Discussion

Discussion
Jaundice is a common clinical problem in the neonatal period. Many neonates develop hyperbilirubinemia that requires intervention. It can progress to severe hyperbilirubinemia, resulting in kernicterus (Bhutani et al., 2004). In the present study we documented 106 cases of hyperbilirubinemia due to ABO incompatibility between mothers and their babies randomly found that O-A group were about 65 cases (61.3%) and O-B group were about 41 cases (39.7%). Bhat YR and Kumar CG; 2012 also made study including 878 deliveries, 151 (17.3%) neonates were ABO incompatible with their mothers. The proportions who were O-A and O-B incompatible were 50.4% and 49.6%, respectively. Table (1) illustrated that male patients were 1.5 times as like female patients, Numan N. Hameed et al; 2011 made study about 100 cases of ABO HDN with age range from 1-12 days. Fifty three percent were males and 47% were females but Mohammad Irshad et al; 2011 studied about 45 cases of ABO incompatibility there were 33 (72%) males and 12 (28%) females. Table (2) showed maternal risk factors in group A and group B patients. Firstly patients delivered by normal vaginal delivery (NVD) 51 patients (48.1%) while 55 patients (51.9%) delivered by caesarian section (CS). Secondly Mothers with oxytocin intake in delivery were 50 cases (47.2%). Also table (15) showed that there are higher mean total serum bilirubin at admission in NVD babies and whose mothers

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took oxytocin in labor. This was in agreement with Oral et al., 2003 who reflected that there is no significant effect of oxytocin infusion on the incidence of neonatal hyberbilirubinemia, disagreeing with keren et al., 2005 and El-Shafie et al.,2003 included that the oxytocin exposure as risk factor for hyperbilirubinemia. D'souza et al, 1979 stated that raised plasma bilirubin levels in cord blood, probably enhanced by breakdown of fetal red cells, appeared to be a dose dependant effect of oxytocin. Also, Buchan, 1979 stated that the vasopressin like action of oxytocin causes osmotic swelling of erythrocytes leading to decreased deformability and hence more rapid destruction with resultant hyperbilirubinemia in the neonates, these studies were done on venous cord blood of 95 healthy newborn infants, 15 were delivered by elective cesarean section, 40 after spontaneous labor and 40 after oxytocin use. There was no significant difference between the first two groups while infants born after oxytocin induced labor showed clear evidence of increased hemolysis with resultant hyperbilirubinemia.

Maisels (1999) stated that there was an association between the use of oxytocin to induce or augment labor and an increased incidence of neonatal hyperbilirubinemia, although the mechanism for this is unclear. Our findings were in accordance with Burgoes et al., 2008 stating that one of the factors associated with decreased likelihood of readmission for jaundice was cesarean section delivery, he found that bilirubin on days 1 and 2 were found to be higher in newborns delivered vaginally than caesarian section. As has been suggested
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neonates are stressed prior to birth and induce conjugative enzymes prior to vaginal delivery. Further newborns delivered by cesarean section are breast-fed relatively infrequently during 1st 48 hours of life than those born by vaginal delivery. Also our findings were in accordance with El-Shafie et al., 2003 stating that normal vaginal delivery was increased risk of hyperbilirubinemia this could be explained by the increased use of oxytocin infusion and the increased incidence of traumatic delivery with in normal delivery than cesarean section delivery. of bilirubin. Zarrinkoub F, Beigi A, 2007 found that there were no statistically significant relationships between jaundice and maternal age, parity, mode of delivery, neonatal gender or previous siblings with jaundice (p>0.05). Table (2) illustrated risk factors of ABO HDN severity, Firstly maternal gravida 1 were 23 cases (21.7%), gravida 2 were 27 cases (25.4%), gravida 3 were 24 cases (22.7%), gravida 4 were 15 cases (14.2%), gravida 5 were 13 cases (13.2%) and gravida 6 were 3 cases (2.8%) and table (15) appeared higher mean serum bilirubin on paragravida . Gitesh Dubal and Varsha Joshi; 2012 indicated strong influence of paragravida on neonatal jaundice and its TSB level. Secondly Mothers with previous blood transfusion were 3 cases (2.8%). Mothers with spontaneous abortions were 28 cases (27.4%). Valentin I. and Govallo, M.D; 1993 had a study about 85 women with ABO-sensitization but only 31 cases had ABO-HDN. Nine of .the women only (29%) had previous spontaneous abortions
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However

Olcay et al., 2004 stated that mode of delivery didn't influence levels

Discussion

The study showed 5 cases with maternal intake of salicylates (4.7%), 1 case with maternal intake of sulfonamide (0.9%), and 33 cases with maternal intake of nitrofurantoin (31.1%). Merck 2009 in his manual of pediatric stated that these drugs intake lead to overproduction due .to hemolytic anemia Table (3) appeared that commonly our patients presented within the 2nd day of life 86% compared with patients presented within the 1st day of life that disagree with Pavan Kumar in an Indian study (2012) but has been stated in many studies like Barbara J. et al; 2004 . Our study shows that 9 cases of O-B group (22%) in contrast with 6 cases of O-A group (9%) presented in the 1st 24 hours of life which stated by Michael Kaplan etal.2010, in which the results demonstrate that more O-B than O-A newborns developed hyperbilirubinemia at <24 hours (93.9% vs. 48.1%, p<0.0001). Most of the patients 78 cases had previous history of jaundice and/or phototherapy and/or exchange transfusion and this result is disagreeing with that ABO-incompatibility is presented in approximately 12% of pregnancies, with evidence of fetal

sensitization in 3% of live births and fewer than 1% of births are associated with significant hemolysis and, this was reported by Mentzer WC, Glader BE, 1998. Table (4) shows family history of jaundice in patients with Abo incompatibility. 78 cases of 106 cases (73.6%) presented with previous family history of jaundice and history of jaundice's treatment, Numan N. Hameed et al; 2011 illustrated that family

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history of neonatal jaundice, history of jaundice's treatment is negative .(in (54% Table (5) showed that 42 patients (39.6%) cases developed pallor with jaundice and 21 patients (19.8%) developed neurological signs like poor feeding, KJ Barrington; 2005 stated that Acute encephalopathy which defined as (a clinical syndrome, in the presence of severe hyperbilirubinemia, of lethargy, hypotonia and poor suck, which may progress to hypertonia with a high-pitched cry and fever, and eventually to seizures and coma) does not occur in fullterm infants whose peak TSB concentration remains below 340 mol/L and is very rare unless the peak TSB concentration exceeds 425 mol/L. Above this level, the risk for toxicity progressively increases. Even with concentrations greater than 500 mol/L, there are still some infants who will escape encephalopathy. All of the reasons for the variable susceptibility of infants are not known; however, dehydration, hyperosmolarity, respiratory distress, hydrops, prematurity, acidosis, hypoalbuminemia, hypoxia and seizures are said to increase the risk of acute encephalopathy in the presence of severe hyperbilirubinemia. In our study table (5) illustrated that there are 10 cases only with sequestrated blood which there's no statistical significant difference between these and others without sequestrated blood regarding mean serum bilirubin level at admission. KJ Barrington; 2005 is in accordance with our study in that sequestrated blood as cephalhematoma, bruises, hematomas, ecchymosis has no statistical significance.

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Table (6) shows high significant difference statistically between O-A and O-B groups in total serum bilirubin level at admission at 6, 12, 24, 36 & 48 hours of admission, while there is no significant difference between O-A and O-B groups in direct serum bilirubin level at admission at 6, 12, 24, 36 & 48 hours of admission. Koura, H.M et al; 2009 stated that There was no significant statistical difference between (Group I treated cases) and (Group II untreated cases) in (TSB) level on admission (p>0.05); while after 24 and 48 hours of therapy the (TSB) level was significantly lower in the treated group (Group I) than the untreated group (Group II) where the p value was 0.000 and 0.001 respectively. Hung wei-min et al; 2006 made study mean daily serum total billirubin concentration reduction (56.49-/+24.05 micromol/L) in treatment group were lower than those in the control group (P<0.01). The jaundice resolution time (23.51-/+11.19 h) and the phototherapy time (3.01-/+0.89 h) for billirubinemia treatment in treatment group were shorter than those in the control group (P<0.01). The patients in the treatment group had higher hemoglobin level after treatment (15.59-/+2.01 g/L) than those of the control group (P<0.01) Table (17) shows that there are highly statistically significant differences about values of reticulocytes and hematocrit and statistically significant differences about values of hemoglobin and serum albumin between O-A & O-B groups. Faris B. alswaf et al; 2009 made study about 55 cases and stated that main investigations done to the patients with ABO-incompatibility includes, Total serum bilirubin >19mg/dl in 22 cases (40.8%), Hemoglobin level ranged from 100- 140g/l in 29 cases, regarding Reticulocyte
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percentage the majority of patients (34 cases) between 5-9 %. Our study showed that O-A group reticulocytes was about 6.88% but in OB group was about 9.3% which is highly statistically significant. Michael Kaplan, et al; 2010 stated that Hb values were somewhat lower for the O-B neonates, the difference between these and the O-A group was not significant (17.0 3.1 g/dl vs. 17.7 2.8 g/dl, p=0.2), in spite of our study showed significant difference between O-A and O-B group regarding hemoglobin level. In accordance with our study, Shu-Huey et al; 2012 stated that Mean Hb and RBC for the AO group were higher and nucleated RBC ratios were lower than for the BO group; however, these differences were also not statistically significant. Interestingly, the mean Hct value of the BO group was significantly lower than that of the AO group (p = 0.04). Faris B. alswaf et al; 2009 made study about 55 cases and stated that main investigations done to the patients with ABOincompatibility includes, Total serum bilirubin >19mg/dl in 22 cases (40.8%), Hemoglobin level ranged from 100- 140g/l in 29 cases, regarding Reticulocyte percentage the majority of patients (34 cases) between 5-9 %. Our study showed that O-A group reticulocytes was about 6.88% but in O-B group was about 9.3% which is highly statistically significant. A slight increase in reticulocytes is a common feature in HDN due to ABO incompatibility according to Rosenfield 1955. In the

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series of fairly severe cases collected by Crawford and co-workers 1953, the reticulocyte count exceeded 15% in 6 out of 11 cases. Table (9) shows no statistical significant difference between O-A and O-B groups in the duration of admission. In accordance with our study, Koura, H.M et al; 2009 also stated that the duration of phototherapy the difference was not statistically significant (p>0.05) where in the patient group the mean duration was (85.07 24.33 hours) and in the treated group the mean duration was (96.33 .(20.48 hours Table (10) shows highly significant difference statistically between O-A and O-B groups in need for exchange transfusion and OB group need more treatment with exchange transfusion than O- A group, BRINK et al. 1969 stated that jaundice occurred in the O-B group it tended to be slightly more ever than in the O-A group. This was indicated by the observation that an exchange blood transfusion was required in 12 out of the 36 jaundiced cases in the O-B group, whereas it was needed in only 24 of the 80 O-A jaundiced cases which .agree with our study Michael Kaplan et al; 2010 showed that Several investigators were unable to show any difference in clinical severity between O-A and OB hemolytic disease of the newborn, although in the former report there was a trend towards performing exchange transfusion during the first 24 hours more frequently in O-B compared with O-A infants. Similarly, a retrospective analysis of ABO hemolytic disease did not find significant relationships between the infants blood type and clinical outcome. Sisson and Kaplan1972 reported no significant
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differences in severity or response to therapy between the two blood types. An infant whose blood group was A was as likely to be affected by ABO hemolytic disease as a blood group B infant. However, Bakkeheim et al; 2009 found a significantly increased rate of invasive treatments, including intravenous immune globulin therapy and exchange transfusion, in O-B infants compared with O-A. Two studies documented a higher need for exchange transfusion in O-B neonates than in O-A.

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