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Correspondence: Valeria Seidl, Estrada dos Bandeirantes Received: December 17, Published: April 13, Risk factors related to severe outcome in RhD hemolytic disease of the fetus and newborn. Obstet Gynecol Int J. DOI: Download PDF. Objective: To determine the major risk factors related to exchange transfusion in pregnancies afflicted with RhD hemolytic disease of the fetus and newborn HDFN. Methods: A cohort study of infants born with this disease between April and June at the Fernandes Figueira Institute.
Data on maternal history, prenatal care, delivery and neonatal parameters were subjected to univariate analysis to determine their relationship to severe disease outcome, represented by the need for exchange transfusion. Significant variables were subjected to multivariate and multi level analysis.
Results: Diverse simulations were performed in the model to choose the most representative ones. As final result, intrauterine transfusion RR: 2,54 [1,,00] , jaundice RR: 2,77 [1,,39] , peak serum bilirubin levels during hospitalization RR: 1,16 [1,,22] , were the variables found to establish an independent and statistically significant relationship with severe outcome. Conclusion: Recognition of risk factors for exchange transfusion in pregnancies afflicted with RhD HDFN is possible and necessary regarding newborn care following delivery.
Keywords: Rh alloimmunization, Risk factors, Hemolytic disease of the fetus and newborn, Exchange transfusion. Hemolytic disease of the fetus and newborn HDFN is a condition in which specific maternal antibodies that cross the placenta reduce the lifespan of fetal red blood cells, causing fetal anemia. Prevalence of RhD disease in the United States was 6.
Since the implementation of protocols that advocate the use of antenatal prophylaxis with anti-D immunoglobulin around the 28th week of pregnancy and up to 72 h postpartum, the disease outcome has undergone great changes, as shown by the swift and significant decrease in cases of maternal alloimmunization. Adequate care requires the screening of Rh D -negative pregnant women, early recognition of those at risk of developing HDFN and the use of adequate prophylaxis for nonsensitized pregnant women.
The treatment of infants with HDFN represents a complex process carried out with pediatric assistance; requiring, admission to a neonatal intensive care unit, need for phototherapy, availability of Rh-D negative screened blood type, and technical expertise for exchange transfusion. We therefore consider that identification of risk factors during prenatal and early neonatal care would be useful in the clinical management of the main complications related to HDFN.
The present work aimed to assess which characteristics of maternal history, prenatal care, delivery and newborn care are most strongly related to severe neonatal outcomes, defined here as the need for exchange transfusion after birth. A cohort study was performed to assess the babies born from April to June that involved those newborn infants with hemolytic disease caused by Rh D incompatibility.
For this purpose, we monitored the pregnancy and delivery of women diagnosed with Rh alloimmunization at the FernandesFigueira National Institute. Access to prenatal care can occur at any gestational age, and the births take place at the institute itself, where the infants are followed at an outpatient clinic that specializes in the first year of life.
Patients with fetal malformation and hydrops resulting from causes other than anti-D alloimmunization were excluded from the study. In order to assess whether an effect was direct or mediated through other factors, variables included in this study were divided into three groups, according to the association level with the outcome distal, intermediate and proximal Table 1.
Table 1 Risk factors variables divided into three groups, according to the association level with the outcome in a multivariate model analysis. Type of delivery vaginal or cesarean section ; complications during labor; 5-minute Apgar score; fetal suffering; the use of oxygen in the delivery room; the use of intermittent mandatory ventilation and the need for resuscitation measures.
Gestational age at birth Ballard score ; gender; birth weight; blood type of the newborn infant ABO, Rh factor, phenotype ; direct Coombs test; anemia; congestive heart failure; clinical complications; jaundice; hematocrit at birth and 24 h and 40 h after birth; total serum bilirubin level in umbilical cord blood; 6 h, 12 h and 40 h total serum bilirubin level after birth; peak serum bilirubin level at hospitalization; platelet count; type and duration of phototherapy; need for and number of postpartum transfusions; total duration of hospital stay days and number of days with negative DAT.
Initially, for the purpose of statistical analysis, exploratory data analysis was performed to assess the consistency of the data and the distribution of the variables of interest.
Poisson regression models with robust variance were applied to determine the factors associated with the incidence of exchange transfusion. The factors associated with the incidence of the clinical outcome were evaluated in groups according to the nature of the independent variables of interest. The study groups were then subdivided into variables related to maternal history and prenatal care, delivery and newborn Figure 1.
The correlation matrix between the explanatory variables was analyzed to assess the possibility of multicollinearity.
In each group, univariate analyses were performed, and the variables with p-values below 0. The choice of factors to be included in the multivariate model was not based purely on statistical associations. A decision on which factors to include was based on a conceptual framework describing the hierarchical relationships between risk factors.
At each level of final multivariate model, variables were controlled by those of same level and above, but not for inferior level. Hence the estimate obtained for each level is related to the effect of the variable adjusted by possible confounding factors, but not to possible mediating variables. The mean age of the maternal population was The median number of pregnancies, births and abortions among the studied patients was three, two and zero, respectively.
The mean gestational age calculated at birth was The gender distribution of the newborns was similar. The variable stillbirth comprised one single case. In terms of maternal history and prenatal care distal level , there was a trend for an association among the need for exchange transfusion with maternal blood type B RR: 0. In the multivariate model for this level, only the need for intrauterine transfusion therapy remained a risk factor for the outcome RR: 2.
In the analysis of birth-related factors intermediate level , there was a trend for an association between exchange transfusion risk and the type of delivery vaginal or cesarean section. Vaginal delivery was defined as a protective factor RR: 0. However in the multivariate model it lost statistical power of association Table 2.
Finally, the newborn variables proximal level associated with exchange transfusion outcome were jaundice RR: 2. After multivariate analysis, these variables were still significantly correlated with the outcome of interest Table 2.
In the hierarchical model Table 2 , the variables that displayed a significant association with the neonatal outcome of interest were the need for intrauterine transfusion therapy, jaundice and peak serum bilirubin level. Table 2 Final hierarchical model with the variables that displayed a significant association with the need for exchange transfusion therapy. Hemolytic disease of the fetus and newborn is an avoidable cause of death in infants younger than five years of age.
The evaluation of the variables regarding maternal variables and prenatal care distal level in the final model revealed that intrauterine transfusion therapy was the only factor that represented an increased risk for a severe neonatal outcome, defined as exchange transfusion.
Van Kamp et al. Hence, performing intrauterine transfusion therapy during prenatal care implies that the fetus is severely afflicted with the disease and at risk of needing neonatal intervention to reduce morbidity. The current method for fetal anemia monitoring and intrauterine transfusion therapy referral is the middle cerebral artery peak systolic velocity measurement established by Mari et al.
Thus, immature fetuses are subjected to intrauterine transfusion therapy to treat moderate or severe anemia and avoid the development of such conditions as hydrops and intrauterine death. When studying the early outcome of infants subjected to intrauterine transfusion therapy, McGlone et al. The authors concluded that infants subjected to intrauterine transfusion therapy remain in the hospital fewer days and require fewer interventions during the neonatal period, especially regarding the need for phototherapy; however, there was no statistically significant association between the need for exchange transfusion and intrauterine transfusion therapy.
This finding differs from the results of the present study, meaning that the inclusion of fetuses with a more severe condition in the study population can result in a significant association between the use of intrauterine transfusion therapy and the exchange transfusion outcome, which can become an indicator of risk in this situation. The maternal blood type B regarding need for exchange transfusion was not confirmed as an independent risk factor after applying the multivariate model. The gestational age at birth and the type of delivery of the pregnancies afflicted with HDFN have changed over time.
More severe fetuses that underwent intrauterine transfusion therapy had scheduled cesarean section deliveries, which increased the rate of complications related to prematurity, such as hyaline membrane syndrome.
This management plan has had good results with respect to neonatal outcome and had even reduced the need for exchange transfusion. Of note, we observed a higher mean gestational age for pregnancies that ended with a vaginal delivery compared with cesarean sections. Neonatal hyperbilirubinemia is treated by a referral to exchange transfusion therapy. Hence, in terms of newborn variables, a strong association between infants who exhibited higher total serum bilirubin levels and a diagnosis of jaundice after birth was expected.
Another important resource is phototherapy. This method reduces serum bilirubin levels by photooxidation and by converting bilirubin into water-soluble substances, a process termed photoisomerization.
The efficacy of this therapy depends on several factors, including the spectral quality of the emitted light, the irradiance, the exposed area of the newborn and the total serum bilirubin level at the beginning of the exposure. It was only of interest for establishing the relationship between the duration of phototherapy and severe outcomes and the impact of this relationship on the total duration of hospital stay.
We observed that infants who were not subjected to exchange transfusion spent more time in phototherapy treatment and exhibited longer total hospital stays. Another therapeutic resource used during this period was human intravenous immunoglobulin IVIg , which has been recommended as an alternative therapy.
The use of this substance is generally associated with phototherapy for the management of HDFN, with the goal of reducing the need for exchange transfusion. The introduction of this therapy, together with anti-D prophylaxis, was the factor that had the highest impact on the progression of HDFN. The improvement in prenatal care, together with the advance in available technologies for ante- and postnatal treatment, has led to an important reduction in morbidity and mortality related to maternal alloimmunization.
However, the prognosis of these infants can also be severely affected by varying degrees of cerebral paralysis, deafness or a developmental deficit. The results exhibited here provide a valuable contribution to the goal of improving the care provided to this at-risk population in the Brazilian context. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.
Withdrawal Guidlines. Publication Ethics. Withdrawal Policies Publication Ethics. Research Article Volume 2 Issue 2. Figure 1 Risk factors variables divided into three groups, according to the association level with the outcome in a multivariate model analysis. MoiseJr KJ. Management of Rhesus Alloimmunization in Pregnancy. Obstet Gynecol.
Rev Assoc Med Bras. Urbaniak SJ. Consensus conference on anti-D prophylaxis, April 7 and 8, final consensus statement. Geaghan SM. Semin Perinatol. Zipursky A, Paul VK. The global burden of Rh disease. Lobato G, Soncini C. Relationship between obstetric history and Rh D alloimmunization severity.
Everyone also has an Rh factor positive or negative. There can be a problem if a mother and baby have a different blood type and Rh factor. This can occur during a miscarriage or fall. It may also happen during a prenatal test. These can include amniocentesis or chorionic villus sampling. These tests use a needle to take a sample of tissue. They may cause bleeding.
Hemolytic disease of the newborn , also known as hemolytic disease of the fetus and newborn , HDN , HDFN , or erythroblastosis foetalis ,  is an alloimmune condition that develops in a fetus at or around birth, when the IgG molecules one of the five main types of antibodies produced by the mother pass through the placenta. Among these antibodies are some which attack antigens on the red blood cells in the fetal circulation , breaking down and destroying the cells. The fetus can develop reticulocytosis and anemia. The intensity of this fetal disease ranges from mild to very severe, and fetal death from heart failure hydrops fetalis can occur. When the disease is moderate or severe, many erythroblasts immature red blood cells are present in the fetal blood, earning these forms of the disease the name erythroblastosis fetalis British English: erythroblastosis foetalis.
PDF | On May 16, , Soumya Das published Hemolytic Disease of the Fetus and Newborn | Find, read and cite all the research you need on ResearchGate.
Written and peer-reviewed by physicians—but use at your own risk. Read our disclaimer. Hemolytic disease of the fetus and newborn HDFN is a condition characterized by the destruction of fetal red blood cells RBC and subsequent anemia.
Regret for the inconvenience: we are taking measures to prevent fraudulent form submissions by extractors and page crawlers. Correspondence: Valeria Seidl, Estrada dos Bandeirantes Received: December 17, Published: April 13,
Coronavirus Guidelines. Visit free Relief Central. Prime PubMed is provided free to individuals by: Unbound Medicine. Hemolytic disease in newborn. Genetic spectrum and clinical early natural history of glucosephosphate dehydrogenase deficiency in Mexican children detected through newborn screening.
This can occur during a miscarriage or fall. It may also happen during a prenatal test. These can include amniocentesis or chorionic villus sampling. These tests use a needle to take a sample of tissue. They may cause bleeding. Your immune system responds by making antibodies to fight and destroy these foreign cells. Your immune system stores these antibodies in case these foreign cells come back again.
Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: Delaney and D. American Society of Hematology. Delaney , D.
Hemolysis should always be investigated even if the anemia is mild and apparently trivial. Based on etiology, hemolysis in newborn can be immune or non-immune mediated. The immune-mediated hemolysis due to blood group incompatibility between the mother and the fetus is the main cause of HDFN. Blood Groups. Hemolysis should always be investigated even if anemia is mild and apparently trivial. Based on etiology, hemolysis in newborn can be immune or nonimmune mediated. Immune-mediated hemolysis of fetal red cells, due to blood group incompatibility, occurs when there is transplacental passage of maternal antibody active against paternal red cell antigen of the infant [ 2 , 3 , 4 ].
Убирайся отсюда немедленно, или я вырву эту булавку из твоих ноздрей и застегну ею твой поганый рот.
Беккер изобразил улыбку. - Я должен идти. Он извинился перед немцем за вторжение, в ответ на что тот скромно улыбнулся. - Keine Ursache.
Чтобы он получил второй ключ. - Что еще за второй ключ. - Тот, что Танкадо держал при .
- Это зависит от оперативности, с которой ARA пересылает почту. Если адресат находится в Штатах и пользуется такими провайдерами, как Америка онлайн или Компьюсерв, я отслежу его кредитную карточку и получу его учетную запись в течение часа. Если он использует адрес университета или корпорации, времени уйдет немного. - Она через силу улыбнулась. - Остальное будет зависеть от .
Беккер терял терпение.
Халохот был профессионалом высокого уровня, сэр. Мы были свидетелями убийства, поскольку находились всего в пятидесяти метрах от места. Все данные говорят, что Танкадо ни о чем таком даже не подозревал. - Данные? - спросил Бринкерхофф. - Какие такие данные.
Энсей Танкадо - это Северная Дакота… Сьюзан попыталась расставить все фрагменты имеющейся у нее информации по своим местам. Если Танкадо - Северная Дакота, выходит, он посылал электронную почту самому себе… а это значит, что никакой Северной Дакоты не существует. Партнер Танкадо - призрак.
У меня нет на это времени, - сказала себе Сьюзан. На поиски вируса может уйти несколько дней. Придется проверить тысячи строк программы, чтобы обнаружить крохотную ошибку, - это все равно что найти единственную опечатку в толстенной энциклопедии. Сьюзан понимала, что ей ничего не остается, как запустить Следопыта повторно.
Meghan Delaney, Dana C.Idelfonso T. 02.06.2021 at 10:47
Hemolytic disease of the newborn HDN is a blood disorder in a fetus or newborn infant.Emelia B. 05.06.2021 at 08:49
Haemolytic disease of fetus & newborn. • Range in severity - detectable only in laboratory. → infant with anaemia/jaundice → stillborn. • Risk of significant fetal.