Dr Veeresh SM

Senior resident Department of Pediatrics SIMS- Shimoga

Case 1
3 day old baby born to gravida 3 mother noticed to have yellowish discoloration on day 2 of life, which gradually increased to palms and sole. Babys blood group was B Positive and mothers blood group was B negative. Being Rh Negetive mother didnt receive Anti D immunoglobulin after first delivery hence second baby was admitted for hyperilirubinemia and died with kernicterus day 5. Patient didnt receive Anti D here also. No other significant history in the family

 O/E female baby with birth weight of 2.4kg without any external anomalies, no birth injuries and cephalhematoma. Icterus was present up to soles. Cry tone activity was good. No convulsions. Baby was started on DSPT and observed. Reports showed indirect hyperilirubinemia reticulocyte count of 16% and DCT positive. Baby kept on minimal IV fluids, breast feeding and cefotaxime (prophylactic). Efforts to get blood for exchange transfusion were started but not successful because of DCT positivity.

 Further investigations showed fall in bilirubin levels along with rapid fall in hemoglobin levels of 7 gm/dl within a period of 3 days and further dropped to 3gms/dl in 7 days But blood bank officer refused to issue blood because of agglutination noticed with all blood types including O negative cells and asked to send fresh sample after 2 days. Hence oral iron was started. Hb dropped to 4gm/dl over next 2 days, still cross matching was not possible(++++).

What to do next?
How to treat anemia? Bilirubin is within physiological limits,

 Decided to give IV immunoglobulin, 1gm/kg of IV IG was infused over 12 hours.

 After 24 hours Cross matching was done which showed matching with o negative blood, and blood was issued with advise of transfusing under strict supervision and high risk consent. Same thing was done and transfusion went uneventful. Repeat HB after 2 transfusions and 3 days after transfusion was 12gm/dl with bilirubin of 12 gm/dl. Hence child was shifted to mother side and observed for another 2 days and sent home. Follow up was done after (day 22 of life)7 days of discharge showed HB 13gm/dl, sr bilirubin of 1.3/0.5 and normal peripheral smear.

Day 3

Day 4

Day 6

Day 8

Day 10 Day 12 Day13

Day 22

Bilirubi 24/1.5 22.8/1. 15.3/1. 11.7/2. 11/2 n T/d 7 7 6 Hb 16 12 7.2 4 3 DCT Retic count CRP positiv e 16% 0.4 positiv positiv positiv e e e

12.3/1. 1.1/0.6 5 13 13

IVIG

Given (1 gm/kg)
+ + + No aggluti nation

aggluti + nation

Case 2
3 day old b/o vasanthi referred from thirthahalli with h/o yellowish discoloration of face skin and 1 episode of GTC convulsions. O/E baby was irritable, tone was increased and icterus present up to soles. Blood sugars and calcium were normal, septic screen was normal. Serum bilirubin was 48mg/dl with direct bilirubin of 1.5mg/dl. Retic count was 12%, baby blood group was B positive ( mother blood group was B Negetive) Direct and indirect coombs test were positive. Child was put on double surface phototherapy and exchange transfusion was planned.

 Efforts to get compatible whole blood went futile as blood bank officer refused to issue blood because of agglutination was noticed with all blood group including O negative because of antibodies present in babies blood (DCT positive). Blood bank officer asked to wait for 1 to 2 days and try again with fresh blood samples. Repeat serum bilirubin was 45mg/dl, on day2 child continued to have convulsions

 Since non availability of compatible blood for exchange transfusion attenders took the baby against medical advise.

 A special thanks to Dr Shreeshail V B Thank you