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Ngan CBM, Kaur R, Jackson DE. Does high body mass index (>25 kg/m 2) or weight (>80 kg) reduce the effectiveness of anti-D prophylaxis in Rh(D)-negative pregnant women? A systematic review and meta-analysis. Vox Sang 2024. [PMID: 38889996 DOI: 10.1111/vox.13693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND AND OBJECTIVES Haemolytic disease of the foetus and newborn (HDFN) occurs when maternal antibodies, often triggered by foetal antigens, destroy foetal and neonatal red blood cells. Factors like antibody strength, quantity and gestational age influence HDFN severity. Routine antenatal anti-D prophylaxis (RAADP) has significantly reduced HDFN cases. However, the effect of overweight/obesity (body mass index [BMI] > 25/30 kg/m2) on anti-D prophylaxis efficacy remains unclear. This systematic review will examine the impact of BMI on anti D prophylaxis effectiveness in Rh(D) negative pregnant women. MATERIALS AND METHODS We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols. We searched databases from 1996 to 2023, focusing on studies exploring the link between high BMI/weight and anti-D serum levels in Rh(D)-negative pregnant women with Rh(D)-positive foetuses. Ten eligible studies were included, three suitable for meta-analysis. Study quality was assessed using the Strengthening the Reporting Observation Studies in Epidemiology (STROBE) checklist. Statistical analyses included Pearson correlation coefficients and risk differences. RESULTS Our meta-analysis revealed a significant negative correlation (r = -0.59, 95% confidence interval [CI]: -0.83 to -0.35, p = 0.007) between high BMI/weight and serial anti-D levels in in Rh(D)-negative pregnant women with Rh(D)-positive foetuses. High BMI/weight had lower odds of serial anti-D level exceeding 30 ng/mL (arcsine risk difference [ARD] = 0.376, 95% CI: 0.143-0.610, p = 0.002). Heterogeneity among studies was low (I2 = 0). CONCLUSION While our analysis suggests a potential linkage between high BMI/weight and reduced efficacy of anti-D prophylaxis, caution is warranted due to study limitations. Variability in study design and confounding factors necessitate careful interpretation. Further research is needed to confirm these findings and refine clinical recommendations.
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Affiliation(s)
- C B M Ngan
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences, STEM College, RMIT University, Bundoora, Victoria, Australia
| | - R Kaur
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences, STEM College, RMIT University, Bundoora, Victoria, Australia
| | - Denise E Jackson
- Thrombosis and Vascular Diseases Laboratory, School of Health and Biomedical Sciences, STEM College, RMIT University, Bundoora, Victoria, Australia
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Christensen RD, Bahr TM, Ohls RK, Ilstrup SJ, Moise KJ, Lopriore E, Meznarich JA. Erythrokinetic mechanism(s) causing the "late anemia" of hemolytic disease of the fetus and newborn. J Perinatol 2024; 44:916-919. [PMID: 38216678 DOI: 10.1038/s41372-024-01872-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
A transfusion-requiring "late anemia" can complicate the management of neonates convalescing from hemolytic disease of the fetus and newborn (HDFN). This anemia can occur in any neonate after HDFN but is particularly prominent in those who received intrauterine transfusions and/or double-volume exchange transfusions. Various reports describe this condition as occurring based on ongoing hemolysis, either due to passive transfer of alloantibody through breast milk or persistence of antibody not removed by exchange transfusion. However, other reports describe this condition as the result of inadequate erythrocyte production. Both hypotheses might have merit, because perhaps; (1) some cases are primarily due to continued hemolysis, (2) others are primarily hypoproductive, and (3) yet others result from a mixture of these two mechanisms. We propose prospective collaborative studies that will resolve this issue by serially quantifying end-tidal carbon monoxide. Doing this will better inform the assessment and treatment of neonates recovering from HDFN.
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Affiliation(s)
- Robert D Christensen
- Women and Newborns Research, Intermountain Health, Murray, UT, USA.
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
| | - Timothy M Bahr
- Women and Newborns Research, Intermountain Health, Murray, UT, USA
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sarah J Ilstrup
- Transfusion Medicine, Department of Pathology, Intermountain Health, Murray, UT, USA
| | - Kenneth J Moise
- Comprehensive Fetal Care Center at Dell Children's Medical Center and Department of Women's Health, Dell Medical School, Austin, TX, USA
| | - Enrico Lopriore
- Division of Neonatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Jessica A Meznarich
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Drozdowska-Szymczak A, Mazanowska N, Pomianek T, Ludwin A, Krajewski P. Incidence and Risk Factors of Cholestasis in Newborns with Hemolytic Disease-A Case-Control Study. J Clin Med 2024; 13:3190. [PMID: 38892901 PMCID: PMC11172419 DOI: 10.3390/jcm13113190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/25/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: One of the rare causes of cholestasis may be hemolytic disease of the fetus and newborn (HDFN). Methods: We retrospectively analyzed 88 medical records of HDFN newborns with cholestasis and 186 records of children with HDFN without cholestasis and conducted an observational, case-control, retrospective study. Results: Factors influencing the risk of cholestasis were lower gestational age at birth (36.83 ± 1.9 vs. 37.57 ± 1.8, p = 0.002), Rh or Kidd HDFN (80.7% vs. 53.2%), and the need for intrauterine transfusion (27.3 vs. 11.8%). The subjects had lower hemoglobin concentrations at birth (14.01 ± 3.8 vs. 16.39 ± 2.8 g/dL) and during whole hospital stay, higher cord blood total bilirubin concentration (4.26 ± 1.8 vs. 2.39 ± 1.4 mg/dL), higher maximum bilirubin concentration (15.27 ± 5.8 vs. 10.24 ± 3.4 mg/dL), and more frequent liver ultrasound abnormalities (19.9 vs. 6.3%). They also required more extended hospitalization due to higher rates of postnatal blood transfusion (33 vs. 3.8%), more frequent need for exchange transfusion (8.8% vs. 2.2%), more extended time and higher risk of phototherapy (94.3 vs. 59.1%), and higher usage of immunoglobulins (55.7 vs. 8.1%), parenteral nutrition (45.5 vs. 12.9%), and antibiotics (14.8 vs. 4.8%). Conclusions: The risk factors for cholestasis in children with HDFN are lower gestational age at delivery, Rh and Kidd serological type of HDFN, and the need for intrauterine transfusions.
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Affiliation(s)
- Agnieszka Drozdowska-Szymczak
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland; (A.D.-S.); (T.P.); (P.K.)
| | - Natalia Mazanowska
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Tomasz Pomianek
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland; (A.D.-S.); (T.P.); (P.K.)
| | - Artur Ludwin
- Department of Obstetrics and Gynecology, Medical University of Warsaw, Pl. Starynkiewicza 1/3, 02-015 Warsaw, Poland;
| | - Paweł Krajewski
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland; (A.D.-S.); (T.P.); (P.K.)
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4
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'Adani SN, Mohd Ashari NS, Johan MF, Edinur HA, Mohd Noor NH, Hassan MN. Red Blood Cell Alloimmunization in Pregnancy: A Review of the Pathophysiology, Prevalence, and Risk Factors. Cureus 2024; 16:e60158. [PMID: 38868295 PMCID: PMC11167514 DOI: 10.7759/cureus.60158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/14/2024] Open
Abstract
This review paper provides an overview of the risk factors and laboratory testing for red blood cell (RBC) alloimmunization in pregnancy. RBC alloimmunization is a significant medical issue that can cause haemolytic disease of the fetus and newborn (HDFN), leading to neonatal morbidity and mortality. Current HDFN prophylaxis targets only Rhesus D (RhD) alloimmunization, with no effective measures to prevent alloimmunization to other RBC antigen groups. Several factors can increase the risk of developing RBC alloimmunization during pregnancy, including fetomaternal haemorrhage, RBC and maternal genetic status, and previous transfusions. Identifying these risk factors is essential to execute the appropriate management strategies to minimize the risk of HDFN. The review also discusses the laboratory methods and overview of pregnancy management. The paper highlights the importance of identifying and managing the risk factors for RBC alloimmunization in pregnancy to minimize the risk of HDFN and improve neonatal outcomes.
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Affiliation(s)
- Sanusi Nurul 'Adani
- Hematology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, MYS
| | | | - Muhammad Farid Johan
- Hematology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, MYS
| | - Hisham Atan Edinur
- Forensic Programme, School of Health Sciences, Universiti Sains Malaysia, Kota Bharu, MYS
| | | | - Mohd Nazri Hassan
- Hematology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, MYS
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Drozdowska-Szymczak A, Proczka J, Mazanowska N, Ludwin A, Krajewski P. Severe Cholestasis in Neonates with Hemolytic Disease of the Fetus and Newborn-A Case Report. J Clin Med 2024; 13:1272. [PMID: 38592131 PMCID: PMC10932254 DOI: 10.3390/jcm13051272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Hemolytic disease of the fetus and newborn (HDFN) may cause severe cholestasis with direct bilirubin concentrations reaching up to 50 times the upper limit of normal. This case report describes twins whose highest direct bilirubin concentrations were 32.2 mg/dL and 50.2 mg/dL, with no significant signs of hepatic impairment. The index pregnancy was complicated by Rhesus factor immunization with anti-D antibodies present in maternal serum, which caused fetal anemia requiring intrauterine blood transfusions. Complementary tests demonstrated Rhesus D alloimmunization as the sole cause of cholestasis. To the best of our knowledge, this is the first study to describe such elevated direct bilirubin concentrations caused by HDFN.
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Affiliation(s)
- Agnieszka Drozdowska-Szymczak
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Julia Proczka
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Natalia Mazanowska
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Artur Ludwin
- Department of Obstetrics and Gynecology, Medical University of Warsaw, Pl. Starynkiewicza 1/3, 02-015 Warsaw, Poland
| | - Paweł Krajewski
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
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Carpenter MC, Souter SC, Zipkin RJ, Ackerman ME. Current Insights Into K-associated Fetal Anemia and Potential Treatment Strategies for Sensitized Pregnancies. Transfus Med Rev 2024; 38:150779. [PMID: 37926651 PMCID: PMC10856777 DOI: 10.1016/j.tmrv.2023.150779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
K-associated anemic disease of the fetus and newborn (K-ADFN) is a rare but life-threatening disease in which maternal alloantibodies cross the placenta and can mediate an immune attack on fetal red blood cells expressing the K antigen. A considerably more common disease, D-associated hemolytic disease of the fetus and newborn (D-HDFN), can be prophylactically treated using polyclonal α-D antibody preparations. Currently, no such prophylactic treatment exists for K-associated fetal anemia, and disease is usually treated with intrauterine blood transfusions. Here we review current understanding of the biology of K-associated fetal anemia, how the maternal immune system is sensitized to fetal red blood cells, and what is understood about potential mechanisms of prophylactic HDFN interventions. Given the apparent challenges associated with preventing alloimmunization, we highlight novel strategies for treating sensitized mothers to prevent fetal anemia that may hold promise not only for K-mediated disease, but also for other pathogenic alloantibody responses.
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Affiliation(s)
| | | | | | - Margaret E Ackerman
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA; Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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Zheng Y, Almeyda-Alejo Y, Tumin D, Redpath NSJ, Guillen-Hernandez J. Three or four doses of intravenous immunoglobulin G treatment for isoimmune hemolytic disease: A case series and literature review. J Neonatal Perinatal Med 2024; 17:153-158. [PMID: 38143377 DOI: 10.3233/npm-230070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Neonates affected by isoimmune hemolytic disease (HDN) are at risk of developing severe hyperbilirubinemia. Studies show that increasing levels of bilirubin impact neonatal neurodevelopment. To avoid complications associated with exchange transfusion, intravenous immunoglobulin G (IVIG) is used to treat hyperbilirubinemia. We included all infants who received more than two doses of IVIG treatment for isoimmune hemolytic disease. We analyzed the incidence of side effects associated with IVIG treatment and the rate of exchange transfusion. METHODS A retrospective chart review performed between October 2011-October 2022 at East Carolina University Health identified neonates who received more than two doses IVIG for HDN. Neonates of postmenstrual age greater than 28 days old, receiving less than three doses of IVIG or received IVIG for other indications were excluded. The occurrences of adverse events, demographics and use of other medical therapies were reviewed. RESULTS Eleven neonates were included in the case series. Most common cause of severe hyperbilirubinemia was attributed to ABO incompatibility. Six patients (54%) received three doses of IVIG, and five patients (45%) received four doses of IVIG with bilirubin levels decreasing below exchange transfusion. No treatment exceeding four doses of IVIG was reported, nor adverse events during treatment. CONCLUSIONS In this cohort of neonates with HDN, bilirubin levels decreased after treatment with multiple doses of IVIG. Future research on recommendations of optimal total number doses of IVIG to reduce the risk for exchange transfusion.
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Affiliation(s)
- Y Zheng
- Department of Neonatology, East Carolina University Health Medical Center, Greenville, NC, USA
| | - Y Almeyda-Alejo
- Department of Pediatrics, East Carolina University Health Medical Center, Greenville, NC, USA
| | - D Tumin
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - N S J Redpath
- Department of Neonatology, East Carolina University Health Medical Center, Greenville, NC, USA
| | - J Guillen-Hernandez
- Department of Neonatology, East Carolina University Health Medical Center, Greenville, NC, USA
- Department of Pediatrics, East Carolina University Health Medical Center, Greenville, NC, USA
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, USA
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Drozdowska-Szymczak A, Proczka J, Chrzanowska-Liszewska D, Truszkowski K, Mazanowska N, Krajewski P. Liver Dysfunction with Severe Cholestasis and Coagulation Disorders in the Course of Hemolytic Disease of the Newborn Requiring Chelation Therapy-A Case Report and Review of the Literature. J Clin Med 2023; 12:7645. [PMID: 38137714 PMCID: PMC10743868 DOI: 10.3390/jcm12247645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Severe hemolytic disease of the fetus and newborn (HDFN) requiring intrauterine transfusions (IUTs) may cause iron accumulation, resulting in liver damage, which may lead to cholestasis and coagulation disorders. In this article, we reported a case of a female neonate who underwent chelation therapy with a positive outcome, and we reviewed the English and Polish literature on chelation therapy in HDFN available in PubMed. The patient with maximum ferritin concentration above 33,511.2 ng/mL developed liver dysfunction with coagulation disorders requiring multiple transfusions of fresh frozen plasma (FFP), Octaplex® and cryoprecipitate, and hypoalbuminemia treated with numerous albumin infusions. Furthermore, severe cholestasis was observed with direct bilirubin levels up to 33.14 mg/dL. Additionally, the child developed transient myelosuppression with neutropenia, thrombocytopenia, and low reticulocyte count due to several blood transfusions. The differential diagnosis tests were conducted to rule out any causes of hepatic failure other than hemolytic disease of the newborn. This case proves that adequate treatment of severe HDFN with anemia requiring IUT and hepatic failure can lead to positive outcomes with no long-term consequences.
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Affiliation(s)
- Agnieszka Drozdowska-Szymczak
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Julia Proczka
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Danuta Chrzanowska-Liszewska
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Krzysztof Truszkowski
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Natalia Mazanowska
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Paweł Krajewski
- Department of Neonatology and Neonatal Intensive Care, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
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Tournier A, Ghesquiere L, Labreuche J, Drumez E, Storme L, Rakza T, Houfflin-Debarge V, Garabedian C. Effect of delayed cord clamping on red blood cell alloimmunization: a retrospective cohort study. Am J Obstet Gynecol MFM 2023; 5:101165. [PMID: 37734659 DOI: 10.1016/j.ajogmf.2023.101165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/18/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Although delayed cord clamping has well-known benefits for preterm and term neonates, it has been inadequately assessed in alloimmunized neonates. OBJECTIVE This study aimed to evaluate the benefits and risks of delayed cord clamping in alloimmunized neonates. STUDY DESIGN This was a retrospective comparative pre-post cohort study conducted from 2003 to 2018 in a tertiary care center in France. All living singleton neonates whose mothers were followed up for red blood cell alloimmunization during gestation and confirmed at birth (N=224) were included. Neonates were either exposed to immediate (n=125) or delayed cord clamping (n=99). Our main outcome was the time from birth to first exchange transfusions and/or transfusions. Secondary outcomes were hemoglobin level at birth, rate of exchange transfusion, number of postnatal transfusions, maximum bilirubin level, and number of phototherapy hours. RESULTS Hemoglobin at birth was significantly higher in case of delayed cord clamping (mean difference, 1.7 g/dL; 95% confidence interval, 0.7-2.8). Among infants treated with exchange transfusion or transfusion, the time to initial treatment was higher in case of delayed cord clamping (median difference, 8 days; rate ratio, 1.51; 95% confidence interval, 1.09-2.10). There were no significant differences in the need for exchange transfusion, the number of transfusions, the maximum total bilirubin level, nor the number of phototherapy hours. In the subgroup analysis of neonates needing intrauterine transfusion during pregnancy (ie, severe alloimmunization), neonates had a lower rate of exchange transfusion in case of delayed cord clamping (odds ratio, 0.36; 95% confidence interval, 0.15-0.82). CONCLUSION Our results indicate a benefit of delayed cord clamping in alloimmunization, regardless of pathology severity, without increased risk of jaundice.
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Affiliation(s)
- Alexane Tournier
- Department of Obstetrics, Centre Hospitalier Universitaire de Lille, Lille, France (Drs Tournier, Ghesquiere, Houfflin-Debarge, and Garabedian)
| | - Louise Ghesquiere
- Department of Obstetrics, Centre Hospitalier Universitaire de Lille, Lille, France (Drs Tournier, Ghesquiere, Houfflin-Debarge, and Garabedian); ULR 2694 METRICS, University of Lille, Centre Hospitalier Universitaire de Lille, Lille, France (Dr Ghesquiere, Mr Labreuche, Ms Drumez, and Drs Houfflin-Debarge and Garabedian)
| | - Julien Labreuche
- ULR 2694 METRICS, University of Lille, Centre Hospitalier Universitaire de Lille, Lille, France (Dr Ghesquiere, Mr Labreuche, Ms Drumez, and Drs Houfflin-Debarge and Garabedian); Department of Biostatistics, Centre Hospitalier Universitaire de Lille, Lille, France (Mr Labreuche and Ms Drumez)
| | - Elodie Drumez
- ULR 2694 METRICS, University of Lille, Centre Hospitalier Universitaire de Lille, Lille, France (Dr Ghesquiere, Mr Labreuche, Ms Drumez, and Drs Houfflin-Debarge and Garabedian); Department of Biostatistics, Centre Hospitalier Universitaire de Lille, Lille, France (Mr Labreuche and Ms Drumez)
| | - Laurent Storme
- Department of Neonatology, Centre Hospitalier Universitaire de Lille, Lille, France (Drs Storme and Rakza)
| | - Thameur Rakza
- Department of Neonatology, Centre Hospitalier Universitaire de Lille, Lille, France (Drs Storme and Rakza)
| | - Véronique Houfflin-Debarge
- Department of Obstetrics, Centre Hospitalier Universitaire de Lille, Lille, France (Drs Tournier, Ghesquiere, Houfflin-Debarge, and Garabedian); ULR 2694 METRICS, University of Lille, Centre Hospitalier Universitaire de Lille, Lille, France (Dr Ghesquiere, Mr Labreuche, Ms Drumez, and Drs Houfflin-Debarge and Garabedian)
| | - Charles Garabedian
- Department of Obstetrics, Centre Hospitalier Universitaire de Lille, Lille, France (Drs Tournier, Ghesquiere, Houfflin-Debarge, and Garabedian); ULR 2694 METRICS, University of Lille, Centre Hospitalier Universitaire de Lille, Lille, France (Dr Ghesquiere, Mr Labreuche, Ms Drumez, and Drs Houfflin-Debarge and Garabedian).
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Whitlock AE, Moskowitzova K, Kycia I, Zurakowski D, Fauza DO. Fetal Alloimmune Hemolytic Anemia (AHA) as a Potential Target for Transamniotic Fetal Immunotherapy (TRAFIT). J Pediatr Surg 2023; 58:1107-1110. [PMID: 36914465 DOI: 10.1016/j.jpedsurg.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
PURPOSE Fetal alloimmune hemolytic anemia (AHA) resulting from maternal antibodies against fetal erythrocytes may require fetal administration of immunoglobulin-G (IgG) via invasive methods. IgG can reach the fetal circulation after transamniotic fetal immunotherapy (TRAFIT). We sought to both develop a model of AHA and to test TRAFIT as a potential treatment. METHODS Sprague-Dawley fetuses (n = 113) received intra-amniotic injections on gestational-day 18 (E18, term = E21) of either saline (control; n = 40), anti-rat-erythrocyte antibodies (AHA; n = 37), or anti-rat-erythrocyte antibodies plus IgG (AHA + IgG; n = 36). At term, blood was procured for red blood count (RBC), hematocrit, or ELISA for inflammatory markers. RESULTS There was no difference in survival [95% (107/113)] across groups (p = 0.87). Both hematocrit and RBC were significantly lower in the AHA group than controls (p < 0.001). Although still significantly lower than controls (p < 0.001), both hematocrit and RBC significantly increased in AHA + IgG group compared to AHA alone (p < 0.001). Pro-inflammatory TNF-α and IL1-β were significantly elevated from controls in the AHA group, but not in AHA + IgG (p < 0.001-0.159). CONCLUSIONS Intra-amniotic injection of anti-rat-erythrocyte antibodies can reproduce manifestations of fetal AHA, constituting a practical model of this disease. Transamniotic fetal immunotherapy with IgG reduces anemia in this model and may emerge as a new minimally invasive means of treatment. TYPE OF STUDY Animal and laboratory study. LEVEL OF EVIDENCE N/A (animal and laboratory study).
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Affiliation(s)
- Ashlyn E Whitlock
- Departments of Surgery, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Kamila Moskowitzova
- Departments of Surgery, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Ina Kycia
- Departments of Surgery, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Departments of Surgery, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Dario O Fauza
- Departments of Surgery, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA.
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11
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Yu D, Ling LE, Krumme AA, Tjoa ML, Moise KJ. Live birth prevalence of hemolytic disease of the fetus and newborn in the United States from 1996 to 2010. AJOG GLOBAL REPORTS 2023; 3:100203. [PMID: 37229151 PMCID: PMC10205505 DOI: 10.1016/j.xagr.2023.100203] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Hemolytic disease of the fetus and newborn (HDFN) is mediated by maternal alloantibodies, a consequence of immune sensitization during pregnancy with maternal-fetal incompatibility with ABO, Rhesus factor (Rh), and/or other red blood cell antigens. RhD, Kell, and other non-ABO alloantibodies are the primary cause of moderate to severe HDFN, whereas ABO HDFN is typically mild. HDFN live birth prevalence owing to Rh alloimmunization among newborns in the United States was last estimated to be 106 per 100,000 births in 1986. HDFN live birth prevalence owing to all alloantibodies was estimated to be 817 to 840 per 100,000 in Europe. There is a need for updated prevalence estimates in the United States and a better understanding of disease demographics, severity, and treatments. OBJECTIVE This study aimed to estimate the live birth prevalence of HDFN and the proportion of severe cases of HDFN in the United States, to describe the associated risk factors, and to compare the clinical outcomes and treatments among healthy newborns, newborns with HDFN, and newborns who are sick without HDFN using a nationally representative hospital discharge database. STUDY DESIGN In this retrospective, observational cohort study, we used data from the 1996 to 2010 National Hospital Discharge Survey to identify live births, defined by inpatient visits with the newborn flag, with and without a diagnosis of HDFN across 200 to 500 sampled hospitals (≥6 beds) per year. Patient and hospital characteristics, alloimmunization status, disease severity, treatment, and clinical outcomes were evaluated. Frequencies and weighted percentages were calculated for all variables. Logistic regression was used to compare the characteristics between newborns with HDFN and other newborns using odds ratios. RESULTS Of 480,245 live births identified, 9810 HDFN cases were recorded. When weighted to the United States population, this corresponded to a live birth prevalence of 1695 per 100,000 live births. Compared with other newborns, newborns with HDFN were more likely to be female, Black, living in the South (vs the Midwest or West), and treated at larger (>100 beds) and government-owned hospitals. ABO and Rh alloimmunization accounted for 78.1% and 4.3% of newborns with HDFN, respectively, whereas HDFN caused by other antigens, such as Kell and Duffy, accounted for 17.6% of the cases. Among newborns with HDFN, 22% received phototherapy, 1% received simple transfusions, and 0.5% received exchange transfusions or intravenous immunoglobulin. Newborns affected by HDFN caused by Rh alloimmunization were more likely to require medical interventions, including simple or exchange transfusions, and more likely to be delivered by cesarean delivery. Overall, HDFN was associated with a longer hospital length of stay in the neonatal intensive care unit when compared with healthy and other sick newborns, a higher rate of cesarean delivery, and a higher rate of nonroutine discharge than healthy newborns. CONCLUSION Overall, the live birth prevalence of HDFN was higher than those previously reported, whereas Rh-induced HDFN live birth prevalence was similar to those previously reported. HDFN live birth prevalence owing to Rh alloimmunization decreased over time, likely because of continued Rh immune globulin prophylaxis. Treatment patterns for newborns with HDFN and the comparative clinical outcomes when compared with healthy newborns confirm the continued clinical needs of this population.
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Affiliation(s)
- Devin Yu
- Janssen Research & Development, LLC, Cambridge, MA (Drs Yu, Ling, Krumme, and Tjoa)
| | - Leona E. Ling
- Janssen Research & Development, LLC, Cambridge, MA (Drs Yu, Ling, Krumme, and Tjoa)
| | - Alexis A. Krumme
- Janssen Research & Development, LLC, Cambridge, MA (Drs Yu, Ling, Krumme, and Tjoa)
| | - May Lee Tjoa
- Janssen Research & Development, LLC, Cambridge, MA (Drs Yu, Ling, Krumme, and Tjoa)
| | - Kenneth J. Moise
- The Department of Women's Health, Dell Medical School, The University of Texas at Austin, Austin, TX (Dr Moise)
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12
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Chatterjee A, Verma S, Dutta S, Singh S, Singh G, Sharma RR, Sachdev S, Attri S, Bhatia P. Novel device for automating exchange transfusions through umbilical venous route in neonates. Eur J Pediatr 2023; 182:1229-1238. [PMID: 36625935 DOI: 10.1007/s00431-022-04791-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023]
Abstract
Manually performed double-volume exchange transfusion (DVET) is tedious, error-prone, and may incur the risk of embolism. We aimed to develop a device that automates the DVET procedure performed through the umbilical venous route. We evaluated changes in blood passing through the device during DVET. We developed an electro-mechanical device with accessories (tubing and valve assembly) to perform a complete DVET. It comprises two syringes driven by a common pump that moves back and forth to withdraw aliquots of the patient's blood and infuse equal volumes of donor blood. In tandem, it draws donor blood from a blood bank bag and pushes the patient blood drawn from the previous cycle into a waste bag, respectively. One-way duckbill valves and a two-way pinch valve ensure the separation of the donor and patient blood. A sensor detects bubbles and clots. A dashboard displays set and measured parameters. We tested the accuracy of the delivered flow rate and volume, electrical safety, embolus detection, and changes in hematological and biochemical values. The delivered flow and volume were within 5% of the set parameters. All electrical safety parameters were within normal limits. The sensor consistently detected microbubbles and clots. There were no clinically significant differences in laboratory parameters between samples drawn directly from the blood bank bag and drawn from the exit port at 80, 100, 120, and 160 s with a fixed aliquot volume. CONCLUSIONS Our prototype of a novel device can safely automate a DVET. Further trials of this device are warranted. WHAT IS KNOWN • Double volume exchange transfusion is often performed manually, but this is time-consuming and error-prone. • Previous attempts at automation were not widely adopted because they involved inserting two catheters and did not have mechanisms to prevent embolism. WHAT IS NEW • This novel device fully automates double volume exchange transfusions through a single-lumen umbilical venous catheter. • It prevents air and clot embolism and has a screen for input and output parameters and alarms.
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Affiliation(s)
- Arindam Chatterjee
- Council of Scientific and Industrial Research- Central Scientific Instruments Organization (CSIR-CSIO), Chandigarh, India
| | - Sanjeev Verma
- Council of Scientific and Industrial Research- Central Scientific Instruments Organization (CSIR-CSIO), Chandigarh, India
| | - Sourabh Dutta
- Neonatology Unit, Department of Pediatrics, PGIMER, Sector 12, Chandigarh, 160023, India.
| | - Sarbjeet Singh
- Council of Scientific and Industrial Research- Central Scientific Instruments Organization (CSIR-CSIO), Chandigarh, India
| | - Gurinderjit Singh
- Council of Scientific and Industrial Research- Central Scientific Instruments Organization (CSIR-CSIO), Chandigarh, India
| | - Ratti Ram Sharma
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Suchet Sachdev
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Savita Attri
- Department of Pediatrics, PGIMER, Chandigarh, India
| | - Prateek Bhatia
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
- Department of Pediatrics, PGIMER, Chandigarh, India
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13
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Mandula PP, Kumar J. Iron Overload in Rh-Isoimmunization. Indian Pediatr 2023. [DOI: 10.1007/s13312-023-2846-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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14
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Rv S, S R. Darbepoetin Alfa for Late-onset Anemia in Neonates with Rhesus Hemolytic Disease. Indian J Pediatr 2023; 90:184-186. [PMID: 36460815 DOI: 10.1007/s12098-022-04411-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/26/2022] [Indexed: 12/04/2022]
Abstract
Neonates with Rhesus hemolytic disease can present with anemia beyond 1 wk of age due to bone marrow suppression and low erythropoietin secretion. Erythropoietin stimulating agents (ESA) were tried to manage anemia in these neonates. Darbepoetin alfa (DA) is a long-acting ESA used to treat anemia in premature neonates and in children with chronic kidney disease or on cancer chemotherapy. The authors present their experience of using DA to treat late-onset hyporegenerative anemia in 3 neonates with Rhesus isoimmunization. Darbepoetin alfa 4 mcg/kg was given subcutaneously at a 1-2-wk interval to target hemoglobin of 10-12 g/dL. No adverse effects were observed, and the treated infants had a reduced need for the packed red blood cell transfusions.
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Affiliation(s)
- Saranyaa Rv
- Department of Pediatrics, PSG Institute of Medical Science & Research, Coimbatore, Tamil Nadu, India
| | - Ramesh S
- Department of Pediatrics, PSG Institute of Medical Science & Research, Coimbatore, Tamil Nadu, India.
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15
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De Winter DP, Hulzebos C, Van 't Oever RM, De Haas M, Verweij EJ, Lopriore E. History and current standard of postnatal management in hemolytic disease of the fetus and newborn. Eur J Pediatr 2023; 182:489-500. [PMID: 36469119 DOI: 10.1007/s00431-022-04724-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 12/07/2022]
Abstract
UNLABELLED Since the discovery of the Rh blood group system in 1940, a greater understanding of hemolytic disease of the fetus and newborn (HDFN) was gained. In the years thereafter, researchers and clinicians came to the current understanding that fetal and neonatal red blood cells (RBC) are hemolyzed by maternal alloantibodies directed against RBC antigens potentially leading to severe disease. Preventative measures, such as Rhesus(D) immunoprophylaxis (RhIG), have greatly decreased the prevalence of Rh(D)-mediated HDFN, although a gap between high-income countries and middle- to low-income countries was created largely due to a lack in availability and high costs of RhIG. Other important developments in the past decades have improved the identification, monitoring, and care of pregnancies, fetuses, and neonates with HDFN. Prenatally, fetal anemia may occur and intrauterine transfusions may be needed. Postnatally, pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for anemia in the late phase of the disease. Through this review, we aim to provide an overview of important historic events and to provide hands-on guidelines for the delivery and postnatal management of neonates with HDFN. Secondarily, we aim to describe recent scientific findings and evidence gaps. CONCLUSION Multiple developments have improved the identification, monitoring, and care of pregnancies and neonates with HDFN throughout the centuries. Pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for late anemia in the late phase of the disease. Future studies should be set in an international setting and ultimately aim to eradicate HDFN on a global scale. WHAT IS KNOWN • Developments have led to a greater understanding of the pathophysiology, an improved serological identification and monitoring of at-risk cases and the current pre- and postnatal treatment. WHAT IS NEW • This review provides the pediatrician with hands-on guidelines for the delivery and postnatal management of neonates with HDFN. • Future studies should be set in an international setting with the ultimate aim of eradicating HDFN.
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Affiliation(s)
- Derek P De Winter
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333, Leiden, The Netherlands. .,Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.
| | - Christian Hulzebos
- Department of Pediatrics, Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske M Van 't Oever
- Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.,Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja De Haas
- Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ejt Joanne Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Albinusdreef 2, 2333, Leiden, The Netherlands
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16
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Jansen SJ, Ree IMC, Broer L, de Winter D, de Haas M, Bekker V, Lopriore E. Neonatal sepsis in alloimmune hemolytic disease of the fetus and newborn: A retrospective cohort study of 260 neonates. Transfusion 2023; 63:117-124. [PMID: 36334304 PMCID: PMC10099948 DOI: 10.1111/trf.17176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Among neonates with hemolytic disease of the fetus and newborn (HDFN), we aimed to describe the frequency of central-line use, indications for insertion, and incidence of confirmed and suspected sepsis, including antibiotic treatment over a 10-year surveillance period. STUDY DESIGN AND METHODS All neonates with HDFN admitted to our neonatal intensive care unit between January 2012 and December 2021 were included in this retrospective, cohort study. Annual proportions of infants with a central-line and central-line-associated bloodstream infection (CLABSI) rates (per 1000 central-line days and per 100 infants) were evaluated. Numbers of confirmed and suspected early- and late-onset sepsis episodes were assessed over the entire study period. RESULTS Of the 260 included infants, 25 (9.6%) were evaluated for suspected sepsis, with 16 (6.2%) having ≥1 confirmed sepsis episode. A total of 123 central-lines were placed in 98 (37.7%) neonates, with impending exchange transfusion (ET) being the most frequent indication. Of the 34 (34.7%) neonates in whom a central-line was placed due to impending ET, 11 (32.4%) received no ET. Overall CLABSI incidence was 13.58 per 1000 central-line days. Neonates with a central-line had a higher risk for confirmed late-onset infection (RR 1.11, 95% CI: 1.04-1.20) and sepsis work-up (RR 1.10, 95% CI: 1.03-1.17) compared to infants without a central-line. CONCLUSIONS Sepsis incidence among neonates with HDFN remains high, in particular in those with a central-line. Considering the substantial proportion of neonates with a central-line without eventual ET, central-line placement should be delayed until the likelihood of ET is high.
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Affiliation(s)
- Sophie J Jansen
- Division of Neonatology, Department of Pediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Isabelle M C Ree
- Division of Neonatology, Department of Pediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center (LUMC), Leiden, The Netherlands.,Department of Hematology, Center for Clinical Transfusion Research, Amsterdam, The Netherlands
| | - Lana Broer
- Division of Neonatology, Department of Pediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Derek de Winter
- Division of Neonatology, Department of Pediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center (LUMC), Leiden, The Netherlands.,Department of Hematology, Center for Clinical Transfusion Research, Amsterdam, The Netherlands
| | - Masja de Haas
- Department of Hematology, Center for Clinical Transfusion Research, Amsterdam, The Netherlands
| | - Vincent Bekker
- Division of Neonatology, Department of Pediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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17
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Ono H, Kakiuchi S, Kusuda S. Immunoglobulin for hemolytic jaundice in Japan: A retrospective survey. Pediatr Int 2023; 65:e15702. [PMID: 38037498 DOI: 10.1111/ped.15702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Intravenous immunoglobulin G (IVIG) is used to treat blood-type incompatibility hemolytic disease of newborns (BTHDN). Although IVIG's efficacy for treating BTHDN has been challenged, as an updated systematic review suggests, IVIG could significantly reduce exchange transfusions. We conducted a mail-in questionnaire survey to ascertain actual use of IVIG for BTHDN in Japan. METHODS The survey, conducted in 2014, included infants born between January 1, 2009, and December 31, 2013. Questionnaires were sent to the heads of neonatal intensive care units (NICUs) at perinatal centers of the Japan Neonatologist Association. RESULTS A total of 195 centers (64.6%) responded to the questionnaire. During the study period, 170 centers (87.2%) reported incidences of BTHDN. Among these centers, there were 1726 diagnosed cases of BTHDN in neonates. Of these cases, 419 infants were treated with IVIG in 127 centers, representing approximately 74.7% of all centers. After the exclusion of cases with missing data and those where consent for data usage was not obtained, a total 916 infants were included in this study. Of these, 219 (23.9%) were treated with IVIG after phototherapy, and 187 (20.4%) of these infants did not require further blood exchange transfusion. The IVIG dosages ranged from 40 to 1200 mg/kg/dose, but the majority were between 500 and 1000 mg/kg/dose, with a median of 800 mg/kg/dose. About 20% of the infants treated with IVIG showed late-onset anemia and required treatment. Adverse events were reported in less than 1% of infants. CONCLUSIONS For the treatment of BTHDN, IVIG administration was widely used in NICUs in Japan without severe adverse events.
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Affiliation(s)
- Hideko Ono
- Department of Neonatal Medicine, Tokyo Women's Medical University, Tokyo, Japan
- Department of Neonatal Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Satsuki Kakiuchi
- Department of Neonatal Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo, Japan
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18
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Pan W, Wu H, Chen J, Mo X, Wang H, Fang Q, Li Y, Huang Y. Fetal and neonatal outcome in severe alloimmunization managed with intrauterine transfusion: 18-year experience in a tertiary referral hospital in China. Front Pediatr 2023; 11:1157004. [PMID: 37124190 PMCID: PMC10130633 DOI: 10.3389/fped.2023.1157004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Background Hemolytic disease of the fetus and newborn (HDFN) due to red cell alloimmunization, is an important cause of fetal and neonatal morbidity and mortality. However, fetal and neonatal outcome of HDFN managed with intrauterine transfusion (IUT) in China are unknown. In addition, fetal and neonatal outcomes according to the type of maternal red cell alloantibodies involved and outcomes of hydrops fetalis are also unclear. Objectives The objective of this study was to evaluate fetal and neonatal outcomes of severe red-cell alloimmunization treated by IUT, to compare the outcomes according to the type of antibody, and to investigate the perinatal and postnatal outcomes of hydrops fetalis due to red cell alloimmunization. Methods A retrospective study of pregnancies affected by HDFN and managed with IUT at a tertiary care university hospital in China between January 2001 and December 2018 was performed. Fetal and neonatal outcomes were investigated, and comparison of outcomes depending on the type of antibody and comparison of outcome between hydrops fetalis and fetuses without hydrops were also conducted. Results 244 IUTs were performed in 81 fetuses from 80 pregnancies. Anti-RhD was the major etiology of HDFN requiring IUT (71.6%). The fetal survival rate was 90.1%. The survival rate of the hydropic fetuses was significantly lower than those of the non hydropic fetuses (61.2% vs. 95.6%) (P = 0.002**). Compared with non hydropic fetuses, hydropic fetuses had significantly lower gestational age and lower hemoglobin level at first IUT. The neonatal survival rate was 98.6%. Exchange transfusions were required in 26% of the neonates. 30.1% of neonates had late anemia and required top-up transfusions, and hydropic fetuses required more late top-up transfusions than fetuses without hydrops. No significant difference in fetal and neonatal outcomes was found among the four subgroups stratified by the antibody involved. Conclusion Our study demonstrates that IUT is an effective and safe therapy for severe HDFN at our institution. Early detection and treatment of hydrops is critical for perinatal outcomes. Particular attention should be paid to late postnatal anemia in affected neonates and top-up transfusion is still commonly needed.
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Affiliation(s)
- Wenxu Pan
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haiyan Wu
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Junlin Chen
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xinyue Mo
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hongxin Wang
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qun Fang
- Fetal Medicine Centre, Department of Obstetrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yijuan Li
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuefang Huang
- Department of Pediatrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Correspondence: Yuefang Huang
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19
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Rodrigues JMDSR, Méio MDBB, Santos MCPD, Costa ACCD, Moreira MEL. Use of prophylactic phototherapy for RhD neonatal disease in a referral service. J Pediatr (Rio J) 2023; 99:53-58. [PMID: 35752322 PMCID: PMC9875278 DOI: 10.1016/j.jped.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE This study aimed to describe the effect of prophylactic phototherapy in the treatment of infants with Neonatal Hemolytic Disease. METHOD A retrospective cohort study was carried out with 199 RhD-positive infants, born to RhD-negative mothers, alloimmunized for RhD antigen, between January 2009 and December 2018. RESULTS The incidence of exchange transfusions in the study population was 9.5%, with a mean maximum bilirubin value of 11.3 mg % (± 4.3mg %). Bilirubin's maximum peak was achieved with a mean of 119.2 life hours (± 70.6h). CONCLUSION The low incidence of exchange transfusion, the extended maximum bilirubin peak for later ages, and the low mean of the maximum bilirubin values may indicate a positive effect of prophylactic phototherapy in the treatment of this disease. Further studies must be carried out to confirm these findings.
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Affiliation(s)
| | - Maria Dalva Barbosa Baker Méio
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Fernandes Figueira, Pós-graduação em Pesquisa Clínica Aplicada, Rio de Janeiro, RJ, Brazil.
| | | | - Ana Carolina Carioca da Costa
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Fernandes Figueira, Unidade de Pesquisa Clínica, Rio de Janeiro, RJ, Brazil
| | - Maria Elisabeth Lopes Moreira
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Pós-graduação em Pesquisa Clínica Aplicada, Rio de Janeiro, RJ, Brazil
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20
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Morgan JM, Peters S, Adusei-Baah C. Hemolytic Disease of the Newborn: A Community Hospitalist Perspective. Clin Pediatr (Phila) 2022; 62:404-408. [PMID: 36324255 DOI: 10.1177/00099228221133175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hemolytic disease of the newborn is commonly diagnosed and managed by pediatric and newborn hospitalists. Severe cases, however, pose unique challenges for community hospitals without higher level neonatal intensive care units. This case highlights the challenges faced by pediatric hospitalists in the community and suggests a focused approach to management.
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Affiliation(s)
- Joy M Morgan
- Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Summer Peters
- Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Charity Adusei-Baah
- Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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21
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van 't Oever RM, Zwiers C, de Winter D, de Haas M, Oepkes D, Lopriore E, Verweij EJJ. Identification and management of fetal anemia due to hemolytic disease. Expert Rev Hematol 2022; 15:987-998. [PMID: 36264850 DOI: 10.1080/17474086.2022.2138853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Hemolytic disease of the fetus and newborn (HDFN) is a condition caused by maternal alloantibodies against fetal red blood cells (RBCs) that can cause severe morbidity and mortality in the fetus and newborn. Adequate screening programs allow for timely prevention and intervention resulting in significant reduction of the disease over the last decades. Nevertheless, HDFN still occurs and with current treatment having reached an optimum, focus shifts toward noninvasive therapy options. AREAS COVERED This review focusses on the timely identification of high risk cases and antenatal management. Furthermore, we elaborate on future perspectives including improvement of screening, identification of high risk cases and promising treatment options. EXPERT OPINION In high-income countries mortality and morbidity rates due to HDFN have drastically been reduced over the last decades, yet worldwide anti-D mediated HDFN still accounts for 160,000 perinatal deaths and 100,000 patients with disabilities every year. Much of these deaths and disabilities could have been avoided with proper identification and prophylaxis. By implementing sustainable prevention, screening, and disease treatment measures in all countries this will systemically reduce unnecessary perinatal deaths. There is a common responsibility to engage in this cause.
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Affiliation(s)
- Renske M van 't Oever
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Immunohematology Diagnostics, Sanquin,Amsterdam, The Netherlands
| | - Carolien Zwiers
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Derek de Winter
- Department of Immunohematology Diagnostics, Sanquin,Amsterdam, The Netherlands.,Willem-Alexander Children's Hospital, department of Pediatrics, division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin,Amsterdam, The Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Willem-Alexander Children's Hospital, department of Pediatrics, division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - E J Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Blyth U, Larsson M, Baird A, Waring G, Athiraman N. Neonatal outcomes following intrauterine transfusion for hemolytic disease of the fetus and newborn: a twenty-year service review. J Matern Fetal Neonatal Med 2022; 35:10220-10225. [PMID: 36121063 DOI: 10.1080/14767058.2022.2122041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The primary objective was to explore perinatal and neonatal outcomes amongst infants who received intrauterine transfusion (IUT) for the management of hemolytic disease of the fetus and newborn (HDFN). The secondary objective was to evaluate the role of key investigations in the fetus at risk of HDFN and assess the relationship with neonatal outcomes. We hypothesized that middle cerebral artery peak systolic velocity (MCA-PSV) and corresponding multiples of the median (MoM) would be predictive of neonatal course. METHODS This was a retrospective observational study conducted at a tertiary center in the United Kingdom between January 2000 and August 2020. Trust approval was obtained to conduct this service review. Pregnancies requiring IUT for HDFN were identified using the fetal medicine department database. Inclusion criteria were infants who received IUT for HDFN. 67 pregnancies were eligible for inclusion in the study with 156 IUT events. Data were extracted using healthcare records. Statistical analysis was performed using SPSS version 28.0, data were assessed for normality and Spearman's correlation analysis was performed with p values < .05 considered significant. RESULTS 67 pregnancies were included in the study which led to the live birth of 68 infants (one twin pregnancy). There were no fetal deaths following IUT. There was one neonatal death due to extreme prematurity following spontaneous vaginal delivery at 23 + 4 weeks gestation, occurring three days following IUT. 97% of infants required admission to the neonatal intensive care unit and 88% required phototherapy. 25% of infants required readmission for red blood cell transfusion due to anemia. There was a significant correlation between maternal anti-D antibody levels and length of neonatal admission r = 0.477, p = .014. MCA-PSV and MoM measured prior to the last IUT had a significant positive correlation with the duration of phototherapy: r = 0.527 (p < .001) and r = 0.313 (p < .05) respectively. Linear regression analysis demonstrated a significant positive relationship between MCA-PSV and corresponding MoM recorded prior to the last IUT with r2= 0.177 (p = .003) and r2= 0.101 (p = .029). CONCLUSION HDFN is an important cause of fetal anemia associated with significant neonatal morbidity. MCA-PSV and MoM may be predictive of neonatal phototherapy requirements. The predictive value of MCA-PSV appears to be dependent on the timing of measurement during the antenatal period and more research is needed. Multicentre collaboration is required to generate a reliable large-scale database to further delineate the value of MCA-PSV and MoM and predict neonatal outcomes in cases of HDFN requiring IUT. This data would assist clinicians in antenatal planning and enable more informed counseling of parents in the antenatal period.
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Affiliation(s)
- Ursula Blyth
- Neonatology, Newcastle Upon Tyne NHS Hospitals, Newcastle-upon-Tyne, United Kingdom
| | - Martina Larsson
- Neonatology, Newcastle Upon Tyne NHS Hospitals, Newcastle-upon-Tyne, United Kingdom
| | - Aimi Baird
- Integrated Laboratory Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Hospitals Foundation Trust, Newcastle-upon-Tyne, United Kingdom
| | - Gareth Waring
- Fetal Medicine, Newcastle Upon Tyne NHS Hospitals, Newcastle-upon-Tyne, United Kingdom
| | - Naveen Athiraman
- Neonatology, Newcastle Upon Tyne NHS Hospitals, Newcastle-upon-Tyne, United Kingdom
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Calderón MJM, Pérez SIA, Becerra N, Suarez JD. Validation of an instrument for the evaluation of exchange transfusion (INEXTUS) via an OSCE. BMC MEDICAL EDUCATION 2022; 22:480. [PMID: 35725443 PMCID: PMC9210713 DOI: 10.1186/s12909-022-03546-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 06/03/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Exchange transfusion is the treatment of choice for patients with severe hyperbilirubinemia who do not respond to phototherapy. This procedure is highly complex and requires substantial expertise to perform, however it´s not done frequently enough to guarantee adequate training. Traditional learning scenarios do not have a space reserved for teaching this procedure or an instrument that fully and objectively evaluates the skills that a professional must acquire. OBJECTIVES: The purpose was to construct and evaluate the INEXTUS instrument´s validity evidence relevant to internal structure, in a simulated scenario through the performance of an objective structured clinical exam (OSCE). MATERIALS AND METHODS: The Delphi consensus methodology was utilized to design the instrument; six experts participated through three rounds using the Google Forms platform. The categories and items previously obtained were subjected to validation by nine experts through a dichotomous survey. Prior to data collection, the evaluators were trained through a pilot test with 10 medical students. Subsequently, all residents of a paediatric programme were evaluated through the OSCE methodology in a simulated scenario, with 6 stations, of a clinical case of a new-born with an explicit need for exchange transfusion. During their participation in the scenario, the residents were first evaluated with the instrument developed. Additionally, audio and video filming of all students who participated was performed with the aim of conducting a second evaluation two weeks after the first four evaluators participated. RESULTS The final INEXTUS instrument consists of 46 subitems grouped into 23 items divided into 6 categories, demonstrating an inter-rater intraclass correlation coefficient of 0.96 (95% CI 0.94, 0.98 p-value < 0.001). For the Fleiss Kappa of the 23 items evaluated, concordance was evaluated for 14 items but could not be determined for the 9 remaining items because all the ratings were equal, either because the items were not performed or they were all performed adequately. Of the 14 items, 9 good scores were obtained (95% CI 0.61 to 0.8; p value < 0.001), and 5 very good scores were obtained (95% CI 0.81 to 1; p value < 0.001). CONCLUSIONS The INEXTUS instrument evaluates exchange transfusion skills in medical personnel in training in simulated scenarios using the OSCE methodology; it has high validity and reliability and is a high-impact educational tool.
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Affiliation(s)
| | | | - Natalia Becerra
- School of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Juan David Suarez
- School of Medicine, Resident of Paediatrics, Universidad de La Sabana, Chía, Colombia
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50 Years Ago in TheJournalofPediatrics: Archived! Intrauterine Transfusion and Exchange Transfusions for Hemolytic Disease of the Newborn. J Pediatr 2022; 245:71. [PMID: 35718383 DOI: 10.1016/j.jpeds.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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25
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Abstract
Neonatal hyperbilirubinemia (NH) is a common phenomenon. In most cases, NH is benign and transient. However, in severe NH cases, neonates can develop encephalopathy and kernicterus. With appropriate screening and treatment, these adverse sequelae can be prevented. This article aims to provide the reader with an in-depth understanding of (1) bilirubin metabolism, (2) risk factors for severe NH, (3) NH screening and treatment, (4) various etiologies of severe NH, and (5) consequences of severe, untreated NH. [Pediatr Ann. 2022;51(6):e219-e227.].
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26
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Global trends in incidence and death of neonatal disorders and its specific causes in 204 countries/territories during 1990–2019. BMC Public Health 2022; 22:360. [PMID: 35183143 PMCID: PMC8858498 DOI: 10.1186/s12889-022-12765-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/09/2022] [Indexed: 12/11/2022] Open
Abstract
Background Neonatal disorders (ND) are a significant global health issue. This article aimed to track the global trends of neonatal disorders in 204 countries/territories from 1990 to 2019. Methods Data was explored from the Global Burden of Disease study 2019. Estimated annual percentage change (EAPC) and age-standardized rate (ASR) were calculated to quantify the trends of neonatal disorders and their specific causes, mainly included neonatal preterm birth (NPB), neonatal encephalopathy due to birth asphyxia and trauma (NE), neonatal sepsis and other neonatal infections (NS), and hemolytic disease and other neonatal jaundice (HD). Results In 2019, there were 23,532.23 × 103 incident cases of ND, and caused 1882.44 × 103 death worldwide. During 1990–2019, trends in the overall age-standardized incidence rate (ASIR) of ND was relatively stable, but that of age-standardized death rate (ASDR) declined (EAPC = -1.51, 95% confidence interval [CI]: -1.66 to -1.36). Meanwhile, decreasing trends of ASDR were observed in most regions and countries, particularly Cook Islands and Estonia, in which the respective EAPCs were -9.04 (95%CI: -9.69 to -8.38) and -8.12 (95%CI: -8.46 to -7.77). Among the specific four causes, only the NPB showed decreasing trends in the ASIR globally (EAPC = -0.19, 95%CI: -0.26 to -0.11). Decreasing trends of ASDR caused by ND underlying specific causes were observed in most regions, particularly the HD in Armenia, with the EAPC was -13.08 (95%CI: -14.04 to -12.11). Conclusions Decreasing trends of death caused by neonatal disorders were observed worldwide from 1990 to 2019. However, the burden of neonatal disorders is still a considerable challenge, especially in low-resource settings, which need more effective health strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12765-1.
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Kumar VS, Balasubramaniam A, Priya S. An overview of recent advances in the prevention of erythroblastosis fetalis. Asian J Transfus Sci 2022. [DOI: 10.4103/ajts.ajts_50_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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28
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Population-based incidence and risk factors for cholestasis in hemolytic disease of the fetus and newborn. J Perinatol 2022; 42:702-707. [PMID: 35194159 PMCID: PMC9184269 DOI: 10.1038/s41372-022-01345-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To estimate the incidence of cholestasis in neonates with hemolytic disease of the fetus and newborn (HDFN) and investigate risk factors and long-term liver disease. STUDY DESIGN A population-based cohort study of all infants born with HDFN within the Stockholm region between 2006 and 2015. The study period was the first 90 days of life, and presence of any chronic liver disease was evaluated at two years of age. RESULTS Cholestasis occurred in 7% (11/149). Median age at detection was 1.1 days. Intrauterine blood transfusions and maternal alloimmunization with multiple red blood cell antibodies including D-, c- or K-antibodies were independent risk factors for cholestasis. No infant had chronic liver disease at two years of age. CONCLUSIONS Infants with severe HDFN have increased risk for cholestasis, particularly those requiring multiple intrauterine transfusions. Early and repeated screening for conjugated hyperbilirubinemia in the first week of life is needed to ensure adequate management.
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Vardar G, Okan MA, Karadag N, Topcuoglu S, Ozalkaya E, Karatepe HO, Karatekin G. Intravenous immunoglobulin in hemolytic disease of the newborn: A moving target in time. Niger J Clin Pract 2022; 25:1262-1268. [DOI: 10.4103/njcp.njcp_1_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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30
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Acosta C, Idris I, Romero R, Ablan L, Montoya Novoa A, Abdalaziz A, Rodriguez A. Early Hyporegenerative Anemia Complicating Hemolytic Disease of the Newborn Secondary to Rhesus Alloimmunization. Cureus 2021; 13:e19603. [PMID: 34926072 PMCID: PMC8673681 DOI: 10.7759/cureus.19603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2021] [Indexed: 11/24/2022] Open
Abstract
Rhesus hemolytic disease of the newborn is rarely found after the implementation of anti-D immunoglobulin prophylaxis. However, it may lead to cholestasis, elevated liver transaminases, hyperbilirubinemia, kernicterus, iron overload, and hyporegenerative anemia. Hyporegenerative anemia is characterized by low hemoglobin and reticulocyte count. It is typically recognized two to six weeks after birth. The etiology of this type of anemia is not identified yet, and treatment is controversial. We report a case of a neonate with rhesus hemolytic disease of the newborn with early hyporegenerative anemia that was noted on day seven of life. The available literature has described a similar age of onset, but after two weeks of life and not as early as on day seven of life as in our case. We treated this type of anemia with the standard of care management that includes phototherapy, intravenous immunoglobulin, and blood transfusions.
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Affiliation(s)
| | - Isra Idris
- Pediatrics, Woodhull Medical Center, New York, USA
| | | | - Lilian Ablan
- Pediatrics, Woodhull Medical Center, New york, USA
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31
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Myle AK, Al-Khattabi GH. Hemolytic Disease of the Newborn: A Review of Current Trends and Prospects. Pediatric Health Med Ther 2021; 12:491-498. [PMID: 34675752 PMCID: PMC8504549 DOI: 10.2147/phmt.s327032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Hemolytic disease of the newborn (HDN), also known as Erythroblastosis fetalis, is a hemolytic condition that predominantly affects rhesus-positive fetuses and infants born to rhesus-negative mothers. The pathophysiology of HDN begins with maternal antibodies attacking fetal red blood cells following alloimmunization due to rhesus or ABO incompatibility between the maternal and fetal blood. Previously, HDN was known to cause fetal death in 1% of all pregnancies, but with the advent of immunoprophylactic therapies, the condition can be currently fairly well managed with fewer complications if diagnosed early. Diagnosis calls for extensive history taking, physical examination, serological studies, and imaging modalities such as pelvic ultrasound scans. To prevent the disease, earlier intravenous immunoglobulin (IVIG) should be given to pregnant Rh- women who have not been sensitized. It is also vital to understand prospective complications such as severe hyperbilirubinemia and develop appropriate remedies. Because of its great incidence and nature, HDN has been thoroughly explored, and more studies are being conducted each year, revealing new insights about the condition. This review covers the disorder's etiology, diagnosis, and management, including the most current findings as of 2021, as well as trends and prospects, to help in future research and evidence-based medical practice.
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Affiliation(s)
- Akshay Kiran Myle
- Department of Clinical Research, General Medicine, Pharmacology, Integrative Medicine, Clinical Researcher. National Institute of Medicine Sciences, Poduru Mandalam City, Andhra Pradesh State, India
- Preventive Medicine and Public Health, Ministry of Health, Makkah City, Kingdom of Saudi-Arabia
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32
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Thomsen WC, Afify ZA. Late Hyporegenerative Anemia Following Successful Management of Rh-D Alloimmunization: Still an Underappreciated Entity. Clin Pediatr (Phila) 2021; 60:399-402. [PMID: 34098759 DOI: 10.1177/00099228211022156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- William C Thomsen
- University of Utah, Salt Lake City, UT, USA.,Primary Children's Hospital, Salt Lake City, UT, USA
| | - Zeinab A Afify
- University of Utah, Salt Lake City, UT, USA.,Primary Children's Hospital, Salt Lake City, UT, USA
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Hemolytic Disease of the Fetus and Newborn Caused by Anti-Group A IgG From a Group B Mother. J Pediatr Hematol Oncol 2021; 43:e785-e787. [PMID: 33003144 DOI: 10.1097/mph.0000000000001948] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/16/2020] [Indexed: 11/26/2022]
Abstract
ABO incompatibility has emerged as the premier reason for hemolytic disease of the fetus and newborn (HDFN). It always occurs in the offspring of blood group O mother. We present a rare case that the fetus of group A got HDFN caused by the anti-group A immunoglobulin G from a group B mother. The direct Coombs test of the fetus blood was negative, but the indirect Coombs test on A1 standard blood cells was strong positive (4+). The acid release test of antibody on the membrane of red blood cells to A1 standard blood cells was also strong positive (4+). Bilirubin of the fetus reached the threshold of exchange transfusion, but she just received 4 days' phototherapy and 2.2 g albumin intravenous injection, with no packed blood cells transfusion, because her family refused, and came to a favorable outcome. This case reminds us not to ignore the possibility of HDFN in offspring of mothers with non-O blood group.
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34
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Sampurna MTA, Mapindra MP, Mahindra MP, Ratnasari KA, Rani SAD, Handayani KD, Angelika D, Harianto A, Utomo MT, Etika R, Sauer PJJ. Kramer Score, an Evidence of Its Use in Accordance with Indonesian Hyperbilirubinemia Published Guideline. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18116173. [PMID: 34200369 PMCID: PMC8200974 DOI: 10.3390/ijerph18116173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/11/2021] [Accepted: 05/27/2021] [Indexed: 01/12/2023]
Abstract
Background: In some hospitals in low/middle-income countries, methods to determine the bilirubin level in newborn infants are unavailable and based on a clinical evaluation, namely a clinical score designed by Kramer. In this study, we evaluated if this score can be used to identify those infants that need phototherapy. Method: Infants admitted between November 2018 and June 2019 to three hospitals in Surabaya, Indonesia were included. The jaundice intensity was scored using the Kramer score. Blood was sampled for total serum bilirubin (TSB) measurement. The infants were categorized into Treatment Needed (TN) group when treatment with phototherapy was indicated and the No Treatment Needed (NTN) group when phototherapy was not indicated, based on the Indonesian Guideline for hyperbilirubinemia. Result: A total of 280 infants with a mean birth weight of 2744.6 ± 685.8 g and a gestational age of 37.3 ± 2.3 weeks were included. Twenty-seven of 113 (24%) infants with Kramer score 2 needed phototherapy, compared with 41 of 90 (46%) infants with score 3 and 20 of 28 (71%) of infants with score 4. The percentage of infants that needed phototherapy was higher with decreasing gestational age. Conclusion: The Kramer score is an invalid method to distinguish between those infants needing phototherapy and those infants where this treatment is not indicated.
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Affiliation(s)
- Mahendra Tri Arif Sampurna
- Neonatology Division, Department of Pediatrics, Dr. Soetomo Academic Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (K.D.H.); (D.A.); (A.H.); (M.T.U.); (R.E.)
- Neonatology Division, Department of Pediatrics, Airlangga University Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya 60115, Indonesia
- Correspondence:
| | - Muhammad Pradhika Mapindra
- Neonatal Research Group Surabaya, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (M.P.M.); (M.P.M.); (K.A.R.); (S.A.D.R.)
| | - Muhammad Pradhiki Mahindra
- Neonatal Research Group Surabaya, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (M.P.M.); (M.P.M.); (K.A.R.); (S.A.D.R.)
| | - Kinanti Ayu Ratnasari
- Neonatal Research Group Surabaya, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (M.P.M.); (M.P.M.); (K.A.R.); (S.A.D.R.)
| | - Siti Annisa Dewi Rani
- Neonatal Research Group Surabaya, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (M.P.M.); (M.P.M.); (K.A.R.); (S.A.D.R.)
| | - Kartika Darma Handayani
- Neonatology Division, Department of Pediatrics, Dr. Soetomo Academic Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (K.D.H.); (D.A.); (A.H.); (M.T.U.); (R.E.)
| | - Dina Angelika
- Neonatology Division, Department of Pediatrics, Dr. Soetomo Academic Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (K.D.H.); (D.A.); (A.H.); (M.T.U.); (R.E.)
| | - Agus Harianto
- Neonatology Division, Department of Pediatrics, Dr. Soetomo Academic Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (K.D.H.); (D.A.); (A.H.); (M.T.U.); (R.E.)
| | - Martono Tri Utomo
- Neonatology Division, Department of Pediatrics, Dr. Soetomo Academic Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (K.D.H.); (D.A.); (A.H.); (M.T.U.); (R.E.)
| | - Risa Etika
- Neonatology Division, Department of Pediatrics, Dr. Soetomo Academic Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya 60285, Indonesia; (K.D.H.); (D.A.); (A.H.); (M.T.U.); (R.E.)
| | - Pieter J. J. Sauer
- Department of Pediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, 9713GZ Groningen, The Netherlands;
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35
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Ree IMC, van 't Oever RM, Jansen L, Lopriore E, de Haas M, van Klink JMM. School performance and behavioral functioning in children after intrauterine transfusions for hemolytic disease of the fetus and newborn. Early Hum Dev 2021; 157:105381. [PMID: 33962361 DOI: 10.1016/j.earlhumdev.2021.105381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022]
Abstract
AIM To investigate the school performance and behavioral difficulties in children with hemolytic disease of the fetus and newborn (HDFN) treated with intrauterine transfusion (IUT) compared to Dutch norm data. STUDY DESIGN Cros-sectional cohort study. SUBJECTS Children who received one or multiple IUTs for severe Rh- or K (Kell)-mediated HDFN between January 2008 and January 2015 at the LUMC. OUTCOME MEASURES School performance reports were assessed as well as behavioral difficulties as assessed with the Dutch child behavioral checklist (CBCL) by parents and caregivers and the Teacher Report Form (TRF) completed by teachers. RESULTS A response rate of 56% (70 children, aged 5-12 years) was obtained. Grade repetition occurred in 13 cases (19%), 16 children (23%) received some form of additional help, most often support by a speech therapist (n = 8), but also support for dyslexia (n = 4), physical therapy (n = 2) and social-emotional support (n = 2). None of the children in our study group attended special-needs education. School performance levels for reading comprehension, spelling and mathematics according to the Dutch National Pupil Monitoring System were similar for the study population and Dutch norm data. The incidence of behavioral problems as reported by parents was similar to the Dutch norm data, teachers reported less behavioral difficulties in the study group. CONCLUSION This study shows favorable and reassuring school development in children treated with IUT in an experienced fetal-therapy center. A normal distribution in school and behavioral development is to be expected for children with HDFN treated with IUTs.
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Affiliation(s)
- I M C Ree
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands; Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands.
| | - R M van 't Oever
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - L Jansen
- Department of Medical Psychology, Leiden University Medical Center, the Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - M de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands; Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands; Department of Immunohematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - J M M van Klink
- Department of Medical Psychology, Leiden University Medical Center, the Netherlands
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Awad MH, Amer S, Hafez M, Nour I, Shabaan A. "Fenofibrate as an adjuvant to phototherapy in pathological unconjugated hyperbilirubinemia in neonates: a randomized control trial.". J Perinatol 2021; 41:865-872. [PMID: 33070152 DOI: 10.1038/s41372-020-00861-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/13/2020] [Accepted: 10/06/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite widespread phototherapy usage, many new-born infants remain in need of other invasive lines of therapy, such as intravenous immunoglobulins and exchange transfusions. OBJECTIVE Assessment of the efficacy and the safety of adding fenofibrate to phototherapy for the treatment of pathological jaundice in full-term infants. DESIGN/METHODS We conducted a double blinded randomized control study on 180 full-term infants with pathological unconjugated hyperbilirubinemia admitted to the NICU at Mansoura University Children's Hospital. They were randomly assigned to receive either oral fenofibrate 10 mg/kg/day for 1 day or 2 days or placebo in addition to phototherapy. The primary outcome was total serum bilirubin values after 12, 24, 36, 48, and 72 h from intervention. Secondary outcomes were total duration of treatment, need for exchange transfusions and intravenous immunoglobulin, exclusive breast-feeding on discharge, and adverse effects of fenofibrate. This study was registered at www.clinicaltrials.gov (NCT04418180). RESULTS A total of 180 full-term infants were included, 60 in each group. Infants in group I and II showed significant reduction of bilirubin levels at 36, 48, and 72 h from intervention compared to group III, respectively. Fenofibrate administration was associated with significantly shorter duration of phototherapy, shorter hospital stay, and higher frequency of exclusive breast-feeding compared to phototherapy alone. CONCLUSION(S) Fenofibrate as an adjuvant to phototherapy in term neonate with pathological jaundice is well tolerated and associated with significant reduction of serum bilirubin levels, a shorter duration of phototherapy, shorter hospital stay and higher frequency of exclusive breast-feeding, without significant adverse effects in either the single or double dosage.
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Affiliation(s)
- Mohammad Hosny Awad
- Department of pediatrics, Mansoura University Children's Hospital, Mansoura, Egypt.
| | - Sahar Amer
- Department of pediatrics, Insurance Hospital, Ministry of health, Mansoura, Egypt
| | - Mona Hafez
- Department of pediatrics, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Islam Nour
- Department of pediatrics, Mansoura University Children's Hospital, Mansoura, Egypt
| | - AbdElaziz Shabaan
- Department of pediatrics, Mansoura University Children's Hospital, Mansoura, Egypt.,Department of pediatrics, New Mowasat Hospital, Salmiya, Kuwait
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Ree IMC, Besuden CFJ, Wintjens VEHJ, Verweij J(EJT, Oepkes D, de Haas M, Lopriore E. Exchange transfusions in severe Rh-mediated alloimmune haemolytic disease of the foetus and newborn: a 20-year overview on the incidence, associated risks and outcome. Vox Sang 2021; 116:990-997. [PMID: 33730387 PMCID: PMC8596394 DOI: 10.1111/vox.13090] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 11/28/2022]
Abstract
Background and objectives Guidelines and indications for exchange transfusion in haemolytic disease of the foetus and newborn (HDFN) have changed drastically in the past decades, causing a decline in exchange transfusion rate. This study aims to evaluate the incidence of exchange transfusions (ETs) in neonates with Rh‐mediated HDFN over the past 20 years at our centre, and report potentially ET‐related complications as well as indicators for bilirubin encephalopathy. Material and methods In this observational study, 438 neonates were included with HDFN, born ≥ 35 weeks gestational age at the Leiden University Medical Centre between January 2000 and July 2020. The incidence of ET and procedure‐related complications were assessed in three consecutive time periods determined by changes in guidelines and indications for ET. Results The incidence of ET in our centre declined from (104/156) 67% (time period 2000–2005), to (39/181) 22% (2006–2015) and to (10/101) 10% (2015–2020, p < 0·001). The maximum bilirubin levels in neonates after birth increased from 13·6 mg/dL (or 233 μmol/L), to 15·0 mg/dL (257 μmol/L) and to 15·3 mg/dL (263 μmol/L). The incidence of complications associated with the use of ET (including sepsis, haematologic disorders and respiratory failure) remained stable throughout the years, and no neonates died during the study period. Conclusion Exchange transfusion incidence declined significantly over the past two decades. Decrease in ET incidence, and concomitant decrease in exposure and expertise, was not associated with an increase in procedure‐related complications.
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Affiliation(s)
- Isabelle M C Ree
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Leiden, the Netherlands.,Centre for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands
| | - Carolin F J Besuden
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Vivianne E H J Wintjens
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joanne (E) J T Verweij
- Department of Obstetrics, Division of Foetal Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Foetal Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Masja de Haas
- Centre for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands.,Department of Immunohaematology and Blood Transfusion, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Immunohematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Leiden, the Netherlands
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Ree IMC, van 't Oever RM, Zwiers C, Verweij EJT, Oepkes D, de Haas M, Lopriore E. Are fetal bilirubin levels associated with the need for neonatal exchange transfusions in hemolytic disease of the fetus and newborn? Am J Obstet Gynecol MFM 2021; 3:100332. [PMID: 33609759 DOI: 10.1016/j.ajogmf.2021.100332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fetal bilirubin is routinely measured at our center when taking a pretransfusion blood sample at intrauterine transfusions in hemolytic disease of the fetus and newborn. However, the clinical value of fetal bilirubin assessment is not well known, and the information is rarely used. We speculated that there could be a role for this measurement in predicting the need for neonatal exchange transfusion. OBJECTIVE This study aimed to evaluate the predictive value of fetal bilirubin for exchange transfusions in severe hemolytic disease of the fetus and newborn. STUDY DESIGN A total of 186 infants with Rh alloantibody-mediated hemolytic disease of the fetus and newborn treated with one or more intrauterine transfusions at the Leiden University Medical Center between January 2006 and June 2020 were included in this observational study. Antenatal and postnatal factors were compared between infants with and without exchange transfusion treatments. The primary outcome was the fetal bilirubin levels before the last intrauterine transfusion in relation to the need for exchange transfusion. RESULTS In a multivariate logistic regression analysis, the fetal bilirubin level before the last intrauterine transfusions (odds ratio, 1.32; 95% confidence interval, 1.09-1.61 per 1 mg/dL) and the total number of intrauterine transfusions (odds ratio, 0.63; 95% confidence interval, 0.44-0.91 per intrauterine transfusion) were independently associated with the need for exchange transfusion. The area under the curve was determined at 0.71. A Youden index was calculated at 0.43. The corresponding fetal bilirubin level was 5 mg/dL and had a sensitivity of 79% and a specificity of 64%. CONCLUSION A high fetal bilirubin level before the last intrauterine transfusion was associated with a high likelihood of neonatal exchange transfusion.
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Affiliation(s)
- Isabelle M C Ree
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands (Drs Ree and Haas); Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands (Dr Ree, Ms Oever, and Dr Lopriore).
| | - Renske M van 't Oever
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands (Dr Ree, Ms Oever, and Dr Lopriore)
| | - Carolien Zwiers
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands (Drs Zwiers, Verweij, and Oepkes)
| | - E J T Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands (Drs Zwiers, Verweij, and Oepkes)
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands (Drs Zwiers, Verweij, and Oepkes)
| | - Masja de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands (Drs Ree and Haas); Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands (Dr Haas); Department of Immunohematology Diagnostics, Sanquin, Amsterdam, the Netherlands (Dr Haas)
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands (Dr Ree, Ms Oever, and Dr Lopriore)
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Alissa R, Williams PD, Baker EL, Hipp JA, Saremian J, Aysola AE. Suitability of Placental Blood Samples of Newborns for Pre-Transfusion Testing. Front Pediatr 2021; 9:661321. [PMID: 33996695 PMCID: PMC8119626 DOI: 10.3389/fped.2021.661321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/16/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To show concordance between heel stick and placental blood sample pairs for newborns' pre-transfusion testing and to validate placental blood's tube and gel methodology. Methods: Placental samples were collected for pre-transfusion testing at birth from 78 singleton and twin newborns admitted to our Mother-Baby Unit to compare with the results of heel stick samples taken from same newborns. Gestational age ≥35 weeks, weight ≥2,000 g. The study was approved by the Institutional Review Board (IRB). Informed consent was obtained from newborn parents. ABO blood group, Rhesus factor (Rh), direct antiglobulin test (DAT), and antibody screen were performed. Ortho ProVue Analyzer was used for tube and gel methods. McNemar's test for paired categorical data was performed. Results: One hundred percent concordance in 78 pairs for ABO and Rh. Seventy-four pairs were tested for antibodies, 72 were both negative, 1 was both positive, and 1 gave discordant result. Ninety-nine percent concordance, p = 0.999. Sixty-five pairs were both DAT negative, seven were both DAT positive, and six gave discordant results. Ninety-two percent concordance, p = 0.68. Placental blood gave identical results comparing tube with gel methods. Conclusions: Placental blood is suitable for pre-transfusion testing and can replace heel sticks. Placental blood tube and gel methods are validated.
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Affiliation(s)
- Rana Alissa
- Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, United States
| | - Patty D Williams
- Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, United States
| | - Erika L Baker
- Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, United States
| | - Jennifer A Hipp
- Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, United States
| | - Jinous Saremian
- Department of Pathology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, United States
| | - Agnes E Aysola
- Department of Pathology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, United States
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40
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Pan J, Zhan C, Yuan T, Chen X, Ni Y, Shen Y, Chen W, Wu T, Yu H. Intravenous immunoglobulin G in the treatment of ABO hemolytic disease of the newborn during the early neonatal period at a tertiary academic hospital: a retrospective study. J Perinatol 2021; 41:1397-1402. [PMID: 33589732 PMCID: PMC8225508 DOI: 10.1038/s41372-021-00963-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 11/12/2020] [Accepted: 01/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of intravenous immunoglobulin G (IVIG) in infants with ABO hemolytic disease of the newborn (HDN). METHODS Infants with moderate-to-severe ABO HDN during early neonatal period (<7 days) at our hospital in 2017 were included in this retrospective study. Patients treated with IVIG and phototherapy were classified as the IVIG group, and those who only received phototherapy were classified as the phototherapy only group. RESULTS Forty-six patients were classified into the IVIG group and 68 other patients were classified into the phototherapy only group. There was no significant difference in duration of phototherapy, hospitalization periods, needs for exchange transfusion, transfusions, and incidence of bilirubin-induced neurological sequelae between these two groups (P = 0.20, 0.27, 0.65, 0.47, 0.78, respectively). CONCLUSION It seems unnecessary to expose neonates to IVIG in moderate-to-severe ABO HDN when the available data show no appreciable benefits.
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Affiliation(s)
- Jiarong Pan
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
| | - Canyang Zhan
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
| | - Tianming Yuan
- Department of Neonatology, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, People's Republic of China.
| | - Xiangxiang Chen
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
| | - Yanyan Ni
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
| | - Ying Shen
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
| | - Weiwei Chen
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
| | - Tai Wu
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
| | - Huimin Yu
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, the Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang People’s Republic of China
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41
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Srinivasan R, Velumani S, Kumar P. Late-onset hyporegenerative anemia in an infant with rhesus isoimmunization. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_24_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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42
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Jackson ME, Baker JM. Hemolytic Disease of the Fetus and Newborn: Historical and Current State. Clin Lab Med 2020; 41:133-151. [PMID: 33494881 DOI: 10.1016/j.cll.2020.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hemolytic disease of the fetus and newborn (HDFN) is an immune-mediated disorder affecting neonates globally, with a range of clinical presentations from severe and life threatening to mild or even asymptomatic. Historically, HDFN has been responsible for a large proportion of perinatal mortality, and, despite advances in diagnosis and management, this morbidity and mortality has not been eradicated. Blood banking techniques and blood transfusion have contributed to improved prophylaxis and management, drastically improving the outcome of newborns with HDFN over the last century.
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Affiliation(s)
- Melanie E Jackson
- The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
| | - Jillian M Baker
- The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada; Unity Health Toronto (St. Michael's Hospital), 61 Queen Street East, 2nd, Floor, Toronto, Ontario M5C2T2, Canada; University of Toronto, 27 King's College Circle, Toronto, Ontario M5S 1A1, Canada.
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43
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Legler TJ. RhIg for the prevention Rh immunization and IVIg for the treatment of affected neonates. Transfus Apher Sci 2020; 59:102950. [PMID: 33004277 DOI: 10.1016/j.transci.2020.102950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rhesus D (RhD) negative pregnant women carrying an RhD positive fetus are at risk of developing anti-D during or after pregnancy. Anti-d-immunoglobulin (RhIg), which is mainly produced from special plasma donated in a few countries for the whole world, is able to prevent an anti-D alloimmunization. Through the introduction of ante- and postnatal anti-d-prophylaxis into clinical routine, the frequency of hemolytic disease of fetus and newborn decreased considerably. Postnatal prophylaxis from the beginning in the 1960s has been applied only to women who delivered an RhD positive newborn. Because the fetal RhD status can be determined with high sensitivity and accuracy from the mother's peripheral blood, targeted antenatal anti-d-prophylaxis is becoming a new standard procedure in more and more countries. Phototherapy and exchange transfusion are still the main pillars for the treatment of RhD hemolytic disease of the newborn. The efficacy of IVIg in the management of these neonates is not conclusive and cannot be recommended until a larger randomized, double-blind, placebo-controlled study is performed.
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Affiliation(s)
- Tobias J Legler
- Department of Transfusion Medicine, University Medical Center, Georg-August-University, Göttingen, Germany.
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44
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Abstract
Rhesus incompatibility in pregnancy may result in haemolytic disease of the fetus and newborn (HDFN). This review discusses the fetal, neonatal and long-term consequences of HDFN and its management. Untreated, the fetal and neonatal prognosis of HDFN is poor. Provision of intravascular intrauterine transfusion (IUT) in a dedicated referral centre significantly reduces perinatal loss. Early-onset, severe fetal anaemia carries a greater risk of adverse fetal and neonatal outcomes and is less amenable to treatment with IUT. Interventions to prevent and treat severe, early onset disease have been investigated, however evidence from randomised controlled trials is required. Neonatal consequences of Rhesus haemolytic disease include early and late postnatal anaemia, and hyperbilirubinaemia leading to bilirubin-induced neurological dysfunction. Neurodevelopmental impairment and adult cardiovascular disease are long-term complications that have been reported in association with severe fetal anaemia. Strategies to prevent fetal hydrops, and further research into the long-term impacts of fetal anaemia may improve health outcomes for adult survivors of HDFN.
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45
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Castleman JS, Moise KJ, Kilby MD. Medical therapy to attenuate fetal anaemia in severe maternal red cell alloimmunisation. Br J Haematol 2020; 192:425-432. [PMID: 32794242 DOI: 10.1111/bjh.17041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 12/01/2022]
Abstract
Haemolytic disease of the fetus and newborn (HDFN) remains an important cause of fetal mortality with potential neonatal and longer-term morbidity. HDFN is caused by maternal red cell alloimmunisation, with IgG antibodies crossing the placenta to destroy fetal erythroid cells expressing the involved antigen. Intrauterine fetal blood transfusion is the therapy of choice for severe fetal anaemia. Despite a strong evidence base and technical advances, invasive fetal therapy carries risk of miscarriage and preterm birth. Procedure-related risks are increased when invasive, in utero transfusion is instituted prior to 22 weeks to treat severe early-onset fetal anaemia. This review focuses upon this cohort of HDFN and discusses intravenous immunoglobin (IVIg) and novel monoclonal antibody (M281, nipocalimab) treatments which, if started at the end of the first trimester, may attenuate the transplacental passage and fetal effects of IgG antibodies. Such therapy has the ability to improve fetal survival in this severe presentation of HDFN when early in utero transfusion may be required and may have wider implications for the perinatal management in general.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Kenneth J Moise
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Kang W, Yuan X, Zhang Y, Song J, Xu F, Liu D, Li R, Xu B, Li W, Cheng Y, Zhu C. Early prediction of adverse outcomes in infants with acute bilirubin encephalopathy. Ann Clin Transl Neurol 2020; 7:1141-1147. [PMID: 32495505 PMCID: PMC7359120 DOI: 10.1002/acn3.51077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/10/2020] [Accepted: 05/12/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Acute bilirubin encephalopathy (ABE) remains one of the important causes of neonatal mortality and child disability, early identification, and intervention which could improve outcomes. The purpose of this study was to evaluate early predictors of adverse outcomes in infants with ABE. METHODS Newborns of gestational age ≥ 35 weeks and diagnosed with ABE were included in the study. Bilirubin-induced neurological dysfunction (BIND) score, total serum bilirubin (TSB) peak value, and serum albumin levels were determined. Adverse outcomes were defined as death or survival with auditory dysfunction and/or cerebral palsy. RESULTS Eighty-two infants were eligible for recruitment in the study. The outcome data from 76 ABE infants (92%) were used for analysis, of which 25 infants got adverse outcomes and 51 live a normal life. Univariate analysis for BIND score, TSB peak value, bilirubin-albumin ratio (B/A), albumin level, abnormal AABR, and neonatal sepsis was performed to elucidate the association with adverse outcomes. Bivariate logistic regression analysis showed B/A (OR 10.48, 95%CI: 1.55-70.81, P = 0.02) and BIND score (OR 3.68, 95%CI: 1.39-9.72, P = 0.01) were correlated with adverse outcomes. ROC curve analysis showed that B/A (≥8.9 mg/g), BIND score (≥6) could predict adverse outcomes of ABE separately; B/A in conjunction with BIND score could increase prediction sensitivity to 100%. INTERPRETATION Both B/A and BIND score can be used to predict adverse outcomes of ABE, and the combination of the two parameters can increase prediction sensitivity significantly.
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Affiliation(s)
- Wenqing Kang
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Xiao Yuan
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Yaodong Zhang
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Juan Song
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Falin Xu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Dapeng Liu
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Rui Li
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Bangli Xu
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Wen Li
- Department of Neonatology, Qilu Hospital of Shandong University, Jinan, China
| | - Yanchao Cheng
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, 40530, Sweden
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47
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Castleman JS, Kilby MD. Red cell alloimmunization: A 2020 update. Prenat Diagn 2020; 40:1099-1108. [PMID: 32108353 DOI: 10.1002/pd.5674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 12/27/2022]
Abstract
Management of maternal red cell alloimmunization has been revolutionized over the last 60 years. Advances in the prevention, screening, diagnosis, and treatment of alloimmune-induced fetal anemia make this condition an exemplar for contemporary practice in fetal therapy. Since survival is now an expectation, attention has turned to optimization of long-term outcomes following an alloimmunized pregnancy. In this review, the current management of red cell alloimmunization is described. Current research and future directions are discussed with particular emphasis on later life outcomes after alloimmune fetal anemia.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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48
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Richmond CM, Campbell S, Foo HW, Lunke S, Stark Z, Moody A, Bannister E, Greenway A, Brown N. Rapid Identification of Biallelic SPTB Mutation in a Neonate with Severe Congenital Hemolytic Anemia and Liver Failure. Mol Syndromol 2020; 11:50-55. [PMID: 32256302 DOI: 10.1159/000505886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 11/19/2022] Open
Abstract
Heterozygous pathogenic variants in SPTB cause autosomal dominant hereditary spherocytosis, an important cause of neonatal nonimmune hemolytic anemia. Biallelic mutations are rarely reported, all with severe neonatal presentation. We describe rapid (68 h) genomic diagnosis of homozygous β-spectrin deficiency in a newborn with severe transfusion-dependent hemolytic anemia, conjugated hyperbilirubinemia, and progressive liver failure. Trio whole-exome sequencing identified a novel biallelic SPTB variant (c.6119C>T; p.Thr2040Ile) located in the critical spectrin repeat region. Pretransfusion blood film showed marked spherocytosis including microspherocytes and nucleated erythrocytes, and eosin-5-maleimide (E5M) staining was markedly reduced, supporting pathogenicity. Both asymptomatic heterozygous parents demonstrated mildly reduced E5M staining, with occasional spherocytes and elliptocytes. Early molecular diagnosis facilitated hypertransfusion to suppress ineffective erythropoiesis and reverse hepatic dysfunction. This report broadens the genotypic and phenotypic spectrum of spectrin deficiency and highlights the utility of rapid genomic testing in facilitating early diagnosis and informing targeted therapy in critically ill patients.
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Affiliation(s)
- Christopher M Richmond
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia.,School of Medicine, Griffith University, Gold Coast, Australia
| | - Sally Campbell
- Department of Haematology, Royal Children's Hospital, Melbourne, Australia
| | - Hee W Foo
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Australia
| | - Sebastian Lunke
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Clinical Pathology, University of Melbourne, Melbourne, Australia.,Australian Genomics Health Alliance, Parkville, Australia
| | - Zornitza Stark
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia.,Australian Genomics Health Alliance, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Amanda Moody
- Department of Neonatal Medicine, Royal Children's Hospital, Melbourne, Australia
| | - Elizabeth Bannister
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Anthea Greenway
- Department of Haematology, Royal Children's Hospital, Melbourne, Australia
| | - Natasha Brown
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Vats K, Watchko JF. Coordinating Care Across the Perinatal Continuum in Hemolytic Disease of the Fetus and Newborn: The Timely Handoff of a Positive Maternal Anti-Erythrocyte Antibody Screen. J Pediatr 2019; 214:212-216. [PMID: 31451186 DOI: 10.1016/j.jpeds.2019.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/22/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Kalyani Vats
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
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50
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Yazer MH, Delaney M, Doughty H, Dunbar NM, Al‐Riyami AZ, Triulzi DJ, Watchko JF, Wood EM, Yahalom V, Emery SP. It is time to reconsider the risks of transfusing RhD negative females of childbearing potential with RhD positive red blood cells in bleeding emergencies. Transfusion 2019; 59:3794-3799. [DOI: 10.1111/trf.15569] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/21/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Mark H. Yazer
- Department of PathologyUniversity of Pittsburgh Pittsburgh Pennsylvania
- Vitalant Pittsburgh Pennsylvania
| | - Meghan Delaney
- Division of Pathology and Laboratory MedicineChildren's National Medical Center Washington District of Columbia
- Department of Pathology and PediatricsGeorge Washington University Medical School Washington District of Columbia
| | | | - Nancy M. Dunbar
- Department of Pathology and Laboratory MedicineDartmouth‐Hitchcock Medical Center Lebanon New Hampshire
| | - Arwa Z. Al‐Riyami
- Department of HematologySultan Qaboos University Hospital Muscat Oman
| | - Darrell J. Triulzi
- Department of PathologyUniversity of Pittsburgh Pittsburgh Pennsylvania
- Vitalant Pittsburgh Pennsylvania
| | - Jon F. Watchko
- Department of PediatricsUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania
| | - Erica M. Wood
- Transfusion Research UnitSchool of Public Health and Preventive Medicine, Monash University Melbourne Australia
- Department of Clinical HaematologyMonash Health Melbourne Australia
| | - Vered Yahalom
- Rabin Medical CenterBlood Services and Apheresis Institute Petah Tiqva Israel
| | - Stephen P. Emery
- Department of Obstetrics, Gynecology and Reproductive SciencesUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania
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