1. IVIG is used to treat neonatal jaundice caused by Rh and ABO blood group incompatibility. The guidelines recommend IVIG for infants with a positive direct antibody test who are at high risk of requiring an exchange transfusion.
2. IVIG works by blocking Fc receptors on immune cells, preventing the destruction of red blood cells and progression of hemolytic anemia. The efficacy of IVIG in reducing the need for exchange transfusions is unclear, as higher quality studies show no benefit while lower quality studies do show a benefit.
3. Additional factors like bilirubin/albumin ratio and immediate exchange transfusion for infants showing neurological symptoms should be considered along with total serum bilirubin
The document discusses how genetic testing and targeted therapies have revolutionized the diagnosis and treatment of breast cancer. It describes two cases of women diagnosed with breast cancer and how genetic testing identified a BRCA1 mutation in one family, allowing for increased screening and preventative options. Precision medicine through companion diagnostics now enables targeted therapies that work more precisely with less side effects compared to traditional chemotherapy.
Jennifer Tremmel - Sex Differences In Cardiovascular DiseaseClayman Institute
This document discusses sex differences in cardiovascular disease. It summarizes that historically, heart disease studies primarily enrolled men. Women represent about half of cardiovascular disease patients but were underrepresented in clinical trials. Risk factors like diabetes and obesity confer greater relative risk of cardiovascular events in women than men. Symptom presentation of heart disease can differ between sexes, with women more likely to experience atypical symptoms. Guidelines recommend against menopausal hormone therapy for primary or secondary prevention of cardiovascular disease in women.
Multiple Sclerosis and pregnancy: Guidelines from the literatureF.R.S. - FNRS
Multiple sclerosis can impact pregnancy outcomes. There is a small increased genetic risk to children if their mother has MS, with about a 2-4% risk if one parent has MS. During pregnancy, MS disease activity is reduced in the third trimester but may rebound after delivery. Therapeutic options during pregnancy include glatiramer acetate and interferon beta, which appear safe, while natalizumab, fingolimod, teriflunomide, and alemtuzumab should be avoided. Corticosteroids can be used for relapses but avoided in the first trimester. Breastfeeding may help reduce post-partum relapses.
This document provides an overview of several topics related to nutritional supplementation in primary care. It discusses 1) how preconceptional vitamins with folic acid for 1 year can reduce preterm labor by 70%, 2) the importance of Coenzyme Q10 supplementation, especially for those taking statins, 3) the benefits of omega-3 oils, probiotics, digestive enzymes and vitamin D, and 4) limitations of observational studies on the effects of supplements.
Prevention of Postpartum Haemorrhage (An Integrated Approach)Akmal Samsor
This document outlines an integrated approach for preventing postpartum hemorrhage (PPH) at both health facilities and in home births. It discusses how hemorrhage is a leading cause of maternal mortality globally. It then describes how active management of the third stage of labor (AMSTL) can prevent PPH for births attended by skilled providers at health facilities. It also discusses evidence that distributing misoprostol in communities can prevent PPH for home births. The document advocates for integrating facility-based AMSTL and community-based misoprostol distribution to provide broader prevention of PPH and reduce maternal mortality.
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )Ahmed AL Blasi
1. Rheumatoid arthritis does not affect fertility or the chances of getting pregnant. It also does not affect the unborn baby.
2. During pregnancy, RA symptoms often improve in the first and second trimesters due to changing hormone levels. Symptoms may worsen in the third trimester or after delivery.
3. Medications like methotrexate and leflunomide must be stopped before pregnancy due to risks. Hydroxychloroquine, sulfasalazine, low-dose steroids are considered safe options during pregnancy and breastfeeding.
The document discusses how genetic testing and targeted therapies have revolutionized the diagnosis and treatment of breast cancer. It describes two cases of women diagnosed with breast cancer and how genetic testing identified a BRCA1 mutation in one family, allowing for increased screening and preventative options. Precision medicine through companion diagnostics now enables targeted therapies that work more precisely with less side effects compared to traditional chemotherapy.
Jennifer Tremmel - Sex Differences In Cardiovascular DiseaseClayman Institute
This document discusses sex differences in cardiovascular disease. It summarizes that historically, heart disease studies primarily enrolled men. Women represent about half of cardiovascular disease patients but were underrepresented in clinical trials. Risk factors like diabetes and obesity confer greater relative risk of cardiovascular events in women than men. Symptom presentation of heart disease can differ between sexes, with women more likely to experience atypical symptoms. Guidelines recommend against menopausal hormone therapy for primary or secondary prevention of cardiovascular disease in women.
Multiple Sclerosis and pregnancy: Guidelines from the literatureF.R.S. - FNRS
Multiple sclerosis can impact pregnancy outcomes. There is a small increased genetic risk to children if their mother has MS, with about a 2-4% risk if one parent has MS. During pregnancy, MS disease activity is reduced in the third trimester but may rebound after delivery. Therapeutic options during pregnancy include glatiramer acetate and interferon beta, which appear safe, while natalizumab, fingolimod, teriflunomide, and alemtuzumab should be avoided. Corticosteroids can be used for relapses but avoided in the first trimester. Breastfeeding may help reduce post-partum relapses.
This document provides an overview of several topics related to nutritional supplementation in primary care. It discusses 1) how preconceptional vitamins with folic acid for 1 year can reduce preterm labor by 70%, 2) the importance of Coenzyme Q10 supplementation, especially for those taking statins, 3) the benefits of omega-3 oils, probiotics, digestive enzymes and vitamin D, and 4) limitations of observational studies on the effects of supplements.
Prevention of Postpartum Haemorrhage (An Integrated Approach)Akmal Samsor
This document outlines an integrated approach for preventing postpartum hemorrhage (PPH) at both health facilities and in home births. It discusses how hemorrhage is a leading cause of maternal mortality globally. It then describes how active management of the third stage of labor (AMSTL) can prevent PPH for births attended by skilled providers at health facilities. It also discusses evidence that distributing misoprostol in communities can prevent PPH for home births. The document advocates for integrating facility-based AMSTL and community-based misoprostol distribution to provide broader prevention of PPH and reduce maternal mortality.
Rheumatoid Arthritis patient wants to get Pregnant ( Clinical Scenario )Ahmed AL Blasi
1. Rheumatoid arthritis does not affect fertility or the chances of getting pregnant. It also does not affect the unborn baby.
2. During pregnancy, RA symptoms often improve in the first and second trimesters due to changing hormone levels. Symptoms may worsen in the third trimester or after delivery.
3. Medications like methotrexate and leflunomide must be stopped before pregnancy due to risks. Hydroxychloroquine, sulfasalazine, low-dose steroids are considered safe options during pregnancy and breastfeeding.
This document discusses treatment considerations for acute myeloid leukemia (AML) patients presenting with comorbidities. It presents 6 scenarios of AML patients with various comorbidities: 1) cardiomyopathy, 2) acute coronary syndrome, 3) chronic renal failure, 4) chronic dialysis, 5) hepatitis B infection, and 6) cirrhosis. For each scenario, it discusses challenges posed by the comorbidity, whether standard AML treatment can be given and any necessary dose adjustments or monitoring, and recommendations for induction, consolidation, and post-transplant therapy tailored to the individual comorbidity.
This document discusses HIV management and life expectancy after antiretroviral therapy (ART) initiation. A study of over 200,000 HIV patients in Thailand found that:
- Median life expectancy after starting ART at age 20 was 25.4 years, but was 51.9 years for those who started with CD4 counts over 350 cells/mm3.
- 83% of patients achieved undetectable viral loads. Starting ART earlier with higher baseline CD4 counts was associated with increased life expectancy.
- These results support guidelines recommending starting ART irrespective of CD4 count.
2014 10-15 LGC Biosciences Autumn seminar CambridgeAlain van Gool
Professor Alain van Gool has had a mixed career in academia, pharmaceutical industry, and applied research focusing on biomarkers and personalized healthcare. He is currently the head of the Radboud Center for Proteomics, Glycomics and Metabolomics and coordinates biomarker research at the Radboud University Medical Center and TNO. The document discusses the evolving role of biomarkers from diagnosis to personalized healthcare and examples of biomarkers guiding treatment for melanoma and metabolic disease. It also presents examples of preclinical research models for studying metabolic disease and the effects of pharmaceutical, nutritional, and lifestyle interventions on conditions like atherosclerosis and obesity.
This document provides a summary of several medical journal articles and studies. Some key findings include:
- Manual removal of the placenta 10 minutes after delivery reduces hemodynamic compromise compared to 15 minutes.
- A 1 mmol/L reduction in LDL cholesterol appears to reduce major vascular events by about 11 per 1000 people over 5 years.
- Occipital nerve stimulation appears to be a safe and effective treatment for chronic migraine and medication overuse headache.
- Singletons from IVF/ICSI have higher risks of obstetric and perinatal complications than spontaneous conceptions.
This document discusses safety data from the NordiNet IOS and ANSWER Program studies on growth hormone replacement therapy. It finds that the therapy has an overall favorable safety profile with low risks of adverse events and serious adverse events. However, risk is higher in certain high risk patient groups. Monitoring of IGF-1 levels is important to ensure levels remain within the normal range and to mitigate risks like benign intracranial hypertension and malignancy.
Cardiovascular Medications in Older Adults PASaskatchewan
This document discusses managing cardiovascular medications in older adults. Key points include:
- Medication requirements often change with age due to physiological changes
- Older adults are at higher risk for both cardiovascular events and adverse drug reactions
- Managing medications for older adults presents challenges like multimorbidity, polypharmacy, altered pharmacokinetics, and adherence issues
- The document reviews these considerations for an individual case study patient and his medications for atrial fibrillation, hypertension, and dyslipidemia. Resources for guiding decisions in older adults are also provided.
Hypertension in pregnancy is a major killer disease, this presentation explores the review of contemporary evidence in the management of acute severe hypertension,
1. The document provides guidelines for using intravenous immunoglobulin (IVIG) in treating neonatal jaundice, including recommendations for when IVIG should be administered.
2. Key recommendations include administering IVIG at a dose of 1 g/kg for infants with a positive direct antibody test who are at high risk of severe disease or need for exchange transfusion.
3. IVIG is also recommended if the total serum bilirubin is rising despite intensive phototherapy or is near the exchange transfusion level, to reduce the need for exchange transfusions in hemolytic diseases like Rh and ABO incompatibility.
approach to Rh Isoimmunization Maternal and neonatal aspects | Dr Habibur RahimDr. Habibur Rahim
This document summarizes the approach and management of a baby born to a Rh-negative mother. The baby presented with respiratory distress and signs of Rh isoimmunization. Key points include:
1) The mother's anti-D titer was 1:64 and Doppler ultrasound revealed increased blood flow, indicating Rh isoimmunization.
2) The baby received an exchange transfusion due to signs of hemolysis and hyperbilirubinemia.
3) With oxygen support and treatment, the baby's respiratory distress resolved within 6 hours and the baby improved after exchange transfusion.
This document summarizes evidence on the use of intravenous immunoglobulin (IVIg) in rheumatic diseases. It finds that IVIg is recommended as an option for treatment-resistant dermatomyositis in combination with other agents. For inclusion body myositis, there is no evidence of sustained benefit from IVIg. IVIg may be considered among treatment options for polymyositis that fails first-line therapies. A study of 20 systemic lupus erythematosus patients found IVIg led to clinical improvement in 85% and normalization of complement and antibody levels.
Rh isoimmunization occurs when a Rh-negative mother develops antibodies against Rh-positive fetal red blood cells. This can cause hemolytic disease in future Rh-positive pregnancies. Prophylaxis with Rh immunoglobulin is highly effective at preventing sensitization. For sensitized pregnancies, maternal anti-D titers and fetal middle cerebral artery Doppler are used to monitor for anemia. Severe anemia may require cordocentesis or intrauterine transfusions. After delivery, affected newborns may need exchange transfusions or other supportive care to manage hyperbilirubinemia and anemia. Prompt and specialized treatment can help prevent complications in isoimmunized pregnancies.
Hemolytic Disease of the Newborn (HDN) is caused by maternal antibodies destroying fetal red blood cells. The most common cause is Rh disease, where an Rh-negative mother produces antibodies against Rh+ antigens from the father. These antibodies cross the placenta and cause anemia or hydrops fetalis in the fetus or newborn. Diagnosis involves serological testing of the mother's blood type and antibody screen during pregnancy. Management may include Rh immunoglobulin injections for the mother or intrauterine transfusions for severe cases of fetal anemia.
Evaluation the efficacy of IVIgG in treatment of Hemolytic Disease of Newborniosrphr_editor
Hemolytic disease of newborn (HDN) is an important cause of hyperbilirubinemia in the
neonatal period,and delayed diagnosis and treatment may lead to permanent brain damage. Traditional
neonatal treatment of HDN is intensive phototherapy and exchange transfusion.Intravenous
immunoglobulin(IVIgG) has been introduced as an alternative therapy to exchange transfusion. This study was
conducted to assess the effect of IVIG in HDN .
This document discusses haemolytic disease of the fetus and newborn (HDFN), specifically Rh disease. It provides details on the pathophysiology, classification, antenatal assessment and management of Rh HDFN. Key points include that Rh HDFN is caused by maternal IgG antibodies crossing the placenta and destroying Rh+ fetal red blood cells. It can be prevented through administration of RhIg to Rh- mothers. Management may involve procedures like amniocentesis, intrauterine transfusions or exchange transfusions in the fetus or newborn if severe haemolysis is detected or predicted.
Immunoglobulin therapy involves pooled immunoglobulins from donor plasma that are administered intravenously or subcutaneously. It is used to treat primary antibody deficiencies and other immune deficiencies by antibody replacement, and can also modulate the immune system for autoimmune and inflammatory conditions. Common adverse reactions include mild infusion effects but also potential for hemolytic anemia, thrombosis, renal impairment, and meningitis. Indications are categorized as high priority for primary immunodeficiencies and secondary uses, versus reasonable evidence but other options for conditions like ITP. Dosing is based on patient weight and treatment duration.
This document discusses ABO incompatibility, which is a type of hemolytic disease caused by a reaction between maternal anti-A or anti-B antibodies and fetal A or B antigens. It is usually milder than Rh incompatibility. The severity of hemolysis is greater in OA incompatibility. Treatment may include phototherapy or exchange transfusion if bilirubin levels are too high.
Rhesus factor is a protein found on red blood cells. If present, one is Rh positive; if absent, Rh negative. Rh factor is inherited from parents. Rh incompatibility occurs when an Rh negative mother is exposed to Rh positive blood, risking complications for her Rh positive baby like hydrops fetalis or jaundice. Management includes screening, anti-D immunoglobulin, monitoring, and timing delivery to prevent baby anemia. Sensitized mothers require additional monitoring and may need intrauterine transfusions or early delivery.
This document discusses immune conflict that can occur during pregnancy between an Rh-negative mother and Rh-positive fetus. Specifically, it describes Rh isoimmunization, where antibodies produced by the mother's immune system in response to Rh antigens on fetal red blood cells can cross the placenta and destroy fetal red blood cells. If left untreated, this hemolytic process can lead to fetal anemia, jaundice, edema, and even hydrops fetalis. The document outlines methods for diagnosing and preventing Rh isoimmunization.
This document provides an overview of hemophilia, including:
- Hemophilia is an inherited bleeding disorder caused by deficiencies in coagulation factor VIII or IX.
- It affects males more often than females and symptoms include prolonged bleeding from cuts or wounds.
- Diagnosis involves screening tests and measuring coagulation factor levels. Severity depends on factor level.
- Treatment involves replacing the missing clotting factor through infusions or using bypassing agents for those who develop inhibitors against factor VIII or IX.
- Bypassing agents work by activating the clotting process without using the deficient factor. The choice of agent depends on factors like the treatment phase and dosing considerations.
- Monitoring is needed to track
A 15-year-old Hispanic female presents with cola-colored urine and edema. Laboratory tests show elevated BUN, creatinine, urine protein, and red blood cells in urine. A renal biopsy reveals findings consistent with lupus nephritis in 18 out of 22 glomeruli. Immunofluorescence demonstrates various immunoglobulin and complement deposits. The most important factor in determining appropriate therapy is the findings on light microscopy, as this will help classify the lupus nephritis and guide treatment decisions.
This document discusses treatment considerations for acute myeloid leukemia (AML) patients presenting with comorbidities. It presents 6 scenarios of AML patients with various comorbidities: 1) cardiomyopathy, 2) acute coronary syndrome, 3) chronic renal failure, 4) chronic dialysis, 5) hepatitis B infection, and 6) cirrhosis. For each scenario, it discusses challenges posed by the comorbidity, whether standard AML treatment can be given and any necessary dose adjustments or monitoring, and recommendations for induction, consolidation, and post-transplant therapy tailored to the individual comorbidity.
This document discusses HIV management and life expectancy after antiretroviral therapy (ART) initiation. A study of over 200,000 HIV patients in Thailand found that:
- Median life expectancy after starting ART at age 20 was 25.4 years, but was 51.9 years for those who started with CD4 counts over 350 cells/mm3.
- 83% of patients achieved undetectable viral loads. Starting ART earlier with higher baseline CD4 counts was associated with increased life expectancy.
- These results support guidelines recommending starting ART irrespective of CD4 count.
2014 10-15 LGC Biosciences Autumn seminar CambridgeAlain van Gool
Professor Alain van Gool has had a mixed career in academia, pharmaceutical industry, and applied research focusing on biomarkers and personalized healthcare. He is currently the head of the Radboud Center for Proteomics, Glycomics and Metabolomics and coordinates biomarker research at the Radboud University Medical Center and TNO. The document discusses the evolving role of biomarkers from diagnosis to personalized healthcare and examples of biomarkers guiding treatment for melanoma and metabolic disease. It also presents examples of preclinical research models for studying metabolic disease and the effects of pharmaceutical, nutritional, and lifestyle interventions on conditions like atherosclerosis and obesity.
This document provides a summary of several medical journal articles and studies. Some key findings include:
- Manual removal of the placenta 10 minutes after delivery reduces hemodynamic compromise compared to 15 minutes.
- A 1 mmol/L reduction in LDL cholesterol appears to reduce major vascular events by about 11 per 1000 people over 5 years.
- Occipital nerve stimulation appears to be a safe and effective treatment for chronic migraine and medication overuse headache.
- Singletons from IVF/ICSI have higher risks of obstetric and perinatal complications than spontaneous conceptions.
This document discusses safety data from the NordiNet IOS and ANSWER Program studies on growth hormone replacement therapy. It finds that the therapy has an overall favorable safety profile with low risks of adverse events and serious adverse events. However, risk is higher in certain high risk patient groups. Monitoring of IGF-1 levels is important to ensure levels remain within the normal range and to mitigate risks like benign intracranial hypertension and malignancy.
Cardiovascular Medications in Older Adults PASaskatchewan
This document discusses managing cardiovascular medications in older adults. Key points include:
- Medication requirements often change with age due to physiological changes
- Older adults are at higher risk for both cardiovascular events and adverse drug reactions
- Managing medications for older adults presents challenges like multimorbidity, polypharmacy, altered pharmacokinetics, and adherence issues
- The document reviews these considerations for an individual case study patient and his medications for atrial fibrillation, hypertension, and dyslipidemia. Resources for guiding decisions in older adults are also provided.
Hypertension in pregnancy is a major killer disease, this presentation explores the review of contemporary evidence in the management of acute severe hypertension,
1. The document provides guidelines for using intravenous immunoglobulin (IVIG) in treating neonatal jaundice, including recommendations for when IVIG should be administered.
2. Key recommendations include administering IVIG at a dose of 1 g/kg for infants with a positive direct antibody test who are at high risk of severe disease or need for exchange transfusion.
3. IVIG is also recommended if the total serum bilirubin is rising despite intensive phototherapy or is near the exchange transfusion level, to reduce the need for exchange transfusions in hemolytic diseases like Rh and ABO incompatibility.
approach to Rh Isoimmunization Maternal and neonatal aspects | Dr Habibur RahimDr. Habibur Rahim
This document summarizes the approach and management of a baby born to a Rh-negative mother. The baby presented with respiratory distress and signs of Rh isoimmunization. Key points include:
1) The mother's anti-D titer was 1:64 and Doppler ultrasound revealed increased blood flow, indicating Rh isoimmunization.
2) The baby received an exchange transfusion due to signs of hemolysis and hyperbilirubinemia.
3) With oxygen support and treatment, the baby's respiratory distress resolved within 6 hours and the baby improved after exchange transfusion.
This document summarizes evidence on the use of intravenous immunoglobulin (IVIg) in rheumatic diseases. It finds that IVIg is recommended as an option for treatment-resistant dermatomyositis in combination with other agents. For inclusion body myositis, there is no evidence of sustained benefit from IVIg. IVIg may be considered among treatment options for polymyositis that fails first-line therapies. A study of 20 systemic lupus erythematosus patients found IVIg led to clinical improvement in 85% and normalization of complement and antibody levels.
Rh isoimmunization occurs when a Rh-negative mother develops antibodies against Rh-positive fetal red blood cells. This can cause hemolytic disease in future Rh-positive pregnancies. Prophylaxis with Rh immunoglobulin is highly effective at preventing sensitization. For sensitized pregnancies, maternal anti-D titers and fetal middle cerebral artery Doppler are used to monitor for anemia. Severe anemia may require cordocentesis or intrauterine transfusions. After delivery, affected newborns may need exchange transfusions or other supportive care to manage hyperbilirubinemia and anemia. Prompt and specialized treatment can help prevent complications in isoimmunized pregnancies.
Hemolytic Disease of the Newborn (HDN) is caused by maternal antibodies destroying fetal red blood cells. The most common cause is Rh disease, where an Rh-negative mother produces antibodies against Rh+ antigens from the father. These antibodies cross the placenta and cause anemia or hydrops fetalis in the fetus or newborn. Diagnosis involves serological testing of the mother's blood type and antibody screen during pregnancy. Management may include Rh immunoglobulin injections for the mother or intrauterine transfusions for severe cases of fetal anemia.
Evaluation the efficacy of IVIgG in treatment of Hemolytic Disease of Newborniosrphr_editor
Hemolytic disease of newborn (HDN) is an important cause of hyperbilirubinemia in the
neonatal period,and delayed diagnosis and treatment may lead to permanent brain damage. Traditional
neonatal treatment of HDN is intensive phototherapy and exchange transfusion.Intravenous
immunoglobulin(IVIgG) has been introduced as an alternative therapy to exchange transfusion. This study was
conducted to assess the effect of IVIG in HDN .
This document discusses haemolytic disease of the fetus and newborn (HDFN), specifically Rh disease. It provides details on the pathophysiology, classification, antenatal assessment and management of Rh HDFN. Key points include that Rh HDFN is caused by maternal IgG antibodies crossing the placenta and destroying Rh+ fetal red blood cells. It can be prevented through administration of RhIg to Rh- mothers. Management may involve procedures like amniocentesis, intrauterine transfusions or exchange transfusions in the fetus or newborn if severe haemolysis is detected or predicted.
Immunoglobulin therapy involves pooled immunoglobulins from donor plasma that are administered intravenously or subcutaneously. It is used to treat primary antibody deficiencies and other immune deficiencies by antibody replacement, and can also modulate the immune system for autoimmune and inflammatory conditions. Common adverse reactions include mild infusion effects but also potential for hemolytic anemia, thrombosis, renal impairment, and meningitis. Indications are categorized as high priority for primary immunodeficiencies and secondary uses, versus reasonable evidence but other options for conditions like ITP. Dosing is based on patient weight and treatment duration.
This document discusses ABO incompatibility, which is a type of hemolytic disease caused by a reaction between maternal anti-A or anti-B antibodies and fetal A or B antigens. It is usually milder than Rh incompatibility. The severity of hemolysis is greater in OA incompatibility. Treatment may include phototherapy or exchange transfusion if bilirubin levels are too high.
Rhesus factor is a protein found on red blood cells. If present, one is Rh positive; if absent, Rh negative. Rh factor is inherited from parents. Rh incompatibility occurs when an Rh negative mother is exposed to Rh positive blood, risking complications for her Rh positive baby like hydrops fetalis or jaundice. Management includes screening, anti-D immunoglobulin, monitoring, and timing delivery to prevent baby anemia. Sensitized mothers require additional monitoring and may need intrauterine transfusions or early delivery.
This document discusses immune conflict that can occur during pregnancy between an Rh-negative mother and Rh-positive fetus. Specifically, it describes Rh isoimmunization, where antibodies produced by the mother's immune system in response to Rh antigens on fetal red blood cells can cross the placenta and destroy fetal red blood cells. If left untreated, this hemolytic process can lead to fetal anemia, jaundice, edema, and even hydrops fetalis. The document outlines methods for diagnosing and preventing Rh isoimmunization.
This document provides an overview of hemophilia, including:
- Hemophilia is an inherited bleeding disorder caused by deficiencies in coagulation factor VIII or IX.
- It affects males more often than females and symptoms include prolonged bleeding from cuts or wounds.
- Diagnosis involves screening tests and measuring coagulation factor levels. Severity depends on factor level.
- Treatment involves replacing the missing clotting factor through infusions or using bypassing agents for those who develop inhibitors against factor VIII or IX.
- Bypassing agents work by activating the clotting process without using the deficient factor. The choice of agent depends on factors like the treatment phase and dosing considerations.
- Monitoring is needed to track
A 15-year-old Hispanic female presents with cola-colored urine and edema. Laboratory tests show elevated BUN, creatinine, urine protein, and red blood cells in urine. A renal biopsy reveals findings consistent with lupus nephritis in 18 out of 22 glomeruli. Immunofluorescence demonstrates various immunoglobulin and complement deposits. The most important factor in determining appropriate therapy is the findings on light microscopy, as this will help classify the lupus nephritis and guide treatment decisions.
This document summarizes information about hepatitis B virus (HBV) genotypes, pathogenesis, transmission routes, clinical phases of acute and chronic HBV infection, treatment options, vaccination schedules, and post-exposure prophylaxis. It discusses that HBV genotype C is associated with more severe liver disease outcomes compared to genotype B. It recommends entecavir or tenofovir as preferred treatments for immune-active chronic hepatitis B and outlines vaccination schedules, treatment in pregnancy/cirrhosis, and a new drug called Myrcludex B that is under clinical trial.
An Rh-negative pregnant woman is at risk of developing antibodies against her Rh-positive baby's red blood cells. This can cause hemolytic disease in future pregnancies.
The document outlines protocols for testing, prevention, and management. All Rh-negative pregnant women should be tested for antibodies at first visit. Anti-D immunoglobulin is given postpartum/abortion to prevent sensitization if the baby is Rh-positive. Precautions like gentle delivery and placenta removal can minimize fetal-maternal bleeding. Developed antibodies can cause anemia, jaundice or fluid buildup in subsequent Rh-positive babies.
This document discusses the prevention of hepatitis B and C. It notes that India has an overall HBsAg positivity rate of 2-4.7% among pregnant women. Hepatitis B can be transmitted through blood or body fluids, from mother to child during birth, or through sexual contact. High-risk groups include those with multiple sexual partners or intravenous drug use. The hepatitis B vaccine is effective at preventing infection and involves a 3-dose series over 6 months. For exposure, hepatitis B immune globulin and vaccination provides good protection if started within 2 weeks. Universal precautions and immunization are key to prevention in healthcare settings.
The GDG stresses that the four-visit focused ANC (FANC) model does not offer women adequate contact with health-care practitioners and is no longer recommended. With the FANC model, the first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks, the third around 32 weeks, and the fourth between 36 and 38 weeks of gestation
“Regulatory experience with monoclonal antibody submissions in the EU”
Provides an overview of the current EU assessment of biotherapeutics, focusing specifically on monoclonal antibodies
1. Neonatal arterial occlusion can result in limb gangrene and loss but early diagnosis and management can preserve the limb.
2. The case report describes a neonate presenting with cyanosis and lack of pulses in the right upper extremity, diagnosed with arterial thrombosis in the axillary and brachial arteries via ultrasound.
3. An emergent thrombectomy was performed successfully, restoring blood flow and normal function without residuals, highlighting the importance of prompt intervention for arterial occlusions of unknown duration.
1. Neonatal arterial occlusion can result in limb gangrene and loss but early diagnosis and management can preserve the limb.
2. The case report describes a preterm infant who presented with right upper extremity ischemia and was found to have an arterial thrombosis from the axillary to brachial arteries.
3. An emergent thrombectomy successfully restored blood flow and the infant recovered full function without complications, highlighting the importance of prompt intervention for arterial occlusions in neonates.
Congenital hyperinsulinism is a rare genetic disorder characterized by inappropriate insulin secretion that causes recurrent episodes of low blood sugar (hypoglycemia). It has an incidence of 1 in 50,000 live births. The condition is caused by mutations in genes that regulate insulin secretion from pancreatic beta cells. Treatment aims to maintain blood glucose levels above 63 mg/dl to prevent neurological harm. Management options include oral medications, intravenous glucose, glucagon injections, octreotide, surgery, and living with frequent feedings. Delayed diagnosis and treatment can lead to long-term neurological issues in over half of patients.
Monkeypox is a rare disease caused by infection with monkeypox virus. It was first discovered in 1958 when outbreaks occurred in monkey colonies. The first human case was in 1970 in the DRC. Symptoms are similar to but milder than smallpox and include fever, headache, muscle aches and a rash that often begins on the face then spreads to other parts of the body. It can spread through contact with infected animals, humans or contaminated materials and from mother to fetus. Differential diagnoses include varicella, smallpox and vaccinia virus infection.
This document discusses CNS infections such as meningitis and encephalitis in children. It begins by defining these conditions and noting that they are common serious problems in pediatric practice that can cause death or neurological sequelae. It then differentiates between meningitis, encephalitis, and other CNS infections based on clinical presentation and causative organisms. The document provides guidance on diagnosing CNS infections through clinical manifestations, CSF examination, and other tests. It also outlines potential complications like death, blindness, deafness, and neurological sequelae. Finally, it discusses management of different CNS infections through appropriate antibiotic therapy and monitoring for complications.
This document discusses neonatal meningitis, including its causes, presentation, diagnosis, and treatment. Group B streptococcus and E. coli are common causes. Signs can be subtle but include fever, irritability, and hypotension. Diagnosis involves lumbar puncture to examine CSF, where pleocytosis and low glucose indicate infection. Complications include cerebral edema, hydrocephalus, and neurological impairments. Treatment requires early, aggressive antimicrobial therapy for at least 2 weeks. Long-term monitoring is also needed due to potential cognitive and developmental issues.
The document outlines congenital hyperinsulinism, which is characterized by inappropriate insulin secretion causing hypoglycemia. It discusses the pathophysiology, causes, diagnosis, and treatment of congenital hyperinsulinism, including medications like diazoxide and octreotide as well as potential surgical interventions. The management of congenital hyperinsulinism is crucial to prevent neurodevelopmental issues associated with prolonged hypoglycemia.
This document provides information on how to read a complete blood count (CBC). It defines a CBC as a series of blood tests that evaluate the cellular components of blood. The CBC measures red blood cell count, white blood cell count, hemoglobin, hematocrit, and platelet count. It also provides indices to characterize red blood cells, such as mean corpuscular volume. The summary discusses the clinical implications of abnormalities in these values, such as indicating infection or anemia.
Bone age assessment is used in pediatrics to evaluate growth, maturity and diagnose disorders. The Greulich-Pyle and Tanner-Whitehouse 2 methods are commonly used, involving left hand and wrist radiographs compared to bone age atlases or scoring systems. Bone age can help diagnose causes of short stature and determine timing of growth hormone treatment. It may also predict pubertal timing, peak height velocity and final adult height. Computerized bone age assessment methods show promise for increased accuracy and usefulness across different populations.
Blancing the use of sedative and analgesia in neonates.pptssuser2dcad1
The document discusses balancing sedation and analgesia in neonates. It describes how pain experiences can impact brain development and outlines tools to assess neonatal pain. Non-pharmacological approaches and commonly used medications are reviewed. The risks of anesthesia exposure include short and long-term neurological effects. Guidelines recommend a stepwise approach combining pharmacological and non-pharmacological pain management tailored to the clinical situation to minimize risks to neurodevelopment.
This document provides guidelines for blood transfusion practice by Dr. Magdy Shafik Ramadan. It outlines the history of blood transfusions and development of blood banking. It describes different blood components like packed red blood cells, platelets, fresh frozen plasma and cryoprecipitate. It provides guidelines on usage, dosage, storage and administration of these components. It discusses the nursing role in blood transfusion which includes preparation, documentation and monitoring the procedure. It also covers transfusion in special conditions and management of transfusion reactions.
The document discusses black fungus (mucormycosis), which has been affecting some COVID-19 patients in India and Egypt. It provides information on:
1) What black fungus is, the types of mucormycosis, and how it spreads (through spore inhalation but not human-to-human).
2) Risk factors like uncontrolled diabetes, steroid use for COVID-19 treatment, and weak immune systems.
3) Symptoms like nasal blockage and eye/orbital involvement.
4) Diagnosis through tissue/fluid samples, imaging, and microscopy of broad, non-septate hyphae.
5) Treatment involving antifungal
The document discusses several case examples of children presenting with a limp and the process of differential diagnosis. Case 1 involves a 18 month old with developmental dysplasia of the hip. Case 2 is a 4 year old boy diagnosed with Legg-Calve-Perthes disease. Case 3 is a 4 year old girl with transient synovitis of the hip.
The document provides a summary of key points to consider when evaluating a limping child, including:
1) Describe the gait pattern and localize the source of limp to structures like the hip, knee, or foot.
2) Consider patient factors such as age, medical history, and family history.
3) Generate a differential diagnosis using the VINDICATE framework including conditions like infection, neoplasm, trauma, and developmental disorders.
4) Five case examples are then presented to demonstrate how history, exam findings, and testing can lead to diagnoses like DDH, Legg-Calve-Perthes disease,
basic imunization and immunization in sepecal situation.pptssuser2dcad1
This document provides information on basic immunization and immunization in special situations. It discusses different types of immunity including active and passive immunity. It describes various immunizing agents such as immunoglobulins, antisera, and different types of vaccines including live, attenuated, inactivated, toxoids, and recombinant vaccines. It also discusses vaccination schedules, adverse reactions to immunization, maintaining the cold chain, and provides guidance on immunization for special populations such as preterm infants, immunocompromised individuals, and hepatitis B-positive mothers and their newborns.
The document discusses black fungus (mucormycosis), which has been affecting some COVID-19 patients in India and Egypt. It provides information on what mucormycosis is, how it spreads, types of mucormycosis infections, clinical features, diagnosis, treatment and prevention. It notes that mucormycosis is caused by exposure to mucor mould commonly found in soil and plants. Improper use of steroids to treat COVID-19 and poor diabetes management are contributing to the increased cases. Treatment involves antifungal therapy like amphotericin B and surgery to remove infected tissues.
Hydrops fetalis is edema of the fetus that is defined as a collection of fluid in at least two fetal compartments. It can be immune or nonimmune in type, with immune hydrops occurring due to red blood cell alloimmunization from maternal antibodies forming against fetal red blood cell antigens, which can cause fetal anemia and hemolysis. Diagnostic methods include determining maternal antibodies, fetal blood typing, amniocentesis to monitor severity of hemolytic disease of the fetus and newborn, fetal blood sampling, and ultrasound.
Vitamin D deficiency is common in critically ill neonates. A study found serum 25-OH vitamin D levels were significantly lower in critically ill neonates compared to healthy newborns, with no correlation to disease severity except in pneumonia cases. The study recommended measuring 25-OH vitamin D levels in critically ill neonates and ensuring adequate maternal vitamin D intake during pregnancy and lactation, as well as vitamin D supplementation for breastfed infants. Guidelines for treating vitamin D deficiency in children include daily or weekly high dose vitamin D supplementation for 4-8 weeks, followed by maintenance doses, while insufficiency is managed with biweekly or monthly lower dose supplementation.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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1. Guidelines for IVIG in the
treatment of neonatal jaundice
By
Dr . Magdy Shafik Ramadan
Senior Pediatric and Neonatology consultant
M.S, Diploma, Ph.D of Pediatrics
2. What Is
IVIG
• Intravenous Immunoglobulin (IVIG) is a
solution of highly purified immunoglobulin
G, derived from large pools of human plasma
that contain antibodies against a broad
spectrum of bacterial and viral agents
3. • 4 Things About
IVIG
1
• It can be given Intravenously (IV
through the vein or subcutaneously
(under the skin).
• MOST IMPORTANTLY IVIG CAN BE
GIVEN SAFELY IN THE
CONVENIENCE OF YOUR HOME.
4. 2
• Some home Infusion companies will
send a nurse to your home
5. 3
• Some companies will even help you
and your doctor complete all necessary
documents.
6. 4
• Insurance companies can be
challenging to deal with in the IVIG
treatment approval process.
7. IVIG is used to treat primary and secondary
immune deficiencies, autoimmune,
infections and neuroimmunological
disorders.
• Patients with primary immune
deficiencies usually receive treatment
therapy for life.
8. IVIG Therapy has been used extensively in
the treatment and prevention of a variety of
infectious and inflammatory diseases.
• Patients with compromised Immune systems
who have these conditions often benefit from
the passive immunity provided by IVIG
therapy.
9. IVIG is used in patients with primary
immunodeficiency's and certain conditions
associated with B-cell Chronic Lymphocytic
Leukemia, Pediatric HIV, and Bone Marrow
Transplant.
• IVIG is also utilized to raise platelet counts in
patients with Idiopathic Thrombocytopenic
Purpura and to treat the symptoms related to
other clinical conditions such as Kawasaki
Syndrome.
10. Various Other Diseases and Immune Disorders
where IGIV Is Used:
• Chronic Sinusitis
• Chronic Inflammatory
• Demyelinating Polyneuropathy
• Multiple Sclerosis (MS)
• Myasthenia Gravis (MG
• Systenic Lupus Erythematosus (SLE)
• Guillain-Barre Syndrome (GBS)
• Autoimmune Diabetic Neuropathy
• Polymyositis
• Multifocal Motor Neuropathy (MMN)
• Dermatomyositis
• Rheumatoid Arthritis (RA)
14. Forms available
• Dosage Forms & Strengths
• injectable solution
• 10% (100mg/mL)
• 5% (50mg/mL)
15. • Contraindications
Hypersensitivity to gamma globulin
Isolated IgA deficiency
Hyperprolinemia (with some products)
Serum sickness like reaction.
Hemolytic anemia can develop
subsequent to IGIV therapy due to
enhanced RBC sequestration
16. IVIG Administration
• Clinical trials of IVIG administration to treat hemolytic
anemia have been promising.
• The immune process involves the formation of an
antibody-antigen complex between the maternal
antibody and the antigen of the fetal or neonatal RBC.
• The lower portion of the maternal antibody is termed the
Fc regionThe lower portion of the maternal antibody is
termed the Fc region
• This portion of the antibody attaches to the Fc receptors
on specific immune system cells, such as macrophages,
stimulating the ingestion and destruction of the antigen-
antibody complex and the RBC.
17. • administration of IVIG blocks the Fc
receptors of the immune cells.17 This
subsequently stops the destruction of
RBCs and the progression of hemolytic
anemia.
18. • Infusion Rates:
• 0.5 ml/kg/hour for the first fifteen (15) minutes
If no problems occur, increase infusion to
• 1 ml/kg/hour for the next fifteen (15) minutes
If no problems occur, increase infusion to
• 2 ml/kg/hour for the next fifteen (15) minutes
If no problems occur, increase infusion to
• 4 ml/kg/hour for the remainder of the infusion
• The maximum rate of infusion for IVIG is 4
ml/kg/hour.
• Stop the infusion or decrease the infusion rate if side
effects occur.
• Potential side effects are:
Hypotension -Tachycardia-Flushing
19. • ABO Incompatibility
• ABO incompatibilities can occur in the following
situations:
• (1) the mother’s blood type is O, and the
neonate’s blood type is A or B;
• (2) the mother’s blood type is B, and the
neonate’s blood type is A or AB;
• (3) the mother’s blood type is A, and the
neonate’s blood type is B or AB
20. • Indication of use in isoimmune heamoltic anemia :
• Rh and ABO incompatibility.
• Not indicated unless Direct Antibody Test (DAT)
is positive.
• Other isoimmune haemolytic disease (no
systematic reviews available).
• Difficulties in obtaining appropriate blood for
ET or parental refusal for ET.
• Do not give if exchange transfusion imminent.
21. Strength of recommendation
Recommendation
Grade
ESCMID strongly suport
recommondation for use
A
ESCMID moderately suport
recommendation for use
B
ESCMID marginally suport
recommendation for use
C
ESCMID suport recommendation (weak )
against use
D
22. Guidelines for treatment of neonatal jaundice
• 1- All pregnant women should be tested for ABO and
Rh (D) blood types and have a serum screen for
unusual isoimmune antibodies (evidence quality B:
benefits exceed harms)
• 2- If a mother has not had prenatal blood grouping
or is Rh-negative, a direct antibody test (or Coombs’
test), blood type, and an Rh (D) type on the infant’s
(cord) blood are strongly recommended (evidence
quality B:
23. • 3-Sick infants and those who are jaundiced at or
beyond 3 weeks should have a measurement of
total and direct or conjugated bilirubin to identify
cholestasis (evidence quality D:.
The results of the newborn thyroid and
galactosemia screen should also be checked in these
infants (evidence quality D
• 4- Measurement of the glucose-6-phosphate
dehydrogenase (G6PD) level is recommended for a
jaundiced infant who is receiving phototherapy
and whose family history or ethnic or geographic
origin suggest the likelihood of G6PD deficiency or
for an infant in whom the response to
phototherapy is poor (evidence quality C
24. • G6PD deficiency is widespread and frequently
unrecognized, and although it is more common in
the populations around the Mediterranean and in
the Middle East.
• G6PD deficiency occurs in 11% to 13% of African
Americans.
• In a recent report, G6PD deficiency was
considered to be the cause of hyperbilirubinemia
in 19 of 61 (31.5%) infants who developed
kernicterus
25. • 5-All hospitals should provide written and verbal
information for parents at the time of discharge,
which should include an explanation of jaundice,
the need to monitor infants for jaundice, and
advice on how monitoring should be done
(evidence quality D
26. 6-Infants with a positive DAT(Direct Antbody
Reaction) who have predicted severe disease based
on antenatal investigation or an elevated risk of
progressing to exchange transfusion based on the
postnatal progression of TSB concentration should
receive IVIG at a dose of 1 g/kg (recommendation
grade A).
7.1.4: In isoimmune hemolytic disease, administration
of intravenous γ-globulin (0.5-1 g/kg over 2 hours) is
recommended if the TSB is rising despite intensive
phototherapy or the TSB level is within 2 to 3 mg/dL
(34-51 μmol/L) of the exchange level If necessary,
this dose can be repeated in 12 hours (evidence
quality B: benefits exceed harms
27. • Intravenous γ-globulin has been shown to reduce
the need for exchange transfusions in Rh and ABO
hemolytic disease.
• Although data are limited, it is reasonable to
assume that intravenous γ-globulin will also be
helpful in the other types of Rh hemolytic disease
such as anti-C and anti-E.
28. • 8-It is an option to measure the serum albumin
level and consider an albumin level of less than 3.0
g/dL as one risk factor for lowering the threshold
for phototherapy use (evidence quality D.
30. • High bilirubin/albumin (B/A) ratios increase the
risk of bilirubin neurotoxicity.
• The B/A ratio may be a valuable measure, in
addition to the total serum bilirubin (TSB), in the
management of hyperbilirubinemia
• In preterm infants of 32 weeks' gestation or less
with hyperbilirubinemia we found no significant
effect of the additional use of B/A ratio compared
to TSB-based treatment on the composite motor
score at 18 to 24 months' corrected age.
31. • Bilirubin/albumin ratio (B/A) may provide a
better estimate of free bilirubin than total serum
bilirubin (TSB).
• Both TSB and B/A are strong predictors of
neurotoxicity, but B/A does not improve prediction
over TSB alone.
• Bilirubin/albumin ratio —
The bilirubin/albumin (B/A) ratio can be used as
an additional factor in determining the need for
exchange transfusion; it should not be used alone
but in conjunction with TB values
32. • Guidelines 9:
If an exchange transfusion is being considered, the
serum albumin level should be measured and the
bilirubin/albumin (B/A) ratio used in conjunction
with the TSB level and other factors in determining
the need for exchange transfusion (evidence quality
D.
10-Immediate exchange transfusion is
recommended in any infant who is jaundiced and
manifests the signs of the intermediate to advanced
stages of acute bilirubin encephalopathy
(hypertonia, arching, retrocollis, opisthotonos, fever,
high-pitched cry) even if the TSB is falling (evidence
quality D
33. • For infants ≥38 weeks gestation, consider
exchange transfusion when
TB (mg/dL)/albumin (g/dL)ratio is >8.0
• For infants 35 to 37 6/7 weeks and well or ≥38
weeks with high risk (eg, isoimmune hemolytic
disease or G6PD deficiency), consider exchange
transfusion when
TB (mg/dL)/albumin (g/dL) ratio is >7.2
• For infants 35 to 37 6/7 weeks with high risk (eg,
isoimmune hemolytic disease or G6PD deficiency),
consider exchange transfusion when
TB (mg/dL)/albumin (g/dL) ratio is >6.8
34. Additional Albumin
• this is the rationale for the recommendation to
administer 25% albumin either 1 hour before an
exchange ( 1 gr / kg )
• No evidence shows that this practice is of practical
value in neonates with normal albumin levels.
• Side effects of this practice( congestive heart
failure)
35. • Intravenous immunoglobulin in isoimmune
haemolytic disease of newborn: an updated systematic review
and meta-analysis.Review articleLouis D, et al. Arch Dis Child Fetal
Neonatal Ed. 2014.Show full citation
• Abstract
• BACKGROUND: Intravenous immunoglobulin (IVIg) is used in neonates
with isoimmune haemolytic disease to prevent exchange transfusion (ET).
However, studies supporting IVIg had methodological issues.
• OBJECTIVE: To update the systematic review of efficacy and safety of IVIg
in neonates with isoimmune haemolytic disease.
• METHODS: MEDLINE, Embase databases and Cochrane Central
Register of Controlled Trials (Cochrane Library) were searched (from
inception to May 2013) for randomised or quasi-randomised controlled
trials comparing IVIg with placebo/controls in neonates with isoimmune
haemolytic disease without any language restriction. Three investigators
assessed methodological quality of included trials. Meta-analyses were
performed using random effect model and risk ratio (RR)/risk difference
(RD) and mean difference with 95% CI
36. • calculated.
• MAIN RESULTS: Twelve studies were included, ten trials
(n=463) of Rh isoimmunisation and five trials (n=350) of
ABO isoimmunisation (three studies had both population).
Significant variations in risk of bias precluded an overall
meta-analysis of Rh isoimmunisation. Studies with high risk
of bias showed that IVIg reduced the rate of ET in Rh
isoimmunisation (RR 0.23, 95% CI 0.13 to 0.40), whereas
studies with low risk of bias that also used prophylactic
phototherapy did not show statistically significant difference
(RR 0.82, 95% CI 0.53 to 1.26). For ABO isoimmunisation,
only studies with high risk of bias were available and meta-
analysis revealed efficacy of IVIg in reducing ET (RR 0.31,
95% CI 0.18 to 0.55).
37. • CONCLUSIONS: Efficacy of IVIg is not
conclusive in Rh haemolytic disease of
newborn with studies with low risk of bias
indicating no benefit and studies with high
risk of bias suggesting benefit. Role of IVIg
in ABO disease is not clear as studies that
showed a benefit had high risk of bias.
38.
39.
40. A new therapy in treatment of neonatal
jundice
• 1-A new therapy currently under
development consists of inhibition of
bilirubin production through blockage of
heme oxygenase.
mesoporphyrins and protoporphyrins
(Stannsoporfin).
2-Supplementation of probiotics appears to
show promise for newborns with pathologic
neonatal jaundice.
41. • 3-Zinc sulfate supplementation is a
controversial potential approach for
treating neonatal jaundice.
Guidelines for exchange transfusion in infants 35 or more weeks’ gestation.Note that these suggested levels represent a consensus of most of the committee but are based on limited evidence, and the levels shown are approximations. See ref. 3 for risks and complications of exchange transfusion. During birth hospitalization, exchange transfusion is recommended if the TSB rises to these levels despite intensive phototherapy. For readmitted infants, if the TSB level is above the exchange level, repeat TSB measurement every 2 to 3 hours and consider exchange if the TSB remains above the levels indicated after intensive phototherapy for 6 hours.The following B/A ratios can be used together with but in not in lieu of the TSB level as an additional factor in determining the need for exchange transfusion52: If the TSB is at or approaching the exchange level, send blood for immediate type and crossmatch. Blood for exchange transfusion is modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant.53