Carboxyhemoglobin levels in neonatal immune hemolytic jaundice treated with intravenous gammaglobulin

In order to examine the effect of intravenous immunoglobulin (IVIG) on the rate of hemolysis in immune hemolytic hyperbilirubinemia, we measured the carboxyhemoglobin levels of 5 newborn infants who were subjected to IVIG treatment. The pretreatment rate of hemolysis, in the 5 patients with isoimmune hemolytic jaundice (3 patients with Rh hemolytic disease of the newborn and 2 patients with ABO hemolytic disease of the newborn), as reflected by carboxyhemoglobin levels was higher than the rate of hemolysis in normal newborn infants. In 4 out of the 5 patients treated with IVIG, there was a rapid decline ( > 30%) of carboxyhemoglobin levels, a pattern which was different from that observed in normal newborn infants with no hemolytic jaundice and in 3 untreated patients with ABO hemolytic disease of the newborn. None of the treated patients required an exchange transfusion. Our preliminary results support the theory that the attenuation of jaundice observed following IVIG treatment in patients with immune hemolytic hyperbilirubinemia is caused, at least in part, by the reduction in hemolysis.

Homozygosity for Waardenburg syndrome

In a large kindred including many individuals affected with Waardenburg (WS) type 1 (WS1) syndrome, a child affected with a very severe form of WS type 3 was born. This child presented with dystopia canthorum, partial albinism, and very severe upper-limb defects. His parents were first cousins, both affected with a mild form of WS1. Molecular analysis of PAX3, the gene that was determined by linkage to cause the disorder in the family, demonstrated a novel missense mutation (S84F) in exon 2 of PAX3 within the paired box. While individuals affected with WS1 were heterozygous for the mutation, the child with WS3 was homozygous for S84F. The observation that the PAX3 homozygote in humans may allow life at least in early infancy and does not cause neural tube defects was unexpected, since, in all the mutations known in mice (splotch), homozygosity has led to severe neural tube defects and intrauterine or neonatal death.

Neonatal limb ischemia following maternal indomethacin treatment in twin pregnancies

The prenatal administration of indomethacin in obstetric management has been implicated as a cause of neonatal cardio-pulmonary, gastrointestinal and renal complications. The present report describes two cases of twin pregnancy resulting in premature delivery at the 33rd and 30th week following prolonged maternal indomethacin treatment for 9 and 4 weeks respectively. Neonatal cardiovascular and renal complications were observed and an unusual severe ischemia of a lower limb occured in each of the first twins following insertion of an umbilical arterial line. It is suggested that prolonged antenatal exposure to the drug may increase the systemic arterial constrictive reactivity in some newborn infants and that special caution should be exercised during arterial catheterization of susceptible cases.

Hyperbilirubinemia in premature infants: relevance to blood transfusion

The rate of hemolysis of transfused adult red blood cells in the premature circulation may be higher than in the native circulation and produce a significant bilirubin load on the immature liver during the first days of life with consequent hyperbilirubinemia. The association between the transfusion of packed red blood cells and consequent change of serum bilirubin level was evaluated in 35 premature infants with birth weight of < 1,250 g during the first 10 days of life, using the analysis of variance method. There was a significant increase of bilirubin level with a mean of 24.3 mumol/l following packed red blood cells transfusion. Birth weight had a significant negative effect and mechanical ventilation for > 2 days had a significant positive effect on bilirubin levels; however, the changes were of small magnitude. The results of our study indicate that a rise of bilirubin level following blood transfusion to very low birth weight infants during the early neonatal period should be anticipated.

Basal ganglia and thalamic calcification following intrauterine intravascular transfusion

In recent years intrauterine intravascular transfusion has become the method of choice for the treatment of severe fetal erythroblastosis. Despite the association of the procedure with fetal complications such as bradycardia and overtransfusion, later neonatal neurological consequences have been only rarely reported. A case is described of a neonate who underwent repeated intrauterine intravascular transfusion for treatment of erythroblastosis and who later developed calcification in the thalamus and the basal ganglia. The possible pathogenetic mechanisms are discussed.

Intravenous immunoglobulin therapy in neonatal immune hemolytic jaundice

Nine cases of newborn patients who developed hyperbilirubinemia due to blood group incompatibility and were treated with high dose (1 gram/Kg) intravenous immunoglobulin (IVIG) are described. In 7 of the 9 patients the rise of bilirubin level was attenuated and exchange transfusion was not required following treatment with IVIG. Of the two patients who did require an exchange transfusion despite IVIG treatment, one had the exchange performed immediately following the IVIG infusion, allowing no time for observation of the therapy effect. Our results suggest that IVIG administration may be efficacious in the treatment of immune hemolytic hyperbilirubinemia of the newborn but further studies are required to validate the efficacy of this treatment.

Nonketotic hyperglycinemia presenting with pin-point pupils and hyperammonemia

We describe two siblings who presented with lethargy, decreased sucking, respiratory failure and seizures in their first days of life. Pin-point pupils were noted in both siblings. Amino acid analysis revealed elevated concentrations of glycine in plasma and cerebrospinal fluid (CSF), with abnormal CSF/plasma ratios, compatible with hyperglycinemia. Urine organic acid analysis was unremarkable. Hyperammonemia was found in both siblings, but this subsided within 24-72 h. We suggest that pin-point pupils may be an additional presenting sign of nonketotic hyperglycinemia and, if looked for early enough, hyperammonemia may be found in this disorder.