Hemolytic disease of the newborn
Hemolytic disease of the newborn (or erythroblastosis) is one of the rare but very serious diseases in which red blood cells are destroyed and die. Hemolytic disease occurs due to the incompatibility of the blood of the mother and fetus according to the Rh factor or the ABO system (group antigens)

What is hemolytic disease of the newborn

Hemolytic disease of the newborn (HDN) is a nightmare for any neonatologist. With HDN, erythrocytes (red blood cells) of a newborn (or fetus, if the pathology arose even in the prenatal period) are massively destroyed. Hemolytic disease of the newborn occurs due to isoserological incompatibility – that is, incompatibility with maternal blood according to the Rh factor or the ABO system (group antigens). That is, the woman’s immune system perceives the erythrocytes of the fetus as foreign elements and produces antibodies to destroy them.

If urgent measures are not taken, the disease can lead to serious consequences or even death of the child.

Causes of hemolytic disease of the newborn

As we said above, the cause of hemolytic disease of the newborn is incompatibility with maternal blood according to the Rh factor (in most cases) or according to the ABO system (group antigens). The conflict between the blood of mother and child occurs in the following cases:

  • A woman with Rh-negative (Rh-) blood develops an Rh-positive (Rh+) fetus;
  • In the future mother, the blood belongs to the 0 (I) group, and in the child – to A (II) or B (III);
  • Sensitization of the mother before pregnancy (that is, she already has an increased sensitivity to blood components – for example, with Rh-negative blood she was transfused with Rh-positive, miscarriages, abortions, childbirth). With each new pregnancy and childbirth, the risk of developing hemolytic disease of the newborn only increases, especially if placental abruption occurred during childbirth or a cesarean section had to be done;
  • Violation of the barrier function of the placenta.

Signs of hemolytic disease of the newborn

Signs of hemolytic disease of the newborn directly depend on the form of the disease. For example, with an edematous form, a child develops severe edema, the skin becomes waxy, muscle tone is sharply reduced, respiratory and cardiac functions are depressed. The abdomen becomes bloated, barrel-shaped (due to enlargement of the liver and spleen).

In the anemic form, the skin and mucous membranes become pale, cyanotic. The abdomen is also enlarged.

With the icteric form, the child’s skin becomes bright yellow (sometimes even orange) in color. The mucous membranes and sclera of the eyes also turn yellow. The child becomes lethargic, drowsy, or vice versa – sharply restless. With nuclear jaundice, the muscles come into a strong tone, the baby arches his back, throwing his head back, while often and piercingly screams and cries.

Forms of hemolytic disease of the newborn

Hemolytic disease of the newborn has several forms, each of which has its own symptoms. As we have already indicated above, experts distinguish three clinical forms of the disease: edematous, anemic and icteric.

edematous form

The edematous form is the most severe and develops even when the baby is in the womb. This can lead to miscarriage or premature birth, and if the child is still born alive, then his condition is extremely difficult. He has severe edema, severe anemia (hemoglobin is almost zero). The skin is waxy, muscle tone is sharply reduced, respiratory and cardiac functions are depressed. The abdomen is greatly distended because the liver and spleen are greatly enlarged. In the cavity around the heart, lungs and abdominal cavity, fluid may accumulate, and the level of protein in the blood is greatly reduced.

Anemic form

The anemic form is considered the mildest form of hemolytic disease of the newborn and has the most favorable prognosis. The child has pallor of the skin and mucous membranes, a decrease in muscle tone, an increase in the size of the liver and spleen, and anemia. At the same time, nothing threatens the condition and life of the child; with timely treatment, the symptoms quickly disappear.

icteric form

The icteric form is the most common. It manifests itself in the first 24 hours after birth (sometimes on the second day), and gradually its symptoms increase. The skin of the child turns yellow (sometimes even becomes orange, orange hue), the sclera and mucous membranes also become yellow. The higher the level of bilirubin in the blood, the worse the condition of the baby – he becomes lethargic, sleepy, and muscle tone decreases.

Also distinguish the severity of the disease. Mild HDN is detected only with minor symptoms or test results. In the moderate form, bilirubin in the blood rises, but there is no serious intoxication yet. In severe form, bilirubin damage to the nuclei of the brain (nuclear jaundice) occurs, respiratory and cardiac functions fail.

Treatment of hemolytic disease of the newborn

Diagnostics

Diagnosis of hemolytic disease of the newborn begins in the prenatal period in order to exclude the immune conflict of the mother and fetus. The blood group and the Rh factor of the mother and father are determined, if the mother has a negative Rh, then she is clarified whether she had previous pregnancies, abortions, miscarriages, whether she had a blood transfusion, etc. Also during pregnancy, the presence of anti-rhesus antibodies in dynamics is determined three times. An ultrasound scan is mandatory, since HDN can be suspected by the following symptoms: thickening of the placenta, polyhydramnios, enlargement of the liver and spleen in the fetus.

After birth, hemolytic disease of the newborn can be diagnosed by such clinical manifestations as: yellowness of the skin and mucous membranes, discolored feces and dark urine, anemia and hepatosplenomegaly.

Be sure to conduct a blood test – HDN can be diagnosed with a hemoglobin level in the blood below 150 g / l, an increase in the level of bilirubin more than 70 μmol / g in the umbilical cord and 310 – 340 μmol / g in the rest of the blood. At the same time, the level of bilirubin in the blood rises every hour. It is also mandatory to conduct a study of incomplete antibodies using the Coombs test and a consultation with a pediatric hematologist is appointed.

Modern treatments

Treatment of hemolytic disease of the newborn directly depends on the form of the disease and its severity. In severe cases, intrauterine blood transfusion is carried out to the fetus. After birth, if necessary, an exchange transfusion is also performed to remove free (indirect) bilirubin and prevent the development of complications. Doctors also often use hemosorption and plasmapheresis – the so-called “blood cleansing”.

– The most common method of treatment is phototherapy, when a newborn is placed in an incubator under a blue light lamp with a certain wavelength, this effectively destroys bilirubin in the skin. In case of severe anemia, a red blood cell transfusion is required. Infusion therapy is carried out only if there are signs of dehydration in the child. Cholagogue therapy can be recommended only in case of development of cholestasis syndrome, explains pediatrician Elena Pisareva.

Prevention of hemolytic disease of the newborn at home

Before giving birth:

The main prevention of hemolytic disease of the newborn is the introduction of anti-Rhesus immunoglobulin at the 28th week of pregnancy and after childbirth (already for a subsequent pregnancy). It is immunoglobulin that blocks the production of antibodies in the mother’s body.

– The main prevention of hemolytic disease of the newborn is the correct management of pregnancy. Before childbirth, this is the detection of anti-Rhesus antibodies in the blood of a woman with a negative Rh (three times during pregnancy). At the same time, it is not the size of the antibody titer that is of great importance, but their dynamics. If a risk is identified, amniotic fluid is analyzed at week 34, – explains pediatrician Elena Pisareva.

Ultrasound control allows you to confirm the development of hemolytic disease of the fetus: this is indicated by thickening of the placenta, polyhydramnios, enlarged liver and spleen of the fetus.

After childbirth:

“After childbirth, it is necessary to take a blood test for bilirubin, a clinical blood test for a child, a Coombs test (detection of anti-Rh and anti-erythrocyte antibodies) to prevent the development of the disease,” the specialist explains.

Clinical practice guidelines for hemolytic disease of the newborn

– In our work, we are guided by clinical guidelines approved by the Ministry of Health of the Federation and approved by the Society of Neonatologists, and specialists from the Association of Perinatal Medicine. In modern recommendations, the indications for a particular method of treatment and the technique of its implementation are clearly spelled out. For example, it clearly states that the use of Phenobarbital and hepatoprotectors for the treatment of hemolytic disease of the newborn is unacceptable. I would also like to emphasize that at present, the abolition of breastfeeding in case of HDN is not indicated, – says pediatrician Elena Pisareva.

Popular questions and answers

Elena Pisareva, a pediatrician at the Gaide clinic, answers questions.

What are the complications and consequences of hemolytic disease of the newborn?

The consequences of hemolytic disease of the newborn may be absent altogether, and may be quite significant. With delayed or inadequate treatment, the icteric form of HDN can be complicated by bilirubin encephalopathy and bile thickening syndrome. When high numbers are reached, indirect bilirubin is able to penetrate the blood-brain barrier and affect the brain. As a result, bilirubin encephalopathy, or kernicterus, develops. More often it develops on 3 – 6 days of life. Drowsiness and lethargy of the child appears, there is a decrease in muscle tone, a monotonous cry appears, convulsions, bulging of a large fontanel, vomiting and regurgitation. With nuclear jaundice, surviving children may have impaired intelligence up to idiocy, impaired physical development, cerebral palsy, deafness, and speech disorders.

With liver damage, the level of direct bilirubin in the blood also rises, thickening of bile develops, its stagnation in the bile ducts and reactive hepatitis. Then jaundice acquires a greenish tint, the liver increases in size, the intensity of urine color increases.

Do parents need to undergo a special examination before planning a pregnancy to exclude hemolytic disease of the newborn?

It will not be possible to exclude the disease, the only way to do this is to choose a suitable partner for your blood type and Rh factor, but in life this is rarely possible. Of course, it is worth knowing the mother’s blood type and Rh in advance in order to assess the likelihood of developing the disease, previous pregnancies, abortions, blood transfusions also matter – you need to tell your doctor about all this. It is important to undergo all the necessary examinations during pregnancy in order to notice the developing problem in time and help the child.

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