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ABO Incompatibility in Newborns

ABO incompatibility is a common and generally mild type of haemolytic disease in babies. The term haemolytic disease means that
red blood cells are broken down more quickly than usual which can cause jaundice, anaemia and in very severe cases can cause
death. During pregnancy, this breakdown of red blood cells in the baby may occur if the mother and baby's blood types are
incompatible and if these different blood types come into direct contact with each other and antibodies are formed.
Significant problems with ABO incompatibility occur mostly with babies whose mothers have O blood type and where the baby is
either A or B blood type. Premature babies are much more likely to experience severe problems from ABO incompatibility, while
healthy full term babies are generally only mildly affected. Unlike haemolytic disease that can result in subsequent babies when a
mother has a negative blood group, ABO incompatibility can occur in first-born babies and does not become more severe in further
pregnancies.
To help you understand ABO incompatibility, it is helpful to review the different blood groups. The genes you inherit from your
parents determine your blood group. There are four blood types; A, B, AB and O. Each blood type has its own individual collection of
chemicals on the blood cell surface known as antigens, so type A has the A antigen, B has the B antigen, AB has both antigens and
O contains no antigen. f different blood types mix, an immune response occurs and the person will produce antibodies to attack the
foreign blood antigen.
During pregnancy the mother's and baby's blood generally do not mix. The mothers and babies circulation is kept separate by the
placental membrane. Oxygen, carbon dioxide, nutrients, certain drugs and some viruses can pass through the placental membrane.
However, some circumstances can cause the two blood types to mix, such as miscarriage, trauma and birth, and sometimes they
may mix for reasons unknown. Antibodies against the foreign blood types A and B may be formed. These antibodies could then
pass across the placental membrane into the baby's circulation and may result in the destruction of some of the baby's red blood
cells. This destruction of red cells causes an increase in the production of bilirubin a waste product. f too much bilirubin is
produced, it can overwhelm the baby's normal waste elimination processes and lead to jaundice.
Causes

1) Check your husband's blood type to see if he has one (heterozygote) or two (homozygote) doses of the A gene. f he has two, then all your babies
with him MUST end up having the A blood type. f he has only one, then half your babies could have O blood types just like you and not be affected by
the antibodies at all

2) f your husband is homozygous, then there would be no sense in testing another baby to find out what its blood type is during the pregnancy since it
would have to have an A blood type and would therefore be 'at risk'. But, if he is heterozygous, that testing could be done (by amniocentesis or direct
testing of the baby's blood by percutaneous umbilical cord blood sampling PUBS) and if the baby has O blood, then you could rest assured and relax
the rest of the pregnancy

3) f fetal anemia is a concern, the degree of fetal anemia caused by the antibodies can be monitored by a noninvasive ultrasound procedure
called Doppler flow velocimetry (DFV). Using DFV we can measure the velocity of blood (peak systolic velocity PSV) in a vessel called the middle
cerebral artery in the baby's brain. f that blood flow velocity is higher than expected at a given gestational age, this might indicate the baby is
developing severe anemia. PUBS could then be done, the degree of anemia determined precisely (as well as the bilirubin levels), and the baby could
be transfused with O blood directly by injection in the umbilical vein

4) For your next pregnancy, if you choose to have one, you should get a consultation with a specialist in Maternal-Fetal Medicine. n fact, you might
even want to do that BEFORE you think seriously about getting pregnant again
Causes
A, B, und O ure LIe LIree mujor bIood Lypes. TIe Lypes ure bused on smuII subsLunces (moIecuIes) on LIe surIuce oI LIe bIood ceIIs. n peopIe wIo Iuve
dIIIerenL bIood Lypes, LIese moIecuIes ucL us Immune sysLem LrIggers (unLIgens).
EucI person Ius u combInuLIon oI Lwo oI LIese surIuce moIecuIes. Type O Iucks uny moIecuIe. TIe dIIIerenL bIood Lypes ure:
O Type A (AA or AO moIecuIes)
O Type B (BB or BO moIecuIes)
O Type AB (one A und one B moIecuIe)
O Type O
!eopIe wIo Iuve one bIood Lype Iorm proLeIns (unLIbodIes) LIuL cuuse LIeIr Immune sysLem Lo reucL uguInsL oLIer bIood Lypes. BeIng exposed Lo
unoLIer Lype oI bIood cun cuuse u reucLIon. TIIs Is ImporLunL wIen u puLIenL needs Lo receIve bIood (LrunsIusIon) or Iuve un orgun LrunspIunL. TIe bIood
Lypes musL be muLcIed Lo uvoId un ABO IncompuLIbIIILy reucLIon.
or exumpIe:
O A puLIenL wILI Lype A bIood wIII reucL uguInsL Lype B or Lype AB bIood
O A puLIenL wILI Lype B bIood wIII reucL uguInsL Lype A or Lype AB bIood
O A puLIenL wILI Lype O bIood wIII reucL uguInsL Lype A, Lype B, or Lype AB bIood
O A puLIenL wILI Lype AB bIood wIII NOT reucL uguInsL Lype A, Lype B, or Lype AB bIood
Becuuse Lype O does noL Iuve uny surIuce moIecuIes, Lype O bIood does noL cuuse un Immune response bused on ABO IncompuLIbIIILy. TIIs Is wIy Lype
O bIood ceIIs cun be gIven Lo puLIenLs oI uny bIood Lype. !eopIe wILI Lype O bIood ure cuIIed "unIversuI donors." However, peopIe wILI Lype O cun onIy
receIve Lype O bIood.
SInce unLIbodIes ure In LIe IIquId purL oI bIood (pIusmu), boLI bIood und pIusmu LrunsIusIons musL be muLcIed Lo uvoId un Immune reucLIon.

Signs and symptoms
For babies affected by ABO incompatibility, anaemia may become an issue after a few weeks. The anaemia is caused by the faster
than normal breakdown of the baby's red blood cells caused by the mother's antibodies. These antibodies can linger in the baby's
circulation for weeks after birth. Because of this, some babies will need to have blood tests to check the level of anaemia.
Routine blood screening tests in pregnancy do not screen for ABO incompatibility. Testing in pregnancy is not recommended as
antibody levels do not correlate well to actual ABO haemolytic disease in the baby. There are no preventative measures that can be
taken.

aundice is caused by bilirubin, a yellow pigment that gives the newborn's skin and whites of the eyes a yellow appearance. The
baby's colour is observed during regular newborn examinations by a midwife or doctor. The baby may need blood tests to check the
level of bilirubin if the baby looks significantly jaundiced. Slight jaundice is very common in newborns and requires no follow up.
Babies with high levels of bilirubin in their blood will require phototherapy and in severe cases they may need an exchange blood
transfusion
Symptoms
TIe IoIIowIng ure sympLoms oI ABO IncompuLIbIe LrunsIusIon reucLIons:
O Buck puIn
O BIood In urIne
O eeIIng oI "ImpendIng doom"
O ever
O eIIow skIn (juundIce)

Laboratory exams
After birth there are two options for testing for ABO incompatibility:
O The cord blood of all babies whose mothers have an O blood group and the father either type A or B blood is tested The theory
behind this approach is that if the baby is type A or B and they test positive in direct antiglobulin tests (DAT), the baby can then
be followed closely for jaundice.
O The alternate approach is to screen any baby who becomes significantly jaundiced (particularly within the first 24 hours).

ams and Tests
TIe IeuILI cure provIder wIII perIorm u pIysIcuI exum. BIood LesLs wIII usuuIIy sIow:
O BIIIrubIn IeveI Is IIgIL
O ompIeLe bIood counL (B) sIows dumuged Lo red bIood ceIIs orunemIu
O TIe puLIenL's und donor's bIood ure noL compuLIbIe

Treatment
TreuLmenL muy IncIude:
O rugs used Lo LreuL uIIergIc reucLIons (unLIIIsLumInes)
O rugs used Lo LreuL sweIIIng und uIIergIes (sLeroIds)
O IuIds gIven LIrougI u veIn (InLruvenousIy)
O edIcInes Lo ruIse bIood pressure II IL drops Loo Iow

OutIook (Prognosis)
ABO IncompuLIbIIILy cun be u very serIous probIem LIuL cun even resuIL In deuLI. WILI LIe rIgIL LreuLmenL, u IuII recovery Is IIkeIy.

PossibIe CompIications
O Idney IuIIure
O ow bIood pressure needIng InLensIve cure
O euLI

en to Contact a MedicaI ProfessionaI
uII your IeuILI cure provIder II you Iuve recenLIy Iud u bIood LrunsIusIon or LrunspIunL und you Iuve sympLoms oI ABO IncompuLIbIIILy

Prevention
ureIuI LesLIng oI donor und puLIenL bIood Lypes beIore LrunsIusIon or LrunspIunL cun prevenL LIIs probIem.

PatopysioIogy
Haemolytic anaemia results from either intravascular or extravascular RBC destruction.
Extravascular haemolysis results from accelerated red cell destruction by cells of the
reticuloendothelial system, due to immune targeting by antibodies, as occurs in a warm
autoimmune haemolytic anaemia. ntravascular haemolysis results from red cell
destruction within the vasculature, due to complement-mediated lysis or direct red cell
trauma from a prosthetic heart valve or microangiopathic process.






aLhophyslology

Neonatal jaundice







Unconjugated
bilirubin

Conjugated
bilirubin









Pathologic

Physiological jaundice of
Neonates

Hepatic

Post-
hepatic










Hemolytic

Non-hemolytic










ntrinsic
causes

Extrinsic causes