Hdn and exchange transfusion

1. HEMOLYTIC DISEASE OF NEW BORN
AND EXCHANGE TRANSFUSION
Sunil Kumar.P
Department of Clinical Pathology
St.John’s Medical College
Bangalore
13 October 20181SUNIL KUMAR.P

2.  Destruction of the RBCs of the fetus or newborn by
antibodies produced by the mother
 Only IgG antibodies are involved because it can cross
the placenta.
HDN
+ Fetal
RBC
= destruction
Mother’s
antibodies
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3.  Rh(D) Hemolytic disease of new born
 ABO Hemolytic disease of new born
 HDN due to antibodies against antigens in other
blood gp system (i.e kell, kidd and Duffy antigen)
 HDN due to other Rh antibodies anti c, anti C and
anti e.
CLASSIFICATION
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4.  fetal RBC +Maternal IgG
Hemolysis of fetal RBC
Accelar Anemia unconjugated BR
erythropoesis bilirubinemia excreted
via
maternal
congestive circulation
cardiac Jaundice after birth
failure
Hydrops foetalis Kernicterus
still birth
pathophysiology
13 October 20184SUNIL KUMAR.P

5.  Anti Rh(D)IgG antibodies are the prime cause of
severe HDN.
 Isoimmunization of Rh(D)neg mother may result from
Rh(D) pos pregnancy or transfusion of Rh(D) pos
blood.
 Moderate to severe and needs treatment
Rh(D) HDN
13 October 20185SUNIL KUMAR.P

6. First pregnancy
Rh pos baby born to Rh neg mother
During delivery-placental separation
Entry of fetal RBC into mothers circulation
immunize mother and- stimulate production of Rh
antibodies(anti D)
Rh Hemolytic disease of new born
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7. Second pregnancy-baby -Rh pos
IgG anti D cross the placenta
Bind to Rh pos infant RBC
HEMOLYSIS
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8. 13 October 20188SUNIL KUMAR.P

9.  Size of foeto maternal haemorrhage /leak.
At delivery by transplacental haemorrhage 10 ml of blood can
enter maternal circulation and sensitize the maternal RBCs.
These antibodies are not demonstrated until a secondary
stimulus of subsequent delivery.
 Zygosity of father
if the father is heterozygous for the Rh antigen there is a
50%chance for HDN.
 History of blood transfusion.
Rh negative mother with Rh(d) positive blood transfusion
leads to Rh HDN in first pregnancy.
Medical termination or miscarriage of pregnancy.
Factors affecting the production of
Rh antibodies
13 October 20189SUNIL KUMAR.P

10. 13 October 201810SUNIL KUMAR.P

11.  Postnatal problems include:
 Pulmonary hypertension
 Pallor (due to anemia)
 Edema (hydrops, due to low serum albumin)
 Respiratory distress
 Coagulopathies (↓ platelets & clotting factors)
 Jaundice
 Kernicterus (from hyperbilirubinemia)
 Hypoglycemia (due to hyperinsulinemia from
islet
cell hyperplasia
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12. Laboratory Findings
Vary with severity of HDN and include:
 Anemia
 Hyperbilirubinemia
 Reticulocytosis (6 to 40%)
 ↑ nucleated RBC count (>10/100 WBCs)
 Thrombocytopenia
 Leukopenia
 Positive Direct Antiglobulin Test
 Hypoalbuminemia
 Rh negative blood type or ABO incompatibility
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13. BloodSmear
 Polychromasia
 Anisocytosis
 Increase NRBCs
 no spherocytes
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14. Detailed obstetric history. (hydrops foetalis, still birth)
women with bad obstetric history should be followed
up.
History of blood transfusion.
Grouping
ABO and Rh grouping including Du grouping.
Antibody screening
sera of both Rh(D)positive and Rh(D) negative should be
screened for red cell antibodies
ANTENATAL ASSESSMENT OF Rh
HDN
13 October 201814SUNIL KUMAR.P

15. Amniotic fluid-Bright yellow(depending upon the degree of
hemolysis)
 Indication-
If maternal IgG titre >32.
Previous history of still birth, hydrops
foetalis.
Done between 28th to 32 nd week.
Amniotic bilirubin is estimated by spectrophotometry
OD are taken and plotted on a graph.
AMNIOCENTESIS
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16. 13 October 201816SUNIL KUMAR.P

17. Liley graph
 The ΔOD is plotted on the Liley graph according to
gestational age
 Three zones estimate the severity of HDN
 Lower: mildly or unaffected fetus (Zone 1)
 Midzone: moderate HDN, repeat testing (Zone 2)
 Upper: severe HDN and fetal death (Zone 3)
13 October 201817SUNIL KUMAR.P

18. 1)Intrauterine transfusion.
Intravascular transfusion.
Intraperitonial transfusion.
packed redcells of group O Rh
negative are given should be less than
5 days old, leucocyte depleted, irradiated,
and compatible with mother’s blood.
2)Premature induction of labour.
3)Plasmapheresis.-250ml -360ml plasma exchanged every week
beginning at 10-20 weeks of pregnancy till birth.
ANTENATAL MANAGEMENT OF Rh
IMMUNIZATION
13 October 201818SUNIL KUMAR.P

19.  Sample-cord blood
 Tests
1)ABO grouping
2)Rh(D)grouping including Du
3)DAT- HDN -positive
4)screening and identification of antibody in cord
blood
5)Hb estimation on cord blood(normal-18.6-19.6)
6)Cord blood bilirubin estimation
Investigation of newborn
13 October 201819SUNIL KUMAR.P

20. Postnatal treatment of infant
about 40% of infant born with DAT pos, require no
treatment while others if untreated, die within a few
hours due to cardiac failure or jaundice
 Blood transfusion
mild HDN who exhibit anaemia- red cell
concentrate.
moderate -severe HDN- Exchange transfusion
Treatment
13 October 201820SUNIL KUMAR.P

21. Removal of part of patient blood and its replacement of blood
obtained from healthy donor
INDICATION
 Correction of anaemia by providing compatible redcells.
 To lower bilirubin
 To remove the offending antibody.
 To remove fetal red blood cells coated with maternal
antibody
Exchange Transfusion
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22. parameter observe Consider exchange Do exchange
At birth
Cord blood
Hb >14g/dl 12-14g/dl <12g/dl
Br <4mg/dl 4-5mg/dl >5mg/dl
After birth
Capillary blood Hb >12g/dl <12g/dl <12g/dl and falling in
48 hrs
Serum bilirubin <18mg/dl 18-20mg/dl 20mg/dl in first 48
hrs
Parameters for exchange transfusion
in Rh HDN
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23.  Should be as fresh as possible(<5 days)
 Rh(D) Neg blood of the same ABO gp as that of baby is
used(ABO GP of baby & mother same/compatible)
If baby’s ABO gp is not compatible with mother,it should be
O Rh(D) Neg blood free from hemolysin Anti-A &Anti B
If more than 1 exchange transfusion is required ,ABO & Rh
type same as that of the first time is used.
SELECTION OF BLOOD FOR EXCHAGE
TRANSFUSION IN Rh-hdn
13 October 201823SUNIL KUMAR.P

24. If mothers antibody is reactive against a high frequency Ag
and no compatible blood is available:
 siblings can be tested
 Unit of blood can be collected from the mother, if
the obstetricians agree that it is safe.
mothers redcells are constitued in AB plasma
13 October 201824SUNIL KUMAR.P

25. BLOOD GROUP OF MOTHER BLOOD GROUP OF BABY CHOICE OF BLOOD
A A A,O
B O
O O
AB A,O
B B B,O
A O
O O
AB B,O
AB A A,O
B B,O
O O
AB AB,A,B,O
O A O
B O
O O
AB O 13 October 201825SUNIL KUMAR.P

26.  The volume should be equal to twice the newborn infants
blood volume.
 The blood volume of a fullterm newborn is apprx 85ml/kg.
 Exchange transfusion with partially concentrated red cells
having HCT of 55-65% is preferable to whole blood.
Volume and haematocrit of blood for
exchange transfusion
13 October 201826SUNIL KUMAR.P

27.  If ABO gp of mother and infant are compatible –
serum obtained from mother is convenient for
testing.
 If ABO gp of mother and infant are incompatible-
baby’s serum or elute from cord cells is used.
 Blood should be cross matched against a mother’s
serum by IAT or enzyme method.
Special consideration in Compatible
testing
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28. PROCEDURE
 Accomplished throug a single vascular access.
 A 3 way stop clock joins the unit of blood,
baby,and the extension tube leads to the
container
 A maximum 5ml/kg is used for each draw
infused.
 The donar blood should be properly mixed.
 Exchange should be completed within 90 min.
13 October 201828SUNIL KUMAR.P

29.  Oxygenation and acid base balance should be
monitored.
 Platelets are administred if post exchange platelet
count is < 25000/mm.
 To counteract hypoglycemia 10% glucose solution is
needed after exchange transfusion.
 1ml of 10% ca gluconate after infusion of 100ml of
blood may be given to avoid citrate toxicity.
13 October 201829SUNIL KUMAR.P

30.  Usual dose-250-300microgm of hyperimmune anti D
immunoglobin.
 Sufficient to counteract the effect of 15ml of Rh D pos red cells
which corresponds to 30ml of foetal blood.
 Given intramuscularly within 72 hrs to Rh (D) neg women who
have:
1) delivered an Rh (D)pos infant and have not developed anti D in
the serum.
2) 2)undergone abortion or medical termination of pregnancy.
3) Undergone amniocentesis
4) Had antipartum haemorrhage.
Prevention of HDN
13 October 201830SUNIL KUMAR.P

31. Kleihauer-Betke acid elution
 Quantitates the number of fetal cells in circulation
 Fetal hemoglobin is resistant to acid and retain their
hemoglobin (appear bright pink)
 Adult hemoglobin is susceptible to acid and leaches
hemoglobin into buffer (“ghost” cells)
13 October 201831SUNIL KUMAR.P

32. Calculating KB test
Step 1) stain and count the amount of
fetal cells out of 1000 total cells counted
Step 2) calculate the amount of fetal
blood in cirulation by multiplying %fetal
cells by 50 mL
Step 3) divide mL of fetal blood by 30
(each vial protects against a 30 mL bleed
Step 4) Round the calculated dose up
and add one more vial for safety
30
50xcellsfetal%
RhIgofdoseRequired 
cellsfetalof%100
)1000(cellstotal
cellsfetal#
x
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33.  Most common form of blood group incompatibility.
 Results from IgG anti A and anti B and commonly
occurs in A and B group babies born to O group
mothers.
 Mild and requires no treatment.
ABO HDN
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34.  Mild because
 A and B Ag are not fully developed in infant RBC.
 Neutralisation effect of tissue A and B Ag of the infant
with the anti A and anti B of mother.
ABO HDN
13 October 201834SUNIL KUMAR.P

35.  Maternal serum Ab screening should be done to
exclude antibodies to other blood gp antigens.
 Mother of gp O with infant of gp A and B generaly
result in ABO HDN.
 Anti A and Anti B titre higher than 1:128 and presence
of hemolysins in mothers may support diagnosis.
 DCT is often negative or weak pos.
CRITERIA FOR DIAGNOSIS OF ABO
HDN
13 October 201835SUNIL KUMAR.P

36.  Test in the mother-
 ABO and Rh D grouping.
 Estimation of IgG anti A and antiB in maternal serum.
 ADCC(antibody dependent cell mediated cytotoxicity) test in
relation to severity.
 Test in infants
 ABO and Rh typing.
 DCT using polyspecific and mono specific AHG sera.
 Serum bilirubin level(↑)
 Haematological parameters
Reticulocytosis(5%).
↑ OF
spherocytes in blood smear
INVESTIGATIONS IN ABO HDN
13 October 201836SUNIL KUMAR.P

37. Phototherapy.
 Blood transfusion with red
cell concentrate.
 Exchange transfusion.
 Whole blood-Br level>20mgdl.
 Gp O dblood of infants Rh
type should be given.
 blood-low titre of anti A and
Anti B.
 O Gp is given to A,B or AB –
redcell concentrate is used.
MANAGEMENT OF ABO HDN
13 October 201837SUNIL KUMAR.P

38. Thank U……
13 October 201838SUNIL KUMAR.P