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when should we top up with packed cells?


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We had a neonate born to rh negative mother. Baby developed hyperbilirubinemia. needed 2 exchange transfusions and 3 top up packed cell transfusions. We send the baby at 13.9 gm%. Has returned back on day 30 with HB of 5 gms%..Now we needed to give packed cells.

Our fetal medicine consultant says that she has seen this happen frequently when the final HB is high. She feels that the hypoxic drive for erythropoitin is gone and hence the lavel is low. Marrow sleeps off. Her advice is to keep HB around 10 gms%.

Give me your feedback?


Erode, India

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There are some different mechanism for anemia in Rh immune disease. It was noted that early anemia during the 2nd and 3rd postnatal weeks is usually associated with some degree of on going haemolytic process due to persistence of maternal anti-D antibodies . This is usually the case when intrauterine transfusion or exchange transfusion were not done and is associated with high retics count.

The other possibility is as you mentioned the low response from the bone marrow. This type of anemia seems to happen later at 4-6 weeks and its related to adult Hb (Hb A) given in either intrauterine transfusion or exchange transfusion. HbA gives more oxygen to the tissue and result in a degree of erythroid hypoplasia by reducing the intensity of the hypoxic stimulation on the bone marrow and hence low levels of of erythropioten .This later condition is associated with low retics counts and the anemia might be severe and prolonged.

Interestingly, this reminds me of Kleihuar -Betke test which we do on neonatal blood in babies with alpha thal who received intrauterine transfusions to see if they have fetal haemoglobin which will predict further increase in their billirubin and hence possible exchange transfusion.

Some series has shown improvement /prevention of late anemia associated with Rh incompatibility but most of these studies also used Vitamin E, iron etc in conjunction with EPO. Iam not aware of a controlled randomized trial on EPO in late Immune Haemolytic anemia and the evidence is lacking.

Omer Hamud


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