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"?T0 =~T 0 DE~T "E~U E T ;?~T@} E@~U  `C~U BOU ;~U N ~U@ DC@V ;?V ;~V  A~VD @:~V"  ;  ~V A`0W?? :?~W@0 @;@~W   $@ W : ~W ?  ~W@K@ X? 9 X9!~X@>!~X >!~X0 @9`!Y 9?!~Y@D 8@!~Y " <!~YD"~Y 078"Z? 7"~ "~Z@  "aZ 6#~ZF  @6#~Z   7  #[? 6?#~[0 @ 7@0#[ 6$~[ 8$~[   @5@$\? 5$~\0 8$~\`  D7`$~]  #4&\ ?3%~\  6%] 3%] 3%~]  C3`%~]0 0@4%] 2?&^ 2?&^ 2?&^? 1~?&~^  `2@&^? 1'_ 1'_ 1'~W@ ! 2@'_ ?/?'_? ?/(~_0  /*` /(~``  1(` /(~` #[a? /?(~a0 0@(a .)~a /)~a` /*b -)b -)b -)~b@/)c?,*~c>@-*c?,*~c>0bc?,*d?,*d,?*~d Xd?+*e*+e*+e*+~e !),e?)+~e \),f?)+~f`8* +f(+f(,~f`Vg(,g?&,~g p 0Uh?&,h %,i?%,i %,~i ATj?$-j ?$-~j 8$-k #-k!#-~k!T~k %-l"#-lH-m?G?-~m`8G@-~mF-nE.~n` F.~nD/oD.~oxD/oD.pC?.~pxB/pA/~ps~qx@/r@/~rx@/r??/s>?/t<0t<0t?;0u;0v:0v:?0v9?0w81x71x71y61y51z41z;22{22{12| 02}.2~-?2,3+3(3?'3&?3%4?#4!4 ?455 5 ?5 ?6 .6 6 ?6  7 `8@8 899 9 :> ;?lR?~U~R`R~?~Sy~l y~az~lz~ly~a$z~Z z~V8x` @ o~V @!o~V `>o~XA4~^  "B o~WF">_~Y@A`~W0 @!@@'@_R???8|?m~V   2FB0 ?@e~V  1 @ ` e~V    @c~V  @ A;@>`Rx^~R $ $@>`9^~S C`D @>D^~U 8 H@  ^^*>?~?|?^~^pB0!    ^fx>??|~^~fH@ @ ^~g@0  @ajx?>?<^rx<^v>~<|^y>><|\~y pD` <8\\^1(@2{7$  . !       ݁Level 1Level 2Level 3Level 4Level 5 d >$"Small Circle"0..H,h Z*Helvetica Regular<\  `(&Roman 10cpi12pt( $ Figure  1  'dxd -0 I&mage <=8C HKKKK  . !       _XXHHk  XuXXX   XXX Xu8^XXdd8XI.NeonatalandObstetricalTransfusionPractice# XuXXX# X  &c%X Xu-X X` XX- &c%% &cA.0  Introduction$$ ?X X` XX X` X?  1.0  Theneonatalperiodisgenerallyconsideredtoextendfrombirthto4monthsofage.t$$   2.0  Indicationsfortransfusionofinfantsdifferswithweight,gestationalage,circumstancesofdeliveryand |$ withsubsequentmaturation.T$$   3.0  Illnewborninfantsaremorelikelytoreceivetransfusionsthanhospitalizedpatientsofanyotherage.  $$ H"X X` ,XX X` XH0    a.0$$Theamountofbloodremovedforlaboratorysamplestomonitortheirprogressmaybequite  \  substantial. 4 $$ 0    b.0$$Eachtimebloodisdrawnthenurse_notates_Ԁitonthechart,oncetheamountbecomessignificantthe <  babymustbetransfused. $$   4.0  Supplyingbloodbanksshouldbecapableofprovidingcomponentstailoredtosatisfythespecific l requirementsofthesetinyrecipientswhosesmallbloodvolumesandimpairedorganfunctionsprovide D littlemarginofsafety.t$$ 0    a.0$$Mustminimizethenumberofdonorsthebabyisexposedto.$$$ 0    b.0$$Thebloodcentersuppliesaunitofbloodwithsatellitebagsattached.|$$ 0    c.0$$Whenanorderisreceivedfortransfusionthetechniciansqueezesoverthenecessaryamountfromthe , primarybagintothesatellitebag(usually1530cc),sealsthetubingandremovesthesatellitebag.\$$ 0    d.0$$Theprimarybagretainsitsoriginalexpirationdate.Thesatellitebagwillhavea24hourexpiration   dateonceithasbeenentered.$$ 0    e.0$$Infantscanreceivetransfusionsfromthesamedonorunitfor28daysoruntilallofthebloodhasbeen < usedup.l $$ B.0  FetalandNeonatal_Erythropoiesis_"$$   1.0  Appropriatetransfusionpracticerequiresknowledgeofneonatalphysiologyandcarefulclinical  t$ observation.!L%$$   2.0  Astheembryodevelops,thepredominantsitesof_hematopoiesis_Ԁchange;ataboutthe9thweekof T# ' gestation,_hematopoiesis_Ԁshiftsfromthewalloftheyolksactotheliver,andataboutthe24thweekfrom ,$!( thelivertothebonemarrow.%")$$   3.0  _Hematopoiesis_Ԁisregulatedbygraduallyincreasingerythropoietinlevelsstimulatedbylowoxygen &\$+ tensionsduringintrauterinelife.'4%,$$   4.0  At40weeks(fullterm),normalinfantshaveacordbloodhemoglobinof19+/2.2g/_dL_.Neonatesof <)&. lowerbirthweighthavelowernormalhemoglobinlevels.*'/$$   t-+3   5.0  Fetalredcellspresentatbirthhavea lifespanof4570days andcontain 5395%hemoglobinF (fetal X  hemoglobin).2$$ 0    a.0$$RedcellsrichinhemoglobinFarephysiologicallywelladaptedtolowintrauterineoxygentensions;  theirhighoxygenaffinityallowfetalredcellstoacquireoxygenfrommaternalRBCthroughout b pregnancyandreleaseittotheirtissues.:$$ 0    b.0$$However,thehighoxygenaffinityresultsinpoortissueoxygenationafterbirth.B$$ 0    c.0$$AshemoglobinA(adulthemoglobin)replaceshemoglobinFafterbirth,oxygendeliverytothetissues    remainssatisfactorydespiteaphysiologicfallinhemoglobinconcentration. r $$ 0    d.0$$Theoxygendissociationcurve(abilityofhemoglobintoreleaseoxygentothetissues)shiftstothe z "  right,reflectingimprovingoxygendeliverytothetissues.R $$ 0    e.0$$Prematureinfantshavelower_hematocrits_ԀandagreaterpercentageofhemoglobinFintheirRBC   thantermnewborns. $$   6.0  Astissueoxygenationinthenewbornimproves,levelsoferythropoietindeclineand_erythropoiesis_ 2 diminishes.b $$ 0    a.0$$ThisdeclineinRBCproducesa"physiologicanemiaofinfancy"andisanormal,expectedprocess.$$ 0    b.0$$Despitehemoglobinlevelsthatwouldindicateanemiainolderchildrenandadults,thenormally j developinginfantusuallymaintainsadequatetissueoxygenation.B$$ '  'C  .0    UniqueAspectsofNeonatalPhysiology'یJ$$ Ќ  0  1.  Introduction$$ 0    a.0$$Differencesbetweennewbornsandadultsmaydictatedifferencesintransfusionpractice.R$$ 0    b.0$$Newbornsaresmallandphysiologicallyimmature.*$$ 0    c.0$$Thoserequiringtransfusionareoften premature,sickandunabletotolerateminimalstresses.Z $$  0  2.0$$Infantsize"$$ 0    a.0$$Fulltermnewbornshaveabloodvolumeofapproximately85ml/kg(a6.6lbbabyhasatotalblood  f$ volumeofapproximately225_mLs_);prematureinfantshaveanaveragebloodvolumeof100ml/kg.!>%$$ 0    b.0$$Assurvivalratescontinuetoimproveforinfantsweighing1000g(2.2lbs)orlessatbirth,bloodbanks F# ' areincreasinglyaskedtoprovidebloodcomponentsforpatientswhosetotalbloodvolumeislessthan $!( 100_mLs_.$")$$ 0    c.0$$Thesmallbloodvolumesofneonatesandtheneedforfrequentlaboratorytestmakesreplacementof &N$+  iatrogenicbloodloss themostcommonindicationfortransfusionofthesepatients.~'&%,$$ 0  3.0$$Infantsdonotcompensatefor _hypovolemia_ aswellasadults.Thiswillcausediminishedcardiacoutput, 2)&. resultinginpoortissueperfusion,lowtissueoxygenationandmetabolicacidosis.*'/$$ 0  4.0$$Theinfant's bonemarrow respondsmoreslowlythanadultmarrowtoanemia.Ifhemolysisisoccurring +f)1 duetomaternalantibodytheremaybenoincreased_erythropoiesis_Ԁfor23weeksinthenewborn.,B*2$$   r-+3 0  5.0$$Coldstress( hypothermia )inthenewborncausesexaggeratedeffects,includingincreasedmetabolicrate, X  hypoglycemia,metabolicacidosisandatendencytoapneicepisodesthatmayleadtohypoxia,_hypotension_ 4 andcardiacarrest.Bloodfortransfusionshouldbewarmedifgiveninlargeamounts,smallamountsreach   RTinabout20minutesanddoesnotneedtobewarmed.$$ 0  6.0$$Infantsare immunologicallyimmature ,andantibodiespresentintheirplasmaoriginatealmostentirely < fromthematernalcirculation.p$$ 0    a.0$$ IgGistheonlyimmunoglobulinclassthatcrossestheplacenta . $$ 0    b.0$$Passivelyacquiredantibodyisconservedduringtheneonatalperiodduetoslowcatabolismbythe  |  fetus. T $$ 0    c.0$$Infantsexposedtoaninfectiousprocessin_utero_Ԁorshortlyafterbirthmayproducesmallamountsof \   IgMdetectablebysensitivetechniques,buttheyrarelyformRBCantibodiesofeitherclassduringthe 4  neonatalperiod.  $$ 0  7.0$$Graftversushostdisease(_GVHD_)d$$ 0    a.0$$_GVHD_Ԁhasbeenreportedinnewbornswhoreceivedintrauterinetransfusionfollowedbypostnatal l exchangetransfusion.D$$ 0    b.0$$Thelymphocytesgivenduringintrauterinetransfusionmayhaveinduced hosttolerance ,sothatthe  lymphocytesgiveninsubsequentexchangetransfusionwerenotrejectedinthenormalway.v$$ 0    c.0$$_GVHD_Ԁisnotfelttobeasignificantclinicalproblemfor immunologicallynormalnewborns who ~& receivemultipleexchangetransfusions.Z$$ 0    d.0$$Irradiationofbloodkillsimmunologicallycompetentlymphocytesandsomeneonatalnurseryunits   provideirradiatedbloodforlowbirthweight,lowgestationalageorsepticprematureneonatesbased  onthebelief,notyetuniversallyaccepted,thatsuchinfantsareimmunologicallymorevulnerableto b _GVHD_.:$$ 0    e.0$$Bloodforintrauterinetransfusionshouldbeirradiated.B!$$ 0    f.0$$Anydirecteddonorbloodfromarelativeshouldbeirradiated.#$$   8.0  Metabolicproblems!J%$$ 0    a.0$$Becauseimmaturekidneyshavereducedglomerularfiltrationrateandconcentratingability,the R# ' newbornmayhavedifficultyexcretingpotassium,acidand/orcalciumloads.*$!($$ 0    b.0$$Acidosisor_hypocalcemia_Ԁmayalsooccur_postransfusion_Ԁbecausetheimmaturelivermetabolizes %#* citrateinthebankedbloodinefficiently.&Z$+$$ 0    c.0$$Studieshaveshownolderunitsdonotaffecttheinfantforroutinetransfusionpurposes.b( &-$$   9.0  2,3_Diphosphoglycerate_Ԁ(2,3_DPG_)*'/$$ 0    a.0$$TissueoxygenationispoorinsicknewbornsduetothehighpercentageofhemoglobinF.Hemoglobin +j)1 Fdoesnotreleaseoxygentothetissueslikeadulthemoglobin.,B*2$$   r-+3 0    b.0$$Infantswithrespiratorydistresssyndrome(_RDS_)orsepticshockhavedecreasedlevelsof2,3_DPG_, X  andalkalosisandhypothermiacanfurtherincreasetheoxygenaffinityofhemoglobin,shiftingthe 0 dissociationcurvetotheleftmakingoxygenevenlessavailabletothetissues.$$ 0    c.0$$Since2,3_DPG_Ԁlevelsdecreaseinstoredblood,newbornsshouldbegiventhefreshestbloodavailable, ` lessthan5daysoldifpossible,toensurethatthetransfusedRBChaveadequate2,3_DPG_Ԁlevels.8$$ 0    d.0$$Thereiscontroversyinthefieldaboutthepracticeofusingfreshblood.Itiscurrentlyfeltbysome @ inthebloodbankfieldthatitisofgreaterimportancetodecreasethenumberofdonorexposures   ratherthangivefreshblood.Theseinstitutionsallow_CPD_Ԁdonorunitstobeputonholdfortheinfant    for21days. p $$   10.0  _Cytomegalovirus_Ԁ(_CMV_)Infectionx $$ 0  0$$0$$a.0 $$Infectionby_CMV_Ԁmayoccurintheperinatalperiod,eitherin_utero_Ԁorduringbirth,bybreast (  feedingorbyclosecontactwithmothersornurserypersonnel.  $ $ 0  0$$0$$b.0 $$_CMV_Ԁmaysalsobetransmittedbytransfusion.Thevirusseemstobeassociatedwithleukocytes X inbloodandcomponents.0 $ $ 0  0$$0$$c.0 $$Infectioninnewbornsisextremelyvariableinitsmanifestations,rangingfromasymptomatic 8 _seroconversion_Ԁtodeath. $ $ 0  0$$0$$d.0 $$Symptomaticinfectionmayproducepulmonary,hepatic,renal,hematologicand/orneurologic h dysfunction.@ $ $ 0  0$$0$$e.0 $$Epidemiologyandpreventionofposttransfusion_CMV_Ԁinneonatalpatientshavebeenunder H intenseinvestigation.Thefollowingobservationshavebeennoted:  $ $ Q%X X`  XX X` ,XQ0  0$$0$$ 1)0| $$Where_CMV_Ԁrateishigh,symptomaticinfectionislow.x| $| $ 0  0$$0$$ 2)0| $$Babiesofseropositivemomsareunlikelytodevelop_CMV_.P| $| $ 0  0$$0$$ 3)0| $$Prematureinfantswhoarebornof_seronegative_Ԁmothers,weighlessthan1200gramsand ( whorequiremultipletransfusionsareatriskforsymptomatic_postransfusion_Ԁinfections.X | $| $ 0  0$$0$$0 $$4)0| $ $Theriskof_CMV_Ԁincreaseswithnumberofdonorexposures.0!| $| $ 0  0$$0$$0 $$5)0| $ $Riskoftransmissiondecreasesbyusing_seronegative_Ԁdonorsorcomponentsdepletedof " leukocytes.#| $| $ 0  0$$0$$f.0 $$Standardsstatesthat,ingeographicareaswhere_postransfusion_Ԁ_CMV_Ԁtransmissionisa !8% problem,bloodwithminimalriskoftransmitting_CMV_Ԁbeusedfornewbornsweighinglessthan h" & 1200g,borntomotherswholack_CMV_Ԁantibodiesorwhoseantibodystatusisunknown. @# ' ( NOTE :Mostbloodbanksmakeitstandardpracticetotransfuse all infantswith_CMV_ $!( negativeblood).$") $ $ '  'sHD  .0    HemolyticDiseaseoftheNewborn(_HDN_)'sHHی&L$+$$ Ќ  0  1.0$$IntroductionT(%-$$ 0    a.0$$ In_HDN_,redcellsofthefetusbecomecoatedwithIgG_alloantibody_Ԁofmaternalorigin,directed ,)&. againstanantigenofpaternaloriginpresentonthefetalcells. *'/$$ 0    b.0$$TheIgGcoatedcellsundergoaccelerateddestruction,bothbeforeandafterbirth.+`)1$$ 0    c.0$$Clinicalseverityofthediseaseis extremelyvariable ,rangingfromintrauterinedeathtoacondition h-+3 thatcanbedetectedonlybyserologictestsonbloodfromanapparentlyhealthybaby.D.+4$$ _ԇ0  2.0$$_Pathophysiology_X$$ 0  0$$a.0$$ShortenedRBCsurvivalcausesfetal_hematopoietic_Ԁtissuetoincreaseproductionofnew_RBCs_,many  ofwhichenterthecirculationprematurelyasnucleatedredcells(_NRBCs_).$$ 0    b.0$$Organscontaining_hematopoietic_Ԁtissueincreaseinsize, particularlytheliverandspleen  8 (_hepatosplenomegaly_).l$$ 0    c.0$$Ifincreased_hematopoiesis_Ԁcannotcompensatefortheimmunedestruction,anemiabecomes   progressivelymoresevere.  $$ 0    d.0$$Theseverelyaffectedfetusmaydevelophighoutputcardiacfailurewithgeneralizededema,a  L  conditioncalled _hydrops_Ԁ_fetalis_ ,anddeathmayoccurin_utero_.| $ $$ 0    e.0$$Ifliveborn,theseverelyaffectedinfantsexhibitsheartfailureandprofoundanemia.. $$ 0    f.0$$Lessseverelyaffectedinfantscontinuetoexperienceacceleratedredcelldestruction,whichgenerates   largequantitiesofbilirubin.^$$ 0    g.0$$Beforebirthseversthecommunicationbetweenmaternalandfetalcirculation,fetalbilirubinis f processedbythemother'sliver,butafterbirththeneonatallivermustconjugateandexcretelarge > quantitiesof_unconjugated_Ԁindirectbilirubin,asubstancetoxictothedevelopingcentralnervous  system.$$ NH Hr$ | XX X`  XN0 r 0r$r$ $$ 0 r h.0r$r$Theimmatureliverisdeficientin _uridine_Ԁ_diphosphoglucoronyl_Ԁ_transferase_Ԁ (theenzymenecessary F toconjugatebilirubinforexcretion)andaccumulationof _unconjugated_Ԁbilirubinconstitutesasevere z" threattotheinfant.T$$ K"H H$ | XH Hr$ | XK0  0$$ 1)0$ $$Totalplasmabilirubinlevelsapproaching 20mg/_dL_ cancausementalretardationordeath.$ $$ $ 0  0$$2)0$ $$Bilirubin,onceitsconcentrationisexcessivecanaccumulateinthelipidrichtissueofthecentral \ nervoussystem,thisisclinicallyknownas kernicterus .4$ $$ $ N" x  [hXH H$ | XN  b I.0 $ Thethreatisincreasedbyprematurity,acidosis,hypoxiaand_hypoalbuminemia_Ԁ(albuminis >! necessary,alongwiththeenzyme,forconjugationofbilirubin)."$ $$ $ 0  0b$$j.0$ b$b$Fortheliveborninfantwith_HDN_,risingbilirubinlevelsmaybeagreaterclinicalproblemthan  n$ thelossofoxygencarryingcapacityresultingfromcontinuinghemolysis.!F%$ $$ $ 0  0b$$k.0$ b$b$Thedecisionofwhenorwhethertoundertakeexchangetransfusionisbasedprimarilyon N# '  bilirubinaccumulation ,andonanemiaandseverityofhemolysisonlytoalesserdegree.&$!($ $$ $ DD 3.0 b _HDN_Ԁisclassifiedinto three categoriesbasedonserologicspecificityofthecausativeIgGantibody. %#* Indescendingorderofseveritytheseare:&Z$+b$b$ 0  0b$$a.0$ b$b$ Rh(D)hemolyticdisease,duetoantiDaloneormorerarelyincombinationwithantiCor b( &- antiE.THISISTHEMOSTSEVERETYPEandmayresultinfetaldeath. WithantiD, >)&. thesecondinfantwillbeseverelyaffected,andfuturepregnancieswillusuallyresultinstillbirth *'/ duetotheincreasingpathogenicityoftheantibody. *(0$ $$ $ 0  0b$$b.0$ b$b$ "Other_HDN_" duetoantibodiesagainstotherantigensintheRhsystem, suchasantic,anti ,J*2 E,orantie, ortheantigensinotherbloodgroupssystems, suchasantiK,anti_Fya_andmany ~-&+3 others.Babyisusuallymildlyaffectedbutsevere_HDN_Ԁhasalsobeendocumented.Z.,4$ $$ $ Ї0  0b$$c.0$ b$b$ ABO_HDN_ , dueusuallytoanti_A,B_ԀinagroupOwoman, butrarelytoantiAorantiB. THIS X ISTHEMOSTCOMMONFORM,BUTALSOTHEMILDEST.4$ $$ $ 0  0b$$ d.0$ b$b$In_HDN_ԀotherthanABO,maternalantibodiesresultfromimmunizationbypreviouspregnancy  ortransfusion.Risingtitersofantibodycanbedocumentedduringthepregnancybyperforming d titrationstudies,andthebabymaybesymptomaticatbirth.<$ $$ $ 0  0b$$e.0$ b$b$InABO_HDN_Ԁtheimmunizingstimulusisseldomknown,theconditioncannotbediagnosedduring D pregnancyandisrarelysymptomaticatbirth. $ $$ $ DD 4.0 b Maternalimmunizationduetopregnancy. t b$b$ 0  0b$$a.0$ b$b$Whenimmunizationresultsfrompregnancy,theantigenicstimulusisentryintothemother's | $  circulationoffetalredcellspossessing paternalantigen whichthemotherdoesnotpossess T  whichsherecognizesasforeign.0 $ $$ $ 0  0b$$b.0$ b$b$TheantigenthatmostfrequentlyinducesimmunizationisD,butanyredcellantigenpresenton   fetalcellsandabsentfromthemothercan,intheory,stimulateantibodyproduction.`$ $$ $ 0  0b$$c.0$ b$b$Smallnumbersoffetalcellsenterthemother'scirculationduringthelasthalfofpregnancy,but h theyarerarelysufficienttoinduceimmunization.@$ $$ $ 0  0b$$d.0$ b$b$Mostimmunizationsresultfromthe_fetomaternal_Ԁhemorrhagethatoccursduringplacental  separationatdelivery.p$ $$ $ 0  0b$$e.0$ b$b$Inapproximatelyhalfofallrecentlydeliveredwomen,smallquantitiesoffetalcellsaredetectable x  inapostdeliverybloodspecimen.P$ $$ $ 0  0b$$f.0$ b$b$ ImmunizationtoDcanoccurwithvolumesoffetalbloodlessthat0.1ml. Theincidenceof  immunizationtoDcorrelateswiththevolumeofDpos_RBCs_ԀenteringtheDnegmother's  circulation.\$ $$ $ 0  0b$$g.0$ b$b$Althoughtheusualimmunizingeventisdelivery,primaryimmunizationdoesoccasionallyoccur d    duringpregnancyorafteramniocentesis,miscarriage,abortion,chorionicvillussampling, <! _cordocentesis_,blunttraumatotheabdomenorruptureofan_ectopic_Ԁpregnancy. "$ $$ $ DD 5.0 b MaternalImmunizationduetoTransfusion. l$b$b$ 0  0b$$a.0$ b$b$InDnegwomenwhoreceivetransfusionsofDpos_RBCs_,subsequentpregnancieswithaDpos t" & fetusarelikelytobecomplicatedbysevere_HDN_.L# '$ $$ $ 0  0b$$b.0$ b$b$Itis extremelyimportant toavoidtransfusingDposbloodtoDnegwomenwhomight $") subsequentlybecomepregnant.%~#*$ $$ $ 0  0b$$c.0$ b$b$The_RBCs_Ԁinplateletorgranulocyteconcentratescanconstituteanimmunizingstimulus,andD '.%, negwomenwhoreceiveplatelettherapyshouldbeconsideredcandidatesforRhprophylaxisif ^(&- thedonorsareDpos.6)&.$ $$ $ 0  0b$$d.0$ b$b$Directeddonortransfusionfromhusbandtowifeshouldbeavoidedifthecoupleplantohave *(0 children,asthisformofdirecteddonationwilllikelyincreasetheriskof_alloimmunization_Ԁofthe +f)1 mother.,>*2$ $$ $  F.+4 DD 6.0 b ABOAntibodiesXb$b$ 0  0b$$a.0$ b$b$TheIgGantibodiesthatcauseABO_HDN_Ԁnearlyalwaysoccurinthemother'scirculationwithout  ahistoryofpriorimmunizationbyforeigntransfused_RBCs_.$ $$ $ 0  0b$$b.0$ b$b$ABO_HDN_Ԁcandevelopinanypregnancyincludingthefirst,butitisrestrictedalmostentirelyto 8 groupAorBbabiesborntogroupOmothers.h$ $$ $ 0  0b$$c.0$ b$b$Thisisapparentlyattributabletothepathogenicantibody,anti_A,B_Ԁbeingpresentonlyingroup   Oindividuals.  $ $$ $ DD 7.0 b _HDN_ԀotherthanABO H b$b$ 0  0b$$a.0$ b$b$Thefirstbabyisnotaffectedorismildlyaffectedifthispregnancyistheimmunizingevent.P $ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $TheantibodiesproducedinaprimaryresponseareIgManddonotcrosstheplacenta.  $ $ 0  0b$$0$ b$b$2)0 $ $$ $AsufficienttiterofIgGmaynotdevelopduringthepregnancy,resultinginanasymptomatic   ormildlyaffectedinfant.X $ $ 0  0b$$b.0$ b$b$In"other"_HDN_,thefirstbabywillnotbeaffectedifthispregnancyistheimmunizingevent.`$ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $Theseverityoffuturebabiesbeingaffectedisextremelyvariable. $ $ 0  0b$$0$ b$b$2)0 $ $$ $Thepathogenicityoftheantibodywillvaryfromindividualtoindividual,andsowillthe  _HDN_Ԁwhichitwillcause.h $ $ 0  0b$$0$ b$b$3)0 $ $$ $Most"other"_HDN_Ԁcauseonlymildlysymptomatic_HDN_.@ $ $ '  'E  .0    PrenatalTests'یH$$ Ќ  0  1.0b$$SerologicStudiesb$b$ 0  0b$$a.0$ b$b$_Alloimmunization_Ԁthatcouldresultin_HDN_Ԁcanbediagnosedduringpregnancywithsuitable P serologictests.($ $$ $ 0  0b$$b.0$ b$b$Initialstudieson all pregnantwomenshouldincludetestsfor ABOandD(includingweakD), 0! andascreenforunexpectedantibodies.  "$ $$ $ 0  0b$$c.0$ b$b$Allpositiveantibodyscreensrequireidentificationoftheantibodyandevaluationoftheclinical  d$ significanceoftheantibodyidentified.!<%$ $$ $ 0  0b$$d.0$ b$b$Themerepresenceofanantibodydoesnotindicatethat_HDN_Ԁwillinevitablyoccur,clinical D# ' significancebasedonhistoryoftheantibodyasitrelatesto_HTR_Ԁand_HDN_.$!($ $$ $ 0  0b$$e.0$ b$b$IgMantibodiesexistingwithoutknownredcellstimulation,notablyantiLeaandantiI,are %t#* relativelycommonduringpregnancybutdonotcrosstheplacenta.&L$+$ $$ $ 0  0b$$f.0$ b$b$Treatingtheserumwith 2MEor_DTT_ willaidindistinguishingIgMantibodiesfromIgG.T(%-$ $$ $ 0  0b$$g.0$ b$b$Thefetusmaybeantigennegativeforthemother'santibody.*'/$ $$ $ 0  0b$$h.0$ b$b$Theresultsofprenatalantibodystudiesshouldbereportedwithsufficientadditionalinformation +`)1 toindicatewhenareportedantibodymayormaynotbeclinicallysignificant.,8*2$ $$ $   h-+3 0  0b$$_i_.0$ b$b$WhenthewomanhasantiD,someobstetricianstestthefathertoestimatethelikelihoodofhis X  beinghomozygousorheterozygousforallelesdeterminingthepresenceoftheDantigen.A 0 _homozygote_ԀwillalwaystransmitageneforDtotheoffspring,whereasinaheterozygousfather,  halfofthechildrenwillbeDneg.$ $$ $ F.0  AmnioticFluidAnalysis8$$ s\?/+b|0R+J `X@E +J +J l 7 sDD 1.0 b Duringgestation,theclinicalhistoryandamnioticfluidanalysiscanbeusedtoassesstheprobable h severityof_HDN_.@b$b$ DD 2.0 b AntiD_HDN_Ԁrarelyoccursinthefirstpregnancy,butonceawomanhasantiD,_HDN_Ԁtendstobecome H moreseverewitheachsucceedingDpospregnancy. b$b$ DD 3.0 b Informationabouttheseverityofthediseaseinpreviousinfantsissomewhathelpfulinpredicting x severityinsubsequentinfants.Pb$b$ DD 4.0 b InawomenwithantiD,theseverityoffetal_HDN_Ԁcorrelatesmodestlywiththematernalantibodytiter.X b$b$ DD 5.0 b Abetterindexofintrauterinehemolysisandfetalwellbeingisthelevelofbilepigmentinthe " amnioticfluid, obtainedbyamniocentesis,ordoinganH&Hontheinfant'sbloodobtainedbydirect # fetalbloodsamplingviatheumbilicalvein. h$b$b$ DD 6.0 b AmniocentesisisusuallyperformedinDnegwomenwithahistoryofpreviouslyaffectedpregnancies p" &  or withantiDtitersabove16.H# 'b$b$ DD 7.0 b Amnioticfluidisobtainedbyinsertingalongneedlethroughthemother'sabdominalwallanduterus $") intotheuterinecavity.Theaspiratedfluidisscannedspectrophotometricallyforachangeinoptical %|#* densityat 450_nm_ ,tomeasuretheconcentrationofbilepigments.&T$+b$b$ 0  0b$$a.0$ b$b$Thisvalueisplottedona_semilogarithmic_Ԁgraphagainsttheestimatedageofgestation,because ^(&- bilepigmentconcentrationhasclinicalsignificanceatdifferentgestationalages.6)&.$ $$ $ 0  0b$$b.0$ b$b$Ingeneral,thehigherthepigmentconcentration,themoreseveretheintrauterinehemolysis.*(0$ $$ $   n-+3 DD 8.0 b Theriskofallowingaseverelyaffectedpregnancytocontinuemustbeweighedagainsttheriskof X  prematuredeliveryandtheproblemsoffetallungimmaturity.0b$b$ 0  0b$$a.0$ b$b$RespiratoryDistressSyndrome(_RDS_)mayresultwhenthereisinadequatesurfactantlecithinand  otherpulmonarylipidstomaintainstablepulmonaryalveolarstructuresinthenewborn.`$ $$ $ 0  0b$$b.0$ b$b$Maturityofthefetallungisassessedbydeterminingtheratiooflecithinto_sphingomyelin_Ԁ(L/S h ratio)andlevelsof_phosphotidylglycerol_Ԁ(PG)intheamnioticfluid.@$ $$ $ 0  0b$$c.0$ b$b$Ifthechangeinopticaldensityat450_nm_Ԁindicatessevere_HDN_ԀbuttheL/Sratioindicatesthe    lungsarenotsufficientlymaturetoprevent_RDS_,intrauterinetransfusionmaybeindicated. p $ $$ $ DD 9.0 b Amniocentesisanddirectfetalbloodsamplingmaybecomplicatedby_fetomaternal_Ԁhemorrhage(_FMH_), x  whichcancauseimmunizationofsusceptiblemothers.P b$b$ 0  0b$$a.0$ b$b$IfamniocentesishasbeenperformedonanDnegwomanwhois not alreadysensitizedtotheD   antigen,Rh_immunophrophylaxis_Ԁshouldbegiven. $ $$ $ 0  0b$$b.0$ b$b$InmostcasestheDstatusofthefetuswillbeunknown,butthelikelihoodishighthatitisDpos 4 andthebleedinginducedbyamniocentesiscouldinduceantiDinanonimmunizedwomen.d $ $$ $ 0  0b$$c.0$ b$b$ _Cordocentesis_ istheprocesswherebyaneedleisinsertedintothebabysumbilicalcordallowing  thedrawingoffetalbloodforlaboratoryanalysis(previouslycalled_percutaneous_Ԁumbilicalblood  samplingPUBS)n$ $$ $  10.0 b Duetothehazardsofamniocentesisand_cordocentesis_,thenoninvasivemonitoringprotocols,including v greateruseofultrasoundevaluationsoffetalwellbeing,arebeingrecommended.Nb$b$ '  'G  .0    IntrauterineTransfusion'ی$$ Ќ  DD 1.0 b Intrauterinetransfusion carriesahighrisktothefetus andshouldbeperformedonlyafter careful  V clinicalevaluation.2b$b$ DD 2.0 b Intrauterinetransfusionisrarelyfeasiblebeforethe20thweekofgestation.:!b$b$ 0  0b$$ b$b$ DD 3.0 b Onceinitiated,theseriesisusuallyadministeredeverytwoweeksuntildelivery.#b$b$ 0  0b$$a.0$ b$b$Itisperformedthroughaneedlepassedwithradiographicmonitoring,throughthemother's !B% abdominalanduterinewallintothefetalabdominalcavity.r" &$ $$ $ 0  0b$$b.0$ b$b$Thetransfusedredcellsenterthefetalcirculationbyabsorptionfromlymphaticchannelsdraining "$!( theperitonealcavity.$")$ $$ $ 0  0b$$c.0$ b$b$Bloodcanalsobeinfuseddirectlyintotheumbilicalveinbyaprocedurecalled_percutaneous_ &R$+ umbilicalbloodtransfusion(_PUBT_)orby_cordocentesis_.'*%,$ $$ $ DD 4.0 b Formaximumsurvival,transfusedcellslessthan5daysoldshouldbeused.2)&.b$b$ DD 5.0 b Washedordeglycerolizedfrozenredcellshavenormalelectrolytelevels,containnoanticoagulantor *(0 plasma,haveverylowlevelsofplateletsandleukocytes,havealowriskof_CMV_Ԁandisthecomponent +b)1 ofchoice.,:*2b$b$  B.+4 DD 6.0 b A_hematocrit_Ԁof80%orgreaterisdesirabletominimizethechanceofvolumeoverloadinthefetus.Xb$b$ DD 7.0 b Theredcells mustbegroupO,Dnegandmustbecompatiblewiththemother'sserum,lackingany  antigenstowhichshemayhaveantibodies. b$b$ DD 8.0 b Thevolumetransfusedrangesfrom75175mLdependingonthefetalsizeandage.8b$b$ DD 9.0 b Bloodforintrauterinetransfusions shouldbeirradiatedbecauseofthepotentialriskof_GVHD_.@b$b$   10.0 b Newbornswhohavehadsuccessfulintrauterinetransfusionsoften typeatbirthasDneg orveryweakly    positive,becauseatbirthover90%oftheircirculating_RBCs_Ԁmaybethoseofthedonors.Similarly,the  v  ABOgroupingandDATmaygivemisleadingresultsaswell. N b$b$ H.0  IntrauterineExchangeTransfusionV $$ DD 1.0 b Newmedicaltechniqueshavebeendevelopedforperformingintrauterineexchangetransfusion. b$b$ DD 2.0 b Underultrasoundguidance,theumbilicalveinis_cannulated_Ԁandabloodsampletakenforimmediate ^ H&Hmeasurementandverificationofcatheterlocationinthefetalcirculation.6b$b$ DD 3.0 b Theasyetunbornbabycanthusundergoandexchangetransfusion.>b$b$ I.0  LaboratoryInvestigationDuringtheNeonatalPeriod$$ DD 1.Introduction F   b a.0 $ Asampleofcordblood,preferablycollectedbysyringe,toavoidcontaminationbyWharton's N jellyandmaternalbloodanddebris,shouldbeobtainedoneverynewborn.&$ $$ $ 0   b b.0$ $$Thistubeshouldbeidentifiedascordbloodandbelabeledinthedeliverysuitewiththemother's ~ name,hospitalnumberanddate.V$ $$ $ 0   b c.0$ $$Samplesshouldbestoredinthebloodbankforatleast7days.Thecordsampleisthenavailable ^  fortestingifthenewborndevelopssignsandsymptomssuggestiveof_HDN_.6!$ $$ $ 0  2.0b$$Postpartumtesting#b$b$ 0   b a.0$ $$ABO,D(includingtestforweakD)andantibodyscreenonthemother.!>%$ $$ $ 0  0b$$b.0$ b$b$Identificationandevaluationof_alloantibodies_Ԁdetectedinmaternalsample.F# '$ $$ $ 0  0b$$c.0$ b$b$ABOtestingonthe_cordblood_Ԁorbabiesbloodreliesentirelyoncellgroupingbecauseantibodies $") inthebabiesserumorplasmaareofmaternalorigin. Reversegroupingisnotdone. %v#*$ $$ $ 0  0b$$d.0$ b$b$Deter_mination_Ԁofthebaby'sDtype(includingDu)mustbedonebutmaybedifficult.'*%,$ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $ Falsenegativedueto"blockedD" ,allDantigensitesarecoatedwithmaternalantiD,no 2)&. sitesleftforattachmentofreagentantiD. *'/ $ $ 0  0b$$0$ b$b$2)0 $ $$ $Falsepositiveduetocontaminationwith Wharton'sjelly .+d)1 $ $  H.+4 0  0b$$e.0$ b$b$ADATshouldbeperformedonthecordcells.X$ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $IftheDATispositive,theantibodycanbe_eluted_Ԁfromthecellsandtestedforspecificity. $ $ 0  0b$$0$ b$b$2)0 $ $$ $TheDATusuallygivesstronglypositiveresultsin_HDN_ԀduetoantiDorantibodiesinother  bloodgroups;reactionsaremuchweakerornegativein_HDN_ԀduetoABO.` $ $ 0  0b$$f.0$ b$b$IftheDATispositiveandthematernalserumhasanegativeantibodyscreeningtest,suspicion h fallsonABO_HDN_Ԁor_HDN_Ԁduetoantibodyagainstalowincidenceantigen.@$ $$ $ 0  0b$$g.0$ b$b$ABOhemolyticdiseasemaybesuspectedonclinicalgroundseventhoughtheDATisnegative.  $ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $InmanycasesitispossibletoeluteantiAorantiBfromtheinfant'scellsdespiteanegative  H  DAT.x  $ $ 0  0b$$0$ b$b$2)0 $ $$ $Iftransfusionisrequired,GroupO,DcompatiblebloodshouldbetransfusedP  $ $ __0  3.0b$$LaboratoryDiagnosisofSeverityof ABO_HDN_  b$b$ 0   b a.0$ $$HemolyticdiseasecausedbyABOincompatibilityis clinicallymild,withjaundicemost Z frequentlydevelopingwithin24hoursofbirth .Thelaboratoryprofileofthisformof_HDN_ 6 consistsof(MEMORIZE)thefollowing:j$ $$ $ 0  0b$$ $ 1) Typeandscreenonmotherb$b$ 0  0b$$ $ 2) Direct_antiglobulin_Ԁtestoninfantb$b$ 0  0b$$ $ 3) ABO/Dtypeofinfantrb$b$ 0  0b$$ $ 4) AntibodyelutiontestingfromcordredbloodcellsJb$b$ 0  0b$$0$ b$b$5) Bilirubinassayoninfantz"$ $$ $ 0  0b$$0$ b$b$6) CBCand_Reticulocyte_ԀcountoninfantR$ $$ $ 0  0b$$b.0$ b$b$ABOgroupingmostcommonlyrevealsthemothertobegroupOandthebabytobegroupAor  B.$ $$ $ 0  0b$$c.0$ b$b$TheDATmaybeeithernegativeorweaklypositive.Thelackofconsistencyinthistestmaybe 2 dueto:b  $ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $Aweakantigenantibodyreaction,whichcausesantibodytoberemovedduringthewashing " phaseoftheDAT,# $ $ 0  0b$$0$ b$b$2) anantibodytiterthatmaybetoolowtobedetectable, j$$ $$ $ 0  0b$$0$ b$b$3) variationinfetalABOantigendevelopment.!B%$ $$ $ 0  0b$$d.0$ b$b$ AntibodyelutionofcordbloodmayrevealthepresenceofimmuneantiAorantiB .An J# ' eluateisoftenmoreusefulthantheDATinassessing_HDN_ԀcausedbyABOincompatibility.&$!($ $$ $ _  b  $   |     X      `      h _0  0b$$e.0$ b$b$Thebilirubinassaymayexceedthenormalvalues.%~#*$ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $_Hyperbilirubinemia_Ԁmayalsobeseeninconditionssuchasprematurebirthor !  $  '.%, maternaldiabetes.^(&- $ $ 0  0b$$0$ b$b$2)0 $ $$ $_HDN_Ԁisjudgedtobeclinicallysignificant(_phototherapy_Ԁtreatment)ifthepeakbilirubinlevel *'/ reaches12mg/_dL_Ԁormore.*(0 $ $  F.+4 _0  0b$$f.0$ b$b$HemoglobinmaybeslightlylowerthaninABOcompatibleinfants.X$ $$ $ 0  0b$$0$ b$b$1) Normalhemoglobinconcentrationsrangefrom15to20g/dL.$ $$ $ 0  0b$$0$ b$b$2)0 $ $$ $TheperipheralsmearmayrevealRBCsabnormalitiessuchashypochromia,  microspherocytosis,andreticulocytosis.ImmaturenucleatedRBCsmaybeincreased.` $ $ 0  4.0b$$TreatmentofABOHDNhb$b$ 0  0b$$a.0$ b$b$ExceptintheextremelyrarecasesofsevereHDNproducedbyABOincompatibility,    phototherapyistheusualtreatment.   $ $$ $ 0  0b$$b.0$ b$b$Phototherapyusesultravioletlightthatreactswithbilirubinnearthesurfaceoftheskin. H $ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $Thisprocessslowlydecomposes/convertsbilirubinintoanontoxicisomer, !  P   photobilirubin, whichistransportedintheplasmatotheliver.(  $ $ 0  0b$$0$ b$b$2)0 $ $$ $Therethemoleculesarerapidlyexcretedintheformofbilewithoutbeingconjugated.  $ $ 0  0b$$c.0$ b$b$TheneedforexchangetransfusionisrareincasesofABOincompatibilitybecauseofthe 2 generallymildnatureofthistypeofHDN.b $ $$ $ 0  0b$$0$ b$b$1)0 $ $$ $Oneoftherisksofexchangetransfusioninthesecasesisthetriggeringofyetmore  hemolysisduetoatechniciantransfusingababywithadultAorBcellsthatwillinteract  withcirculatingmaternalIgGantiA,Binthebaby'scirculation.j $ $ 0  0b$$0$ b$b$2)0 $ $$ $ ThebloodforexchangemustbecompatiblewithbabyANDmother.IfmotherisGroup r OthanbloodfortransfusionmustbeGroupOandDcompatiblewiththeinfant. L $ $ 0  5.0b$$LaboratoryDiagnosisofHDNdueto"Other"BloodGroupAntibodies.b$b$ 0  0b$$a.0$ b$b$Whenperformingatypeandscreenonthemother theantibodyscreenispositive. T$ $$ $ 0  0b$$b.0$ b$b$Apanelisperformed,onthemother'sserumand theantibodyisidentified ,anditisdetermined `  thatitisaclinicallysignificantantibody(IgG).Morethan40antigenshavebeenidentifiedas <! causingHDN."$ $$ $ 0  0b$$c.0$ b$b$TheDATperformedontheinfant'scordbloodispositive.Thestrengthofreactionmayvaryfrom  l$ weaklytostronglypositive.!D%$ $$ $ 0  0b$$d.0$ b$b$ Aneluateisperformedonthecordcells ,theeluateistestedagainstapanelofRBCs(including L# ' AandBcellsifmotherisOandbabyisAorB). Thespecificityoftheantibodyisdetermined. ($!($ $$ $ 0  0b$$e.0$ b$b$Bilirubinlevelsaredeterminedandevaluated.%#*$ $$ $ 0  0b$$f.0$ b$b$CBCandreticulocytecountaredeterminedandevaluated.'4%,$ $$ $ 0  6.0b$$Treatment<)&.b$b$ 0  0b$$a.0$ b$b$Iftheantibodyisdetectedprenatally,antibodytitersandamniocentesesmaybeindicated.*(0$ $$ $ 0  0b$$b.0$ b$b$Dependingontheantigenstrengthonthebaby'scellsandothervariables, theseverityofthe ,D*2 disordercanrangefrommildtosevere. x- +3$ $$ $  T.+4 0  0b$$c.0$ b$b$ MostcasesofHDNdueto"other"bloodgroupantibodiessimplyrequirephototherapy. X$ $$ $ 0  0b$$d.0$ b$b$ Insomerareinstancesexchangetransfusionisnecessary.Thebloodforexchangemustbe   compatiblewithbabyandmother,andlacktheantigen(s)towhichthemotherhasproduced  antibody(ies). h$ $$ $  '  Q% x  [hX x  [hXQ'XJ  .0 t   HDNCausedbyDIncompatibility'X یpt$t$ Ќ  0 t 1.0t$t$History $$ 0 t 0t$t$a.0b$$Intheearly1930'sDiamond,BlackfanandBatymadetheclassicobservationsthat kernicterus,hydrops  x  fetalisandanemia inthenewbornrepresenteddifferentgradesofclinicalseverityofthesameunknown  R  process.Unfortunately,theydidnotsuspectthatthissyndromewasamanifestationofhemolyticanemia  ,  affectingthefetus.Thisprocesswasoriginallyreferredtoas erythroblastosisfetalis .\  b$b$ 0 t 0t$t$b.0b$$In1938Darrowsuggestedthatthisprocesswasahemolyticanemiacausedbythetransferofimmune   bodiesfromthemothertothefetus.Becauseshehadnodatatosupportherhypothesis,sheincorrectly   selectedfetalhemoglobinasthecausativeagent.fb$b$ 0 t 0t$t$c.0b$$ThedevelopmentalworkontheRhfactor(Dantigen)conductedbythemajorinvestigators,Landsteiner n andWiener,ledLevinetoestablishthattheDantigenwastheimmunizingagentinthebloodofthe F fetus.b$b$ 0 t 0t$t$0b$$1)0$ b$b$HespeculatedthattheDantigenwasnotpresentinthemotherbutinheritedbythefetusfromthe v father.N$ $$ $ 0 t 0t$t$0b$$2)0$ b$b$In1941,Levineconcluded,basedonexperimentalandcasestudydata,thatthemajorityofcases V ofHDNinthefetus/newbornresultedfromimmunizationofanDnegativemothersbytheD . positiveerythrocytesofthefetus.$ $$ $  t DD 2.0 b TypesofResponderstoImmunizationtotheDAntigen^b$b$ 0 t 0t$t$0b$$a.0$ b$b$TheimmunizationofDnegativemothersdependsonboththedosageofDpositiveRBCsandthe f  mother'sabilitytorespondtotheseforeignDantigens.>!$ $$ $ 0 t 0t$t$0b$$b.0$ b$b$AboutonethirdofallDnegativepersonsareclassifiedasnonresponders.Nonrespondersfailto # formantiDdespiterepeatedinjectionsofDposRBCs. n$$ $$ $ 0 t 0t$t$ b c.0$ $$Inadditiontothenonresponderstatus,twoothercategoriesexist:respondersandhyperresponders.v" &$ $$ $ 0 t 0t$t$0b$$ $ 1)0 b$b$ResponderandhyperrespondersdifferintermsofthetypeandquantityofantiDantibody &$!( thattheyproduce.$") $ $ 0 t 0t$t$0b$$ $ 2)0 b$b$HyperrespondersproduceextremelyhightitersofbothIgMandIgGtypesofantiD.&V$+ $ $ 0 t 0t$t$0b$$d.0$ b$b$ThenormalpatternofimmunizationinaDnegmotherinvolvesprimaryimmunizationdueto ^(&- previouslyDpospregnancyorbloodtransfusionwhichstimulatestheproductionoflowtitered 6)&. antiD.*'/$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $Subsequentantigenicstimulationsuchasfetalmaternalhemorrhageinawomanpregnant +f)1 withaDposfetuselicitsasecondaryresponse.,>*2 $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $CharacterizedbythepredominanceofincreasingtitersofantiDoftheIgG_class.F.+4 $ $ Ї0 t 0t$t$0b$$e.0$ b$b$Levineobservedasearlyas1943thata conditionof_HDN_ԀduetoABOincompatibilitybetween X themotherandfetus reducedthechanceofmaternalimmunizationtheDantigen. 4$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $DnegwomenwithgroupObloodandABOincompatible,Dposbabiesweremorestrongly  protectedduetotheABOantibodies(especiallyanti_A,B_)inthematernalcirculation.h $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $Thisantibodycausesdestructionofthebabycellsbeforetheycanberecognizedasforeign p bythemother.H $ $  t DD 3.0 b Signs,SymptomsandPhysiologyof_HDN_ԀCausedbyantiD  b$b$ 0 t 0t$t$0b$$a.0$ b$b$Exceptinrareinstances,the firstborn DposinfantofaDnegmotherseldomshowsclinicalsigns  P  of_HDN_ԀandmaysimplyhaveapositiveDAT. * $ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Ifsevere_HDN_ԀisobservedinafirstbornDposinfant,itmustalwaysbesuspectedthatthemother 2  waspreviouslyimmunizedbeforethepregnancybymeansofapreviousbloodtransfusion,    abortion,etc. $ $$ $ 0 t 0t$t$0b$$c.0$ b$b$WhenthemotherhasbeenpreviouslyimmunizedandsubsequentlyproducesantiDoftheIgG : typeinresponsetoaDposfetus,thefollowingactivitiesoccur:j$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $ThepassageofIgGantiDintothefetalcirculationinduces_RBCs_Ԁhemolysisandanemiaof  varyingdegreesofseverity. $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $Thisanemiamayproduceheartfailureandhypoxiaintheunbornchild,causingstillbirth J orrapidaccumulationofbilirubininthenewborn.z" $ $ 0 t 0t$t$0b$$d.0$ b$b$Oncean_alloantibody_ԀsuchasantiDhasbeenidentifiedinmaternalserum,arisingantibodytiter * isevidenceofapresentlyactiveimmuneresponse.$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $Theseverityof_HDN_,however,doesnotcorrelatewellwithmaternalantiDtiter.Z $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $Thediscrepancyobservedbetweentheseverityof_HDN_Ԁandtheantibodytitermaybedue b   todifferencesinthenatureofIgGantibodies.:! $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $FetalhemolysisisessentiallyduetoantibodiesoftheIgG1andIgG3subclasses.# $ $ 0 t 0t$t$0b$$ b$b$ 0 t 0t$t$4.0b$$LaboratoryDiagnosisof_HDN_ԀDuetoAntiD!B%b$b$ 0 t 0t$t$0b$$a.0$ b$b$Adetectableantibodytiterisrarelyobservedbefore28weeksgestationinthefirstimmunizing J# ' pregnancy."$!($ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $WhenantiDdevelopsduringthefirstpregnancy,itismostcommonlydetectedataboutthe %z#* 35thweekofgestationorlater.&R$+ $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $Thetiterisusuallylow.'*%, $ $ 0 t 0t$t$0b$$b.0$ b$b$Insubsequentpregnanciesamniocentesismaybeperformedincaseswheretheserumtiterofanti 2)&. Dis16orhigherinawomanwithahistoryofapreviouschildwhoneededanexchange  *'/ transfusion,oraprogressiveriseinantiDto64withoutahistoryofanaffectedfetusorchild.*(0$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$Insuchcases,aninitialamniocentesiswouldbedoneat24to28weeksofgestationor6to8 ,:*2 weeksbeforethegestationalageofpreviousfetallossduetoantiD.Twosequentialamniotic j-+3 specimensarerequiredtoassesschangeinthestatusofthefetus.B.+4$ $$ $ Ї0 t 0t$t$0b$$d.0$ b$b$ Theidentificationof_HDN_ԀpostpartumduetoantiDischaracterizedbythefollowingtest X results:2$ $$ $  0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $Dbloodtyping(babyisDorweakDpositive) $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $_Cordblood_ԀDATispositiveandthemotherdemonstratesapositive_IAT_ԀwithantiD ` identifiedastheantibody.8 $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $EluateperformedoncordcellsrevealsthepresenceofantiD.h $ $ 0 t 0t$t$0b$$0$ b$b$4)0 $ $$ $Hemoglobinlevelsofbabymaybemoderatelytoseverelydecreased.@ $ $ 0 t 0t$t$0b$$0$ b$b$5)0 $ $$ $Infantbilirubinlevelsof20mg/_dL_Ԁormoreatbirtharepresentinseverelyaffectedfullterm   infants,andlowerlevelsinprematureinfantsarepresentinseverelyaffectedinfants.   $ $ 0 t 0t$t$0b$$0$ b$b$6)0 $ $$ $CBConinfantindicativeofsevereanemia. p  $ $  t DD 5.0 b Treatmentx b$b$ 0 t 0t$t$0b$$a.0$ b$b$Intheseverelyaffectedinfant exchangetransfusion isneededtosavetheinfant.( $ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Removingthebabiesplasma reducestheloadofaccumulatedbilirubinandthenumberof   unboundmaternalantibodymolecules. ^$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$Replacementwithdonorplasmarestoresalbuminandanyneededcoagulationfactors.f$ $$ $ 0 t 0t$t$0b$$d.0$ b$b$ Antibodycoatedcells,whosedestructionwouldfurtherraisethebilirubinload,areremoved  andreplacedwith_RBCs_Ԁcompatiblewiththematernalantibody,whichwillhaveanormal  survivalrate.r$ $$ $ 0 t 0t$t$0b$$ e.0$ b$b$Theimmediateeffectivenessofatwovolumeexchangetransfusionis4550%.Thebaby'splasma z" bilirubintendsto riseorrebound afteranexchangetransfusionbecause:R$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $oftheentryofbilirubinfromthe_extravascular_Ԁspacesandtissuesand, $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $partlybecauseofcontinuedproductionofbilirubinfromresidualmaternalantibodycoating  newlyreleased_RBCs_.\ $ $ 0 t 0t$t$0b$$f.0$ b$b$Additionalexchangesarenecessaryifthebilirubinlevelthreatenstoexceed20mg/_dL_Ԁinafull d   terminfant.<!$ $$ $ 0 t 0t$t$0b$$g.0$ b$b$_Phototherapy_Ԁisusedasanadjunctinthissituation.#$ $$ $ 0 t 0t$t$0b$$ b$b$ '  '/K  .0 t   ExchangeTransfusion'/J ی!D%t$t$ Ќ  0 t DD 1.0bt$t$Exchangetransfusion,originallyusedalmostexclusivelyastreatmentfor_HDN_,hasrecentlybeen L# ' advocatedasadjunctivetherapyforavarietyoflifethreateningdiseasesaffectingnewbornsincluding $$!( _RDS_,_DIC_Ԁandsepsis.$")b$b$ 0 t DD 2.0bt$t$Theprocedurecarriesamortalityrateofapproximately1%andtheremaybesubstantialmorbidity.&T$+b$b$ 0 t DD 3.0bt$t$Exchangetransfusionisoftenquantified(_eg_,twovolume,singlevolume)toreflecttheeffectonthe \(&- infant'stotalbloodvolume.4)&.b$b$ 0 t DD 4.0bt$t$ Bloodselectedforexchangetransfusionshouldbeasfreshaspossible,preferablylessthan7days *(0 old,negativeforhemoglobinSand_CMV_Ԁnegative. +f)1b$b$ 0 t DD 5.0bt$t$ Thebloodmustlackallantigenstowhichthemotherhasantibodies .l-+3b$b$  F.+4 0 t DD 6.0bt$t$ To_crossmatch_Ԁbloodforexchangetransfusion,theserumorplasmaofeitherthemotherorinfant X maybeused. 4b$b$ 0 t 0t$t$0b$$a.0$ b$b$Themother'sserumhastheadvantageofbeingavailableinlargequantity,havingtheantibody  presentinhighconcentration,andiscapableofbeingaccuratelyandcompletelyanalyzedbefore d birth.<$ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Iftheinfantistobetransferredtoanotherfacility,aspecimenofmaternalbloodshould D accompanythechild. $ $$ $ 0 t DD 7.0bt$t$ Ifthematernalbloodisnotavailable,orifitisunsuitableforimmediateusein_crossmatching_,  t  eithertheinfant'sserumor,ifnecessary,aneluatefromtheinfant'scells,orbothcanbeusedfor  P  _crossmatching_.  ( b$b$ 0 t 0t$t$0b$$a.0$ b$b$Theeluateprovidesaconcentratedpreparationoftheantibodiesresponsiblefor_RBCss_ 0  destruction,butwillnotcontainantibodiesagainstantigensabsentfromtheinfant'scells. $ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Theserummaynotcontainahighconcentrationoftheantibodyifmostofthemoleculesare ` boundtothe_RBCs_.8$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$Neithertheinfant'sserumnoreluatealoneisidealfor_crossmatching_.Useofeitherorbothmay, @ however,bepreferabletodelayingtransfusionwhileamaternalspecimenisobtainedorwhilethe  antibodiesinthemother'sserumareseparatedandidentified.$ $$ $ 0 t DD 8.0bt$t$Selectionofbloodfor_HDN_ԀduetoantiDHb$b$ 0 t 0t$t$0b$$a.0$ b$b$ABO_HDN_ԀusegroupO,DspecificP$ $$ $ 0 t 0t$t$0b$$b.0$ b$b$ForantiDuseDnegative($ $$ $ 0 t 0t$t$0b$$c.0$ b$b$NoteveryexchangerequiresOnegative.IfmomandbabyareofthesameABOgroup,group  specific_RBCs_Ԁcanbeused,iftheantibodyisnotantiD,Dspecificmaybeused.$ $$ $ 0 t 0t$t$9.0b$$Whenindoubt,ausefulconsiderationtokeepinmindtopreventfurtherdamagetotheinfantisthatthe 0 bloodselectedshouldbe negativeforantigenswhichthemotherhasantibodiestoandbe_crossmatch_ `  compatiblewithbabyandmother. :!b$b$ L.0 t ObstetricalConsiderations#t$t$ 0 t DD 1.0bt$t$RhImmuneGlobulin(_RhIg_)isaconcentratedsolutionofIgGantiDderivedfromhumanplasma.!@%b$b$ 0 t 0t$t$0b$$a.0$ b$b$A1mlfulldosevial,containing 300_ug_ԀofantiD ,issufficientto counteracttheimmunizing H# ' effectsof15mlofDpos_RBCs_;thiscorrespondsto30mloffetalwholeblood. $$!($ $$ $ 0 t 0t$t$0b$$b.0$ b$b$_RhIG_,likeotherimmunoglobulinpreparations,doesnottransmithepatitisorHIVinfection.%|#*$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$Theprotectiveeffectof_RhIG_ԀonDnegindividualsexposedtoDpos_RBCs_Ԁprobablyresultsfrom ',%, interferencewithantigenrecognitionintheinductionphaseofprimaryimmunization.\(&-$ $$ $ 0 t 0t$t$0b$$d.0$ b$b$_RhIG_Ԁwasinitiallyutilizedexperimentally._RBCs_ԀwerecoatedwithantiDinvitrotheninjected  *'/ intoDnegindividuals.AfterrepeatedinjectionsoftheDposcoatedcells,Dnegindividuals *(0 failedtoproduceantiD.+d)1$ $$ $ 0 t 0t$t$0b$$e.0$ b$b$ThiswasamajorbreakthroughinthepreventionofhemolyticdiseaseduetoantiD.l-+3$ $$ $  D.+4 0 t 0t$t$0b$$f.0$ b$b$Thefrequencyof_HDN_ԀcausedbyantiDhasdeclineddramaticallyintheU.S.sincethe X introductionofwidespreadpostpartumadministrationof_RhIG_.In1968,_RhIG_Ԁbegantobecome 0 availabletopostpartumDnegwomenwhohaddeliveredanDposinfant.$ $$ $ 0 t 0t$t$0b$$g.0$ b$b$Inarelativelyshorttime,theincidenceofimmunizationwiththedemonstrationofantiDdropped ` dramaticallydroppedfrom8%afterthefirstpregnancy,withanadditional8%developingantiD 8 duringtheirsecondpregnancy,to1to2%.h$ $$ $  t DD 2.0 b _Antepartum_Ԁadministration b$b$ 0 t 0t$t$0b$$a.0$ b$b$ItwasdiscoveredthateventhoughanDnegwomanwasidentifiedandgiven_RhIG_Ԁaftergiving  p  birthtoanDposchild,therewerestill _RhIG_Ԁ"failures" ,thewomancameinwithasecond  H  pregnancyandtestingrevealedthatshehadbecomesensitizedtotheDantigen.z " $ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Theriskof1%immunizationisdecreasedfurtherto0.1%if_RhIG_Ԁisgiven_antepartum_Ԁat28weeks *  gestation, inadditiontothepostpartumdose.  $ $$ $ 0 t 0t$t$0b$$c.0$ b$b$TheAmericanCollegeofObstetriciansandGynecologistshasrecommended_RhIG_Ԁ_antepartum_ \ prophylaxis.4$ $$ $ 0 t 0t$t$0b$$d.0$ b$b$When_antepartum_Ԁ_RhIG_Ԁisgiven,goodcommunicationmustexistbetweenthepatient'sphysician < andthebloodbankstaffofthehospitalwherethepatientwillbedelivered,sothatlaboratorytests  madeatthetimeofdeliverywillbecorrectlyinterpreted.$ $$ $ 0 t DD 3.0bt$t$TestingatDelivery.Db$b$ 0 t 0t$t$0b$$a.0$ b$b$StandardsdoesnotrequirethatbloodfromDnegwomenbetestedatthetimeofdeliveryforthe L presenceofunexpectedantibodies,butitisstandardpracticeinthefieldtoperformaTypeand $ Screenonallwomenadmittedfordelivery,abortionoranyinvasiveobstetricprocedure.$ $$ $ 0 t 0t$t$0b$$b.0$ b$b$TheDtestonthemothershouldincludeDuifthereisnotimmediateagglutinationwithantiD.T$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$CordbloodfrominfantsborntoDnegmothersshouldhaveanABOandDtypeperformed.\ $ $$ $ 0 t 0t$t$0b$$d.0$ b$b$Themother'santibodystatusandtheinfant'sclinicalconditionshoulddictatewhetherornota  " DATshouldbedone.InsomehospitalsitisroutinetoperformABO,DandDATtestingonall # DnegandGroupOmothers. d$$ $$ $  t DD 4.0 b Womenwho arenotcandidatesfor_RhIG_ includethefollowing( MEMORIZE ):l" &b$b$ 0 t 0t$t$0b$$a.0$ b$b$DnegwomenwhohaveDneginfants. $!($ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Dposwomen.Althoughonecaseof_HDN_Ԁhasbeenreportedinvolvinganinfantwhosemother %x#* wasoftheDuphenotype,thisisextremelyrareanddoesnotjustifyroutine_RhIG_Ԁprophylaxisin &P$+ womenoftheDuphenotype.'(%,$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$DnegwomenknowntobeimmunizedtoD.SincethepresenceofantiDinthepostpartum 0)&. specimenmayactuallybeduetoprenatalpassiveimmunization,postpartum_RhIG_Ԁmaybe *'/ indicated. Anaccuratehistoryisessentialinsuchcases. *(0$ $$ $  D.+4 _0 t DD 5.0bt$t$EvaluationofantiDinthePostpartumSpecimenXb$b$ 0 t 0t$t$0b$$a.0$ b$b$ThewomanwhohasreceivedantepartumRhIGoftenhasantiDpresentinanantibodyscreening  testdoneatdelivery. SuchawomanstillshouldreceivepostpartumRhIG. $ $$ $ 0 t 0t$t$0b$$b.0$ b$b$OnlyiftheantiDpresentatdelivery isknown tobetheresultofactiveimmunizationcan < administrationofRhIGbeomitted.p$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$Therearesomelaboratorycluesthatmayhelpdistinguishtheoriginoftheantibody. $ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $PassivelyadministeredRhIGisIgG.Ifawoman'santiDissalinereactiveorcanbe  x  inactivatedbytreatingtheserumwith2MEorDTT,itprobablyrepresentsactive  P  immunization. (  $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $PassivelyacquiredantiDisusuallyweaklyreactive, rarelyachievingatiterabove4.  0  HightiteredantiDislikelytobeofmaternalorigin.   $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $ However,confirmationshouldalwaysbesoughtfromthephysician'srecords.d $ $ 0 t 0t$t$0b$$0$ b$b$ 4)0 $ $$ $ RhIGshouldbegivenwheneverthereisdoubtthatcannotberesolved. p $ $  t DD 6.0 b AdministrationofRhIG.$b$b$ 0 t 0t$t$0b$$a.0$ b$b$TheantepartumdoseofRhIGisgivenbetween28and30weeksofgestation,arecommendation | basedonthefactthat,ofwomenwhodevelopantiDduringpregnancy,92%dosoat28weeks T orlater.,$ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Asampleofbloodforlaboratorytestingshouldbeobtained before injectionofRhIG.4$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$Testsonthespecimendrawnat2830weeksshouldinclude:$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $ABO,DincludingDu.h $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $Antibodyscreen.@ $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $Identificationofantibody,ifpresent.Thepresence,inanDnegwoman,ofantibodiesother p  thanantiDdoesnotprecludegivingRhIG.H! $ $ 0 t 0t$t$0b$$d.0$ b$b$TheantiDfromaninjecteddoseofRhIGmayremaindetectibleforaslongas6months.#$ $$ $ 0 t 0t$t$0b$$e.0$ b$b$Thehalflifeofaninjecteddoseisapproximately23days;ofthe300ugofantibodygivenat28 !P% weeks,2030ugshouldremainatthetimeofdelivery12weekslater."( &$ $$ $ 0 t 0t$t$0b$$f.0$ b$b$PostpartumRhIGshouldbeinjected within72hours ofdelivery,whetherornotRhIGhasbeen 0$!( givenduringthepregnancy. %")$ $$ $ 0 t 0t$t$0b$$g.0$ b$b$Itis extremelyimportant thatRhIGadministrationnotbeomittedordelayedbecauseof &d$+ uncertaintyininterpretinganantibodyscreeningtest.'@%,$ $$ $ 0 t 0t$t$0b$$h.0$ b$b$IfforsomereasonRhIGwasnotgivenwithin72hours, lateradministrationshouldnotbe H)&. withheld. $*'/$ $$ $  \.,4 0 t DD 7. b The"UtilizationGap"Xt$t$ 0 t 0t$t$0b$$a.0$ b$b$AdministrationofRhIGisindicated,butsometimesinadvertentlyomitted,afterseveralcommon  events(MEMORIZE):$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $abortion/miscarriage` $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $ectopicpregnancy8 $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $antepartumhemorrhageh $ $ 0 t 0t$t$0b$$0$ b$b$4)0 $ $$ $fetaldeath@ $ $ 0 t 0t$t$0b$$0$ b$b$5)0 $ $$ $amniocentesis  $ $ 0 t 0t$t$0b$$0$ b$b$6)0 $ $$ $chorionicvillussampling   $ $ 0 t 0t$t$0b$$0$ b$b$7)0 $ $$ $cordocentesis p  $ $  t  0 b 0$ b$b$8)0 $ $$ $blunttraumatotheabdomen H  $ $ 0 t 0t$t$0b$$b.0$ b$b$DuringamniocentesisfetomaternalhemorrhagemayoccurcausingDimmunizationofthemother.P $ $$ $ 0 t 0t$t$0b$$c.0$ b$b$TheDnegwomanwhohasamniocentesisat1618weeksforgeneticanalysisshouldreceivea   300ugdoseofRhIG. $ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $Asecondantenataldoseshouldbegiven12weekslater(28weeks)asusual.0 $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $AthirddoseisgivenafterdeliveryiftheinfantisDpos.` $ $ 0 t 0t$t$8.0b$$DetectionandQuantitationofFetomaternalHemorrhage(FMH)b$b$ 0 t 0t$t$0b$$a.0$ b$b$PostpartumDimmunizationcanoccurdespiteRhIGadministrationifthequantityofDposfetal h RBCsenteringthemother'scirculationexceedsthe30mlofwholebloodcoveredbyasingle300 @ ugdoseofRhIG.p$ $$ $ 0 t 0t$t$0b$$b.0$ b$b$Theincidenceoftransplacentalhemorrhagegreaterthan30mlhasbeenestimatedatonlyabout   0.3%,butlargefetomaternalhemorrhageisanimportantandpreventablecauseoffailureof  immunoprophylaxis.x$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$StandardsrequiresthatapostpartumspecimenbeexaminedfromallDnegwomenatriskof ( immunizationtodetectthepresenceoffetomaternalhemorrhagelargerthanthatforwhichone X  doseofRhIGprovidesprotection.0!$ $$ $ 0 t 0t$t$0b$$d.0$ b$b$ThemicroDuusedtobetheonlyscreeningprocedureavailable.AfterCoomb'sthemother'sDu # wasexaminedmicroscopically. `$$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $Small,tight,clumpsofcells(mixedfield)weretheonlyindicationthataFMHhadoccurred.h" & $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $Thistestwasveryinsensitiveandrequiredskilltodetectbleedsaround30mLs.@# ' $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $InaCAPsurvey12%oflabsfailedtodetectDposcellsinaspecimensimulatinga $!( hemorrhageofapproximately30ml.$") $ $ 0 t 0t$t$0b$$e.0$ b$b$Therosettetestisthemostpracticalmethodtouseasascreeningtestforthedetectionofalarge &H$+ FMH.x' %,$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $TherosettetestutilizesDposindicatorcellstoformeasilyidentifiedrosettesaround ()&. individualDposfetalcellsthatmaybepresentinthematernalcirculation.*'/ $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $ThismethodwilldetectFMHsofapproximately10ml.Suchsensitivityprovidesamargin +X)1 ofsafetythatisdesirableforascreeningtest.,0*2 $ $  _ `-+3 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $Therosettetestgivesonly qualitativeresults ,andpositiveresultsmustbefollowedbythe X  quantitative_Kleihauer_Ԅ_Betke_Ԁ(KB)acidelutiontestorenzymelinked_antiglobulin_Ԁtest 2 (_ELAT_)to_quantitate_Ԁthehemorrhage.  $ $ 0 t 0t$t$0b$$f.0$ b$b$WeakDpositive(Du)cellsfromtheinfantdonotreactasstronglyintherosetteprocedureas b normalDposcells. IfthenewborntypesasweakDpositive,thenaKBacidelutiontest : shouldbedoneroutinely. n$ $$ $ 0 t DD 9. b _Kleihauer_Ԅ_Betke_ԀAcidElution" t$t$ 0 t 0t$t$ b a.0$ $$Thistechniqueutilizesthefactthatfetalhemoglobinisresistanttoacidelution,whereasadult  z  hemoglobinisnot. R $ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $Whenathinbloodsmearisexposedtoanacidbuffer,theadult_RBCs_Ԁlosetheirhemoglobin Z   intothebuffersothatonlythestromaremains.2  $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $Fetal_RBCs_Ԁareunaffected(bright,pinkand_refractile_)andretaintheirhemoglobin.  $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $ Thenumberoffetalcellscountedin2000adultcellsiscalculatedoutintoapercentage .: $ $ 0 t 0t$t$0b$$b.0$ b$b$Thepercentageoffetalcellsinthematernalbloodfilmisusedtocalculatetheapproximate D volumeof_FMH_.$ $$ $ 0 t 0t$t$0b$$c.0$ b$b$Theprecisionoftheprocedureispoor,eveninhighlyexperiencehands,andsafetyfactorsare t addedtotheproceduretocompensateforthelackofprecision.L$ $$ $ 0 t 0t$t$0b$$d.0$ b$b$Tocalculatethevolumeof_fetomaternal_Ԁhemorrhage,thispercentageoffetalcellsismultiplied T by50(5000mlrepresentsthemother'sarbitrarilyassignedbloodvolume).Sinceone300_ug_Ԁdose , of_RhIG_Ԁwillprotectagainstatransplacentalhemorrhageof30mlofDposfetalblood,the  volumeoffetalbloodshouldbedividedby30todeterminethenumberofvialsrequired.$ $$ $ 0 t 0t$t$0b$$e.0$ b$b$ Example: 4$ $$ $ 0 t 0t$t$0b$$0$ b$b$1)0 $ $$ $KBreportedas1.3%@! $ $ 0 t 0t$t$0b$$0$ b$b$2)0 $ $$ $1.3x50=65mloffetalblood" $ $ 0 t 0t$t$0b$$0$ b$b$3)0 $ $$ $65/30=2.2dosesof_RhIG_Ԁrequired.# $ $ 0 t 0t$t$0b$$0$ b$b$4)0 $ $$ $Whenthenumbertotherightofthedecimalpointislessthan5,rounddownandaddone  p$ doseof_RhIG_:2.2dosesgive3doses.!H% $ $ 0 t 0t$t$0b$$0$ b$b$5)0 $ $$ $Whenthenumbertotherightofthedecimalpointis5orgreater,rounduptothenext x" & numberandaddonedoesof_RhIG_:2.8dosesgive4doses.P# ' $ $ 0 t 0t$t$0b$$f.0$ b$b$Notmorethanfivedosesof_RhIG_Ԁshouldbeinjectedatonetimeintoeachbuttock.Ifmorethan %") fivedosesarerequired,theinjectionsmaybespacedovera72hourperiod.Anoptimumtime %#* sequencefortheseinjectionshasnotbeenestablished.&X$+$ $$ $ 0 t 0t$t$0b$$g.0$ b$b$ArecentpaperaddressestheissuebycomparingtheKBtechniquewithflow_cytometry_.The `(&- authorsfoundtheKBtesttobeaccurateandprecisewithhemorrhagesof25mlorgreater. 8)&. However,flow_cytometric_Ԁdeterminationsappeartobemoreaccurate.*'/$ $$ $ % %    Exam5Online +f)1 LectureTopicXI ,<*2 Labs8and9