Rh incompatibility

1. Dr. Shawon Debnath
MD,Paediatrics(Phase-A)
ICMH,Matuail,Dhaka
Date:02-01-2023

2. Particulars of the patient
Name : B/O Nasrin
Age : 30 hours
Sex : Male
Weight : 2000 gm
Address : Gaibandha Sador, Gaibandha
DOB : 05/12/22 at 4:00 pm
DOA : 06/12/22 at 10:00 pm

3. Presenting complaints
• Yellowish coloration of whole body and sclera
since 19 hours of age
• Reluctant to feed for 10 hours

4. History of present illness
According to the statement of informant father baby
was reasonably well upto 19 hours of age. Then he
developed yellowish coloration of skin which first
appeared on the face and progressing to the
abdomen then over the whole body.

5. History of present illness Cont’d
Father gave no H/O diarrhoea, vomiting,
convulsion, fever,bleeding from any sites,rash,
taking any oral or injectable drug. With this
complaints they got admitted her son in NICU of
ICMH for further management and better
evaluation.

6. Maternal details
Mother Nasrin
 25 years old
 Blood group (A-ve)
 Normotensive
 Non-diabetic
 Para 1+3 (H/O previous 3 Abortion)
 No H/O taking any anti-D injection
 No h/o heart or liver disease or any others
chronic disease

7. Birth history
Antenatal
She was not under regular ANC. She completed
tetanus toxoid vaccine before her marriage. She had no
h/o fever with rash, excessive PV bleeding, foul smelling
PV discharge and no exposure to any offending drugs.
Natal
At 37 weeks of pregnancy baby was born by normal
vaginal delivery at home at term with low birth weight,
cried just after birth and was breast fed since birth.
APGAR score was not documented.

8. Birth history cont’d
Postnatal
Started breast feeding and suckling was good.
Urine and stool passed within 24 hours of life.
19 hours after birth mother noticed that her child
developed yellowish coloration of whole body
and increased gradually.

9. Feeding history
The baby got no pre-lacteal feed. Breast
feeding initiated within 1 hour after birth and
was on exclusive breast feeding since birth but
20hous of age baby developed reluctant to
feed.

10. Immunization history
Not started.

11. Family history
He is 1st issue of non consanguineous
parents.Other family members were in
average health and no such types of illness
in others family member. Father blood group
O(+ve).

12. Family history cont’d

13. Treatment history
None.

14. Socio-economic history
The child came from lower middle class family
 Father -Farmer
 Mother - Housewife

15. General examination
 Appearance : Lethargic
 Colour : Mildly pale
 Jaundice : Icteric up to thigh
 Breathing : Regular
 RR : 48 breath/min.
 HR : 130 beat/min.
 Spo2 : 92% in room air
 Temperature : 98°F
 Capillary refill time: <3 sec
 Skin survey : Normal
 Fontanel : Open but not bulged

16. On Examination cont’d
 Scalp
 Face
 Eyes Normal
 Palate
 Neck
 Chest : -Chest indrawing : absent
-Breath sound : vesicular
-Added sound : absent
 Heart -S1&S2 audible in 4 cardiac areas
- Added sound: absent

17. On Examination cont’d
 Abdomen -Soft , not distended, no ascitis
-Liver and spleen just palpable
-Bowel sound: present
 Umbilicus -Healthy
 Tone -Normal
 Genitalia -Male pattern
 Anus -Patent

18. On Examination cont’d
• Spine -Normal
• Extremities -Talipes equinovarus of
right foot
• Primitive reflex
Moro reflex
Rooting reflex Poor
Sucking reflex
 Others Congenital anomaly: Absent

19.  Weight - 2 kg ( lies below 10th centile)
 Length - 48 cm(lies between 25th to 50th centile)
 OFC - 34 cm (lies on 10th percentile)
Anthropometry

20. Salient feature
Baby of Nasrin, 30 hours old male baby, 1st issue
of his nonconsanguineous parents was admitted to
ICMH with the complaints of yellowish coloration of
whole body and sclera since 19 hours of age
which first appeared on the face and progressing to
the abdomen then over the thigh. He also
developed reluctant to feed for last 10 hours.

21. Salient feature cont`d
Mother was a 25 years old, non diabetic,
normotensive having blood group A(-ve). She had
h/o previous 3 abortions but did not get any anti-D
injection.She did not get any antenatal checkup in
this pregnancy. At 37 weeks of pregnancy baby
was born by normal vaginal delivery at home at
term with low birth weight, cried just after birth and
was breast fed since birth.

22. Salient feature cont`d
On examination, the baby was lethargic, icteric upto
thigh, mildly pale. RR 48/min, HR 130/min, Temp
980F, fontanelle open but not bulged. Abdomen soft,
not distended, liver and spleen just palpable, bowel
sound present. Baby tone was normal, reflexes
were poor, talipes equinovarus of right foot. Baby’s
weight was 2000 gm, which was below 10th centile.

23. Provisional diagnosis
Term, SGA with Neonatal Jaundice (due to Rh
incompatibility) with Early Onset Neonatal
Sepsis with Talipes Equinovarus of right foot.

24. Differential diagnosis
 G-6-PD deficiency

25. G-6-PD deficiency
Points in favour Points in against
 Male child
 Jaundice
 No maternal family
history
 Jaundice appear within
24hours

26. Investigations
CBC:
Hb% : 18.9 gm/dl
TC of WBC : 27780/ cu mm
DC : Neutrophils : 84%
Lymphocytes : 10%
Monocyte : 6%
Eosinophils : 2%
Basophils : 0%

27. Investigations cont’d
PBF : Non specific findings
Blood group : Baby A(+ve)
Mother A(_ve)
S Bilirubin on 06.12.22 : Total -15.3 mg/dl
Direct -1.2 mg/dl
Indirect-14.1 mg/dl

28. Investigations cont’d
 Reticulocyte count : 12%(2%-6%)
 Direct Coombs’ test: Positive
 S. Electrolyte: Na+ : 142.1 mmol/L
K+ : 5.2 mmol/L
Cl- : 108.6 mmol/L
 CRP : <6 mg/dl
 S. Albumin : 2.8 g/dl(3.4-5.4gm/dl)
 S.Creatinine : 0.6 mg/dl
 S. Calcium : 9.5 mg/dl(8.6-10.3 mg/dl)
 CBG : 6.2 mmol/L

29. Final diagnosis
Term, SGA with Neonatal Jaundice (due to Rh
incompatibility) with Early Onset neonatal
Sepsis with Talipes Equinovarus of right foot.

30. Treatment
Counseling :
Counseling to the parents about
-Disease process
-Treatment option
-Its outcome

31. Management
 NPO
 Keep the baby warm
 O2 inhalation 2L/min by nasal cannula
 Infusion 10% B/S 100ml/kg+20%(240ml/day)
 Inj.Ampicillin-100mg/kg/dose 12 hourly
 Inj. Gentamycin- 5mg/kg/dose 24 hourly
 Double surface photo-theraphy with covering of
both eyes and genitalia
 Inj. Albumin (20%) 5ml/kg/dose

34. Follow up (On 07.12.22 D1)
Subjective Objective Assess
ment
Plan
•Lethargic App -sick
Color – Icteric
CRT - <3sec
CBG: 6.4mmol/L
H/R -138/min
R/R - 48/min
Temp. 980F
Bowel- moved
Urine- passed
Reflex-poor
Fontanel-open, not
bulged
Sick •Double surface
photo therapy
continued
•Inj.Albumin
•MEN start

35. Follow up cont’d (On 09.12.22 D4 )
Subjective Objective Assessm
ent
Plan
Sick
looking
App- lethargic
Icteric upto sole
CRT- <3sec
CBG: 4.8 mmol/L
H/R-142/min
R/R- 44/min
Temp. 980F
Reflex- poor
Fontanel-open, not
bulged
Umbilicus- Healthy
Sick Continue double
photo therapy and
Inj.Albumin
Change anitibiotic
to
Inj.Ceftazidime Inj.
Amikacin
Repeat inv. Sent

36. Follow up cont’d (On 10.12.22 D-3)
Subjectiv
e
Objective Assessment Plan
Lethargic App- Sick looking but active
Icteric upto sole
CRT- <3sec
CBG: 5.8mmol/L
Reflex- Moderate
S.Bilirubin:
Total 20.1 mg/dl
Direct 6.0 mg/dl
Indirect 14.1 mg/dl
Hb : 16.4 gm/dl
TWBC:13,050/cumm
PC :1,53,000/cumm
• Sick
Continue Double
surface photo-
theraphy

38. Follow up (On 12.12.22 D-6)
Subjectiv
e
Objective Assessme
nt
Plan
No new
complaint
App- Active with spontaneous
movement
Color- icteric upto thigh
Vitals: Normal
Reflex-good
Umbilicus- Healthy
CRT<3sec
CBG: 4.6mmol/L
Improving Continue
Double surface
photo-theraphy
Plan for
discharge next
day
Repeat inv.
Sent

39. Follow up (On 13.12.22 D-7)
Subjective Objective Assessme
nt
Plan
No new
complaint
App- well alert
Color-Icteric up to chest
Vitals- Normal
Reflex- Good
Umbilicus- Healthy
CRT<3sec
CBG: 6.4mmol/L
B/B: Normal
S Bilirubin:
Total 12.2 mg/dl
Direct 2.6 mg/dl
Indirect 9.6 mg/dl
Hb : 17.8 gm/dl
TWBC:14,050/cumm
PC :2,05,000/cumm
Improved Discharge

41. During Discharge
 F/U after 2 days
 Investigations: S bilirubin, CBC, S TSH, FT4
 Keep the baby warm
 Feeding Advice
 Immunization Advice
 Infection control( hand wash, avoid gathering)
 Inform about danger sign and when to return
immediately

43. Thnk You