ABO INCOMPATIBILITY

[salameh101]

A full term male baby, normal delivery, normal Apgar score, Bwt 3 kg.

> Mother?s blood group o-ve and baby B+ve, family history of ABO

> incompatibility, found to be jaundice in first 2 hrs, Hb 11gram/dl

> at birth, at 2 hrs Hb 8 gram/dl and sb 145 Mmol,Direct combs test

> +ve anti B ,placed under intensive phototherapy and given 15 ml

O +VE RBC in AB +ve plasma.

> Which is more beneficial for the baby?

> 1- To do partial exchange transfusion.

> 2- To do exchange transfusion.

> 3- To give first PRBC TO CORRECT ANEMIA.

> Thank you

Edited May 4, 2010 by salameh101
MISSING WORD

[Guest Omer]

There is a well known ameliorating effect of ABO incopatibility on RH disease. This is due to early distruction of fetal ABO incompatible cell before sensitization to Rh antigen occur.

In the above case scenario;maternal history is imporatnt. Maternal antibody screen during pregnancy, parity, previous abortions.The presence of antiB antibodies in the baby's blood direct you to ABO incopmatibility of course. Keep in mind that ABO incompatibility can be a severe disease leading to a double exchange transfusion.

The presence of anemia and the dropping Haemoglobin is more alarming here. It indicate an ongoing on haemolytic process(possibily severe)due to presence of a good amount of antibodies.Although you gave a top-up transfusion, the antibodies are still there. As you are on the right tract; keep in mind that you might need a DOUBLE volume exchange transfusion at the end of the 4hrs of intensive photherapy. Be prepared with ready blood, UAC and UVC insitu. Any further drop in haemoglobin might indicate the need for getting rid of the circulating antibodies.Although it depend on your unit policy , I believe the isovolumetric exchange is more easier and satisfactory that the pull and push method; but as I said it depends on the degree of comfort and expereince (nurses should be comfortable about any bedside intervention) of you team.

another important point is wether to correct the anemia first or not to do so; I think it depend on the duration and degree of anemia. check the antenatal charts for any abnormal doppler studies of the middle cerebral artery or any degree of hydrops. Although in my undrestanding this was not the case.If the anemia is chronic with a very low HB then rapid correction with blood transfusion might result in heart failure.We correct chronic anemia(not due to haemolysis) with small aliquots of blood transfusion. I think in the above case a top-up (as you have done) would not be harmful, but SHOULD not take your attension away from a possible double exchange transfusion.

I hope you hear more opinions from other so we can all learn.

Cheers

Omer Hamud

Toronto

Edited June 23, 2010 by Omer

[Shantharama Karanth]

In our unit we would try IVIG - Intravenous Immune Globulin 1 gram/kg and "Intense Phototherapy" if the bilirubin is approaching "exchange level"

Shanta Karanth

Manassas, VA

[rehman_naveed]

I would go for exchange transfusion after intensive phototherapy failed after 4 hrs while keeping the blood ready with UAC and UVC in situ, IV immunoglobulins and in the end of exchange will transfuse 5ml/kg as extra PRBC.

[selvanr4]

A double volume exchange transfusion will reduce the bilirubin load by atleast 40% and help in removing the antibodies. IVIG is a good add on early

[abomran]

I think as you did a top-up transfusion with 5 -10 ml of PRBCs together with intensive phototherapy and IVIg would be a good start, but be ready for EBT.

[JACK]

> Mother?s blood group o-ve and baby B+ve

Why cant this be a case of Rh iso-immunization?

given 15 ml

O +VE RBC in AB +ve plasma.

Why was O negative RBC not used ?

> Which is more beneficial for the baby?

> 1- To do partial exchange transfusion.

> 2- To do exchange transfusion.

> 3- To give first PRBC TO CORRECT ANEMIA.

> Thank you

The most important think for the baby are the ABC's, so if anemia is causing hemodynamic instability, that has to be corrected. But at the same time if jaundice is requiring exchange transfusion, both can be addressed at one go by doing a double volume exchange transfusion - request the blood bank to make the PRBC+FFP=whole blood with a higher hematocrit.

IVIG is always good to stop further hemolysis though it will not reverse the current condition.

Partial exchange is an option when you have sever anemia and you think that a PRBC transfusion might overload the circulatory system.

[salameh101]

Sorry; for PRBC O-ve blood not o+ve, the pt is doing well, under D- phototherapy, SB AND HB within normal range.

Exchange transfusion was not needed.

[Guest Dukstar]

Hello,

Can anyone explain to me the concepts of "double exchange volume transfusion", "simple exchange volume transfusion" and "partial exchange volume transfusion", with practical points (volume, blood, albumin, etc...° ,

Many thanks

[thabit]

Hi all..

for me i would start intense phototherapy and double volume exchange all at once...that will correct all the abnormalities

[JACK]

We have escaped from exchange transfusion, in many cases , thanks to intense phototherpy ( we call it capsule !). As long as we can avoid an exchange transfusion, we should stay away from it, as exchange transfusion and the associated central line placement and the blood products used - all have their associated adverse effects.

[Guest Omer]

@Dukstar.

Exchange transfusion was first reported in 1925 by Dr. A.P. Hart from the Hospital for Sick Children here in Toronto. Dr.Hart described the procedure which was called" exsanguination, venesection, substitution transfusion" as that time. He had done it on a baby with erythroblastosis fetalis. He used the technique which was developed by Dr. Bruce Roberts, a Toronto surgeon who used it as a treatment for patients with septic shock due to severe burn and sepsis.

Dr.Hart transfused 350 ml of blood through an ankle vein while simultaneously aspirating 300 ml of blood from the saggital sinus through the anterior fontanelle.

In 1946 Dr.H . Wallerstein from New York used the procedure described by Dr.Hart but removed 50 ml aliquots while infusing blood through a peripheral vein cut down.

Dr.L.K.Diamond ,in 1946 demonstrated that the serum of infant who had erythroblastosis fetalis and had been transfused with Rh negative red blood cells still contained free maternal anti-Rh antibodies and that the remaining infant red blood cells are coated with the antibodies. He thought and reasoned that the most effective way of removing the antibodies was replacing the baby's blood with Rh negative blood and he used the umbilical vein. Dr.Diamond had many publications about the exchange transfusion and erythroblastosis fetalis.

In 1963 ,Dr. A .W. Lily described the correlation between the amniotic fluid density and the degree of anemia at birth. The amniotic fluid spectroscopy became an standard method in sensitized pregnant women at that time and clinical Normograms of the delta OD 450 were constructed to determine early induction of labour at 32-34 weeks before death due to hydrops fetalis. they were faced with the intricate complex pathways of prematurity. Intaperitoneal transfusion were common at that time specially with the improved use of ultrasound. However, with better technique in ultrasound the fetal umbilical vein could be cannulated in utero and hemoglobin be measured and/or blood transfusion be given.This had led to the amniotic fluid spectroscopy to fall out of practice "you can find it described in old textbook of neonatology" .

Then of course came the Rhogam for Rh negative mother with better ways and techniques of exchange transfusion; and of course phototherapy, IVIG and intensive photherapy.

The incidence of Rh incompatibility had dramatically dropped and its extremely rare to see a case of Rh incompatibility.The exchange transfusion is a procedure that is associated with complications. But in a situation of severe hyperbilrubinemia, early contact with Tertiary centers should be instituted for transport .

In a double exchange transfusion : you replace the baby's blood twice . The normal newborn blood volume is about 80-85ml/kg. In a double volume exchange your calcu is 2x80x wt. The blood bank prepare it as O Rh negative blood suspended in AB plasma .A single volume exchange is usually done for anemia in cases of hydrops. A partial exchange transfusion is usually done for treatment of polythcythemia in newborn to prevent sinus thrombosis in the brain and it has a certain formula used to reduce the haematocrite level(its done with Normal saline and some people use human albumin). Other condition where exchange transfusion might be needed are ;severe hyperammoniemia, severe sickle cell disease with acute chest syndrome etc.

As Jack had mentioned above, thanks to the intensive photherapy but do good monitoring and be prepared . The "light capsule" do a real good job in 4 hrs.

Omer Hamud

Toronto

NB: The Historical part is from an article in NeoReviews .Vol. 4 N.7 2003 el69, Written by Alistair G.S Philip ,MD.FRCPE " Rise and Fall of Exchange Transfusion"

Edited June 23, 2010 by Omer

[Guest Dukstar]

@ Omer

Many thanks

I have managed to get the review !

[rehman_naveed]

May I know what is the time duration that we can use Intense Phototherapy ( or what you call as Capsule) and how much fluid a baby must receive while on intensive phototherapy. Any evidence regarding this?? we here use it for 4hrs and fluids we give @180ml/kg/day, but i dont know whether we are practicing right or wrong?

[JACK]

we give 60 ml/kg/24 hrs as phototherapy allowance for babies in capsule. We have kept babies in capsule for max of 3 days. Results are excellent.

[rehman_naveed]

Quite strange, two extreeme practices. May I ask on what basis you are starting fluids at 60ml/kg/day( Which according to me is too little) and on the top to continue intensive phototherapy for 3 days wow, too much intense light . Thats why i share this topic to have my practice an evidence based because i dont know whether I am doing it correctly or not

[JACK]

The total fluid given is not 60 ml/kg/day but 60ml/kg (the 'photo-allowance') is added to the the days fluid calculation.

3 days is not used in all cases, most remain in capsule for 8-12 hours (based on the bilirubin fall) .

But i remember a case which required 3 days of total capsule, because of persistent hyperbilirubinemia (fall and rebound). Nothing untoward was noted in the case.