1. Neonatal Jaundice
Li weizhong

2. Introduction
Neonatal Jaundice is known as the visible clinical manifestation of dying skin and sclera yellow during the neonatal period, resulting from deposition of bilirubin in the neonatal bodies.

3. Introduction
Jaundice is observed during the 1st wk in approximately 60% of term infant and 80% of preterm infant.
Hyperbilirubinemia can be toxic, with high levels resulting in an encephalopathy known as kerni-cterus.

4. Metabolism of Bilirubin
Increased bilirubin production
Less effective binding and transportation
Less efficient hepatic conjugation
Enhanced absorption of bilirubin via the enterohepatic circulation

5. Clinical Manifestation
Jaundice may be present at birth or at any time during the neonatal period.
Jaundice usually begins on the face and, as the serum level increases, progresses to the chest and abdomen and then the feet.
Jaundice resulting from deposition of indirect bilirubin in the skin tends to appear bright yellow or orange; jaundice of the obstructive type (direct bilibrubin), a greenish or muddy yellow.

6. Methods of Diagnosis A complete diagnostic evaluation
Determination of direct and indicrect bilirubin fractions
Determination of hemoglobin
Reticulocyte count
Blood type
Coombs’ test
Examination of the peripheral blood smear

7. Classifications Direct-reacting hyperbilirubinemia Hepatitis
Cholestasis
Inborn errors of metabolism
Sepsis

8. Classifications Indirect-reacting hyperbilirubinemia Hemolysis
Reticulocytosis
Evidences of red blood cell destruction
A positive Coomb’s test
Blood group incompatibility
Positive results of specific examination

9. Classifications Direct and indirect- reactin hyperbilirubinemia
Hepatitis
Sepsis
Liver damage complicated by Hemolysis

10. Classifications Physiologic jaundice
Clinical jaundice appears at 2-3 days.
Total bilirubin rises by less than 5 mg/dl (86 umol/L) per day.
Peak bilirubin occurs at 3-5 days of age.
Peak bilirubin concentration in Full-term infant <12mg/dl (205.2 umol/L)
Peak bilirubin concentration in Premature infant <15mg/dl (257umol/L)
Clinical jaundice is resolved by 2 weeks in the term infant by 3-4 weeks in the Preterm infant.

11. Classifications Pathologic jaundice
Clinical jaundice appears in 24 hours of age.
Total bilirubin rises by higher than 5 mg/dl (86 umol/L) per day.
Peak concentration of total bilirubin is more than 12 mg/dL in the term infant and 15 mg/ dL in the preterm infant.

12. Classifications Pathologic jaundice
Clinical jaundice is not resolved in 2 weeks in the term infant and in 4 weeks in the Preterm infant.
Clinical jaundice appears again after it has been resolved.
Direct bilirubin concentration is more than 1.5 mg/dL (26umol/L).

13. Causes of Pathologic Jaundice
Infective jaundice
Neonatal hepatitis
TORCH infection
Neonatal sepsis

14. Causes of Pathologic Jaundice
Jaundice associated without infection
Hemolytic disease of the newborn
ABO incompatibility
Rh incompatibility
Biliary atresia
Jaundice associated with breast- feeding

15. Causes of Pathologic Jaundice
Breast milk jaundice
It is caused by prolonged increased enterohepatic circulation of bilirubin. (β-GD↑)
The hyperbilirubinemia peaks at days of age.
The level of unconjugated hyperbilirubinemia is at mg/dL ( umol/L).
If nursing is interrupted for 72 hours, the bilirubin level falls quickly.

16. Causes of Pathologic Jaundice
Genetic disease
Congenital deficiencies of the enzymes
glucose-6-phosphate dehydrogenase (G-6-PD)
Thalassemia
Cystic fibrosis
Drug
Vitamin k
Novobiocin

17. Hemolytic Disease of the Newborn
Li weizhong

18. Introduction Hemolytic disease of the newborn
It is an isoimmunity hemolysis associated with ABO or Rh incompatibility.
It results from transplacental passage of maternal antiboddy active against RBC antigens of the infant, leading to an increased rate of RBC destruction.
It is an important cause of anemia and jaundice in newborn infant.

19. Etiology and Pathogenesis
ABO hemolytic disease
ABO incompatibility
Type O mothers
Type A or B fetuses
Presence of IgG anti-A or Anti-B antibodies in type O mother
Frequently occurring during the first pregnancy without prior sensitization

20. Etiology and Pathogenesis
Rh hemolytic disease
Rh blood group antigens (C, c, D, d, E, e)
D>E>C>c>e
Pathophysiology of alloimmune hemolysis resulting from Rh incompatibility
An Rh-negative mother
An Rh-positive fetus
Leakage of fetal RBC into maternal circulation
Maternal sensitization to D antigen on fetal RBC

21. Etiology and Pathogenesis
Production and transplacental passage of maternal anti-D antibodies into fetal circulation
Attachment of maternal antibodies to Rh-positive fetal RBC
Destruction of antibody-coated fetal RBC

22. Etiology and Pathogenesis
Rh hemolytic disease was rare during the first pregnancy involving an Rh-positive fetus.
Once sensitization has occurred, re-exposure to Rh D RBC in subsequent pregnancies leads to an anamnestic response, with an increase in the maternal anti-Rh D antibody titer.
The likelihood of an infant being affected increased significantly with each subsequent pregnancy.

23. Etiology and Pathogenesis
Significant hemolysis occurring in the first pregnancy indicates prior maternal exposure to Rh-positive RBC.
Fetal bleeding associated with a previous spontaneous or therapeutic abortion
Ectopic pregnancy
A variety of different prenatal procedures
Transfusion of some other blood product containing Rh D RBC in an Rh-negative mother

24. Clinical Manifestations
Jaundice
Anemia
Hydrops
Massive enlargement of the liver and spleen
Bilirubin encephalopathy (Kernicterus)

25. Clinical Manifestations
Clinical Features Of Hemolytic Disease
Clinical Features Rh ABO
Frequency Unusual Common
Anemia Marked Minimal
Jaundice Marked Minimal to moderate
Hydrops Common Rare
Hepatosplenomegaly Marked Minimal
Kernicterus Common Rare

26. Laboratory Diagnosis Laboratory Features Rh ABO
Laboratory Features Of Hemolytic Disease
Laboratory Features Rh ABO
blood type of Mother Rh negative O
blood type of Infant Rh positive A or B
Anemia Marked Minimal
Direct Commb’s test Positive Negative
Indirect Commb’s test Positive Usually positive
Hyperbilirubinemia marked Variable
RBC morphology Nucleated RBC Spherocytes

27. Diagnosis
The definitive diagnosis requires demonstration of blood group incompatibility and of corresponding antibody bound to the infant’s RBC.

28. Diagnosis Antenatal Diagnosis History Expectant parents’ blood types
Maternal titer of IgG antibodies to D or E (>1:32)
At 12～16 wk
At 28～32 wk
At 36 wk
Fetal Rh and ABO status
Fetal jaundice level

29. Diagnosis Postnatal diagnosis Jaundice at < 24 hr
Anemia (Hematocrit and hemoglobin examination)
Rh or ABO incompatibility
Coomb’s test positive
Examination for RBC antibodies in the mother’s serum

30. Differential Diagnosis
Congenital nephrosis
Neonatal anemia
Physiological jaundice

31. Treatment
Main goals
To prevent intrauterine or extrauterine death of fetal or infant form severe anemia and hypoxic
To avoid neurotoxicity from hyperbilirubinemia

32. Treatment Treatment of the unborn infant Utero transfusion Indication
Hydrops
Anemia (Hematocrit<30%)
Method
Packed RBC matching with the mother’s serum
Umbilical vein transfusion

33. Treatment Delivery in advance Indication Pulmonary maturity
Fetal distress
Maternal titer of Rh antibodies > 1:32
35～37 wk of gestation

34. Treatment Treatment of the liveborn infant
Immediate resuscitation and supportive therapy
Temperature stabilization
Correction of acidosis: 1-2mEq/kg of sodium bicarbonate
A small transfusion compatible packed RBC
Volume expansion for hypotension
Provision of assisted ventilation for respiratory failure

35. Treatment Phototherapy Blue spectrum of 427-475 nm (or White or Green)
Irradiance:10-12μW/cm2
Protection of eyes and genital
Indication
Bilirubin≥10mg/dl at ＜12 hr
Bilirubin≥12-14mg/dl at ＜18 hr
Bilirubin≥15mg/dl at ≥24 hr

36. Treatment Side effect of phototherapy Diarrhea Dehydration
Riboflavin destruction
Hypocalcemia
Bronze-baby syndrome

37. Treatment Exchange transfusion Indication Hemoglobin＜120g/L
Hydrops, hepatosplenomegaly and heart failure
Bilirubin in the 1st 12 of life>0.75mg/dl/hr
Bilirubin concentration>20mg/dl
Factors supporting early exchange transfusion:
Previous kernicterus in a sibling, reticulocyte counts greater than 15%, asphyxia of neonate and premature infant

38. Treatment Blood volume of exchange transfusion
Double-volume exchange transfusion : ml/kg
Blood choose of Rh incompatibility
Rh in accordance with mother
ABO in accordance with neonate
Blood choose of ABO incompatibility
Plasm of AB type
RBC of O type

39. Treatment Drug treatment Intravenous immune globulin (IVIG)
Human albumin
Protoporphyrins : Sn-PP; Zn-PP
Glucocorticoids: Dexamethasone
Inducer of liver enzyme: Luminal

40. Prevention
Intramuscular injection of 300ug of human anti-D globulin to an Rh-negative mother
Within 72 hr of delivery of an ectopic pregnancy
Abdominal trauma in pregnancy
Amniocentesis
Chorionic villus biopsy
Abortion