Role of IVIG in the management of neonatal isoimmune hemolytic jaundice

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‘ROLE OF IVIG IN THE MANAGEMENT OF
NEONATAL ISOIMMUNE HEMOLYTIC
JAUNDICE’

MEETA SACHDEV
G.MALINI, P.N.AGRAWAL, S.M.DEWANGAN

DEPTT. OF PEDIATRICS
JLN HOSPITAL & RESEARCH CENTRE
BHILAI

A Free sample background from www.awesomebackgrounds.com

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INTRODUCTION

 Neonatal jaundice: Common in 1st wk of life

 60% of term & 80% of preterm infants.

 Clinical jaundice: Bilirubin >7 mg/dl.

 Mostly physiologic


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NONPHYSIOLOGIC JAUNDICE IN
WELL INFANT

 Hemolytic disease of newborn (ABO/Rh)

 Incidence of ABO incompatibility : 25%

significant jaundice : 2.5%

 Incidence of Rh incompatibility : 4.8%

significant jaundice : 0.17 – 0.31%

Gupte et al. Natl Med J India 1994; 7: 65-66

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WHY WORRY
 Clinically indistinguishable

 Bilirubin rises to toxic levels

 Acute bilirubin
encephalopathy

 Left with sequelae-
KERNICTERUS

 Athetosis, sensorineural
deafness, intellectual deficits

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CONVENTIONAL MANAGEMENT

 Intensive phototherapy
(excretion by alternative
pathways)

 Maintain hydration &
increase feeds
(decreases enterohepatic
circulation)

 Exchange transfusion
(mechanical removal)


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EXCHANGE TRANSFUSION
Prerequisites
 Invasive procedure

 Trained personnel

 Well-equipped setup

 Sepsis screen & blood culture

 Parentral fluids &
prophylactic antibiotics

 Near- fatal complications(5%)
& mortality (1%)


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COMPLICATIONS OF EXCHANGE
TRANSFUSION
 RISK OF EXPOSURE TO BLOOD
 COMPLICATIONS OF UVC
 Hypocalcaemia , hypomagnesaemia, hyperkalemia
 Hypoglycemia, acid-base disturbances
 Cardiovascular, apnea, seizures
 Bleeding, hemolysis
 Infection
 Misc- hypo/hyperthermia, NEC. Etc.


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IVIG IN HDN -AAP GUIDELINES
(Pediatrics 2004;114:297-316)

 Indication: Hemolytic disease of newborn with significant
hyperbilirubinemia

 Dose: 0.5-1gm/kg

 Mode of administration: Infusion given over 2-4 hrs.

 Monitoring: For adverse reactions


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Y

Y
Y

Y
YY

Y
Maternal

Y
Fetal RBC Antibodies

MECHANISM OF IVIG
Blockade
Y
Y RE cell
IVIG
Y
Y

Fc
Immunoglobulin Lysis of RBC

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WHY THIS STUDY

 After publication of AAP guidelines,

IVIG is being used more frequently in HDN.

 Is IVIG useful only to bring down the bilirubin level ?

 Are there any more advantages?

 What is our experience?


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AIMS & OBJECTIVES

 To evaluate the efficacy of IVIG in HDN

 To compare the stay, cost of treatment

& complications between IVIG & Exchange group

 Which is safer?


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MATERIAL & METHODS

 TYPE OF STUDY : OBSERVATIONAL

 TIME FRAME : JAN 2010 – DEC 2011

 NO. OF SUBJECTS : 16(16)

 INCLUSION CRITERIA : Healthy neonates (>35wks), HDN
& significant hyperbilirubinemia

 EXCLUSION CRITERIA : Sick neonates & gestation <35 wks.


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MATERIAL & METHODS

 Blood grouping of infants whose mother’s blood

group is O/Rh negative

 Close monitoring for clinical jaundice

 Measurement of serum bilirubin levels


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MATERIAL & METHODS

 INTENSIVE PHOTOTHERAPY & Maintain hydration

 INTRAVENOUS IMMUNOGLOBULIN INFUSION :
Rising bilirubin level despite intensive phototherapy
OR
bilirubin levels were within 2-3 mg % of exchange levels

 EXCHANGE TRANSFUSION :
Bilrubin level >5mg% of exchange threshold


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AAP GUIDELINES FOR PHOTOTHERAPY
(Pediatrics 2004;114:297-316)


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AAP GUIDELINES FOR EXCHANGE
TRANSFUSION
(Pediatrics 2004;114:297-316)


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OBSERVATIONS


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SEX DISTRIBUTION

Female : male = 1.28: 1

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GESTATION


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WEIGHT


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INCOMPATIBILITY


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BIRTH ORDER


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SERUM BILIRUBIN LEVELS
Peak bilirubin
After After After
Mean value
24 hrs 48 hrs 72 hrs
(Age in days)

16.31 13.16 9.95

19.53
IVIG
(2.5 Days)
p < 0.005 p< 0.001 p < 0.001
Significant Highly significant Highly significant

18.82 13.23 9.68
Exchange 25.09
transfusion (3.75 Days)
p < 0.001 p < 0.001 p < 0.001
Highly significant Highly significant Highly significant

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PARENTRAL FLUIDS & ANTIBIOTICS

ANCILLARY EXCHANGE
IVIG
TREATMENT TRANSFUSION

IV FLUIDS 3 (19%) 16 (100%)

First line 3 (19%) 0

ANTIBIOTICS Broad spectrum 2 (13%) 9 (56%)

Extended spectrum 0 7 (44%)

2-5 D 5 (31%) 4 (25%)
DURATION OF
6-10 D 0 4 (25%)
ANTIBIOTICS
11-14 D
0 8 (50%)

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DURATION & COST OF T/T

Blood exchange p value
MEAN VALUES IVIG group
group (Unpaired T test)
Significance

DURATION OF
5.5 Days 4.5 Days
PHOTOTHERAPY p > 0.05
Not significant

HOSPITAL STAY 7.2 Days 9.6 Days p < 0.05
Significant

COST ( Rs) 13,500 22,200 p < 0.005
Highly significant

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ADVERSE EFFECTS IN
EXCHANGE TRANSFUSION
100%

80%
% of patients

60%
44%
40%
25%
19% 19%
20% 13%
0%
0%


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CONCLUSION
 Predicting the risk of severe jaundice, close monitoring &
follow-up is crucial in ABO & Rh incompatibility

 Early intervention with intensive phototherapy & IVIG is
helpful in averting exchange transfusion, its associated
risks & complications significantly

 Duration of stay & cost of treatment is significantly
reduced

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REFERENCES
 Alcock GS, Liley H. Immunoglobulin infusion for isoimmune hemolytic
jaundice in neonates (review). Cochrane Database Syst Rev 2001;(4)

 Vinayaka G et al. role of intravenous immunoglobulin in the management
of hemolytic disease of newborn. Pediatrics Today Vol XII No. 6,2009

 Alpay F et al. High dose intravenous immunoglobulin therapy in neonatal
immune hemolytic jaundice. Acta Pediatr 1999;88:216-119

 Patra K. Adverse effects associated with neonatal exchange transfusion in
the 1990s. J Pediatr 2004;144:626-31

 Mukhopadhyay K et al.Intravenous immunoglobuin in rhesus hemolytic
disease. Indian J Pediatr 2003;70:697-9

 Miqdad AM et al. IVIG therapy for significant hyperbilirubinemia in ABO
hemolytic background from www.awesomebackgrounds.com Matern Fetal Neonatal Med 2004;16:163-6
A Free sample
disease of newborn. J

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TIMING OF FOLLOW-UP
(Pediatrics 2004;114:297-316)

Infant discharged follow-up by

Before age 24 h 72 h

Between 24 & 48 h 96 h

Between 48 & 72 h 120 h


Role of IVIG in the management of neonatal isoimmune hemolytic jaundice

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