Neonatal Jaundice And Rhesus Immunozation Flashcards
In which days can Physiological Jaundice appear
Appear day 3-5
When does physiological jaundice peak?
Peak- days 4-6
When does physiological jaundice resolve?
Resolve= days 7-10
Name 4 causes of pathological Jaundice
- Increased haemolysis
- prematurity
- decreased albuim binding capacity/competition for albuim binding sites
- lack of or reduction in enzymes and carrier proteins
- lack of O2 an glucose
- hepititas or liver damage slow the process of transport
- Congenital builiary artesia
- slower bowel motility
What is haemolytic disease?
A disease of the new born, THIS is when red blood cells rupture
What is the physiology of bilirubin?
Billirubin is a product of broke red blood cells. When broken down the RBCs produce unconjugated bllirubin and can only become conjugated if they bind to albumin. some bilirubin of the are still free to circulate and can go to the brain.
the unconjugated bilirubin have to pass through the liver to undergo a process to become conjugated with albumin
the conjugated bilirubin then passes through the gut which is converted into urobilinogen and is excreted in the urine and faeces.
How would u recognise Jaundice, using the NICE guidelines ?
Yellow colouration of skin and eyes caused by increase of unconjugated bilirubin in skin and mucus membranes in mouth. NICE (2016)
What do NICE (2016) suggest that Jaundice is caused by?
raised billirubin levels in the body which is known as hyperbilirubineaemia
With reference, what is the incidence of Jaundice?
Approximately 60% of term and 80% of pre-term babies develop jaundice in the first week of life, after 24hrs old, 10% of breastfed babies are still jaundice at 1 month
(NICE,2016)
what is it about breastfed babies and Jaundice
They are more likely to get physiological Jaundice than bottle-fed babies within the first week of life.
What is prolonged Jaundice?
Jaundice that continues beyond the first 2 weeks , usually harmless but can be indication for serious liver disease
What does hyperbilirubinaemia mean?
when there is a high amount of bilirubin in the blood
What is Clinical Jaundice
visually detectable Jaundice
Significant Hyperbilirubinaemia
An elevation of serum bilirubin to a level requiring treatment (NICE)
What are the causes of Pathological Jaundice (Jaundice before 24 hrs old)
- Increased haemolysis of red blood cells (Rupture of RBC)
- Prematurity
- There are not enough albumin binding sites are there is a decreased albumin binding capacity
- Lack of oxygen and glucose
- Hepatitis or liver damage
when will Jaundice be required to be investigated and possibly treated?
if it occurs within 24hrs
if it appears within 48 hours
if SBR continues to rise rapidly between days 3 and four
if Jaundice foes not subside by day 5-6
if jaundice continues after 12-14 days
if SBR is abnormally high
if baby shows signs of being unwell
name the four facts when identifying jaundice in the 1st 24hours
Always pathological
Relates to causes already present at birth, usually blood incompatibility
May have been predicted by maternal antibody levels
SBR rises very quickly and it is a paediatric emergency
Name three facts when trying to identify Jaundice due to infection
SBR tends to rise steadily
Starts to rise related to time of infection
if the infection was an intrauterine infection, the Jaundice may appear 48hrs after birth.
what does it mean if a baby’s conjugated bilirubin level greater than 25mcmol/l ?
May indicate serious liver disease.
What is the danger of hyperbuilirubinaemia?
This condition can cause bilirubin to penetrate the membrane that lies between the blood and the brain, and once it has penetrated it can be toxic to the fetus and it’s CNS. This can cause long and short term neurological dysfunction.
Dangers of pathological jaundice?
Bilirubin levels are higher than physiological jaundice and they stay higher for longer.
More at risk of brain damage caused by Jaundice (kernicterus). 50% babies with this condition die.
What should u do before discharging the baby and the parents? With ref
Inform parents of neonatal jaundice and what they should do.
How to check their baby for jaundice
Urgency in seek help if Jaundice occurs in the first 24hrs
Midwifery Care for babies with Jaundice
examine the baby for jaundice at every opportunity especially in the first 72 hours.
check the naked baby in bright and preferably natural light. examination of the sclerae, gums and blanched skin is useful across all skin tones.
Check nappy for pale chalky stools and dark urine
How do you measure bilirubin level?
use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours
–if a transcutaneous bilirubinometer is not available, measure the serum bilirubin
–if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin
How would u perform an SBR?
Always use SBR when measuring the bilirubin of a baby with Jaundice in the first 24hours
Always use SBR when measurement when trying to determine the level of bilirubin levels in babies that are less than 35wks.
Always use SBR when measurement if the baby is at or above the relevant treatment threshold for thier postnatal age and all subsequent measurements.
What additional urgent care would you give for a baby with visible jaundice in the first 24hrs?
Do SBR urgently for 2hrs in all babies that is suspected or has jaundice on the first 24hrs of life
Continue to measure SBR, every 6hrs for all babies with suspected or obvious jaundice, in the first 24hrs of life until the level of both:
- Below the treatment threshold
- Stable and or falling
Why is feeding important to Jaundice?
Breast milk speeds passage of meconium, increasing conversion in bowel to conjugated
bilirubin
•Adequate energy is needed for liver function
•Adequate fluid is needed if baby is hot under
phototherapy
•Supplementary fluid should be avoided as this
reduces intake of breast milk. Breastmilk provides adequate fluid
How would you management and treatment of hyperbilirubinaemia
Offer parents or carers information about treatment for hyperbilirubinaemia, including:
- anticipated duration of treatment
- reassurance that breastfeeding, nappy-changing and cuddles can usually continue. Breaks should be for up to 30 minutes NICE (2016)
- Encourage mothers of breastfed babies with jaundice to breastfeed frequently, and to wake the baby for feeds if necessary.
- Provide lactation/feeding support to breastfeeding mothers whose baby is visibly jaundiced
How does phototherapy work physiology?
Phototherapy works by changing bilirubin under the skin from its unconjugated form to non toxic bilirubin products that can be excreted without conjugation by the live
How would you care for a baby receiving photo therapy
frequency of observations •Regular feeding (breastfeeding preferably) •Protect eyes •Nurse baby naked •Temperature control
When and what would you do when the baby needs blood transfusion
If the SBR is high then an exchange of blood transfusion
This will take place in SCBU
SBR level needs to be checked 2 hours after the exchange
(NICE,2010)
Incidence of Exchange transfusion
0.3%-0.4% mortality
it is a complete change over of blood this removes the maternal antibodies
What are a mother’s experiences of neonatal jaundice
Physical and emotional exhaustion •Distressed by baby’s appearance •Loss of control •Maternal vigilance •‘feeling robbed’ •Negative feelings (defensive or ‘being at fault’) •Family impact •Supportive environment
(Brethauer and Carey, 2010)
What is the definition of haemolytic disease?
A disease suffered suffered by newborn the maternal immune system has been ‘immunised’ against aspects of the baby’s blood group.
- Rhesus immunisation
ABO incompatablity
(Myles,2010)
Causes of Haemolytic disease?
Prev pregnancy or miscarriage where fetal blood enters maternal bloodstream
CVS or amniocentesis
ECV
IUD
Explain Rhesus isoimmunisation?
Rhesus isoimmunisation is ussually caused by Rhesus factor D.
if the Mother is Rh negative blood and the partner is Rh positive, the fetus can be Rh positive. However if the fetuses blood enters the mothers bloodstream (Fetus Rh positive antigens enter BS) then the mother will start to produce antibodies against the fetus’ antibodies as it is recognised as an antigen.
Once this has happened, the maternal bloodstream has now created Rh antibodies in her immune system and therefore will react to any future fetus which is Rh positive (Sensitisation)
What happens to the baby/fetus as a result of the antibodies?
The anti-D antibodies pass through the placenta and bind to the fetuses RBC because the mother’s antibodies recognise it as an antigen, these RBC with antibodies are completely removed from fetal circulation. As a result of this, fetal anaemia occurs especially as the RBC are being destroyed quicker than they are being produced. This anaemia can lead to heart failure, fluid retention and swelling and IUD.
When RBC are broken down bilirubin is released, which is cleared by the placenta, but can postnatally cause Jaundice which will most likely require photo therapy and exchange transfusion
How can ABO immunisation and what does NICE recommend?
The administration of Anti-D can neutralise the Rh D antigen and can be given in three different ways
2 doses (500iu) @28 and 34 wks
2 doses (1000-1650iu) @ 28 and 34wks
1 dose (1500iu) @ 28- 34wks
What action should be taken after delivery?
Blood samples need to be taken:
Maternal blood( Kleihauer test): to determine the number of fetal cells in blood
Fetal blood (Usually cord blood): to determine fetal blood group
Coombs test: to determine maternal antibodies
What would u consider when administering Anti-D?
ensure that the Blood product is suitbale to use, check date and name
Midwifery exemption: NO STUDENT MIDWIFE ADMINISTRATION (NMC, 2011).
When administering, place IM into deltoid muscle.
Informed Gain consent
If there is a known rhesus isoimmunisation what do u do?
Immediate cord clamping
immediate blood test and transfer to SCBU
immediate photo therapy or exchange transfusion depending on SBR level
Frequent monitoring of SBR
40% of affected babies need no treatment
95% survive with modern treatment
How does ABO incompatibility work
This is less severe than rhesus isoimmunisation
mother may be of blood group O and may develop A or B antigens which is most common
Mother blood group A may develop B antigens, Mother blood group A may develop B antigens (this is very rare)
What happens to the fetus because of ABO incompatibility
fetus is usually apparent before 36 hours old
May become anaemic and require blood transfusion
may become jaundice
