mother resulting in maternal-fetal blood group incompatibility.
As the incidence of Rh D alloimmunization has decreased after the introduction of anti-D prophylaxis, ABO-incompatibility is now the major cause of immune hemolytic disease of the newborn
Problems encountered from ABO maternal antibodies to the corresponding A or B antigens on the fetal red cells stimulated this study

3. AIM
To evaluate predictors for risk of hyperbilirubinaemia in ABO- incompatible neonates with emphasize on maternal IgG anti-A ⁄ B titres
To assess if maternal antibodies were associated with increased duration of phototherapy or repeated invasive treatment with IVIG or EXT

4. METHODS OF STUDY
Cross sectional study, for a period of one and half years
Inclusion criteria - O group mothers who had good obstetric history
- Maternal antibody screen negative for other blood group systems
- A and B group babies with same Rh-D status as that of mother
with no predisposition to other causes of hyperbilirubinemia
Consent when admitted for labor/immediate postnatal period
627 healthy Blood group O women recruited/ 200 with A or B infants .
Baby’s sample- ABO and Rh typing, DAT
Maternal sample- ABO and Rh typing,
- IgG anti-A/B titre estimation by tube technique (with DTT)

5. DEMOGRAPHIC CHARACTERISTICS OF 200 NEWBORNS WITH ABO INCOMPATIBILITY
Total (n=200)
Gestational Age
Preterm(36wks)
Term (37-40wks)
Post term (>40wks) 7
192 1
Birth weight
2–2.49 kg kg
≥4 kg 17
180 3
Gender
Male
Female
115 85
Blood group A B
Parity
Primigravida
Multigravida 99
101 89
111
DEMOGRAPHIC CHARACTERISTICS OF 200 NEWBORNS WITH ABO INCOMPATIBILITY
Gender and birth weight had no relation with clinical outcome
ABO incompatibility was observed in 31.8% of pregnancies with almost equal O–A (99)
and O–B (101) frequencies
Number of affected newborns were
higher in primigravidae (39/93)

6. CLINICAL CHARACTERISTICS OF 200 NEWBORNS WITH ABO INCOMPATIBILITY
Total
Number
Significant hyperbilirub-
inaemia
Yes No
93 (46.5%)
107
Initial Hb
≥17 (no anemia)
(mild-mod)
≤12 (severe)
115 (57.5%) 81 4
Evidence of hemolysis
Present
Absent
21 (10.5%)
179
Reticulocyte count
≥6.5%
<6.5% 17
183
DAT
Positive
Negative
23 (11.5%)
177
46.5% had significant hyperbilirubinemia and
required phototherapy of which 59% (55/93)
belonged to O-A group
Jaundice- detected within the first 24 hours in 25.5%
Remaining 40  hyperbilirubinemia in subsequent days
Most of the newborns had their peak level of bilirubin
in the 2nd or the 3rd day
History of neonatal jaundice in siblings, positive DAT &
high maternal antibody titre had significant association
with higher chance of elevated bilirubin levels (p<0.05)

7. CLINICAL CHARACTERISTICS OF 200 NEWBORNS WITH ABO INCOMPATIBILITY…
Total
Number
Significant hyperbilirub-
inaemia
Yes No
93 (46.5%)
107
Initial Hb
≥17 (no anemia)
(mild-mod)
≤12 (severe)
115 (57.5%) 81 4
Evidence of hemolysis
Present
Absent
21 (10.5%)
179
Reticulocyte count
≥6.5%
<6.5% 17
183
DAT
Positive
Negative
23 (11.5%)
177
In infants with ABO HDFN,
high maternal antibody titre
high bilirubin levels
DAT positivity
significantly associated with higher risk
for the development of anemia.
The proportion of ABO HDFN was found
to be 3.6% (23/627)

8. CLINICAL CHARACTERISTICS OF 200 ABO INCOMPATIBLE NEWBORNS BASED ON DAT STATUS
DAT Negative (n=177)
DAT Positive
(n=23)
P value
Blood group - A B 82 95 17 6
0.011
Mean G.A
38.15
38.04 NS
Mean Birth weight
2.98
2.95
Mean of First measured bilirubin
3.56
8.24
<0.05
Mean Peak bilirubin
11.07
15.18
Ab titre ≥128 26 20
Phototherapy 71 23
IVIG 3 8
EXT 2
0.013
NNTX 1
Positive DAT was significantly associated with increased risk of high bilirubin levels, anemia
and high maternal Ab titre in ABO HDFN and it had positive correlation with intensity of treatment.

9. TREATMENT MODALITIES IN THE 200 INFANTS WITH ABO INCOMPATIBILITY
Majority of the affected neonates (80/93) improved with phototherapy alone
10 cases received IVIG when (one of them
required a second dose of IVIG) so that
exchange transfusion could be avoided
Phototherapy + IVIG + exchange transfusion
in 2 infants - referred cases with severe
hyperbilirubinemia on presentation

10. ANTIBODY TITRE IN THE MOTHER OF ABO INCOMPATIBLE NEWBORNS
23% of mothers had antibody titre ≥128
2 severely affected infants with ABO
HDFN had Ab titre of 512
Maternal Ab in ABO HDFN positively
correlated with bilirubin levels,
DAT positivity and intensity of treatment &
was negatively correlated with initial hemoglobin levels

11. MATERNAL IgG ANTIBODY TITRE LEVELS IN RELATION TO DAT, EVIDENCE OF HEMOLYSIS AND MODE OF TREATMENT AMONG ABO INCOMPATIBLE NEONATES
Ab Titre N
Hemolysis
DAT
Phototherapy
IVIG
EXT
NNTX 8 12 16 37 4 32 57 15 64 48 3 31 1
128 25 5 22
256 11 13
512 2
Total
200 21 23 93 10
P value
<0.05
Out of the 10 neonates received treatment with IVIG, 7 (70%) were DAT positive and 80% had titre ≥256.
Positive DAT & maternal antibody titre ≥256 had significant association with intensity of treatment & ICU stay.

12. COMPARISON OF MEAN VALUES BETWEEN O-A AND O-B INFANTS WITH SIGNIFICANT HYPERBILIRUBINEMIA (THE AFFECTED NEWBORNS)
Parameters
Mean
P value
Significance
Blood group A
(n= 55)
Blood group B
(n=38)
Birth weight
2.93
2.88
0.507 NS
First bilirubin
5.88
5.48
0.441
Peak bilirubin
14.16
13.40
0.185
Initial Hb
16.29
16.58
0.505
Reticulocyte count
4.44
4.16
0.725
Duration of hospital stay
3.39
0.995
In affected neonates, no significant difference in levels of bilirubin, Hb, DAT, signs of hemolysis and intensity of treatment between the O-A and O-B groups though most affected neonates belonged to blood group A.

13. CONCLUSION
ABO incompatibility was observed in 31.8% of pregnancies with almost equal O–A (99) and O–B (101) frequencies.
Majority of ABO incompatible newborns were unaffected.
Infants with history of neonatal jaundice in siblings had significantly higher bilirubin levels.
Maternal IgG anti-A ⁄-B titres contribute to the prediction of risk of severe hyperbilirubinaemia in ABO-incompatible neonates, in addition to blood- grouping and DAT testing.

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