pathological jaundice

1. Prepared by:
Shraddha Dahal
Roll no: 25
B.Sc. Nursing 4th year

2. General Objective
At the end of this session, all the B.Sc.
Nursing 3rd year students will be able to
explain about pathological jaundice .

3. Specific Objectives
At the end of this session, all the B.Sc.
Nursing 3rd year students will be able to:
• define pathological jaundice.
• state prevalence of pathological jaundice.
• list out the causes of pathological
jaundice.
• list out the risk factors of pathological
jaundice.
• list out the clinical features of pathological
jaundice.

4. • identify the diagnostic measures for
pathological jaundice.
• describe the management of pathological
jaundice.
• explain nursing management of
pathological jaundice.
• identify the prognosis of pathological
jaundice.
• list out the complications of pathological
jaundice.

5. Pathological Jaundice
Severe type of jaundice usually appears
within 24 hours of birth which is
characterized by a rapid rise in serum
bilirubin level by more than 5 mg/dl/24
hours, yellow discoloration of the skin,
mucous membrane and sclera for prolonged
time which is called pathological jaundice.

6. …contd
Criteria for Pathological Jaundice are:
• Appears within 24 hours of life.
• Last longer than 14 days in preterm infant and
more than 7-10 days in term infant.
• Increase in serum bilirubin level by more than 5
mg/dl per day.
• Total serum bilirubin more than 15mg/dl in
preterm babies and more than 12.9 mg/dl in term
babies.
• Direct bilirubin more than 2 mg/dl.

7. Causes
A. Excessive destruction of RBC's
• Feto maternal blood group
incompatibilities
• Increased red cell fragility
• Deficient red cell enzyme
• Neonatal sepsis
• Extravasation of blood

8. Hemolysis

9. ….contd
• Polycythemia
• Thalassemia

10. …contd
B. Defective conjugation and decreased
clearance
• Defective production of enzyme glucoronyl
transferase
• Dehydration, starvation, hypoxia
• Crigler-Najjar syndrome
• Gilbert syndrome

11. …contd
C. Metabolic Disorder
• Hypothyroidism and galactosemia
• Low plasma albumin level
• Factors that affect binding of bilirubin to
albumin : Fatty acid, acidosis and
hypothermia

12. …contd
D. Miscellaneous
• Hepatic obstruction caused by congenital
anomalies
• Absence of common bile duct

13. Risk Factors

14. Clinical Features
Yellowish Discoloration

15. Clay Colored Stool

16. Diagnostic Measures

17. Hereditary Spherocytosis

18. Ingram Icterometer

19. Ingram Icterometer

20. Transcutaneous Bilirubinometer

21. Management
Three methods of treatment are used to
reduce the level of unconjugated bilirubin:
• Pharmacologic therapy
• Phototherapy
• Exchange transfusion

22. 1. Drug Therapy
• Phenobarbitone :2 mg/kg/dose PO TDS for 3-
5 days is administered.
• High dose intravenous immunoglobulin:
500-1000 mg/kg over 4 hours is effective
in reducing need for exchange transfusion
in haemolytic jaundice such as in Rh or
ABO incompatibility.

24. 2. Phototherapy

25. Phototherapy
• Phototherapy is the application of fluorescent
light to the infant exposed skin which
promotes the conversion of unconjugated
bilirubin into conjugated bilirubin.
• The bilirubin molecule isomerizes to
harmless forms under blue-green light (460-
490 nm).
• It works on 3 principles : geometric
photoisomerization, structural isomerization
and oxidation

26. …contd
Indications of phototherapy :
• Prophylactic phototherapy is started
quickly at lower bilirubin level in the infant
who are smaller or preterm, who are sick
particularly with hemolysis and in whom
jaundice appears within 12 to 24 hours.
• Bilirubin level indicating phototherapy:
More than 15 mg /dl for term and near
term infant.

27. ….contd
For preterm infants:
Gestation (weeks
completed)
Bilirubin cut off points for
phototherapy (mg/dl)
< 28 5-6
28-29 6-8
30-31 8-10
32-33 10-12
34 12-14

28. ….contd
Side effects of phototherapy:
• Frequent loose green stools
• Skin rashes
• Hyperthermia
• Bronze baby syndrome.

29. 3. Exchange blood transfusion

30. Exchange blood transfusion
• Exchange transfusion is life saving
procedure in severely affected haemolytic
disease of newborn.
• It is done in seriously affected Rh-
isoimmunised erythroblastic babies to
remove anti RBC antibodies.

31. …contd
• It is given when phototherapy fails to
prevent a rise in bilirubin to toxic levels.
• Double-volume exchange replaces 85
percent of circulating red blood cells and
reduces bilirubin level by 50 percent.
• Umbilical vein is used and cannulated for
the procedure.

32. …contd
• This usually is 5 mL for infants 1,500 g, 10
mL for infants 1,500 to 2,500 g, 15 mL for
infants 2,500 to 3,500 g, and 20 mL for
infants 3,500 g.
• The recommended time for the exchange
transfusion is 2 hour.
• This is usually continued until a total
volume of 160-180ml per /kg of infant
blood has been replaced.

33. Indications
Birth Weight Bilirubin Cut Off
Point for Exchange
Transfusion (mg/dl)
<1000 10-12
1000-1500 12-15
1500-2000 15-18
2000-2500 18-20

34. ….contd
Nature and Amount of Blood transfused :
• Type O Rh-negative blood is used.
• The blood should be freshly collected (
fresh blood drawn within or less than 72
hours) and the quantity of blood used is
160-180 ml/kg for one exchange
transfusion to replace 80-90 % of fetal
blood.

35. Nursing Management
A. Care of baby undergoing phototherapy:
• Eye care
• Cover genital area with diaper
• Skin care
• Temperature monitoring
• Encourage the mother to breastfeed the
baby

36. …contd
• If the baby is receiving IV fluid or EBM ,
increase the volume of fluid or milk by 10% of
the total daily volume per day as long as the
baby is under the phototherapy units.
• Check for hydration: Monitor fluid intake and
urine output .Frequency, amount and color of
urine and stool pattern.
• Estimation of serum bilirubin every 4 to 8
hourly to determine effectiveness of
phototherapy

37. …contd
• Discontinue phototherapy when the serum
bilirubin level is below the level at which
phototherapy was started.
• Watch for side effects of phototherapy.
• Parental support
• After phototherapy is permanently
discontinued, a follow-up serum bilirubin
level should be checked.

38. B. Care of The Baby Going
Exchange Transfusion:
• Procedure carried out in a neonatal
intensive care unit under strict aseptic
technique. The process should be very
slow and continued over an hour.
• The stomach contents should be aspirated
before procedure. The infant receives
nothing by mouth (NPO) during the
procedure.

39. ……contd
• A peripheral infusion of dextrose and
electrolytes is established.
• Baby's cardiac status and temperature
should be monitored continuously. If the
sign of cardiac or respiratory problems
occurs, the procedure is stopped
temporarily and resumed once the cardio
respiratory function is stabilized.

40. .…contd
• Documentation of blood volume
exchanged including in and out volume of
blood exchanged, heart rate, respiratory
rate, oxygen saturation, temperature and
colour of the baby and any problems arise
or any drugs administered.
• Hemoglobin and bilirubin estimation can
be done before and after procedure.

41. …contd
• After the procedure is completed the nurse
inspects the umbilical site for evidence of
bleeding every half hourly for first few
hours and then 4 hourly.
• Usually catheter remains in place in case
of repeated exchange are required , serum
bilirubin level are estimated 4 hourly.
• Parental support

42. Complications

43. Kernicterus [Bilirubin Encephalopathy]

44. Prognosis

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