Rh incompatibility occurs when an Rh-negative mother has an Rh-positive baby. The mother's immune system produces antibodies against the Rh factor in her baby's red blood cells. These antibodies can cross the placenta and destroy the baby's red blood cells, causing hemolytic disease of the newborn. The severity depends on the maternal antibody titer and increases with each subsequent Rh-positive pregnancy. Clinical features in the baby range from mild jaundice to severe anemia, liver and spleen enlargement, heart failure, and hydrops fetalis. Diagnosis involves blood typing of the mother and baby as well as tests for antibodies in the mother and baby's blood. Management may include phototherapy, exchange transfusion,

1. NEONATAL HYPERBILIRUBINEMIA
Bilirubin
1. It is an end product of heme catabolism
2. Anti oxidants like Vit.E, Catalase, superoxide dismutase
are deficient in NB
3. Bilirubin is a powerful antioxidant
4. Peroxyl scavenger
5. It protects NB from oxygen toxicity

2. Sources of Heme
1. Hemoglobin: 80% from senile RBC and
ineffective erythropoiesis
2. Myoglobin
3. Cytochrome P450
4. Other Hemoproteins: catalase, heme
peroxidase, and endothelial nitric oxide
synthase.

3. •
FATE OF RED BLOOD CELLS
1. Life span in blood stream is 60-120
days
2. Senescent RBCs are phagocytosed or
lysed in the reticuloendothelial system
3. Lysis can also occur intravascularly (in
blood stream)

4. Extravascular Pathway for RBC Destruction
(Liver, Bone marrow,
& Spleen)
Hemoglobin
Globin
Amino acids
Amino acid pool
Heme Bilirubin
Fe2+
Excreted
Phagocytosis & Lysis

5. 1. Hemoglobin →Heme + Globin+ (by lysosomal
enzymes of RE cells)
1. Heme------------------→ Biliverdin+ Iron+ CO
Heme oxygenase
1. Biliverdin--------------→Bilirubin
Biliverdin reductase

6. Formation of Bilirubin
Heme is liberated from
»Senile RBCs
»Defective RBCs
• Structure - sickle cell; Thalassemia
• Enzymes - G6PD
• Membrane - Spherocytosis
»Ineffective erythropoiesis

7. Fate of bilirubin
1. Transported from RE system to blood stream
and bound to albumin
2. Carried to liver and released; In liver cell it is
carried by ligandin to mitochodria
3. Conjugated with 2 molecules of glucuronic
acid to bilirubin diglucuronide and excreted
to bile

8. DIRECT AND INDIRECT BILIRUBIN
VAN DEN BERGH TEST
To detect bilirubin in serum
1. Ehrlich diazo reagent containing sulphanilic
acid and sodium nitrite
2. Dirct:
1. Serum + reagent → reddish purple
3. Indirect:
1. Serum + reagent + alcohol→ reddish purple

9. Classification of
Hyperbilirubinemia
1. Physiological: appear after 24 hour, always
indirect
2. Pathological: appear withn in 24 hours &
direct or indirect hyperbilirubinemia

10. Indirect or unconjugated hyperbilirubinemia
1. Hemolytic
1. ABO
2. Rh
3. Enzyme defect- G6PD
4. Membrane defect: Spherocytosis
5. Hemoglobin defect: Thalassemia
2. Non Hemolytic
1. Breast milk jaundice
2. Criggler najar I&II
3. Gilbert
4. Infection

11. 1. Familial:
1. Dubin Jhonson
2. Rotar
2. Infection
1. Neonatal
hepatitis
(TORCHS)
2. Neonatal sepsis
3. Giant cell
hepatitis
3. Obstructive:
1. Biliary
Obstruction
2. Choledochal cyst
4. Metabolic:
1. Cystic fibrosis
2. Galactosemia
3. Alpha1-antitrypsin
deficiency
4. Tyrosinemia

12. 1st 24 hr of life
1. Erythroblastosis fetalis (Rh)
2. Concealed hemorrhage,
3. Sepsis,
4. Congenital infections: TORCHES
5. Infants who have received intrauterine
transfusions for erythroblastosis fetalis

13. Jaundice on the 2nd day
1. Physiologic jaundice
2. Crigler-Najjar syndrome
3. Early-onset breast-feeding jaundice

14. 3-7th day
1. Bacterial sepsis or
2. Urinary tract infection;
3. It may also be due to TORCHS infection

15. II week
1. Breast milk associated jaundice,
2. Septicemia
3. Congenital atresia of the bile ducts,
4. Hepatitis,
5. Galactosemia,
6. Hypothyroidism,
7. Cystic fibrosis, and
8. Congenital hemolytic anemias

16. Persisting for more than a month
1. Hyperalimentation-associated cholestasis,
2. Hepatitis, TORCHS
3. Congenital atresia of the bile ducts,
4. Galactosemia,
5. Inspissated bile syndrome
6. Rarely, physiologic jaundice may be
prolonged for several weeks, as in infants
with hypothyroidism or pyloric stenosis.

17. Clinical assessment of jaundice:
1. cephalocaudal progression
2. Kramer Rule:
• face, ≈5 mg/dL;
• mid-abdomen, ≈15 mg/dL;
• soles, ≈20 mg/dL
3. transcutaneous bilirubinometer that
correlate with serum levels

18. PHYSIOLOGICAL JAUNDICE
Icterus neonatorum
1. Jaundice after 24 hrs of life
2. Increase by less than 5 mg/dl/day
3. Maximum 12 mg/dl in tern and 15 mg in
preterm
4. Peak in 3-5 days and subside in 7 days in term
and 14 days in preterm
5. Direct less than 1 mg

19. Causes of physiological jaundice
1. Increased Hb% in NB
2. Low UDPGT
3. Increased enterohepatic circulation
1. Increased b-glucoridase activity
2. Decreased intestinal flora
3. Decreased intestinal motility
4. Delay in passage of meconium
5. Oxytocin (in the mother)

20. Risk factors
1. Maternal diabetes,
2. Prematurity,
3. Cretinism
4. Polycythemia,
5. Male sex,
6. Asian children
7. Trisomy 21,
8. Cephalohematoma,
9. Oxytocin induction,
10. Drugs: vitamin K3, novobiocin

21. Premature infants
1. longer duration
2. results in higher levels,
3. peak being reached between the 4th
and 7th days;
4. Peak levels of 8-12 mg/dL
5. Kernicterus at 15 mg/dL

22. Diagnosis:
1. established only by precluding known causes
of jaundice
2. it is unlikely to be physiological if there is:
1. A family history of hemolytic anemia,
2. Pallor,
3. Hepatomegaly, splenomegaly,
4. Failure of phototherapy
5. Sepsis
6. Light-colored stools,

23. 1. Treatment: No specific treatment is required
for physiologic jaundice
2. Predict risk for pathological jaundice in the
1st 24-72 hr of life based on hour-specific
bilirubin levels by graph of Bhutani VK, et al

25. Physiological jaundice Pathological jaundice
Jaundice after 24 hrs of life Jaundice appear within 24 hours of life
Increase by less than 5 mg/dl/day Increase by more than 5 mg/dl/day
Reaches a maximum 12 mg/dl in term
and 15 mg in preterm
May cross threshold level for developing
kernicterus
Peak in 3-5 days and subside in 7 days in
term and 14 days in preterm
Rapid rise and produce any time depending
on the severity and type
Includes only indirect hyperbilirubinemia Includes both indirect and direct
hyperbilirubilemia
Causes of physiological jaundice:
Increased Hb%
Low UDPGT
Decreased intestinal flora
Decreased intestinal motility
Increased enterohepatic circulation
Causes of pathological jaundice: Eg:
1) Immune hemolysis-Rh and ABO
2) RBC membrane defect: Spherocytosis
3) Hemoglobin defect: Thallasemia
4) Enzyme defect: G6PD
5) Biliary atresia
Progosis is good Kernicterus is possible
No need for treatment Phototherapy and exchange blood
transfusions are indicated

26. Pathologic jaundice
Immune Hemolytic - Erythroblastosis fetalis
ABO

27. ABO incompatibility
1. A1 more antigenic
2. O mother - A1 infant severe incompatibility due to
more Ig.G production
3. ABO in 20-25 % pregnancies
4. Among them 10 % develop hemolysis
5. Overall incidence is 1-2 %
6. Even first pregnancy can be affected
7. Less jaundice but anemia may be significant
8. < 10% may go for exchange transfusion

28. Pathophysiology
1. Natural maternal antibody produces
microspherocytes and hemolysis; no prior
sensitization required
2. usually IgM antibodies & do not cross the
placenta. However, IgG antibodies to A antigen
do cross the placenta
3. Due to less no. antigenic sites on the fetal
erythrocytes and more competitive binding sites
in other tissues produce only mild hemolysis.

29. Risk factors:
1. A1 antigen
2.Antepartum intestinal parasitism
3.third-trimester immunization with tetanus
toxoid
4.Birth order is not a risk factor in contrast to Rh
disease.

30. Clinical presentation
1. The onset is usually within the first 24 h of
life.
2. The jaundice evolves at a faster rate than
physiologic jaundice.
3. Anemia: Because of the effectiveness of
compensation by erythropoiesis, anemia is
less severe.

31. Diagnosis
1. Blood grouping and Rh typing in the mother and the
infant.
2. Increase in reticulocyte count will support the
diagnosis of hemolytic anemia.
3. Direct Coombs' test: weakly positive
4. Blood smear: microspherocytosis, polychromasia
and normoblastosis.
5. Bilirubin levels: Indirect hyperbilirubinemia
6. Maternal IgG titer: Elevated IgG titers against the
infant's blood group

32. Management:
1. Antepartum treatment: not indicated.
2. Postpartum treatment
–Phototherapy: may entirely obviate the need
for exchange transfusion
–Exchange transfusion for jaundice crossing
threshold values.
–Packed cells for anemia

33. –Intravenous immunoglobulin (IVIG). high-
dose IVIG (1 g/kg over 4 h) has been shown
to reduce serum bilirubin levels
–Synthetic blood group trisaccharides:
decreases in exchange transfusion rates
• Prognosis: the overall prognosis is
excellent.

34. Rh Incompatibility

35. Inheritance
1. The Rh antigenic determinants are autosomal
recessive
2. A child will be Rh negative if both its parents are Rh
negative. Otherwise the child may be Rh positive or
Rh negative.
3. Thus an Rh+ individual may be homozygous (+/+) or
heterozygous (+/-), while an Rh- individual must be
homozygous (-/-).
4. <15% of population is Rh negative; 55% of Rh-
positive fathers are heterozygous (D/d)

36. Antigens in RBC
1. Rh factor has many antigens: D, C, E, Kell, Kidd,
K, M, Duffy
2. 90 % Rh disease due to D antigen; C&E 10%
3. Rh incompatibility develops between an Rh-
negative mother previously sensitized to the Rh
(D) antigen and her Rh positive fetus.
4. Only about 5% of Rh –ve mothers with Rh +ve
fetus has babies with hemolytic disease.

37. Reasons for reduced incidence
• If ABO incompatibility is coexisting, the mother
is partially protected against Rh sensitization
• severity will increase with each successive Rh
incompatible pregnancy. In restricred familysize
Rh incompatibility may not manifest.
• The use of Rh immunoglobulin
• 10-15% of Rh-negative mothers (10-50%) fail to
develop specific IgG-Rh antibody

38. Rh sensitization
• 1 ml of fetal blood can produce adequate
sensitization
• Ig M and IgG antibodies are produced
• Ig G crosses placenta into fetal circulation
• Adheres to fetal RBC
• Produce haemolysis by compliment activation

39. Rh Sensitization
• Rh –ve Mother sensitized by fetal Rh + RBC by feto
maternal transfusion that occurs during:
– Normal Delivery
– Internal versions
– Invasive procedures
– Abortions
– Tubal pregnancies
– Abdominal injury

40. Risk factors
• Repeat pregnancies are at a progressive risk
• Fetomaternal hemorrhage.
• Coexistent ABO incompatibility reduce the risk
of maternal Rh sensitization to 1.5-3.0%.
• Cesarean section increases the risk of
significant fetomaternal transfusion
• Male infants have an increased risk
• Maternal immune response. .

41. Clinical features
Fetal:
1. In severe cases, bilirubin pigments stain the
amniotic fluid, cord, and vernix caseosa
yellow
2. Profound anemia results in cardiac
decompensation, massive anasarca, and
circulatory collapse
3. Preterm labour can occur

42. NB
1. Disease may range from mild hemolysis (15%
of cases) to severe anemia with massive
enlargement of the liver and spleen
2. Hypoglycemia occurs frequently and may be
related to hyperinsulinism and hypertrophy of
the pancreatic islet cells
3. Petechiae, purpura, and thrombocytopenia
may also be present in severe cases

43. Laboratory Data:
1. Blood type and Rh type (mother and infant)
2. The cord blood hemoglobin is proportional to
the severity of the disease;
3. The white blood cell count is usually normal
but may be elevated; thrombocytopenia may
develop in severe cases.
4. Cord bilirubin is generally between 3 and 5
mg/dL; the directre acting (conjugated)
bilirubin content may also be elevated

44. 5. Direct antiglobulin (DAT or Coombs') test. A
strongly positive test is diagnostic
6. If Rh immunoglobulin was given at 28 weeks'
gestation a false-positive direct Coombs' test
occurs
7. Blood smear. Polychromasia and
normoblastosis are present.
8. Spherocytes are not usually present.
9. The nucleated RBC (Normoblast) count will
often be >10 per 100 white blood cells.

45. 10. Bilirubin levels.
1. Progressive elevation of unconjugated
bilirubin
2. Bilirubin-binding capacity tests:
Measurements of serum albumin
11. Carbon monoxide (CO). CO Hb levels are
increased in neonates with hemolysis.

46. In Mother
Indirect Coombs' test.
1.This test detects the presence of antibodies in
the maternal serum.
2.Rh-positive RBCs are incubated with the
maternal serum.
3.The RBCs now coated with anti-D are
agglutinated by an antihuman globulin serum
and gives positive Coomb’s reaction.

47. Antenatal tests
1. Maternal titer of IgG antibodies to D antigen
should be assayed at 12-16, 28-32, and 36 wk
of gestation.
2. A rapid rise in titer, or a titer of 1:64 or greater
suggests significant hemolytic disease.
3. Fetal Rh status can be determined by isolating
fetal cells (APT test)
4. fetal DNA (plasma) from the maternal
circulation

48. 1. Real-time ultrasonography:
1. Skin or scalp edema, pleural or pericardial
effusions, and ascites.
2. organomegaly (liver, spleen, heart), the double–
bowel wall sign (bowel edema), and placental
thickening.
2. Doppler ultrasonography:
1. Demonstration of an increase in the peak velocity
of systolic blood flow in the middle cerebral artery
indicates severe anemia.
3. Assesses fetal distress by demonstrating increased
vascular resistance in fetal middle cerebral arteries;

49. • Spectrophotometric scanning of amniotic fluid
wavelengths demonstrates a positive optical
density (OD) deviation of absorption for
bilirubin from normal at 450 nm.
• Percutaneous umbilical blood sampling (PUBS)
is performed to determine fetal hemoglobin
levels and to transfuse packed RBCs in those
with serious fetal anemia

50. Antepartum management
1. Maternal antibody titer should be determined
antenatally. Usual range is 1:16- 1:32
2. RhoGAM. Current obstetric guidelines suggest giving
immunoprophylaxis at 28 weeks' gestation
3. Intrauterine transfusion. Intrauterine transfusion may
be indicated to prevent fetal death or fetal hydrops.
Intravascular (umbilical vein) transfusion of packed by
slow-push infusion after being cross-matched against
the mother’s serum.
4. Reduction of maternal antibody level. Maternal plasma
exchange and high-dose IVIGs to reduce circulating
maternal antibodies levels by >50%.

51. • Delivery indications are:
• pulmonary maturity,
• fetal distress,
• complications of PUBS, and
• 35-37 wk of gestation.

52. Postpartum treatment
1. Resuscitation:
1. Anemic infants may require immediate single-
volume exchange blood transfusion at delivery to
improve oxygen-carrying capacity.
2. Correction of acidosis with 1-2 meq/kg of sodium
bicarbonate;
3. Assisted ventilation for respiratory failure.
2. Phototherapy: decreases bilirubin levels and
reduces the number of total exchange
transfusions required.

53. Exchange transfusion indications
1. Cord hemoglobin value of 10 g/dL or less and
bilirubin concentration of 5 mg/dL or more
2. previous kernicterus or severe erythroblastosis
in a sibling,
3. reticulocyte counts >15%,
4. A rise of >5 mg/dL over 24 h within the first 2
days of life or more than 20 mg/dL in term and
> infants and > 15 mg in preterm

54. 1. Heme oxygenase inhibitors
(metalloporphyrins) are currently
investigational. The enzyme reduces the
conversion of heme to biliverdin.
2. IVIG. Early administration of intravenous
immunoglobulin (IVIG) may reduce hemolysis,
peak serum bilirubin levels, and the need for
exchange transfusions. dose 0.5-1 gm/kg.

55. Prevention Rh disease
1. The risk reduced to less than 1% by IM 300 μg of
human anti-D globulin (1 mL of RhoGAM) within 72 hr
of delivery of an Rh-positive infant, ectopic pregnancy,
abdominal trauma in pregnancy, amniocentesis,
chorionic villus biopsy, or abortion.
2. RhoGAM Administration of human anti-D globulin at
28-32 wk and again at birth (40 wk) is more effective
than a single dose.
3. The amount of fetal blood entering the maternal
circulation may be estimated using the Kleihauer-
Betke acid elution technique during the immediate
postpartum period.

56. Complications
1. Anemia
2. Cholestasis: Inspissated bile syndrome
3. Portal vein thrombosis and portal
hypertension and a mild GVH reaction may
manifest as diarrhea, rash, hepatitis, or
eosinophilia may occur in children who have
been subjected to exchange transfusion
4. Kernicterus → CP

57. Prognosis
Prognosis improves with:
1.Antenatal immune prophylaxis
2.amniotic fluid spectrophotometry,
3.intrauterine transfusion, and
4.advances in neonatal intensive care,

58. Exchange transfusion
• O –ve fresh blood cross matched with infant and
mother’s sera
• Double volume: 85X2/kg ml
• 20 ml exchanged each time via umbilical venous
catheter placed at IVC or hepatic vein
• Removes 80% sensitized cells and mat. antibodies
and 50 % of bilirubin

59. Complications of ExchangeTrf:
• Sudden death
• Necrotizing enterocolitis
• Portal vein thrombosis
• Sepsis
• Anemia
• Electrolyte changes
• Hypocalcemia
• Thrombocytopenia

60. Phototherapy
• Light in blue-green spectrum 425-475 nm
• Blue florescent tubes
• Converts Unconjugated bilirubin in the skin to water
soluble stereoisomer
• 30-40% bilirubin can be reduced in the first24 hrs
• Started at 5mg less of exchange levels
• Eyes covered; single and double surface
• Electronic phototherapy unit

61. Complications of Phototherapy
• Loose stools
• Bronze baby syndrome
• Purpueric rash
• Hypo or hyperthermia
• Elevation of direct bilirubin

62. Non immune hemolytic jaundice
• Hereditary spherocytosis:
– Autosomal dominant
–Membrane proteins spectrin and ankyrin
are defective
– Spherical shape of RBC
–Osmotic fragility test + ve
– Splenectomy is the cure

63. G-6 PD deficiency:
– Enzyme defect
– X-linked inheritance
– Mild form
– Aggravated by Gilbert
– Low level of G6PD

64. Non Hemolytic Jaundice
• Crigler-Najjar:
–Type I :
• autosomal recessive
• Lack of UDPGT
–Type II:
• autosomal dominant
• Milder form
• Phenobarbitone useful

65. Gilbert Syndrome:
–Autosomal dominant
–Decreased hepatic UDPGT
–10 % population affected
–Prolongs physiological and breast milk
jaundice

66. Rare forms
• Lucy - Driscol syndrome:
–Indirect hyperbilirubinemia
–Due unknown inhibitor of bilirubin
conjugation

67. Direct Hyperbilirubinemia
• Greenish yellow skin
• Pale stools
• Hepatomegaly
• Causes:
– TORCHS
– Con.Biliary atresia
– Hep.A,B
– Insipissated bile syndrome

68. • Dubin-Jhonson:
–Conjugated bilirubin not excreted into bile
–Direct hyperbilirubinemia
–Autosomal recessive
–Pigmentation of liver
• Rotar:
–Same as Dubin-Jhonson without liver
pigmentation

69. Kernicterus
• Bilirubin deposited in
– basal ganglia,
– brainstem,
– Hippocampus
– Olfactory nuclei
– cerebellum etc
• Neuronal loss due damage to cell membrane
and interference to O2 utilization

70. Early stage
• Lethargy
• Poor feeding
• Loss of moro
• High pitched cry
• Hypertonia
• Opisthotonus
• Bulging fontanell
• Convulsions
• Spasticity
• Death

71. Chronic stage
• Hypotonia
• Mental retardation
• Seizures
• Squint
• Ataxia
• Deafness