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Yilmaz Yegit C, Yasa B, Ince EZ, Sarac Sivrikoz T, Coban A. An ongoing problem: Rhesus hemolytic disease of the newborn - A decade of experience in a single centre. Pediatr Neonatol 2024:S1875-9572(24)00022-6. [PMID: 38490905 DOI: 10.1016/j.pedneo.2024.02.004] [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: 08/17/2023] [Revised: 01/26/2024] [Accepted: 02/16/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND The objectives were to evaluate the descriptive features of newborns with a diagnosis of Rhesus (Rh) hemolytic disease, to determine the morbidity and mortality rates, to evaluate the treatment methods and the factors affecting treatment requirements and clinical outcomes during a ten-year period at a tertiary center. METHODS Newborn infants who had a positive direct Coombs test and/or had a history of intrauterine transfusion (IUT) due to Rh hemolytic disease were included. The data regarding the prenatal, natal and postnatal periods were collected from hospital records. RESULTS A total of 260 neonates were included of which 51.2% were female. The mean ± standard deviation gestational age was 36.9 ± 2.7 weeks. The rate of preterm birth was 41.2%. Of 257 mothers whose obstetric medical history could be accessed, 87.2% were multigravida, whereas 76.3% were multiparous. Among mothers who had a reliable history of anti-D immunoglobulin prophylaxis (n=191), 51.3% had not received anti-D immunoglobulin prophylaxis in their previous pregnancies. The antenatal transfusion rate was 31.7% and the frequency of hydrops fetalis was 8.8%. While combined exchange transfusion (ET) and phototherapy (PT) was performed in 15.4% of the babies, the majority either needed phototherapy only (51.1%) or no treatment (33.5%). The mortality rate was 3.8 % (n = 10), and nine babies out of these 10 were those with severe hydrops fetalis. CONCLUSION This study showed that Rh hemolytic disease is still a major problem in developing countries. Multiple comorbidities may occur in addition to life threatening complications, including hydrops fetalis, anemia and severe hyperbilirubinemia. High rates of multiparity and low rates of anti-D immunoglobulin prophylaxis are potential barriers for the eradication of the disease. It should be remembered that Rh hemolytic disease is a preventable disease in the presence of appropriate antenatal follow-up and care facilities.
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Affiliation(s)
- Cansu Yilmaz Yegit
- Department of Pediatrics, Istanbul University Faculty of Medicine, Istanbul, Turkey.
| | - Beril Yasa
- Department of Pediatrics, Division of Neonatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Elmas Zeynep Ince
- Department of Pediatrics, Division of Neonatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Tugba Sarac Sivrikoz
- Department of Obstetrics and Gynecology, Division of Perinatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Asuman Coban
- Department of Pediatrics, Division of Neonatology, Istanbul University Faculty of Medicine, Istanbul, Turkey
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Rasiah S, Jegathesan T, Campbell DM, Shah PS, Sgro MD. Intravenous immunoglobulin G therapy for neonatal hyperbilirubinemia. Pediatr Res 2023; 94:2092-2097. [PMID: 37491586 PMCID: PMC10665189 DOI: 10.1038/s41390-023-02712-0] [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: 01/05/2023] [Revised: 06/06/2023] [Accepted: 06/19/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Neonatal hyperbilirubinemia (NHb) results from increased total serum bilirubin and is a common reason for admission and readmission amongst newborn infants born in North America. The use of intravenous immunoglobulin (IVIG) therapy for treating NHb has been widely debated, and the current incidence of NHb and its therapies remain unknown. METHODS Using national and provincial databases, a population-based retrospective cohort study of infants born in Ontario from April 2014 to March 2018 was conducted. RESULTS Of the 533,084 infants born in Ontario at ≥35 weeks gestation, 29,756 (5.6%) presented with NHb. Among these infants, 80.1-88.2% received phototherapy, 1.1-2.0% received IVIG therapy and 0.1-0.2% received exchange transfusion (ET) over the study period. Although phototherapy was administered (83.0%) for NHb, its use decreased from 2014 to 2018 (88.2-80.1%) (P < 0.01). Similarly, the incidence of IVIG therapy increased from 71 to 156 infants (1.1-2.0%) (P < 0.01) and a small change in the incidence of ET (0.2-0.1%) was noted. CONCLUSION IVIG therapy is increasingly being used in Ontario despite limited studies evaluating its use. The results of this study could inform treatment and management protocols for NHb. IMPACTS Clinically significant neonatal hyperbilirubinemia still occurs in Ontario, with an increasing number of infants receiving Intravenous Immunoglobulin G (IVIG) therapy. IVIG continues to be used at increasing rates despite inconclusive evidence to recommend its use. This study highlights the necessity of a future prospective study to better determine the effectiveness of IVIG use in treating neonatal hyperbilirubinemia, especially given the recent shortage in IVIG supply in Ontario. The results of this study could inform treatment and management protocols for neonatal hyperbilirubinemia.
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Affiliation(s)
- Saisujani Rasiah
- Department of Pediatrics, St. Michael's Hospital, Toronto, ON, Canada
| | - Thivia Jegathesan
- Department of Pediatrics, St. Michael's Hospital, Toronto, ON, Canada
| | - Douglas M Campbell
- Department of Pediatrics, St. Michael's Hospital, Toronto, ON, Canada
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Prakeshkumar S Shah
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Michael D Sgro
- Department of Pediatrics, St. Michael's Hospital, Toronto, ON, Canada.
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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3
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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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4
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de Winter DP, Kaminski A, Tjoa ML, Oepkes D. Hemolytic disease of the fetus and newborn: systematic literature review of the antenatal landscape. BMC Pregnancy Childbirth 2023; 23:12. [PMID: 36611144 PMCID: PMC9824959 DOI: 10.1186/s12884-022-05329-z] [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] [Received: 09/20/2022] [Accepted: 12/21/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Prevention of pregnancy-related alloimmunization and the management of hemolytic disease of the fetus and newborn (HDFN) has significantly improved over the past decades. Considering improvements in HDFN care, the objectives of this systematic literature review were to assess the prenatal treatment landscape and outcomes of Rh(D)- and K-mediated HDFN in mothers and fetuses, to identify the burden of disease, to identify evidence gaps in the literature, and to provide recommendations for future research. METHODS We performed a systematic search on MEDLINE, EMBASE and clinicaltrials.gov. Observational studies, trials, modelling studies, systematic reviews of cohort studies, and case reports and series of women and/or their fetus with HDFN caused by Rhesus (Rh)D or Kell alloimmunization. Extracted data included prevalence; treatment patterns; clinical outcomes; treatment efficacy; and mortality. RESULTS We identified 2,541 articles. After excluding 2,482 articles and adding 1 article from screening systematic reviews, 60 articles were selected. Most abstracted data were from case reports and case series. Prevalence was 0.047% and 0.006% for Rh(D)- and K-mediated HDFN, respectively. Most commonly reported antenatal treatment was intrauterine transfusion (IUT; median frequency [interquartile range]: 13.0% [7.2-66.0]). Average gestational age at first IUT ranged between 25 and 27 weeks. weeks. This timing is early and carries risks, which were observed in outcomes associated with IUTs. The rate of hydrops fetalis among pregnancies with Rh(D)-mediated HDFN treated with IUT was 14.8% (range, 0-50%) and 39.2% in K-mediated HDFN. Overall mean ± SD fetal mortality rate that was found to be 19.8%±29.4% across 19 studies. Mean gestational age at birth ranged between 34 and 36 weeks. CONCLUSION These findings corroborate the rareness of HDFN and frequently needed intrauterine transfusion with inherent risks, and most births occur at a late preterm gestational age. We identified several evidence gaps providing opportunities for future studies.
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Affiliation(s)
- Derek P. de Winter
- grid.508552.fDepartment of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands ,grid.417732.40000 0001 2234 6887Department of Immunohematology Diagnostic Services, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Allysen Kaminski
- OPEN Health, Bethesda, MD USA ,grid.253615.60000 0004 1936 9510Present address: The George Washington University, Washington, DC, USA
| | - May Lee Tjoa
- grid.497530.c0000 0004 0389 4927Janssen Pharmaceuticals, Raritan, NJ USA
| | - Dick Oepkes
- grid.10419.3d0000000089452978Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, K-06-35, PO Box 9600, Leiden, 2300 RC The Netherlands
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5
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Hansen TWR, Akkök CA, Watchko JF. International guidelines regarding the role of intravenous immunoglobulin in the management of RhD- and ABO-mediated haemolytic disease of the newborn-reconsidering the recommendations. Br J Haematol 2022; 199:452-453. [PMID: 35993219 DOI: 10.1111/bjh.18421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Cigdem Akalin Akkök
- Section of Immunohematology, Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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6
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Lieberman L, Lopriore E, Baker JM, Bercovitz RS, Christensen RD, Crighton G, Delaney M, Goel R, Hendrickson JE, Keir A, Landry D, La Rocca U, Lemyre B, Maier RF, Muniz‐Diaz E, Nahirniak S, New HV, Pavenski K, dos Santos MCP, Ramsey G, Shehata N. International guidelines regarding the role of IVIG in the management of Rh- and ABO-mediated haemolytic disease of the newborn. Br J Haematol 2022; 198:183-195. [PMID: 35415922 PMCID: PMC9324942 DOI: 10.1111/bjh.18170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/16/2022] [Indexed: 01/08/2023]
Abstract
Haemolytic disease of the newborn (HDN) can be associated with significant morbidity. Prompt treatment with intensive phototherapy (PT) and exchange transfusions (ETs) can dramatically improve outcomes. ET is invasive and associated with risks. Intravenous immunoglobulin (IVIG) may be an alternative therapy to prevent use of ET. An international panel of experts was convened to develop evidence-based recommendations regarding the effectiveness and safety of IVIG to reduce the need for ETs, improve neurocognitive outcomes, reduce bilirubin level, reduce the frequency of red blood cell (RBC) transfusions and severity of anaemia, and/or reduce duration of hospitalization for neonates with Rh or ABO-mediated HDN. We used a systematic approach to search and review the literature and then develop recommendations from published data. These recommendations conclude that IVIG should not be routinely used to treat Rh or ABO antibody-mediated HDN. In situations where hyperbilirubinaemia is severe (and ET is imminent), or when ET is not readily available, the role of IVIG is unclear. High-quality studies are urgently needed to assess the optimal use of IVIG in patients with HDN.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical PathologyUniversity Health NetworkTorontoOntarioCanada
- Department of Laboratory Medicine & PathobiologyUniversity of TorontoTorontoOntarioCanada
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Enrico Lopriore
- Division of NeonatologyDepartment of Pediatrics, Leiden University Medical CenterLeidenThe Netherlands
| | - Jillian M. Baker
- Department of PediatricsUnity Health Toronto (St. Michael's Hospital)TorontoOntarioCanada
- Division of Haematology‐OncologyThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Rachel S. Bercovitz
- Division of HematologyOncology, and Stem Cell Transplant, Department of Pediatrics, Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Robert D. Christensen
- Divisions of Neonatology and Hematology/OncologyUniversity of Utah HealthSalt Lake CityUTUSA
- Department of Women and Newborn's ResearchIntermountain HealthcareSalt Lake CityUtahUSA
| | - Gemma Crighton
- Department of HaematologyRoyal Children's HospitalMelbourneAustralia
| | - Meghan Delaney
- Division of Pathology & Laboratory MedicineChildren's National HospitalWashingtonDistrict of ColumbiaUSA
- Department of Pathology & PediatricsThe George Washington University Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Ruchika Goel
- Division of Transfusion MedicineDepartment of Pathology, School of Medicine, Johns Hopkins UniversityBaltimoreMarylandUSA
- Simmons Cancer Institute at SIU School of MedicineSpringfieldIllinoisUSA
| | - Jeanne E. Hendrickson
- Departments of Laboratory Medicine and PediatricsYale UniversityNew HavenConnecticutUSA
| | - Amy Keir
- SAHMRI Women and KidsSouth Australian Health and Medical InstituteNorth AdelaideSouth AustraliaAustralia
- Adelaide Medical School and the Robinson Research Institutethe University of AdelaideNorth AdelaideSouth AustraliaAustralia
| | | | - Ursula La Rocca
- Department of Translational and Precision MedicineSapienza UniversityRomeItaly
- Italian National Blood CentreNational Institute of HealthRomeItaly
| | - Brigitte Lemyre
- Department of PediatricsUniversity of OttawaOttawaOntarioCanada
| | - Rolf F. Maier
- Children's HospitalUniversity Hospital, Philipps UniversityMarburgGermany
| | - Eduardo Muniz‐Diaz
- Department of ImmunohematologyBlood and Tissue Bank of CataloniaBarcelonaSpain
| | - Susan Nahirniak
- Alberta Precision Laboratories and Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Helen V. New
- Clinical DirectorateNHS Blood and TransplantLondonUK
- Centre for HaematologyImperial College LondonLondonUK
| | - Katerina Pavenski
- Department of Laboratory Medicine and PathologyUnity Health Toronto (St. Michael's Hospital)TorontoOntarioCanada
| | | | - Glenn Ramsey
- Department of PathologyFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Nadine Shehata
- Departments of MedicineLaboratory Medicine and Pathobiology, Institute of Health, Policy Management and Evaluation, University of Toronto, Mount Sinai HospitalTorontoOntarioCanada
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7
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Wiedmeier SE, Bahr TM, Ohls RK, Christensen TR, Baer VL, Ilstrup SJ, Cail K, Christensen RD. Exchange transfusion for hemolytic hyperbilirubinemia: could some be averted by emergent administration of an inhibitor of bilirubin production? J Perinatol 2021; 41:860-864. [PMID: 32669646 DOI: 10.1038/s41372-020-0736-8] [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: 05/04/2020] [Revised: 06/01/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The objective of this study is to explore the hypothetical number of neonates where an exchange transfusion (ET) could be prevented by emergency administration of an inhibitor of bilirubin production. STUDY DESIGN We identified all neonates who received an ET in our NICUs during the past 12 years. We reviewed the indications for ET and recorded the time between ordering and beginning the exchange. RESULTS Forty-six neonates underwent ET, 37 (80.4%) for hemolytic hyperbilirubinemia (36.9 ± 2.9 weeks gestation and 2.5 ± 2.1 days old at ET). The mean delay period was 7.5 ± 3.5 h. Nine (19.6%) had ET not involving bilirubin. CONCLUSIONS A trial testing compounds that can inhibit bilirubin production would have about three eligible neonates/years in our system. Since our births are 1% of national, up to 300 neonates/years might qualify for such a study.
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Affiliation(s)
- Susan E Wiedmeier
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA.
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | | | - Vickie L Baer
- Women and Newborns Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Sarah J Ilstrup
- Department of Pathology, Intermountain Medical Center, Murray, UT, USA
| | - Kelly Cail
- ARUP Laboratories, Salt Lake City, UT, USA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA.,Women and Newborns Research, Intermountain Healthcare, Salt Lake City, UT, USA.,Division Hematology/Oncology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
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8
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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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9
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D'Mello RJ, Hsu CD, Chaiworapongsa P, Chaiworapongsa T. Update on the Use of Intravenous Immunoglobulin in Pregnancy. Neoreviews 2021; 22:e7-e24. [PMID: 33386311 DOI: 10.1542/neo.22-1-e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.
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Affiliation(s)
- Rahul J D'Mello
- Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology and.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI
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10
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Alsaleem M. Intravenous Immune Globulin Uses in the Fetus and Neonate: A Review. Antibodies (Basel) 2020; 9:E60. [PMID: 33158209 PMCID: PMC7709108 DOI: 10.3390/antib9040060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/07/2020] [Accepted: 11/02/2020] [Indexed: 02/07/2023] Open
Abstract
Intravenous immune globulin (IVIG) is made after processing plasma from healthy donors. It is composed mainly of pooled immunoglobulin and has clinical evidence-based applications in adult and pediatric populations. Recently, several clinical applications have been proposed for managing conditions in the neonatal population, such as hemolytic disease of the newborn, treatment, and prophylaxis for sepsis in high-risk neonates, enterovirus parvovirus and COVID-19 related neonatal infections, fetal and neonatal immune-induced thrombocytopenia, neonatal hemochromatosis, neonatal Kawasaki disease, and some types of immunodeficiency. The dosing, mechanism of action, effectiveness, side effects, and adverse reactions of IVIG have been relatively well studied in adults but are not well described in the neonatal population. This review aims to provide the most recent evidence and consensus guidelines about the use of IVIG in the fetus and neonate.
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Affiliation(s)
- Mahdi Alsaleem
- Pediatrics Department, Neonatology, Children’s Mercy Hospital, Kansas City, MO 64108, USA;
- Pediatrics Department, University of Kansas, Wichita, KS 67208, USA
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11
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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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12
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Ree IMC, de Haas M, Middelburg RA, Zwiers C, Oepkes D, van der Bom JG, Lopriore E. Predicting anaemia and transfusion dependency in severe alloimmune haemolytic disease of the fetus and newborn in the first 3 months after birth. Br J Haematol 2019; 186:565-573. [PMID: 31140599 DOI: 10.1111/bjh.15962] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/16/2019] [Indexed: 12/18/2022]
Abstract
Infants with haemolytic disease of the fetus and newborn (HDFN) often require erythrocyte transfusions in the first 3 months of life. We aimed to evaluate the incidence, timing and potential predictors of transfusion-dependent anaemia. An observational cohort of 298 term and near-term infants with severe HDFN treated with or without intrauterine transfusion (IUT) was evaluated. Transfusions were administered to 88% (169/193) of infants with IUT and 60% (63/105) without IUT. The following potential predictors were associated with less anaemia: K compared to D immunisation [odds ratio (OR) 0·13, 95% confidence interval (CI): 0·03-0·55], higher reticulocyte count at birth [per 10 parts per thousand (‰) higher, OR 0·99, CI: 0·97-1·00] and exchange transfusion (OR 0·11, 95% CI: 0·03-0·50). Without IUT, these variables were: lower reticulocyte count at birth (per 10‰ lower, OR 1·02, 95% CI: 1·00-1·03), lower maximum bilirubin after birth (per 10 μmol/l lower, OR 1·01, 95% CI: 1·01-1·02) and exchange transfusion (OR 0·07, 95% CI: 0·01-0·20). In conclusion, potential predictors for anaemia in infants with severe HDFN varied between infants treated with and without IUT and are useful for selecting subgroups of infants at increased risk of anaemia.
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Affiliation(s)
- Isabelle M C Ree
- Centre for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands.,Department of Paediatrics, Division of Neonatology, 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 Immunohaematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - Rutger A Middelburg
- Centre for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Carolien Zwiers
- Centre for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands.,Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Johanna G van der Bom
- Centre for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Leiden, the Netherlands
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13
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Mayer B, Hinkson L, Hillebrand W, Henrich W, Salama A. Efficacy of Antenatal Intravenous Immunoglobulin Treatment in Pregnancies at High Risk due to Alloimmunization to Red Blood Cells. Transfus Med Hemother 2018; 45:429-436. [PMID: 30574060 DOI: 10.1159/000490154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/15/2018] [Indexed: 01/14/2023] Open
Abstract
Background Alloimmunization to red blood cells (RBCs) may result in fetal anemia prior to 20 weeks gestation. The question as to whether early commencement of antenatal treatment with high-dose intravenous immunoglobulins (IVIG) may prevent or at least delay the development of fetal anemia in the presence of alloantibodies to RBCs is highly relevant. Patients and Results Here we describe a patient with high-titer anti-K and two other severely affected pregnant women with a history of recurrent pregnancy loss due to high-titer anti-D or anti-D plus anti-C. Early commencement of treatment with IVIG (1 g/kg/week) resulted in prevention of intrauterine transfusion (IUT) in the former two cases, and in a significant delay of development of fetal anemia in the remaining case (26 weeks gestation). Conclusion Based on our findings and of previously published cases, early initiation of treatment of severely alloimmunized women with IVIG (1 g/kg/week) could potentially improve the outcome of fetuses at risk.
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Affiliation(s)
- Beate Mayer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Larry Hinkson
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Wiebke Hillebrand
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Abdulgabar Salama
- Department of Gynecology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
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14
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Zwiers C, van der Bom JG, van Kamp IL, van Geloven N, Lopriore E, Smoleniec J, Devlieger R, Sim PE, Ledingham MA, Tiblad E, Moise KJ, Gloning KP, Kilby MD, Overton TG, Jørgensen DS, Schou KV, Paek B, Walker M, Parry E, Oepkes D, de Haas M. Postponing Early intrauterine Transfusion with Intravenous immunoglobulin Treatment; the PETIT study on severe hemolytic disease of the fetus and newborn. Am J Obstet Gynecol 2018; 219:291.e1-291.e9. [PMID: 29902448 DOI: 10.1016/j.ajog.2018.06.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/18/2018] [Accepted: 06/05/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intrauterine transfusion for severe alloimmunization in pregnancy performed <20 weeks' gestation is associated with a higher fetal death rate. Intravenous immunoglobulins may prevent hemolysis and could therefore be a noninvasive alternative for early transfusions. OBJECTIVE We evaluated whether maternal treatment with intravenous immunoglobulins defers the development of severe fetal anemia and its consequences in a retrospective cohort to which 12 fetal therapy centers contributed. STUDY DESIGN We included consecutive pregnancies of alloimmunized women with a history of severe hemolytic disease and by propensity analysis compared index pregnancies treated with intravenous immunoglobulins (n = 24) with pregnancies managed without intravenous immunoglobulins (n = 28). RESULTS In index pregnancies with intravenous immunoglobulin treatment, fetal anemia developed on average 15 days later compared to previous pregnancies (8% less often <20 weeks' gestation). In pregnancies without intravenous immunoglobulin treatment anemia developed 9 days earlier compared to previous pregnancies (10% more <20 weeks), an adjusted 4-day between-group difference in favor of the immunoglobulin group (95% confidence interval, -10 to +18; P = .564). In the subcohort in which immunoglobulin treatment was started <13 weeks, anemia developed 25 days later and 31% less <20 weeks' gestation (54% compared to 23%) than in the previous pregnancy. Fetal hydrops occurred in 4% of immunoglobulin-treated pregnancies and in 24% of those without intravenous immunoglobulin treatment (odds ratio, 0.03; 95% confidence interval, 0-0.5; P = .011). Exchange transfusions were given to 9% of neonates born from pregnancies with and in 37% without immunoglobulin treatment (odds ratio, 0.1; 95% confidence interval, 0-0.5; P = .009). CONCLUSION Intravenous immunoglobulin treatment in mothers pregnant with a fetus at risk for hemolytic disease seems to have a potential clinically relevant, beneficial effect on the course and severity of the disease. Confirmation in a multicenter randomized trial is needed.
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Affiliation(s)
- Carolien Zwiers
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Center for Clinical Transfusion Research, Sanquin Research, Leiden University Medical Center, Leiden, The Netherlands
| | - Inge L van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Medical Statistics and Bio-informatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - John Smoleniec
- Feto-Maternal Unit, Liverpool Hospital, Liverpool, Australia
| | - Roland Devlieger
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Pauline E Sim
- Ian Donald Fetal Medicine Unit, Queen Elizabeth Hospital, Glasgow, United Kingdom
| | - Marie Anne Ledingham
- Ian Donald Fetal Medicine Unit, Queen Elizabeth Hospital, Glasgow, United Kingdom
| | - Eleonor Tiblad
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Kenneth J Moise
- McGovern Medical School, UT Health; Fetal Center, Children's Memorial Hermann Hospital, Houston, TX
| | | | - Mark D Kilby
- Fetal Medicine Center, Birmingham Women's and Children's Foundation Trust, and Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, Birmingham, United Kingdom
| | | | - Ditte S Jørgensen
- Center of Fetal Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Katrine V Schou
- Center of Fetal Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bettina Paek
- Evergreen Fetal Therapy Program, Evergreen Health Medical Center, Kirkland, WA
| | - Martin Walker
- Evergreen Fetal Therapy Program, Evergreen Health Medical Center, Kirkland, WA
| | - Emma Parry
- Maternal-Fetal Medicine, Auckland District Health Board, Auckland, New Zealand
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Masja de Haas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands; Center for Clinical Transfusion Research, Sanquin Research, Leiden University Medical Center, Leiden, The Netherlands; Immunohematology Diagnostic Services, Sanquin Blood Supply, Amsterdam, The Netherlands
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15
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Mreihil K, Benth JŠ, Stensvold HJ, Nakstad B, Hansen TWR. Phototherapy is commonly used for neonatal jaundice but greater control is needed to avoid toxicity in the most vulnerable infants. Acta Paediatr 2018; 107:611-619. [PMID: 29119603 DOI: 10.1111/apa.14141] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/12/2017] [Accepted: 11/02/2017] [Indexed: 11/30/2022]
Abstract
AIM Limited information is available about how guidelines on phototherapy for neonatal jaundice are applied in practice and toxicity is a concern. We studied the use of phototherapy in relation to birthweight and gestational age (GA) in Norwegian neonatal intensive care units (NICUs). METHODS The study population was all 5382 infants admitted to the 21 NICUs in Norway between September 1, 2013 and August 31, 2014. Data were recorded daily in the Norwegian Neonatal Network database and anonymised data on patient characteristics, diagnoses, duration, the ages at the start and discontinuation of phototherapy were analysed. RESULTS More than a quarter (26.6%) of all infants admitted to Norwegian NICUs during the study period received phototherapy. The use of phototherapy was inversely related to GA and birthweight. More than 80% of the preterm infants under 28 weeks of GA received phototherapy. The duration was significantly longer in the lowest birthweight and GA groups and decreased with increasing birthweight and GA. CONCLUSION Phototherapy is proved to be a strong candidate for the most common therapeutic modality in NICU infants. However, in the light of reported toxicity in the smallest, most vulnerable infants, we recommend increased emphasis on quality control.
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Affiliation(s)
- Khalaf Mreihil
- Department of Pediatric and Adolescent Medicine; Akershus University Hospital; Lørenskog Norway
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
- HØKH, Research Center; Akershus University Hospital; Lørenskog Norway
| | - Hans Jørgen Stensvold
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Britt Nakstad
- Department of Pediatric and Adolescent Medicine; Akershus University Hospital; Lørenskog Norway
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
| | - Thor Willy Ruud Hansen
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
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16
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Zwiers C, Scheffer‐Rath MEA, Lopriore E, de Haas M, Liley HG. Immunoglobulin for alloimmune hemolytic disease in neonates. Cochrane Database Syst Rev 2018; 3:CD003313. [PMID: 29551014 PMCID: PMC6494160 DOI: 10.1002/14651858.cd003313.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Exchange transfusion and phototherapy have traditionally been used to treat jaundice and avoid the associated neurological complications. Because of the risks and burdens of exchange transfusion, intravenous immunoglobulin (IVIg) has been suggested as an alternative therapy for alloimmune hemolytic disease of the newborn (HDN) to reduce the need for exchange transfusion. OBJECTIVES To assess the effect and complications of IVIg in newborn infants with alloimmune HDN on the need for and number of exchange transfusions. SEARCH METHODS We performed electronic searches of CENTRAL, PubMed, Embase (Ovid), Web of Science, CINAHL (EBSCOhost), Academic Search Premier, and the trial registers ClinicalTrials.gov and controlled-trials.com in May 2017. We also searched reference lists of included and excluded trials and relevant reviews for further relevant studies. SELECTION CRITERIA We considered all randomized and quasi-randomized controlled trials of IVIg in the treatment of alloimmune HDN. Trials must have used predefined criteria for the use of IVIg and exchange transfusion therapy to be included. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane and its Neonatal Review Group. We assessed studies for inclusion and two review authors independently assessed quality and extracted data. We discussed any differences of opinion to reach consensus. We contacted investigators for additional or missing information. We calculated risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) for categorical outcomes. We calculated mean difference (MD) for continuous variables. We used GRADE criteria to assess the risk of bias for major outcomes and to summarize the level of evidence. MAIN RESULTS Nine studies with 658 infants fulfilled the inclusion criteria. Term and preterm infants with Rh or ABO (or both) incompatibility were included. The use of exchange transfusion decreased significantly in the immunoglobulin treated group (typical RR 0.35, 95% CI 0.25 to 0.49; typical RD -0.22, 95% CI -0.27 to -0.16; NNTB 5). The mean number of exchange transfusions per infant was also significantly lower in the immunoglobulin treated group (MD -0.34, 95% CI -0.50 to -0.17). However, sensitivity analysis by risk of bias showed that in the only two studies in which the treatment was masked by use of a placebo and outcome assessment was blinded, the results differed; there was no difference in the need for exchange transfusions (RR 0.98, 95% CI 0.48 to 1.98) or number of exchange transfusions (MD -0.04, 95% CI -0.18 to 0.10). Two studies assessed long-term outcomes and found no cases of kernicterus, deafness or cerebral palsy. AUTHORS' CONCLUSIONS Although overall results show a significant reduction in the need for exchange transfusion in infants treated with IVIg, the applicability of the results is limited because of low to very low quality of evidence. Furthermore, the two studies at lowest risk of bias show no benefit of IVIg in reducing the need for and number of exchange transfusions. Based on these results, we have insufficient confidence in the effect estimate for benefit of IVIg to make even a weak recommendation for the use of IVIg for the treatment of alloimmune HDN. Further studies are needed before the use of IVIg for the treatment of alloimmune HDN can be recommended, and should include blinding of the intervention by use of a placebo as well as sufficient sample size to assess the potential for serious adverse effects.
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Affiliation(s)
- Carolien Zwiers
- Leiden University Medical CenterDepartment of ObstetricsLeidenNetherlands
| | - Mirjam EA Scheffer‐Rath
- Leiden University Medical CenterDepartment of Pediatrics, Division of NeonatologyJ6‐S, PO box 9600LeidenNetherlands2300
| | - Enrico Lopriore
- Leiden University Medical CenterDepartment of Pediatrics, Division of NeonatologyJ6‐S, PO box 9600LeidenNetherlands2300
| | - Masja de Haas
- Leiden University Medical CenterImmunohematology and Blood TransfusionLeidenNetherlands
- Sanquin Diagnostic ServicesImmunohematology DiagnosticsAmsterdamNetherlands
| | - Helen G Liley
- Mater Mothers' Hospital, Mater Research, The University of QueenslandSouth BrisbaneAustralia
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17
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Ree IMC, Smits-Wintjens VEHJ, van der Bom JG, van Klink JMM, Oepkes D, Lopriore E. Neonatal management and outcome in alloimmune hemolytic disease. Expert Rev Hematol 2017; 10:607-616. [DOI: 10.1080/17474086.2017.1331124] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Isabelle M. C. Ree
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
- Sanquin Blood Supply, Clinical Transfusion Research, Leiden, Zuid-Holland, The Netherlands
| | | | - Johanna G. van der Bom
- Sanquin Blood Supply, Clinical Transfusion Research, Leiden, Zuid-Holland, The Netherlands
| | | | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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18
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Villanueva G, de Jong JLO, McNeer JL. Intravenous Immunoglobulin in the Treatment of Hematologic Disorders in Pediatrics. Pediatr Ann 2017; 46:e13-e18. [PMID: 28079913 DOI: 10.3928/19382359-20161213-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intravenous immunoglobulin (IVIG) is pooled immunoglobulin G derived from human blood donors. It was introduced in the early 1980s to treat immunodeficiency disorders. Since then, its use has expanded to other fields such as neurology, rheumatology, and hematology. IVIG has been used to provide passive immunity in qualitative and quantitative immunoglobulin disorders, to neutralize antibodies in immune-mediated diseases, and as an immune modulatory agent. The difficulty of producing IVIG in high quantities, in addition to a growing list of "off-label" indications, has resulted in a worldwide shortage and increase in cost. From a pediatric hematology perspective, IVIG is considered an appropriate therapeutic option in autoimmune cytopenias, sometimes coadministrated with steroids. Its use in other hematologic disorders is questionable, and there is not sufficient evidence to recommend it. This article provides clear information to the general pediatrician about indications for IVIG therapy in children with hematologic disorders. [Pediatr Ann. 2017;46(1):e13-e18.].
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19
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Uwingabiye J, Zahid H, Labrini F, El Khazraji A, Yahyaoui A, Hadef R, Messaoudi N. Severe hemolytic disease of the premature newborn due to RH1 incompatibility: a case report. ACTA ACUST UNITED AC 2016; 89:565-568. [PMID: 27857529 PMCID: PMC5111500 DOI: 10.15386/cjmed-578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 07/01/2016] [Accepted: 09/12/2016] [Indexed: 12/25/2022]
Abstract
We report a case of dramatic outcome of severe hemolytic disease in a newborn due to RH1 incompatibility. A newborn with A RH1 blood group was admitted in the Mohammed V Military Teaching Hospital for the problem of hydrops fetalis associated with RH1 incompatibility. The blood group of his mother, aged 31, was AB RH1-negative and that of his 37 year old father was A RH1. The mother had a history of 4 term deliveries, 3 abortions, and 1 living child. There was no prevention by anti-D immunoglobulin postpartum. The mother’s irregular agglutinin test was positive and the pregnancy was poorly monitored. The laboratory tests of the newborn showed a high total serum bilirubin level (30 mg/L) and macrocytic regenerative anemia (Hemoglobin=4 g/dL, mean corpuscular volume = 183 fL, reticulocytes count =176600/m3). The blood smear showed 1256 erythroblasts per 100 leukocytes, Howell–Jolly bodies and many macrocytes. The direct antiglobulin test was positive. He was transfused with red blood cell concentrates and treated with conventional phototherapy. The evolution was unfavourable; he died three days after the death of his mother. The monitoring of these high-risk pregnancies requires specialized centers and a close collaboration between the gynaecologist and the blood transfusion specialist to strengthen the prevention, as well as clinico-biological monitoring in patients with a history of RH1 fetomaternal alloimunization.
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Affiliation(s)
- Jean Uwingabiye
- Laboratory of Hematology and Immunohematology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Hafid Zahid
- Laboratory of Hematology and Immunohematology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Fayçal Labrini
- Laboratory of Hematology and Immunohematology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Abdelhak El Khazraji
- Laboratory of Hematology and Immunohematology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Anass Yahyaoui
- Laboratory of Hematology and Immunohematology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Rachid Hadef
- Laboratory of Hematology and Immunohematology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Nezha Messaoudi
- Laboratory of Hematology and Immunohematology, Mohammed V Military Teaching Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
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20
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Lieberman L, Spradbrow J, Keir A, Dunn M, Lin Y, Callum J. Use of intravenous immunoglobulin in neonates at a tertiary academic hospital: a retrospective 11-year study. Transfusion 2016; 56:2704-2711. [PMID: 27459953 DOI: 10.1111/trf.13721] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/20/2016] [Accepted: 05/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) is used to treat a variety of diseases in the neonatal intensive care unit (NICU). Although audits have reported on the spectrum of IVIG use in adults, the indications and utilization in neonates has not been investigated. The objectives of this study were to describe the usage pattern of and indications for IVIG in a tertiary care NICU. STUDY DESIGN AND METHODS A retrospective chart review was performed of all neonates who received IVIG in the NICU from January 2003 to December 2013. Data collected included patient demographic features, antenatal maternal details, neonatal laboratory results, treatment details, adverse events, and patient outcome. RESULTS Thirty-seven neonates received IVIG over the 11-year period. Twenty-three (67%) were treated for hemolytic disease of the newborn (HDN); 13 treatments were ABO related, six were anti-D related, and four were for clinically significant antibodies. Fourteen (33%) were treated for non-HDN causes, including eight for septic neonates, two for neonates with necrotizing enterocolitis, two for neonates with a clinically significant antibody but without evidence of hemolysis, and two for neonates with glucose 6-phosphate dehydrogenase deficiency. A complete hemolytic workup was not performed consistently before the receipt of IVIG. CONCLUSIONS This novel assessment of IVIG use in the NICU revealed the spectrum of disease for which IVIG is ordered. This study also found that key diagnostic tests needed to confirm an immune etiology for idiopathic jaundice are not performed routinely before IVIG receipt. Neonatal transfusion-related databases are needed to carry out pragmatic clinical trials to establish better evidence-based guidelines for IVIG therapy in the NICU.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jordan Spradbrow
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre
| | - Amy Keir
- Robinson Research Institute, School of Medicine, University of Adelaide, South Australia, Australia
| | - Michael Dunn
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Yulia Lin
- Department of Clinical Pathology, University Health Network.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Clinical Pathology, University Health Network.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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21
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Waterham M, Bhatia R, Donath S, Molesworth C, Tan K, Stewart M. Phototherapy in transport for neonates with unconjugated hyperbilirubinaemia. J Paediatr Child Health 2016; 52:67-71. [PMID: 26289553 DOI: 10.1111/jpc.12984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2015] [Indexed: 11/29/2022]
Abstract
AIM In Victoria, neonates with severe unconjugated hyperbilirubinaemia at risk of requiring exchange transfusion are retrieved by the Paediatric Infant Perinatal Emergency Retrieval Service and transferred to a Neonatal Intensive Care Unit where an exchange transfusion can be performed if necessary. Transfer may result in prolonged periods without phototherapy in neonates at risk of developing bilirubin encephalopathy. We aimed to describe our experience of the introduction of phototherapy using a portable phototherapy unit during transport. METHODS Neonates with a primary diagnosis of severe unconjugated hyperbilirubinaemia were identified from the Paediatric Infant Perinatal Emergency Retrieval clinical database over an 11-year period. Demographic and clinical data including gestation, age at transport, serum bilirubin levels pre- and post-transport, use of phototherapy during transport (PTDT), likely diagnosis, and use of exchange transfusion were included. RESULTS A total of 147 neonates were included with 104 neonates receiving PTDT and 43 who did not. Neonates who received PTDT were less likely to require exchange transfusion, 19.2% versus 34.9%, odds ratio 0.44 (95% CI 0.2-0.98), P = 0.05. However, after correction for factors appearing to be related to use of exchange transfusion, the odds ratio increased to 0.58 (95% CI 0.21-1.63), P = 0.3. There was a greater reduction in the pre- to post-transport total serum bilirubin levels (μmol/L) for the group receiving PTDT (mean 46.3, SD 64.6) versus no PTDT (mean 26.1, SD 62.5), but this did not reach significance, P = 0.08. CONCLUSIONS Phototherapy during neonatal transport is feasible and safe and may result in a decreased requirement for subsequent exchange transfusion.
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Affiliation(s)
- Michelle Waterham
- Paediatric Infant Perinatal Emergency Retrieval Service, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Risha Bhatia
- Paediatric Infant Perinatal Emergency Retrieval Service, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Donath
- Clinical Epidemiology and Biostatistics Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Charlotte Molesworth
- Clinical Epidemiology and Biostatistics Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kenneth Tan
- Monash Newborn, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Michael Stewart
- Paediatric Infant Perinatal Emergency Retrieval Service, Royal Children's Hospital, Melbourne, Victoria, Australia
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Recommendations for the prevention and treatment of haemolytic disease of the foetus and newborn. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:109-34. [PMID: 25633877 DOI: 10.2450/2014.0119-14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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van Klink JMM, van Veen SJ, Smits-Wintjens VEHJ, Lindenburg ITM, Rijken M, Oepkes D, Lopriore E. Immunoglobulins in Neonates with Rhesus Hemolytic Disease of the Fetus and Newborn: Long-Term Outcome in a Randomized Trial. Fetal Diagn Ther 2015; 39:209-13. [PMID: 26159803 DOI: 10.1159/000434718] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/27/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Prophylactic intravenous immunoglobulin (IVIg) does neither reduce the need for exchange transfusion nor the rates of other adverse neonatal outcomes in neonates with rhesus hemolytic disease of the fetus and newborn (rhesus HDFN) according to our randomized controlled trial analysis. Our objective was to assess the long-term neurodevelopmental outcome in the children included in the trial and treated with either IVIg or placebo. METHODS All families of the children included in the trial were asked to participate in this follow-up study. The long-term neurodevelopmental outcome in children at least 2 years of age was assessed using standardized tests. The primary outcome was the incidence of neurodevelopmental impairment defined as at least one of the following: cerebral palsy, severe cognitive and/or motor developmental delay (with a test score of less than -2 SD), bilateral deafness or blindness. RESULTS Sixty-six of the 80 children (82.5%) who had been recruited to the initial randomized controlled trial participated in the follow-up study. The children were assessed at a median age of 4 years (range 2-7). The median cognitive score was 96 (range 68-118) in the IVIg group and 97 (range 66-118) in the placebo group (p = 0.79). There was no difference in the rate of neurodevelopmental impairment between the IVIg and the placebo group [3% (1/34) vs. 3% (1/32); p = 1.00]. CONCLUSIONS The long-term neurodevelopmental outcome in children treated with IVIg was not different from that in children treated with placebo. Standardized long-term follow-up studies with large enough case series and sufficient power are needed to replicate these findings.
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Affiliation(s)
- Jeanine M M van Klink
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Louis D, Patil S, Saini SS, Kumar P. A Doppler velocimetry evaluation of intestinal blood flow characteristics in neonates receiving intravenous immunoglobulin therapy: a prospective observational study. Indian J Pediatr 2015; 82:553-7. [PMID: 25598445 DOI: 10.1007/s12098-014-1678-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate intestinal blood flow changes after intravenous immunoglobulin (IVIg) infusion among neonates with Rh isoimmunization and alloimmune thrombocytopenia. METHODS This prospective observational study was conducted in level III NICU from July 2011 through August 2012. Thirty three consecutive instances (30 neonates) of IVIg treatment (1 g/kg) were studied. Celiac (CA) and superior mesenteric artery (SMA) doppler evaluations were performed immediately prior (baseline), immediately after and 12 to18 h following IVIg infusion. Peak systolic velocity, end diastolic velocity, time-averaged mean velocity, pulsatility index, resistive index and systolic/diastolic ratio were measured. The doppler indices measured immediately after and 12 to 18 h after IVIg infusion were compared with the baseline values. RESULTS The mean gestation and birth weight of the cohort were 36 ± 2 wk and 2597 ± 563 g respectively. Doppler flow variables measured immediately after and 12 to 18 h after IVIg were comparable to baseline values, in both the arteries. However, systolic/diastolic ratio in SMA immediately post-IVIg was lower than baseline, [median (IQR): 5 (3, 9) vs. 7 (4, 14), respectively; p=0.02]. None of the study infants developed feed intolerance or necrotizing enterocolitis (NEC). CONCLUSIONS There was no significant change in the celiac and SMA blood flows following IVIg therapy in neonates with Rh isoimmunization and alloimmune thrombocytopenia.
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Affiliation(s)
- Deepak Louis
- Newborn Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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de Haas M, Thurik FF, Koelewijn JM, van der Schoot CE. Haemolytic disease of the fetus and newborn. Vox Sang 2015; 109:99-113. [PMID: 25899660 DOI: 10.1111/vox.12265] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 01/11/2015] [Accepted: 02/02/2015] [Indexed: 12/12/2022]
Abstract
Haemolytic Disease of the Fetus and Newborn (HDFN) is caused by maternal alloimmunization against red blood cell antigens. In severe cases, HDFN may lead to fetal anaemia with a risk for fetal death and to severe forms of neonatal hyperbilirubinaemia with a risk for kernicterus. Most severe cases are caused by anti-D, despite the introduction of antental and postnatal anti-D immunoglobulin prophylaxis. In general, red blood cell antibody screening programmes are aimed to detect maternal alloimmunization early in pregnancy to facilitate the identification of high-risk cases to timely start antenatal and postnatal treatment. In this review, an overview of the clinical relevance of red cell alloantibodies in relation to occurrence of HDFN and recent views on prevention, screening and treatment options of HDFN are provided.
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Affiliation(s)
- M de Haas
- Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands.,Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - F F Thurik
- Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - J M Koelewijn
- Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of General Practice, University Medical Centre, Groningen, the Netherlands
| | - C E van der Schoot
- Department of Experimental Immunohaematology, Sanquin Research Amsterdam and Landsteiner laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Bujandric N, Grujic J. Exchange Transfusion for Severe Neonatal Hyperbilirubinemia: 17 Years' Experience from Vojvodina, Serbia. Indian J Hematol Blood Transfus 2015; 32:208-14. [PMID: 27065585 DOI: 10.1007/s12288-015-0534-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 03/24/2015] [Indexed: 11/28/2022] Open
Abstract
This study aimed to evaluate the frequency of the main risk factors for severe neonatal hyperbilirubinemia, to determine the incidence of exchange transfusion (ET) in the Autonomous Province of Vojvodina (the northern part of Serbia) and to describe the experience with ET performed in premature and term infants during the past 17 years. We performed a retrospective data analysis of 398 newborn infants who underwent a double volume ET from 1997 to 2013. During the 17 year study period, a decreasing incidence of ET, expressed per thousand newborns, was observed. A total of 468 double volume ET were performed: 328 (82.4 %) infants had one treatment and 70 (17.6 %) had repeated treatments. A total of 262,830 mLs of blood were transfused, an average of 660 mLs per child. There were 221 male and 177 female infants, with a sex ratio 1.25:1. The frequencies of risk factors for developing hyperbilirubinemia were as follows: (1) 38 % RhD incompatibility; (2) 38 % ABO incompatibility (26 % group A infant of group O mother, 12 % group B infant of group O mother); (3) 7 % low birth weight/preterm birth; (4) 17 % other factors. Risk factors for neurotoxicity were identified in 56.3 % of infants. No deaths or complications were reported arising from the treatment. ABO and Rh incompatibilities were found to be the main risk factors for severe neonatal hyperbilirubinemia in Vojvodina. Exchange transfusion, used as therapy for severe hyperbilirubinemia, trended downwards over the period of this study.
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Affiliation(s)
- Nevenka Bujandric
- The Department of Clinical Transfusion Medicine, Therapeutic Services, Blood and Blood Products Distribution, Blood Transfusion Institute Vojvodina, Hajduk Veljkova 9A, 21000 Novi Sad, Serbia
| | - Jasmina Grujic
- The Department of Clinical Transfusion Medicine, Therapeutic Services, Blood and Blood Products Distribution, Blood Transfusion Institute Vojvodina, Hajduk Veljkova 9A, 21000 Novi Sad, Serbia
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Louis D, More K, Oberoi S, Shah PS. Intravenous immunoglobulin in isoimmune haemolytic disease of newborn: an updated systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2014; 99:F325-31. [PMID: 24514437 DOI: 10.1136/archdischild-2013-304878] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIg) is used in neonates with isoimmune haemolytic disease to prevent exchange transfusion (ET). However, studies supporting IVIg had methodological issues. OBJECTIVE To update the systematic review of efficacy and safety of IVIg in neonates with isoimmune haemolytic disease. METHODS MEDLINE, Embase databases and Cochrane Central Register of Controlled Trials (Cochrane Library) were searched (from inception to May 2013) for randomised or quasi-randomised controlled trials comparing IVIg with placebo/controls in neonates with isoimmune haemolytic disease without any language restriction. Three investigators assessed methodological quality of included trials. Meta-analyses were performed using random effect model and risk ratio (RR)/risk difference (RD) and mean difference with 95% CI calculated. MAIN RESULTS Twelve studies were included, ten trials (n=463) of Rh isoimmunisation and five trials (n=350) of ABO isoimmunisation (three studies had both population). Significant variations in risk of bias precluded an overall meta-analysis of Rh isoimmunisation. Studies with high risk of bias showed that IVIg reduced the rate of ET in Rh isoimmunisation (RR 0.23, 95% CI 0.13 to 0.40), whereas studies with low risk of bias that also used prophylactic phototherapy did not show statistically significant difference (RR 0.82, 95% CI 0.53 to 1.26). For ABO isoimmunisation, only studies with high risk of bias were available and meta-analysis revealed efficacy of IVIg in reducing ET (RR 0.31, 95% CI 0.18 to 0.55). CONCLUSIONS Efficacy of IVIg is not conclusive in Rh haemolytic disease of newborn with studies with low risk of bias indicating no benefit and studies with high risk of bias suggesting benefit. Role of IVIg in ABO disease is not clear as studies that showed a benefit had high risk of bias.
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Improving the management and outcome in haemolytic disease of the foetus and newborn. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:484-6. [PMID: 24120585 DOI: 10.2450/2013.0147-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Smits-Wintjens VEHJ, Rath MEA, van Zwet EW, Oepkes D, Brand A, Walther FJ, Lopriore E. Neonatal morbidity after exchange transfusion for red cell alloimmune hemolytic disease. Neonatology 2013; 103:141-7. [PMID: 23235106 DOI: 10.1159/000343261] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/07/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Exchange transfusion (ET) is a high-risk procedure. The type and rate of complications in neonatal red cell alloimmune hemolytic disease exclusively are not clear. OBJECTIVES Our aim was to study the type and rate of complications associated with ET in a large series of neonates with hemolytic disease of the fetus and newborn (HDFN) due to red cell alloimmunization. METHODS All neonates with HDFN due to red cell alloimmunization admitted to our center between January 2001 and June 2011 were eligible for this study. We recorded the number and rate of complications during admission in the group of neonates treated with ET (ET group) and not treated with ET (no-ET group). Multivariate logistic regression analysis was performed to measure the independent risk of complications of ET treatment. RESULTS A total of 347 infants with red cell alloimmune hemolytic disease were included; 39% (134/347) were treated with at least one ET (ET group), and 61% (213/347) did not require ET (no-ET group). Comparison between the ET group and no-ET group showed that ET treatment was independently associated with proven sepsis [8 vs. 1%, respectively; odds ratio (OR) 8.3, 95% confidence interval (CI) 1.7-40.3; p = 0.009], leukocytopenia (88 vs. 23%, respectively; OR 36.0, 95% CI 17.5-73.8; p < 0.001), severe thrombocytopenia (platelet count <50 × 10(9)/l; 63 vs. 8%, respectively; OR 31.4, 95% CI 14.0-70.4; p < 0.001), hypocalcemia (22 vs. 1%, respectively; OR 27.4, 95% CI 5.9-126.8; p < 0.001) and hypernatremia (8 vs. 0%, respectively; p < 0.001). There were no neonatal deaths in the ET group. CONCLUSION ET in neonates with HDFN is associated with an increased risk of sepsis, leukocytopenia, thrombocytopenia, hypocalcemia and hypernatremia.
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Rath ME, Smits-Wintjens VE, Lindenburg IT, Folman CC, Brand A, van Kamp IL, Oepkes D, Walther FJ, Lopriore E. Postnatal outcome in neonates with severe Rhesus c compared to Rhesus D hemolytic disease. Transfusion 2012; 53:1580-5. [DOI: 10.1111/j.1537-2995.2012.03937.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 08/30/2012] [Accepted: 09/10/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Mirjam E.A. Rath
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Vivianne E.H.J. Smits-Wintjens
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Irene T.M. Lindenburg
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Claudia C. Folman
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Anneke Brand
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Inge L. van Kamp
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Dick Oepkes
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Frans J. Walther
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics; Division of Fetal Medicine, Department of Obstetrics; Sanquin Blood Bank, Southwest Region and Department of Immuno-Hematology and Blood Transfusion; Leiden University Medical Center; Leiden
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An approach to the management of hyperbilirubinemia in the preterm infant less than 35 weeks of gestation. J Perinatol 2012; 32:660-4. [PMID: 22678141 DOI: 10.1038/jp.2012.71] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We provide an approach to the use of phototherapy and exchange transfusion in the management of hyperbilirubinemia in preterm infants of <35 weeks of gestation. Because there are limited data for evidence-based recommendations, these recommendations are, of necessity, consensus-based. The recommended treatment levels are based on operational thresholds for bilirubin levels and represent those levels beyond which it is assumed that treatment will likely do more good than harm. Long-term follow-up of a large population will be needed to evaluate whether or not these recommendations should be modified.
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Beken S, Hirfanoglu I, Turkyilmaz C, Altuntas N, Unal S, Turan O, Onal E, Ergenekon E, Koc E, Atalay Y. Intravenous Immunoglobulin G Treatment in ABO Hemolytic Disease of the Newborn, is it Myth or Real? Indian J Hematol Blood Transfus 2012; 30:12-5. [PMID: 24554813 DOI: 10.1007/s12288-012-0186-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 08/06/2012] [Indexed: 11/30/2022] Open
Abstract
Intravenous Immunoglobulin G (IVIG) therapy has been used as a component of the treatment of hemolytic disease of the newborn. There is still no consensus on its use in ABO hemolytic disease of the newborn routinely. The aim of this study is to determine whether administration of IVIG to newborns with ABO incompatibility is necessary. One hundred and seventeen patients with ABO hemolytic disease and positive Coombs test were enrolled into the study. The subjects were healthy except jaundice. Infants were divided into two groups: Group I (n = 71) received one dose of IVIG (1 g/kg) and LED phototherapy whereas Group II (n = 46) received only LED phototherapy. One patient received erythrocyte transfusion in Group I, no exchange transfusion was performed in both groups. Mean duration of phototherapy was 3.1 ± 1.3 days in Group I and 2.27 ± 0.7 days in Group II (p < 0.05). Mean duration of hospital stay was 5.34 ± 2.2 days in Group I and 3.53 ± 1.3 days in Group II (p < 0.05). Mean duration of phototherapy was 4.0 ± 1.5 days and 2.73 ± 1.1 days in double and single doses of IVIG respectively, and this was statistically significant (p < 0.05). IVIG therapy didn't decrease neither phototherapy nor hospitalization duration in infants with ABO hemolytic disease. Meticulus follow-up of infants with ABO hemolytic disease and LED phototherapy decreases morbidity. IVIG failed to show preventing hemolysis in ABO hemolytic disease.
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Affiliation(s)
- Serdar Beken
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Ibrahim Hirfanoglu
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Canan Turkyilmaz
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Nilgun Altuntas
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Sezin Unal
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Ozden Turan
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Esra Onal
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Ebru Ergenekon
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Esin Koc
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
| | - Yildiz Atalay
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Gazi University, 06500 Besevler, Ankara Turkey
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Corvaglia L, Legnani E, Galletti S, Arcuri S, Aceti A, Faldella G. Intravenous immunoglobulin to treat neonatal alloimmune haemolytic disease. J Matern Fetal Neonatal Med 2012; 25:2782-5. [DOI: 10.3109/14767058.2012.718387] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Santos MC, Sá C, Gomes Jr SC, Camacho LA, Moreira ME. The efficacy of the use of intravenous human immunoglobulin in Brazilian newborns with rhesus hemolytic disease: a randomized double-blind trial. Transfusion 2012; 53:777-82. [DOI: 10.1111/j.1537-2995.2012.03827.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Contopoulos-Ioannidis DG, Seto I, Hamm MP, Thomson D, Hartling L, Ioannidis JPA, Curtis S, Constantin E, Batmanabane G, Klassen T, Williams K. Empirical evaluation of age groups and age-subgroup analyses in pediatric randomized trials and pediatric meta-analyses. Pediatrics 2012; 129 Suppl 3:S161-84. [PMID: 22661763 DOI: 10.1542/peds.2012-0055j] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND An important step toward improvement of the conduct of pediatric clinical research is the standardization of the ages of children to be included in pediatric trials and the optimal age-subgroups to be analyzed. METHODS We set out to evaluate empirically the age ranges of children, and age-subgroup analyses thereof, reported in recent pediatric randomized clinical trials (RCTs) and meta-analyses. First, we screened 24 RCTs published in Pediatrics during the first 6 months of 2011; second, we screened 188 pediatric RCTs published in 2007 in the Cochrane Central Register of Controlled Trials; third, we screened 48 pediatric meta-analyses published in the Cochrane Database of Systematic Reviews in 2011. We extracted information on age ranges and age-subgroups considered and age-subgroup differences reported. RESULTS The age range of children in RCTs published in Pediatrics varied from 0.1 to 17.5 years (median age: 5; interquartile range: 1.8-10.2) and only 25% of those presented age-subgroup analyses. Large variability was also detected for age ranges in 188 RCTs from the Cochrane Central Register of Controlled Trials, and only 28 of those analyzed age-subgroups. Moreover, only 11 of 48 meta-analyses had age-subgroup analyses, and in 6 of those, only different studies were included. Furthermore, most of these observed differences were not beyond chance. CONCLUSIONS We observed large variability in the age ranges and age-subgroups of children included in recent pediatric trials and meta-analyses. Despite the limited available data, some age-subgroup differences were noted. The rationale for the selection of particular age-subgroups deserves further study.
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Affiliation(s)
- Despina G Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California 94305, USA.
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Smits-Wintjens VEHJ, Rath MEA, Lindenburg ITM, Oepkes D, van Zwet EW, Walther FJ, Lopriore E. Cholestasis in neonates with red cell alloimmune hemolytic disease: incidence, risk factors and outcome. Neonatology 2012; 101:306-10. [PMID: 22354012 DOI: 10.1159/000335333] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 11/24/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Etiology of cholestatic liver disease in neonates with hemolytic disease of the newborn (HDN) has been associated with iron overload due to intrauterine red cell transfusions (IUTs). Data on the incidence and severity of cholestasis in neonates with HDN are scarce, and little is known about pathogenesis, risk factors, neonatal management and outcome. OBJECTIVE To evaluate incidence, risk factors, management and outcome of cholestasis in neonates with red cell alloimmune hemolytic disease. METHODS All (near-) term neonates with HDN due to red cell alloimmunization admitted to our center between January 2000 and July 2010 were included in this observational study. Liver function tests (including conjugated bilirubin) were routinely performed in the neonatal period. We recorded the presence of cholestasis, investigated several potential risk factors and evaluated the management and outcome in affected neonates. RESULTS A total of 313 infants with red cell alloimmune hemolytic disease treated with or without IUTs were included. The incidence of cholestasis was 13% (41/313). Two risk factors were independently associated with cholestasis: treatment with at least one IUT (OR 5.81, 95% CI 1.70-19.80, p = 0.005) and rhesus D type of alloimmunization (OR 4.66, 95% CI 1.05-20.57, p = 0.042). Additional diagnostic tests to investigate possible causes of cholestasis were all negative. In 5 infants (12%), supportive medical and nutritional therapy was started, and one neonate required iron chelation therapy. CONCLUSION Cholestasis occurs in 13% of neonates with HDN due to red cell alloimmunization, and it is independently associated with IUT treatment and rhesus D type of alloimmunization.
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Rath MEA, Smits-Wintjens VEHJ, Oepkes D, van Zwet EW, van Kamp IL, Brand A, Walther FJ, Lopriore E. Thrombocytopenia at birth in neonates with red cell alloimmune haemolytic disease. Vox Sang 2011; 102:228-33. [DOI: 10.1111/j.1423-0410.2011.01539.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hematological morbidity and management in neonates with hemolytic disease due to red cell alloimmunization. Early Hum Dev 2011; 87:583-8. [PMID: 21798676 DOI: 10.1016/j.earlhumdev.2011.07.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/05/2011] [Indexed: 11/21/2022]
Abstract
Treatment of severe anemia with intrauterine red cell transfusions in fetuses with red cell alloimmunization has led to a dramatic increase in perinatal survival. Due to this increased survival focus is nowadays shifting towards improving postnatal treatment options. Phototherapy, exchange transfusions and intravenous immunoglobulin are used to treat hyperbilirubinemia and prevent kernicterus. Postnatal treatment of anemia consists of top-up transfusions, supplements to support erythropoiesis such as folic acid and iron, and occasionally erythropoietin treatment. In addition to anemia, other hematological complications such as thrombocytopenia, coagulation disturbances, leucopenia and iron overload have been reported. This review focuses on the hematological morbidity in neonates with red cell alloimmunization and summarizes the current evidence on management options.
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