(P) Hemolytic Disease of the newborn part 1 Flashcards
Most important red cell antigen after A and B antigens in blood banking
D antigen
What is the other name for the hemolytic disease of the newborn
erythroblastosis fetalis
It is termed as erythroblastosis fetalis due to the
presence of ______
erythrolasts
T or F
A person with Rh negative blood can develop Rh antigens if he / she receives blood from a person with Rh positive blood
F (develop Rh ANTIBODIES)
T or F
A person with Rh positive blood can receive blood from a person with Rh negative blood without any problems
T
A condition in which the fetus or neonate’s red blood cell
are destroyed by IgG antibodies produced by the
mother.
HEMOLYTIC DISEASE OF THE NEWBORN
Definition of terms
breaking down of RBC
hemolytic
Definition of terms
The making of immature red blood cells resulting to the preence of erythroblasts in the blood
erythroblastosis
Definition of terms
refers to the fetus
fetalis
True for the causes of HDFN except:
a. Rh incompatibility
b. ABO
c. other system antibodies incompatibility
d. Rh positive mother, Rh negative baby
e. none of the above
d
A. Rh-HDN
B. ABO-HDN
- rare, declining, severe, clinically significant
- more common, mild, subclinical
- A
- B
other causes of HDN except
a. Anti-c (hr’)
b. Anti-E (rh’’)
c. IgM
d. Anti-Lea, Anti-Leb
e. Anti-P1, Anti-M, and Anti-N
c
familiarize the factors of HDN
- pregnancy
- factors affecting immunization
- immune response
- antigenic exposure
Factors of HDN
required for HDN to occur, as it is vital for antigenic exposure leading to HDN
Pregnancy
types of immune response
a. Non-responders
b. hyper-responders
- increases the titer of Anti-D or IgM
- Indifferent to antigenic stimulation
- B
- A
In hyper-responders, what is the product of the increase in titer of anti-D?
multiple antibody formation
Rh negative individual exposed to one unit of Rh-positive blood are ______% immunized
50%
Rh negative women with Rh positive fetus are ___%
immunized
10
____mL is needed in immunization to stimulate a response and create
antibodies in the process of stimulation
0.5mL
- Occurs when the volume of fetal red cells is insufficient.
- This occurs in primary immunization, and within the
secondary immunization is the rapid production of
antibody.
ANAMNESTIC RESPONSE
which pregnancy is of higher risk for Rh-HDN?
a. first
b. second
c. third
d. fourth
b
Rh incompatibility greatly affects a person’s quality of life and give rise to problems during pregnancy
a. first statement is true, second is false
b. second statement is true, first is false
c. both statements are true
d. neither statements are true
b
a. first pregnancy
b. second pregnancy
- antibodies are produced due
to the exposure of the maternal blood to the neonate’s blood - In the ___________ antibodies produced from
the x pregnancy attacks the fetus with Rh positive
blood - It is still considered safe but the mother who is RhD-
- a
- b
- a
what are the symptoms in mild cases of HDN
mild anemia and jaundice
what are the presenations in severe HDN
*death
* increased bilirubin
* CNS damage (kernictus)
DIK / DIC
Explain the progression of Rh factor sensitization
- Rh- Mother’s and Rh+ Baby’s blood mix
- Mother forms antibodies agains Rh positive antigens
- Mother’s antibodies enter baby’s blood and attack
familiarize the effects of red cell distribution
a. anemia
b. marked erythrophagocytosis
c. organ enlargement
d. hyperbilirubinemia
e. hydrops fetalis
what type of anemia is in HDN
Hemolytic anemia
- Due to the immature liver of the newborn and inability to
conjugate the unconjugated _________ result in the
unconjugated __________increasing and crossing the blood
brain barrier causing _______________.
- bilirubin
- bilirubin
- kernictus / CNS damage
matching type
a. 18 mg/dL
b. 20 mg/dL
c. >30 mg/dL
- Already considered increased
- Kernicterus, death
- Mental Retardation
- a
- c
- b
_________ results from high
levels of unconjugated bilirubin in the fetus blood which is
more than 20 mg/dL
kernictus / bilirubin encelopathy
Because unconjugated bilirubin are lipid soluble and toxic, it
can cross the blood brain barrier and it will penetrate
__________ and ________________causing neurotoxicity
neuronal and glial membranes
familiarize the severe permanent neurologic symptoms secondary to kernicterus
*choreoathetosis
* spaticity
* muscular rigidity
* ataxia
* deafness
* mental retardation
hydrops fetalis
these are the organs that increase in size due to the increased production of red cells as the fetus’s anemia worsen
liver and spleen
is an abnormal accumulation of fluid beneath the
skin. This condition in the detus is known as hydrops fetalis
edema
process of the removal of
amniotic fluid which is
used in bilirubin testing
amniocentesis
who performs amniocentesis?
a. RMT
b. RN
c. MD
d. all of the above
c
aminotic fluid is measured using??
spectrophotometry
for infants with HDN amniocentesis is done during the _______ week of gestation
28th week
for infants with severe HDN amniocentesis is done during the _______ week of gestation
22nd week
enumerate the tests for neonatal studies
- ABO typing
- Rh typing
- Direct antiglobulin test
Direct coombs test
employed using
anti-human globulin
Direct coombs test
reagent:
coomb’s reagent
Direct coombs test
detect:
antibody that coats the RBC in vivo, producing agglutniation
The baby’s sample is positive for the presence of
the mother’s antibody on the surface of RBCs in condition called
erythroblastosis fetalis
What is the best blood that can be given if this is blood
transfusion?
Rh -, ABO type specific
Maternal _____ antibodies with specificity for the ABO blood
group system pass through the placenta to the fetal
circulation where they can cause hemolysis of fetal red
blood cells which can lead to fetal anemia and HDN
IgG
ABO HDN occurs commonly in the
a. first born
b. second born
c. equally in all offsprings
a
which is more common in ABO HDN
a. symptomatic
b. asymptomatic
symptomatic
ABO HDN commonly occurs in mothers that are of what blood type?
a. A
b. B
c. O
c
familiarize the complications of ABO HDN
- High at birth or rapidly rising bilirubin
- Prolonged hyperbilirubinemia
- Bilirubin induced Neurological Dysfunction
- Cerebral Palsy
- Kernicterus
- Neutropenia
- Thrombocytopenia
- Hemolytic Anemia: MUST NOT be treated with iron
- Late onset anemia: MUST NOT be treated with iron. This can
persist up to 12 weeks after birth.
Causes of ABO HDN (3)
- exposure
- fetal-maternal transfusion
- blood transfusion
What type of antibody are anti-a and anti-b usually?
IgM
what type of antibody are anti-a and anti-b that can cross the placenta?
IgG
Exposure to A-antigens and B-antigens, which are both
widespread in nature, usually leads to the production of
(IgM/IgG) anti-A and IgM anti-B antibodies but occasionally IgG
antibodies are produced
IgM
- In about a third of all ABO incompatible pregnancies
maternal IgG anti-A or IgG anti-B antibodies pass through the
placenta to the fetal circulation leading to a _______
direct Coombs test for the neonate’s blood
weakly positive
ABO HDN is generally mild and short-lived and only
occasionally severe because
- IgG anti-A and anti-B enter fetal circulation
- fetal RBC surface A and B antigens are not fully developed
ABO serology
If mother has IgM, she is treated with ___ and ___, neutralizing A and B substances
2-mercaptoethanol and dithiothreidol
T or F
Routine antenatal antibody screening blood tests or indirect
Coombs test does notscreen for ABO HDN
T
T or F
If IgM anti-A or IgM anti-B antibodies are found in the
pregnant woman’s blood, they are not reported with the
test results, because they do not correlate well with ABO
HDN
F (IgG)
HDN diagnosis is usually made by investigation of a newborn
baby who has developed jaundice during the ________of
life.
first week
ABO SEROLOGY
test is run using cord blood
a. Direct Coombs
b. Hemoglobin
c. both
d. neither
c (+ bilirubin also)
ABO SEROLOGY
Tested in vitro
a. Direct Coombs
b. Indirect Coombs
c. both
d. neither
b
Why is Direct Coombs test done after the birth of the baby?
to confirm the antibodies attached to the infant’s RBC
high reticulocyte count:
a. infant needs transfusions
b. infant does not need additional transfusion
b
low reticulocyte count
a. HDN from anti-kell
b. ABO-HDN
A (and in infants that have been treated with intrauterine transfusion)
why is ferritin checked in infants?
most infants with HN are have iron overload syndrome
What type of cells is predominant in Rh?
macrocytes
CONSEQUENCES OF HDN
Jaundice in ABO: ___
Jaundice in Rh : ____
o Jaundice in ABO: Icterus praecox
o Jaundice in Rh: Icterus gravis
T or F
hydrops fetalis and kernicterus are common in ABO HDN
F (uncommon)
INDICATIONS OF HDN
bilirubin at birth: ___ mg/dl
Cord bilirubin: ____ mg/dl
- Bilirubin at birth: 5 mg/dL
- Cord Bilirubin is more than 4
INDICATIONS OF HDN
- 12 hours: ____mg/dL
- 24 hours: ____mg/dL
- Hgb: ___g/dl
- 12 hours: 11.5mg/dL
- 24 hours: 16 mg/dL
- Hgb: 8 g/dL
Intrauterine Fetal Blood Transfusion for Rh Disease:
___________ is done to determine the position of the fetus
and placenta
fetoscopy
The risk of Intrauterine Blood Transfusion (IUT) depends on (2)
prior condition of fetus and gestational age
What are the three conditions that signals the need for the analysis of amniotic fluid
- titer >32 for anti-D
- titer > 8 for anti-kell
- fourfold increase of the titer
INDICATIONS FOR AMNIOCENTESIS
To perform amniocentesis at ___ weeks of gestation in the
previous child
26
INDICATIONS FOR AMNIOCENTESIS
To perform amniocentesis at __ weeks of gestation if the
previous child is severely affected
22
INDICATIONS FOR AMNIOCENTESIS
Perform if the maternal antibody of the mother increases
before the __ week. The mother’s antibody is being
monitored.
34th
INDICATIONS FOR AMNIOCENTESIS
High values of bilirubin shown by ____ method or
hemoglobin concentration of cord blood below ____
Liley method
10
LILEY’S GRAPH
a. bottom zone
b. middle zone
c. upper zone
- minimally affected
- affected or very mildly affected
- moderate to marked hemolysis in the fetus
- b
- a
- c
BLOOD TO BE USED
1. if anti-D is present
2. if anti-D is absent
3. for intrauterine transfusion
- Rh positive
- Rh negative
- O negative
at what bilirubin levels is phototherapy not effective?
0.5 to 2 mg/dL
familiarize the treatments available
- intravenous immunoglobulin therapy
- exchange transfusion
- plasma exchange
- intravenous immune globulin
TREATMENT
- used to successfully treat many cases of HDN
- used on anti-D and anti-E
- reduces the need for exchange transfusion and shortens length of phototherapy
- recommended for treatment in isoimmune hemolytic disease by the American Association of Pathologist
- reduce the need
for exchange transfusions in Rh and ABO hemolytic
disease.
Intravenous Immunoglobulin therapy (IVIG)
IVIG is recommended for what total serum bilirubin levels?
TSB level is within 2
to 3 mg/dL (34-51 μmol/L) of the exchange level
Can IVIG be repeated within 12 hours (yes / no)
yes if necessary
T or F
infants always needs both exchange transfusion and phototherapy
F ( rarely needs exchange transfusion)
At what total bilirubin level is exchange transfusion done?
as high as 20 mg/dL and continues to rise
what blood type is used for exchange transfusion
fresh, O negative
packed RBCs and type specific fresh frozen plasma
T or F
the O negative packed RBCs for exchange transfusion is crossmatched against the baby
F (against the mother)
TREATMENT
*widely used treatment of immune-mediated disease
*applied to the pregnant women with high
antibody titer, or that has past history of stillbirth due to HDN
- effective in decreasing the antibody titer
and quantity of antibody. - a way to delay the need for fetal intervention
that has been hydrops fetalis (edema) in which before 22
week gestation in a previous pregnancy.
Plasma exchange
TREATMENT
plasma exchange can reduce the antibody titer up to how many percent?
75%
TREATMENT
- use strengthened body immune system beside
to treat immune deficiency - found to decrease
hemolysis leading to reduction in serum bilirubin level. - The immunoglobulin could act by occupying the FC receptors
of reticulo-endothelial cells preventing them from taking up
and lysing antibody coated RBCs. This subsequently leads
to decrease in the need for exchange transfusion.
Intravenous Immune Globulin
What is the prevention done against HDFN?
Rh immune globulin (RhIG or Rhogam)
PREVENTION
Antenatal (during pregnancy): The first injection of RHIG
is recommended to be administered during the ________ week of pregnancy.
28th week of
pregnancy
PREVENTION
Postnatal (after birth): Another injection is advised within
____hours after delivery. The injection contains 1 vial, and
each vial is composed of 300 μg/15 mL of Rh-positive fetal
red blood cells (RBCs).
72 HOURS
PREVENTION
What is prevented by the administration of Rh immune globulin in pregnant women
alloimmunization
RhIG is a concentrate of __________ prepared from pooled
human plasma of D-negative people who have been
exposed to the D antigen and who have made antibodies
to it.
IgG anti-D
SIGNIFICANCE OF RhIG
- RhIG prevents alloimmunization in D-negative mother
exposed to D-positive fetal red cells. In the meantime, it
protects mother from being __________ to D antigen of fetal
during pregnancy and after delivery of infant.
sensitized
SIGNIFICANCE OF ADMINISTRATION OF RhIG
The following are true except:
a. RhIG suppress the mother’s immune response following exposure to D-positive fetal red cells
b. RhIG encourages the mother to produce anti-D
c. RhIG protects subsequent D-positive pregnancies.
d. none of the above
b
USE OF RhIG
RhIG is administered to (Rh-negative / Rh-positive) patients who
have received Rh-positive (Rh+) cells, such as Whole
Blood Concentrate or Platelet Concentrate
Rh-negative
In Hemolytic Disease of the Newborn (HDN), RhIG is administered except for when:
a. Mother is Rh (-) and Du (-)
b. Mother is not immunized yet to D antigen
c. infant is Rh (-) Du (-)
d. in abortion: the infant is assumed to be Rh+
c
GUIDELINES FOR RhIG ADMINISTRATION IN D-NEGATIVE
PREGNANT WOMAN:
1. All doses should be given within ___ hours of delivery or
procedure. If she is not given RhIG within ___ hours after the
birth of an Rh-positive baby, she will begin to make
antibodies to the fetal blood cells
72
GUIDELINES FOR RhIG ADMINISTRATION IN D-NEGATIVE
PREGNANT WOMAN:
Woman (should / should not) be sensitized to D antigen
should not be
Provide the dose needed:
Up to 12 weeks of gestation for abortion,
miscarriage and end period of ectopic
pregnancy.
50ug
Provide the dose needed
✓ End period of pregnancy which is after 12th
week of gestation.
✓ After amniocentesis.
✓ After delivery of D-positive infant.
120ug
