Overview of the state of the art of Rh disease: history, current clinical management, and recent progress

Hemolytic Disease of the Fetus and Newborn: Historical and Current State

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.

The effect of Rh-negative disease on perinatal mortality: some evidence from the Skellefteå region, Sweden, 1860-1900

The Rh-negative gene is a well-known cause of perinatal mortality. In this article, we analyze the possible role of Rh disease in perinatal mortality and stillbirths in a particular historical setting: the Skellefteå region in northern Sweden between 1860 and 1900. The data used for the study cover 23,067 children born to 4,943 women. The exact impact is not possible to establish using historical data, but the typical pattern of the disease allows us to make estimations. The expected levels based on knowledge of blood group distribution, the risk of sensitization from Rh incompatability, and the risk of perinatal mortality in births by sensitized mothers are compared with the observed levels. The results show that Rh disease was important for perinatal mortality and clustering of deaths within families.

Maternal antibrain antibodies in autism

Autism is a neurodevelopmental disorder of prenatal onset that is behaviorally defined. There is increasing evidence for systemic and neuroimmune mechanisms in children with autism. Although genetic factors are important, atypical prenatal maternal immune responses may also be linked to the pathogenesis of autism. We tested serum reactivity in 11 mothers and their autistic children, maternal controls, and several groups of control children, to prenatal, postnatal, and adult rat brain proteins, by immunoblotting. Similar patterns of reactivity to prenatal (gestational day 18), but not postnatal (day 8) or adult rat brain proteins were identified in autistic children, their mothers, and children with other neurodevelopmental disorders, and differed from mothers of normal children, normal siblings of children with autism and normal child controls. Specific patterns of antibody reactivity were present in sera from the autism mothers, from 2 to 18 years after the birth of their affected children and were unrelated to birth order. Immunoblotting using specific antigens for myelin basic protein (MBP) and glial acidic fibrillary protein (GFAP) suggests that these proteins were not targets of the maternal antibodies. The identification of specific serum antibodies in mothers of children with autism that recognize prenatally expressed brain antigens suggests that these autoantibodies could cross the placenta and alter fetal brain development.

Single versus double volume exchange transfusion in jaundiced newborn infants

BACKGROUND

Double volume exchange transfusion is commonly used in newborns with severe jaundice in order to prevent kernicterus and other toxicity related to hyperbilirubinemia. Most commonly, exchange transfusions are used in infants with rhesus hemolytic disease.

OBJECTIVES

To compare the effectiveness of single volume exchange transfusion (SVET) with that of double volume exchange transfusion (DVET) in producing survival without disability and reducing bilirubin levels in newborn infants with severe jaundice.

SEARCH STRATEGY

MEDLINE, EMBASE (Excerpta Medica online), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), SCISEARCH (Science Citation Index), Reference lists from the articles identified in the search of the databases, and from review articles were searched through March 2006. Personal communication with experts in the field was used to identify unpublished data.

SELECTION CRITERIA

All Randomised and quasi randomised control trials comparing single volume and double volume exchange transfusions in jaundiced newborn infants were included.

DATA COLLECTION AND ANALYSIS

Safety and efficacy of single and double volume exchange compared with regards to long term neurodevelopment, reduction in bilirubin levels and other complications during exchange transfusion. Data was evaluated separately with regards to the cause of jaundice. Relative risk (RR) and weighted mean difference (WMD) were calculated for dichotomous and continuous variables respectively. 95% confidence intervals were used and a fixed effects model was assumed.

MAIN RESULTS

Only one study fulfilled the criteria (Amato 1988). 20 full term babies requiring exchange transfusion for hemolytic jaundice due to ABO incompatibility were randomly allocated to receive single or double volume exchange transfusion. Base line characteristics of both groups were similar with regards to birth weight 3260 (SD 390) g vs. 3350 SD (410) g, gestational age 39 (SD 1) week vs. 40 (SD 0.8) week, immediate pre exchange bilirubin level 199 (SD 33) micromol/L vs. 216 (SD 55) micromol/L. Both groups were treated equally apart from the volume of blood used for exchange transfusion. Total bilirubin levels immediately after exchange transfusion were not significantly different in either group. No long term neurodevelopmental outcome was examined in this study.

AUTHORS' CONCLUSIONS

There was insufficient evidence to support or refute the use of single volume exchange transfusion as opposed to double volume exchange transfusion in jaundiced newborns. A change from the current practice of double volume exchange transfusions for severe jaundice in newborns infant, cannot be recommended on current evidence.