Extern Conference

Extern ConferenceThursday 27th September 2007

History

A preterm AGA 8 days old male infant with complaint of jaundice

History

PI : the patient was born at 35+6 weeks of gestational age (on 14th sep 07) by spontaneous vertex delivery, with birth weight 2610 gm AGA, HC 32 (P3-10 ) cm and body length 48 cm(P3-10). Apgar scores were 10,10 at 1&5 minutes, respectively. Prenatal history was normal.

Maternal history

His mother is 15-years old. G1P0A0. First ANC at GA 26 weeks x 4 times. Her blood group is B with Rh positive. Blood serology was all negative. Hct 35%, MCV 90

No family history of hematologic diseaseShe came to the hospital with premature

contraction, no PROM.

History

On the 2nd date of birth ,he developed visible jaundice. Physical examination was unremarkable. GA 36 weeks by Ballard’s score. ABO and Rh blood types of the patient and his mother revealed no incompatibility. G-6-PD enzyme was normal. Coombs’ test was negative. Blood smear showed no hemolysis. Reticulocyte count was 7.22

History

At that time, phototherapy was started and continued for 4 days. The microbilirubin was declined. He was discharged home on 18thsep 07, the 5th day of birth.

BW was 2560 gm on the discharged day.

History

After discharge home (DOL 3D21HR), he was given only breast feeding, about 10 times per day, 20 minutes each feed. Frequency of urination was 10 times per day, yellowish color. Frequency of defecation was 3-4 times per day, yellowish color

History

On the admission day (DOL=7), his mother brought him to Siriraj hospital to follow up his jaundice clinical. He had no fever, active but still icteric.

History

Diet : breast feeding only Immunization : HBV , BCG at birthNo history of neonatal jaundice in family

Physical examination

V/S : T 37c, BP 55/35mmHg ,RR 54/min, PR 141/min

BW 2470 gm HC 32 cm BL 48 cm GA : active, mildly pale, marked jaundice, no

petechiae or rash, no dyspnea. HEENT : no cephalhematoma, no macroglossia,

no tongue tie, AF 2x3 cm ,PF 1x1 cm Eyes : no cataract ,cornea clear

CVS : normal s1 and s2, no murmur RS : normal breath sound, no adventitious

sound.

Abdomen : soft, no distention, bowel sound positive, liver and spleen can’t be palpated.

CNS : normal reflexes, normal muscle tone

Physical examination

Problem list

Maternal teenage pregnancyPreterm AGA male infant, NL, BW 2610 g ,

Apgar 10,10History of visible jaundice on 2nd day of

life with phototherapy treatment for 4 daysRecurrent visible jaundice on DOL 7

Neonatal jaundice

A yellow discoloration of the skin, mucous membrane, and sclera in the first 4 weeks of life after birth.

Neonatal jaundice is visible when total serum bilirubin exceeds 5 mg/dl

Physiologic jaundice Pathologic jaundice

After 48 hr of life In 24 hr or after 2 wk

Total serum bilirubin

< 12 mg/dl (term)

< 15 mg/dl (preterm)

< 5 mg/dl/d

Total serum bilirubin

> 12 mg/dl (term)

> 15 mg/dl (preterm)

> 5 mg/dl/d

Persist

7 d of age (term)

14 d of age (preterm)

Persist

> 14 d of age (term)

> 21 d of age (preterm)

Common disease in neonatal jaundice

Unconjugated hyperbilirubinemia

Conjugated hyperbilirubinemia

• Hemolytic disease of the new born• G-6-PD deficiency• Sepsis• Breast feeding / Breast milk jaundice • Extravasation

•Biliary atresia•Neonatal hepatitis

Pathology

Bilirubin productionHemolysisExtravasation

Bilirubin conjugationImpaired hepatic function

Bilirubin excretionBiliary tract obstructionIntestinal obstructionIncrease enterohepatic circulation

In this patient

DDXHemolytic jaundiceBreast feeding jaundice

Investigation

CBC with slideTB/DB/MBreticulocyte countTSHCoombs’ test G6PD Blood group

normal

Investigation (21/9/07)

The blood examination was performed.Microbilirubin : 21.4 mg/dL.TB : 26.2DB : 2.5CBC : Hb 9.8 Hct 27.4% WBC 9440 (N 46% L

49% M 3% E 2%) Plt 484000 MCV 83 RDW 18.1 anisocytosis 1+

poikilocytosis 1+ reticulocyte count 3.11 (0.1-1.3) TSH 3.08 mcu/ml (0-18)

Review blood smear

Normochromic normocytic RBCAnisocytosis 2+ , poikilocytosis 1+,

polychromasia few

spherocyte 2+WBC no band formPlatelets adequate

Problem list

Maternal teenage pregnancyPreterm AGA male infant, NL, BW 2610 g ,

Apgar 10,10History of visible jaundice on 2nd day of

life with phototherapy treatment for 4 daysRecurrent visible jaundice on DOL 7anemia

Neonatal jaundice

Direct hyperbilirubinemia Indirect hyperbilirubinemia

•Neonatal hepatitis

- Intrauterine infection

•Biliary atresia

•Sepsis

etc

Coombs’ Test ,Blood types

Negative Positive

Dx:Isoimmunization

•Rh

•ABO

•OtherHemoglobin or Hct

Low or normal High

Coombs’ test negative

Low or normal High

Dx: Polycythemia

•Maternal-fetal transfusion

•Twin-twin transfusion

•Delay cord clamping

•Intrauterine hypoxia

Reticulocyte count

Normal

High

RBC morphology

Dx:-Physiologic jaundice

-Extravascular blood in body tissue

-Increase enterohepatic circulation

-Breast milk jaundice

-Hypothyroidism

-Metabolic errors -Hormone+drugs

AbnormalNon-specific DiagnosticDx : -RBC abnormality

-Hemoglobinopathy

-Enzyme deficiency

-Hemolysis -DIC /sepsis

Dx: -Spherocytosis

-Elliptocytosis

-Stomatocytosis

-Pyknocytosis

Hemoglobin or Hct

DDx

Hemolytic jaundiceBreast feeding jaundice

DDx

Hemolytic jaundice

Most likely diagnosis

Indirect hyperbilirubinemia from hemolysis

-HS

-Thalassemia

GoalsPrevention of kernicterusTreatment of underlying conditionsMaintenance of hydration and

nutrition Interventions

Intensive PhototherapyExchange transfusion

Treatment

Indication for early phototherapy Bilirubin rising faster than 0.5mg/dL/hr or

5mg/dL/d Persistent, severe metabolic or respiratory

acidosis Sepsis Sick VLBW infants

Indication for phototherapy in infants >35 weeks gestation

AAP: Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks Gestation, July 2004

Phototherapy

In this case

Indication in infants 35 weeks gestation or more

Exchange transfusion

In this patient

Double phototherapy Hct/MB : 32/22.2

4 hours

Hct/MB : 32/22.7


Pre-transfusion : Hct/MB 21/15.4

Post-transfusion : Hct/MB 31/8.9

ActionReplacement of the neonate’s blood with donor

blood that has normal level of serum bilirubin Mechanism: removes bilirubin and antibodies

from circulation and correct anemia Most beneficial to infants with hemolysis Generally never used until after intensive

phototherapy attempted



Indication Intensive phototherapy

fails TB exceed the level

indicated in guideline Despite intensive phototherapy

for 6 hrs

Signs of acute bilirubin encephalopathy

Principle of exchange transfusion

Two-volume exchange (160 ml/kg)Push-pull method (5 ml/kg/2-3min) Time 60-90 min In case of blood group incompatibility ,

choose bl gr. which compatible with both mom and baby.

Complication

Phototherapy Exchange transfusion

Tanning, Bronze baby syndrome, lactose intolerancehemolysis, skin burns, dehydration, skin rashes

Diarrhea

Retinal Change

*prevent by shielding eyes from light

Riboflavin deficiency (occur in prolongd phototherapy)

* prevent by daily riboflavin intake of 0.3 mg.

From the procedure.

Embolization with air or thrombi, thrombosis, arrythmia, overheparinization, apnea, bradycardia, cyanosis, vasospasm, hypothermia, volume overload, arrest, From blood products. Hyperkalemia, hypernatremia, hypocalcemia, acidosis, coagulation disturbance, blood-borne infections.

*Monitoring of electrolytes, platelet count, coagulation parameters, and arterial blood

gases is recommended.

Progression

Date and time Hct /MB Nutritional

status

22/9/07 : 7D18Hr

45/12.5 (15) NPO

10%D/N/5

22/9/07 :

8D

46/11.1 (15) BM/SI

22/9/07 : 8D10Hr

44/11.6 (15) BM/SI

23/9/07 : 8D23Hr

39/7.5 (15) Off photo

BM/SI

Progression

Date and time Hct /MB Nutritional

status

23/9/07:

9D11Hr

39/9.1 BM/SI

24/9/07:

10D3Hr

43/8.9 BM/SI

Plan of management

Continue breast feedingConsult hematologist to find out the

cause of hemolytic anemia

-Inclusion body test : negative

-Hb typing : pendingObserve clinical of kernicterus

Complication of neonatal jaundice

Acute bilirubin encephalopathyThe acute manifestations of bilirubin toxicity in

the 1st week after birth.Early phase: lethargic and hypotonicIntermediate phase: stupor, irritability, high pitched cry

fever, hypertoniaAdvance phase: Retrocollis-opisthotonos, shrill cry,

apnea, coma, sometimes seizure and death

KernicterusThe chronic and permanent clinical sequelae of

bilirubin toxicity

Discharge

Assessment before dischargePredischarge bilirubin

Use nomogram to determine risk zone

Assessment of risk factorsTSB Zone before discharge Newborns

n (%)

Newborns Who Subsequently

Developed a TSB Level

> 95th Percentile, n (%)

High-risk zone 6 39.5

High intermediate-risk zone 12.5 12.9

Low intermediate-risk zone 19.6 2.26

Low-risk zone 61.8 0

Follow-up Care

Plan based onAge in hours at dischargeRisk of excessive hyperbilirubinemiaAvailability and reliability of follow-up

Infant Discharged Should be Seen by age

Before age 24 hours 72 hours

Between 24-48 hours 96 hours

Between 48-72 hours 120 hours

Follow-up Care

• Timing of follow-up

Follow up assessment should includeBody weight, % change from BW,

adequacy of intake, the pattern of voiding and stooling, presence or absence of jaundice

Clinical judgment should be used to determine the need for a bilirubin measurement.

If there is any doubt about the degree of jaundice. Blood testing should be done.

Follow-up Care

Some harmful advice and beliefs have to be changed. All health personnel should not advise parents to supplement water or dextrose water to newborns or expose newborns to sunlight.

Follow-up Care

Parents should be educated and provided with adequate educational materials at discharge regarding jaundice, feeding adequacy and symptoms to watch for, the risks of untreated hyperbilirubinemia, and the need for close follow-up of their infants after discharge

Follow-up Care

THANK YOU

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