Specific causes of Jaundice

Question 1

Specific causes of jaundice

Answer 1

1 Antibody-mediated haemolysis: ABO and Rh disease
2 Breastfeeding jaundice
3 Infection
4 Prolonged jaundice
5 Late onset jaundice

Question 2

What is antibody-mediated haemolysis in newborns?

Answer 2

Antibody-mediated haemolysis in newborns refers to the destruction of red blood cells (haemolysis) caused by antibodies produced by the mother’s immune system that recognize and attack the baby’s blood cells.

Question 3

What are the most common causes of haemolytic disease of the newborn?

Answer 3

Haemolytic disease of the newborn most commonly arises from incompatibilities between the mother and fetus in either the Rhesus (Rh) or ABO blood groups.

Question 4

What are some less common causes of haemolytic disease of the newborn related to blood group incompatibility?

Answer 4

Less commonly, other blood group incompatibilities may lead to haemolytic disease of the newborn, including Kell, Duffy, and Kidd blood group systems.

Question 5

How does haemolytic disease of the newborn occur in Rh or ABO blood group incompatibility?

Answer 5

In Rh or ABO blood group incompatibility, maternal antibodies cross the placenta and attack the baby’s red blood cells, leading to haemolysis and subsequent jaundice or other complications in the newborn.

Question 6

Why is it important to identify and manage haemolytic disease of the newborn promptly?

Answer 6

Prompt identification and management of haemolytic disease of the newborn are crucial to prevent complications such as severe jaundice, anaemia, and kernicterus, which can lead to long-term neurological damage or even death

Question 7

What is haemolytic disease due to ABO incompatibility in newborns?

Answer 7

Haemolytic disease due to ABO incompatibility occurs when a mother with blood group O produces antibodies (usually IgG) against the A or B antigens present on the red blood cells of her infant who has blood group A or B. These antibodies can cross the placenta and lead to the destruction of fetal red blood cells.

Question 8

Why has haemolytic disease due to ABO incompatibility become the most common cause of haemolytic disease in newborns?

Answer 8

Haemolytic disease due to ABO incompatibility has become the most common cause of haemolytic disease in newborns because of the widespread use of Rh(D) immune globulin (RhoGAM) to prevent Rh haemolytic disease, which has reduced the incidence of Rh incompatibility.

Question 9

What are the characteristics of mothers and infants typically involved in ABO incompatibility?

Answer 9

In ABO incompatibility, the mother is typically blood group O, while the infant is blood group A or B. All group O mothers produce antibodies against both A and B antigens, which can lead to haemolytic disease in their infants.

Question 10

How do the antibodies produced by group O mothers cause haemolysis in A or B blood group infants?

Answer 10

The antibodies produced by group O mothers against A or B antigens can cross the placenta and destroy the red blood cells of their infant if they are blood group A or B, leading to haemolytic disease.

Question 11

What distinguishes haemolytic disease due to ABO incompatibility from Rh disease?

Answer 11

Unlike Rh disease, haemolytic disease due to ABO incompatibility is typically milder and rarely causes severe complications such as hydrops fetalis (in utero haemolysis, anaemia, and cardiac failure).

Question 12

How does ABO jaundice typically present in newborns?

Answer 12

ABO jaundice usually presents with early onset jaundice within the first 24 hours after birth.

Question 13

What are some laboratory findings associated with ABO jaundice?

Answer 13

Laboratory findings in ABO jaundice may include low-normal levels of hemoglobin, a positive direct Coombs test in about 30% of cases, an elevated reticulocyte count, and the presence of spherocytes on a peripheral blood smear.

Question 14

What is the typical total serum bilirubin (TSB) level at 6 hours in infants with ABO jaundice?

Answer 14

In infants with ABO jaundice, the TSB at 6 hours is usually above 80 µmol/l.

Question 15

How is ABO jaundice managed in most cases?

Answer 15

In most cases of ABO jaundice, phototherapy is sufficient to prevent bilirubin levels from rising to dangerous levels. Intravenous gamma globulin may also be useful in delaying haemolysis.

Question 16

What is the recommended approach for monitoring jaundice in infants born to mothers with blood group O?

Answer 16

If the mother’s blood group is known to be group O, infants should have their TSB measured at 6 hours after delivery or before discharge from the birth unit.

Question 17

What is the recommended approach for monitoring jaundice in infants born to mothers with an unknown blood group?

Answer 17

If the mother’s blood group is not known, infants should undergo a clinical examination 6-12 hours after delivery. If clinically jaundiced, bilirubin levels should then be measured.

Question 18

What is haemolytic disease due to Rh incompatibility in newborns?

Answer 18

Haemolytic disease due to Rh incompatibility occurs when an Rh-negative mother (D negative) produces antibodies against Rh-positive (D positive) red blood cells of her Rh-positive fetus. These antibodies can cross the placenta and attack the fetus’s red blood cells, leading to haemolysis and subsequent jaundice or other complications in the newborn.

Question 19

How does sensitization to the Rh antigen occur in Rh haemolytic disease?

Answer 19

Sensitization to the Rh antigen occurs when an Rh-negative mother is exposed to Rh-positive red blood cells, either during pregnancy or through a previous incompatible transfusion. This exposure triggers the production of anti-Rh antibodies (anti-D).

Question 20

Why is haemolytic disease due to Rh incompatibility more common in subsequent pregnancies rather than the first pregnancy?

Answer 20

Haemolytic disease due to Rh incompatibility typically occurs in subsequent pregnancies because sensitization to the Rh antigen occurs during the first pregnancy when fetal Rh-positive red blood cells may cross the placenta and trigger the production of anti-Rh antibodies in the mother. These antibodies can then cause haemolytic disease in subsequent Rh-positive pregnancies.

Question 21

What are some other Rhesus blood groups that may cause haemolytic disease, and how do they differ from Rh incompatibility?

Answer 21

Other Rhesus blood groups, such as C, c, E, and e, may also cause haemolytic disease, but they generally result in less severe manifestations compared to Rh incompatibility.

Question 22

How can haemolytic disease due to Rh incompatibility be prevented?

Answer 22

Haemolytic disease due to Rh incompatibility can be prevented by administering Rh immunoglobulin (RhIG) to Rh-negative mothers during and after pregnancy to prevent sensitization to the Rh antigen. This prevents the production of anti-Rh antibodies and reduces the risk of haemolytic disease in subsequent pregnancies.

Question 23

Group D incompatibility may present as:

Answer 23

1. Hydrops fetalis: severe anaemia causing heart failure; fetus is usually stillborn
   with gross oedema, ascites and anaemia.
2. Early onset jaundice: due to progressive haemolytic anaemia.
3. Gradual onset of mild jaundice with severe anaemia during the first few weeks
   after birth; may develop cardiac failure.

Question 24

What is the recommended screening protocol for blood group during antenatal care?

Answer 24

Blood group should be screened at the initial booking appointment during antenatal care.

Question 25

What additional testing is recommended for Rh-negative mothers during antenatal care?

Answer 25

Rh-negative mothers should be tested for anti-D antibodies at booking and periodically throughout pregnancy.

Question 26

What should be done if anti-D antibodies are detected in an Rh-negative mother during pregnancy?

Answer 26

If anti-D antibodies are present in an Rh-negative mother during pregnancy, referral to a tertiary hospital is recommended for further evaluation and management.

Question 27

How is fetal anaemia assessed during pregnancy?

Answer 27

Fetal anaemia is assessed through ultrasonography during pregnancy.

Question 28

What interventions may be necessary if fetal anaemia is detected during pregnancy?

Answer 28

If fetal anaemia is detected, interventions such as intrauterine blood transfusion or early induction of labor may be required to manage the condition and prevent complications.

Question 29

What are the clinical features of haemolytic disease in the newborn during postnatal management?

Answer 29

Clinical features may include a pale large placenta, anaemia, jaundice, an enlarged liver and spleen, oedema and ascites, and a “blueberry muffin rash” due to extramedullary erythropoiesis in the skin.

Question 30

How should respiratory distress be managed in newborns with haemolytic disease?

Answer 30

If respiratory distress is present, assist ventilation if required and correct hypoxia.

Question 31

What metabolic imbalances should be corrected during postnatal management of haemolytic disease?

Answer 31

Correct any metabolic imbalances such as acidosis, hypoglycaemia, and hypothermia.

Question 32

What laboratory tests are important during postnatal management of haemolytic disease?

Answer 32

Check the newborn’s blood group, perform a direct Coombs test, and measure serum bilirubin and haemoglobin levels.

Question 33

What is the immediate treatment for jaundice in newborns with haemolytic disease?

Answer 33

Start phototherapy immediately while waiting for blood test results and check total serum bilirubin (TSB) levels every 2–4 hours.

Question 34

How may intravenous immunoglobulin (IVIG) be utilized in the management of haemolytic disease in newborns?

Answer 34

Intravenous immunoglobulin (IVIG) may be administered to slow down the process of haemolysis in newborns with haemolytic disease.

Question 35

When may exchange transfusion be required in the management of haemolytic disease in newborns?

Answer 35

Exchange transfusion may be required to remove bilirubin and prevent bilirubin encephalopathy, correct anaemia, and remove anti-D antibodies. Indications include raised cord bilirubin, severe anaemia, hydrops fetalis, and rapidly rising bilirubin despite phototherapy.

Question 36

What is the purpose of a straight blood transfusion in newborns with haemolytic disease?

Answer 36

A straight blood transfusion may be performed to manage late anaemia that occurs in the weeks following an exchange transfusion or in Coombs-positive infants who did not require exchange transfusions.

Question 37

How should haemoglobin levels be monitored in newborns with haemolytic disease?

Answer 37

Monitor serial haemoglobin levels over time and reticulocyte counts. Transfuse if symptomatic or if haemoglobin is less than 6g/dL.

Question 38

What are the key considerations in the post-exchange transfusion management of newborns with haemolytic disease?

Answer 38

Monitor the newborn’s haemoglobin levels and reticulocyte counts regularly. Consider transfusion if symptomatic or if the haemoglobin drops below 6g/dL

Question 39

How should healthcare providers determine the need for exchange transfusion in newborns with haemolytic disease?

Answer 39

The need for exchange transfusion should be determined based on specific indications such as raised cord bilirubin, severe anaemia, hydrops fetalis, and rapidly rising bilirubin levels despite phototherapy, as outlined in the exchange transfusion chart.

Question 40

How can Rh disease be prevented in Rhesus-negative women during pregnancy and childbirth?

Answer 40

: Rhesus-negative women should receive anti-D immunoglobulin by intramuscular injection within 72 hours of delivery. This should also be administered after other potential times of feto-maternal blood mixing, such as miscarriage, amniocentesis, antepartum hemorrhage, or external cephalic version

Question 41

What is the purpose of administering anti-D immunoglobulin to Rhesus-negative women?

Answer 41

Administering anti-D immunoglobulin to Rhesus-negative women helps prevent iso-immunization, where the mother’s immune system produces antibodies against the Rh-positive blood cells of her Rh-positive fetus. This prevents the development of Rh disease in subsequent pregnancies.

Question 42

When should Rhesus-negative women receive anti-D immunoglobulin?

Answer 42

Rhesus-negative women should receive anti-D immunoglobulin within 72 hours of delivery. Additionally, it should be administered after other potential events that could lead to feto-maternal blood mixing, such as miscarriage, amniocentesis, antepartum hemorrhage, or external cephalic version.

Question 43

How effective is anti-D immunoglobulin in preventing iso-immunization and Rh disease?

Answer 43

Anti-D immunoglobulin is very effective at preventing iso-immunization and Rh disease. Due to the widespread use of this preventative measure, Rh disease has become uncommon in pregnancies where Rh-negative women receive timely administration of anti-D immunoglobulin.

Question 44

How common is infection as a cause of jaundice in otherwise healthy infants?

Answer 44

Infection is an uncommon cause of jaundice in otherwise well infants.

Question 45

How can bacterial infection lead to jaundice in infants?

Answer 45

Bacterial infection can cause jaundice by inducing haemolysis, impairing hepatic conjugation of bilirubin, or obstructing bile flow, leading to an increase in both conjugated and unconjugated bilirubin levels.

Question 46

What are the clinical manifestations that may raise suspicion of occult infection in infants with jaundice?

Answer 46

Unexplained jaundice, especially if associated with reluctance to feed, drowsiness, or vomiting, should raise suspicion of occult infection, often involving the urinary tract.

Question 47

How should healthcare providers approach the evaluation of jaundice in infants suspected of having an infection?

Answer 47

Healthcare providers should conduct a thorough assessment of the infant, including a detailed history, physical examination, and appropriate laboratory investigations to identify the underlying cause of jaundice, particularly if infection is suspected. This may include blood tests, urine analysis, and imaging studies as needed.

Question 48

Why is prompt recognition and management of infection-related jaundice important in infants?

Answer 48

Prompt recognition and management of infection-related jaundice are important to prevent complications and initiate appropriate treatment, as infections can lead to serious consequences if left untreated.

Question 49

What are the typical characteristics of breastfeeding jaundice in infants?

Answer 49

Breastfeeding jaundice often occurs in infants of young mothers who struggle with latching or feeding. The infants may appear small, irritable, dehydrated, and deeply jaundiced. In severe cases, they may also present with hypernatremia.

Question 50

How does inadequate breastfeeding contribute to the development of breastfeeding jaundice?

Answer 50

Inadequate breastfeeding leads to insufficient milk intake, resulting in dehydration and reduced excretion of bilirubin. This can cause elevated bilirubin levels, leading to jaundice.

Question 51

What are the clinical signs of dehydration in infants with breastfeeding jaundice?

Answer 51

Clinical signs of dehydration may include sunken fontanelles, decreased urine output, dry mouth, lethargy, and poor skin turgor.

Question 52

How can healthcare providers manage breastfeeding jaundice in infants?

Answer 52

Healthcare providers can focus on rehydration and establishing adequate feeds. They may provide support to the mother in improving breastfeeding techniques, ensure sufficient milk supply, and closely monitor the infant’s hydration status and bilirubin levels.

Question 53

What is the prognosis for infants with breastfeeding jaundice with appropriate management?

Answer 53

With timely intervention, including rehydration and establishment of adequate feeding, infants with breastfeeding jaundice typically respond well and recover without long-term complications. However, close monitoring and follow-up are essential to ensure the infant’s well-being.

Question 54

Jaundice persisting more than 14 days (term) and 21 days (preterm).

Answer 54

a) Breast milk jaundice: A common cause of jaundice in well breastfed infants. The
jaundice is due to increased enterohepatic circulation of bilirubin. The infant
is usually thriving. No treatment is necessary as it rarely gives high levels of
bilirubin.
b) Hypothyroidism: Rare but treatable. Routine screening of TSH in the cord blood at
delivery makes early diagnosis possible.
c) Infection (UTI or other systemic infection) – common cause of prolonged jaundice.

Question 55

Jaundice starting after day 14 of life

Answer 55

a) Obstruction to bile flow: intrahepatic (hepatitis); extrahepatic (biliary atresia,
choledochal cyst). Conjugated jaundice suggests bile duct obstruction: needs
urgent ultrasound, as surgical intervention must happen before hepatic
injury occurs.
b) Galactosaemia: Rare. Associated vomiting, poor feeding, failure to thrive with
prolonged jaundice. Check for reducing substances in the urine.