CASE STUDIES: CASE STUDIES: HYPERBILIRUBINAEMIAHYPERBILIRUBINAEMIA

BY: NICOLE STEVENS

Case Study 1

Maternal history:Gravida 5, Para 4 (after birth of Eric)Blood group O+ve; anti-c, anti-e

antibodies posGBS neg, Hep B/syph/HIV negHep C posSmoker (15 day)Normal morphology scan; 32/40 scan

showing asymmetrical growth restriction

Case Study 1

Induction of labour for IUGR & polyhydramnios

16/5 @ 1225hrs, Normal vaginal birthLive born male, Apgars 9@1, 9@5mins36.6wks, Birth weight: 2600gsTransferred to postnatal ward for ongoing

careMother planning to breastfeed

Case Study 1

17/5 On examination by midwife at 33hrs of age, noted to be jaundiced.

Had been feeding 2-3/24; had not passed mec since birth

SBR taken: 228 micromol/L (in exchange range); paediatric team notified

Seen by paed, admitted to SCN, quadruple phototherapy lights commenced

Case Study 1

Plan (17/5):Feed to maintain TFI at 80mL/kg;

EBM/formula 3x8Bloods to be taken in 4hrs (Blood group,

coombs and repeat SBR) Monitor abdomen, notify paeds of

distention or feed intolerance.Note: large mec stool passed shortly after

admission to SCN

Case Study 1

SBR 4 hrs later (37hrs): 212 (out of exchange range); passing concentrated urine

Plan:Continue quadruple lights, remain in isoletteRepeat SBR in 6hrs: 178 (out of phototherapy

range)Plan (18/5):Feeds increased to 100mL/kgReduce to double phototherapyNote results back from group and coombs: O

Pos, pos coombs, anti-IgG pos, anti-C3 neg

Case Study 1

Plan 19/5 – 20/5 (day 4 – 5):Increased TFI to 120mLs/kgOut of isolette for feedsMum suppressed lactation, bottle feeding

on NanHaDaily blood tests continuingBaby examining well, alert vigorous, fully

suck feeding. Normal weight loss post birth

Case Study 1

Day 6 down to single lights. Continue daily bloods, regular feeds

Day 10 back up to triple lights.Day 11 back to birth weight. Day 12 decrease to double lights

Case Study 1

Day 13 continuing decrease in Hb, pale, slightly lethargic, but haemodynamically stable

Given blood transfusion. IV bung inserted and given 50mLs PRBC (19mL/kg), expected to raise Hb by 4.7g/dL

6 grams intragram P also given, IV, over several hours

Case Study 1

Day 14 reduced to single lightsDay 15 phototherapy ceasedHome day 18 with paediatric clinic follow

up with repeat Hb and retics prior to this appointment

Discharge wt: 2790g, 39.3wks CADischarge medications: Folate and ferrous

suphate daily.

10. Pathology summary

Date Time SBR Hb other17/5 0945 228/618/5 0500 212/6 16.8 Hct 48.8%, plat 225

18/5 1220 178/6 Opos, coombs pos, anti-C3:neg, anti-IgG: pos

19/5 1030 192/12 20/5 0930 291/821/5 1143 233/722/5 0910 207/723/5 0805 263/724/5 0945 244/10 11.625/5 1130 262/2926/5 1050 294/33 10.1

11. Pathology summary

Date Time SBR Hb other27/5 0800 280/828/5 0830 258/16 8.629/5 1200 233/35 6.9 PRBC transfusion30/5 1000 182/8 10.91/6 1155 101/14 10.43/6 0730 84/8 10.8

DISCHARGED HOME 19/6 (outpt f/up) 8.4 retics 3.1%6/7 8.6 retics 2.6%25/8 11.419/9 13.5

12. Considerations

Communication from antenatal care providers to paediatric team regarding maternal anti-e, anti-c antibodies

Early screening of SBR (cord blood)Closer monitoring and awareness in first 24 hrsPhysiological v’s Pathological jaundiceEarly onset jaundice can be a neonatal

emergencyHaemolytic disease of the newbornAction of phototherapy

Case study 2Case study 2

MultiparaG3P2, 39+2wks gestationRepeat elective caesarean section bookedO+ve, antibodies neg, rubella immuneGBS –ve, well through pregnancyNo other history of note

Case Study 2Case Study 2

Date of birth 29/7/11Time of birth 0930hrsLive female infantBorn via EL LUSCSApgars 6@1min, 10@5minsTo postnatal ward for routine careWeight 3590g

Case Study 2Case Study 2

Noted to be jaundiced at 26 hrs of ageSBR taken: 188/12 (30/07/11 @ 1130hrs)Just at treatment lineDouble phototherapy commencedBreast feeds + 90mL/kg topupsFurther bloods taken at 2020hrs (35hrs old):SBR:

186/12. Going away from treatment line (below)Blood group: A+ve, DAT: positive, Hb: 12.9, WCC: 25.5, Platelets: 267

Case Study 2Case Study 2

Double lights continued Bloods repeated 31/7 @ 0615hrs (45hrs

old): SBR: 158/9 Phothotherapy ceased Bloods repeated 12 hrs later: SBR

168/11 Remained out of lights Bloods repeated 24 hrs later (69hrs old): SBR: 171/12, Hb: 12.7 Minimal rise, unconcerning

Case Study 2Case Study 2

Mum suppressed lactationDischarged home Day 4, bottle feedingFollowed up by DOM serviceNo further issues

NICE guidelines currently the tool in use in SCN at BHS, other places will have different tools which will slightly alter the ranges. (National Institute for Health and Clinical Excellence: treatment threshold graphs for babies with neonatal jaundice).

ABO incompatabilityABO incompatability

A common and generally mild type of haemolytic disease in babies

Occurs, usually, with an O group mum and an A or B group baby

Prem babies will be more severely affected than healthy term babies.

Does not become more severe in future pregnancies (such as with the negative blood group mothers)

ABO incompatability

Review of blood types:The genes you inherit from your parents

determine your blood group; there are 4 (major) types:A, B, AB & O

Each type has an individual collection of chemicals on the blood cell surface, known as antigens

A has A antigen, B has B antigen, AB has both and O has none

If different blood types mix, an immune response occurs and antibodies will be produced to attack the foreign antigen

ABO incompatability

Generally during pregnancy mother and fetus’ blood doesn’t mix, but it can (miscarriage, trauma, birth and sometimes for unknown reasons)

The O group mum may produce antibodies against an A, B or AB group baby, these antibodies can cross the placental membrane and increase the rate of haemolysis (red blood cell destruction), hence increasing the production of bilirubin – a waste product

Jaundice and length of stay

Readmit from home, dehydrated, no underlying haemolytic disease – if treated and fed usually only 24 – 48 hrs stay required. Increase education to parents, if breastfeeding, provide lactation support

Premature baby, may be a reoccurring problem over first 1 – 2 weeks of life, usually resolved by the time baby otherwise ready for home

Pathological/haemolytic cause: can be protracted length of treatment over 1 – 2 wks (sometimes longer), with rebounds. Long term anaemia may result in need for top up transfusions.

Breast milk jaundice: months, low levels persisting over prolonged period of time, not usually requiring treatment beyond the first 1 – 2 weeks. Diagnosed by exclusion after several weeks.

Nursing Care

Educate parentsMaximise time under lights and surface area

exposed (lights above and below in more severe cases). Big nappies covering half the body need to be folded down/minimised; don’t over nest and reduce exposure to lights.

Consider nappy off & staying in incubator to feed in pathological cases (in early days if levels high)

If coming out for feeds, keep it brief. Eye careSkin careFeeding support/establishment of lactation

CASE STUDY 3

MultiparaG3P2, 39.2wks gestationRepeat elective caesarean section bookedO+ve blood group, antibodies neg, rubella

immune, GBS –veWell through pregnancyNo other history of note

CASE STUDY 3

Time of birth 0930hrs (day 1)Live female infantBorn via EL LUSCSApgars 6@1min, 10@5minsTo postnatal ward for routine careWeight 3590g

CASE STUDY 3

Noted to be jaundiced at 26hrs of ageSBR taken: 188/12 @ 1130hrs (day 2)Double phototherapy lights commencedBreast feeds and 90mL/kg topups givenFurther bloods taken at 2020hrs (35hrs of

age): SBR: 186/12; blood group: A +ve, DAT positive; Hb: 12.9, WCC: 25.5, Platelets: 267

CASE STUDY 3

Double lights continuedBloods taken @ 0615hrs (45hrs old, day

3), SBR: 158/9Phototherapy ceasedBloods repeated 12 hrs later, SBR: 168/11Remained out of lightsBloods repeated 24hrs later (69hrs old),

SBR: 171/12, Hb: 12.7

CASE STUDY 3

Mum suppressed lactation Discharged home day 4, bottle feedingFollowed up by DOM serviceNo further issues

Questions

Would you call this a physiological or a pathological jaundice?

What is your diagnosis?

Are there any ‘warning bells’ in the maternal history?

Questions

Would you take this baby out of the isolette for breastfeeds?

Nappy on or off?

Why would bloods be repeated again the same day?

There was minimal change in the SBR after several hours of treatment, would that be expected in this case?

QUESTIONS

What are some other causes for pathological jaundice?

What is the common factor no matter the cause? Hint, regularly monitor the babies FBE as well as their SBR

Parent education – how do we explain jaundice and phototherapy to parents?

G6pd

What is that an abbreviation for?

Why is it significant when we talk about jaundice in newborns?

What are some of the triggers that exaccerbate this condition?

G6pd

Does it affect men or women more?

Which nationalities are more commonly affected?

Is it hereditary?

CASE STUDY 4

G1P1, PPROM (4 days prior to birth), 33wks, received oral then IV antibiotics

O+ve blood group, GBS+ve, normal USSHospitalised after ROM’sUnexpected, precipitate, breech vaginal

birth in wardObstetric response calledPaed team arrived as male infant born

CASE STUDY 4

Required IPPV with air and then oxygen for over first 5 mins of life, CPAP for several more minutes, weaned to air, off and managed well.

Extensive bruising noted to upper legs, buttocks and scrotum

Apgars 4@1min and 8@5mins.Admitted to SCN; BW: 2230g

CASE STUDY 4

IV bung inserted, bloods taken for CRP, cultures & FBE, surface swabs taken and gastric aspirate taken

Significant malodour noted from babyMoved to isolette commenced on IV 10%

dextrose @ 60mL/kgAntibiotics continued for 5 days, fluids increased

daily, enteral feeds increased and IV fluids decreased accordingly

Baby remained well respiratory wise

CASE STUDY 4

Baby B +ve, DAT negHb: 16.9Other bloods NAD, gastric aspirate grew

ureaplasma urealyticum (associated with PROM’s)

SBR taken @ 47hrs of age 219/8; phototherapy commenced

SBR 166/7 @ 73hrs of age; ptx ceasedSBR 173/11 @ 97hrs of age; remained out of ptx

QUESTIONS

Is this a pathological or physiological jaundice?

What are this babies risks factors for elevated SBR levels?

Nursing considerations – in or out for feeds? Nappies on or off?

Eye care? BA’s – what to expect and what to explain to

parents?Documentation, funding etc