CASE STUDIES HYPERBILIRUBINAEMIA BY NICOLE STEVENS Maternal history

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CASE STUDIES: HYPERBILIRUBINAEMIA BY: NICOLE STEVENS

CASE STUDIES: HYPERBILIRUBINAEMIA BY: NICOLE STEVENS

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

Maternal history: Gravida 5, Para 4 (after birth of Eric) Blood group O+ve; anti-c, anti-e antibodies pos GBS neg, Hep B/syph/HIV neg Hep C pos Smoker (15 day) Normal morphology scan; 32/40 scan showing asymmetrical growth restriction Case Study 1

 Induction of labour for IUGR & polyhydramnios 16/5 @ 1225 hrs, Normal vaginal

Induction of labour for IUGR & polyhydramnios 16/5 @ 1225 hrs, Normal vaginal birth Live born male, Apgars [email protected], [email protected] mins 36. 6 wks, Birth weight: 2600 gs Transferred to postnatal ward for ongoing care Mother planning to breastfeed Case Study 1

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

17/5 On examination by midwife at 33 hrs 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 80 m. L/kg; EBM/formula 3 x 8

Plan (17/5): Feed to maintain TFI at 80 m. L/kg; EBM/formula 3 x 8 Bloods to be taken in 4 hrs (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 (37 hrs): 212 (out of exchange range); passing concentrated

SBR 4 hrs later (37 hrs): 212 (out of exchange range); passing concentrated urine Plan: Continue quadruple lights, remain in isolette Repeat SBR in 6 hrs: 178 (out of phototherapy range) Plan (18/5): Feeds increased to 100 m. L/kg Reduce to double phototherapy Note results back from group and coombs: O Pos, pos coombs, anti-Ig. G pos, anti-C 3 neg Case Study 1

Plan 19/5 – 20/5 (day 4 – 5): Increased TFI to 120 m. Ls/kg

Plan 19/5 – 20/5 (day 4 – 5): Increased TFI to 120 m. Ls/kg Out of isolette for feeds Mum suppressed lactation, bottle feeding on Nan. Ha Daily blood tests continuing Baby 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

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

Day 13 continuing decrease in Hb, pale, slightly lethargic, but haemodynamically stable Given blood transfusion. IV bung inserted and given 50 m. Ls PRBC (19 m. L/kg), expected to raise Hb by 4. 7 g/d. L 6 grams intragram P also given, IV, over several hours Case Study 1

 Day 14 reduced to single lights Day 15 phototherapy ceased Home day 18

Day 14 reduced to single lights Day 15 phototherapy ceased Home day 18 with paediatric clinic follow up with repeat Hb and retics prior to this appointment Discharge wt: 2790 g, 39. 3 wks CA Discharge medications: Folate and ferrous suphate daily. Case Study 1

Date 17/5 18/5 Time 0945 0500 1220 SBR 228/6 212/6 178/6 Hb 19/5 20/5

Date 17/5 18/5 Time 0945 0500 1220 SBR 228/6 212/6 178/6 Hb 19/5 20/5 21/5 22/5 23/5 24/5 25/5 26/5 1030 0930 1143 0910 0805 0945 1130 1050 192/12 291/8 233/7 207/7 263/7 244/10 11. 6 262/29 294/33 10. 1 16. 8 other Hct 48. 8%, plat 225 Opos, coombs pos, anti-C 3: neg, anti-Ig. G: pos 10. Pathology summary

Date Time SBR Hb other 27/5 0800 280/8 28/5 0830 258/16 8. 6 29/5

Date Time SBR Hb other 27/5 0800 280/8 28/5 0830 258/16 8. 6 29/5 1200 233/35 6. 9 PRBC transfusion 30/5 1000 182/8 10. 9 1/6 1155 101/14 10. 4 3/6 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. 4 19/9 13. 5 11. Pathology summary

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

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 hrs Physiological v’s Pathological jaundice Early onset jaundice can be a neonatal emergency Haemolytic disease of the newborn Action of phototherapy 12. Considerations

 Multipara G 3 P 2, 39+2 wks gestation Repeat elective caesarean section booked

Multipara G 3 P 2, 39+2 wks gestation Repeat elective caesarean section booked O+ve, antibodies neg, rubella immune GBS –ve, well through pregnancy No other history of note Case study 2

 Date of birth 29/7/11 Time of birth 0930 hrs Live female infant Born

Date of birth 29/7/11 Time of birth 0930 hrs Live female infant Born via EL LUSCS Apgars [email protected] min, [email protected] mins To postnatal ward for routine care Weight 3590 g Case Study 2

 Noted to be jaundiced at 26 hrs of age SBR taken: 188/12 (30/07/11

Noted to be jaundiced at 26 hrs of age SBR taken: 188/12 (30/07/11 @ 1130 hrs) Just at treatment line Double phototherapy commenced Breast feeds + 90 m. L/kg topups Further bloods taken at 2020 hrs (35 hrs old): SBR: 186/12. Going away from treatment line (below) Blood group: A+ve, DAT: positive, Hb: 12. 9, WCC: 25. 5, Platelets: 267 2 Case Study

Double lights continued Bloods repeated 31/7 @ 0615 hrs (45 hrs old): SBR: 158/9

Double lights continued Bloods repeated 31/7 @ 0615 hrs (45 hrs old): SBR: 158/9 Phothotherapy ceased Bloods repeated 12 hrs later: SBR 168/11 Remained out of lights Bloods repeated 24 hrs later (69 hrs old): SBR: 171/12, Hb: 12. 7 Minimal rise, unconcerning Case Study 2

 Mum suppressed lactation Discharged home Day 4, bottle feeding Followed up by DOM

Mum suppressed lactation Discharged home Day 4, bottle feeding Followed up by DOM service No 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). Case Study 2

 A common and generally mild type of haemolytic disease in babies Occurs, usually,

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

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,

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 ABO incompatability

 Readmit from home, dehydrated, no underlying haemolytic disease – if treated and fed

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. Jaundice and length of stay

 Educate parents Maximise time under lights and surface area exposed (lights above and

Educate parents Maximise 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 care Skin care Feeding support/establishment of lactation Nursing Care

 Multipara G 3 P 2, 39. 2 wks gestation Repeat elective caesarean section

Multipara G 3 P 2, 39. 2 wks gestation Repeat elective caesarean section booked O+ve blood group, antibodies neg, rubella immune, GBS –ve Well through pregnancy No other history of note CASE STUDY 3

 Time of birth 0930 hrs (day 1) Live female infant Born via EL

Time of birth 0930 hrs (day 1) Live female infant Born via EL LUSCS Apgars [email protected] min, [email protected] mins To postnatal ward for routine care Weight 3590 g CASE STUDY 3

 Noted to be jaundiced at 26 hrs of age SBR taken: 188/12 @

Noted to be jaundiced at 26 hrs of age SBR taken: 188/12 @ 1130 hrs (day 2) Double phototherapy lights commenced Breast feeds and 90 m. L/kg topups given Further bloods taken at 2020 hrs (35 hrs of age): SBR: 186/12; blood group: A +ve, DAT positive; Hb: 12. 9, WCC: 25. 5, Platelets: 267 CASE STUDY 3

 Double lights continued Bloods taken @ 0615 hrs (45 hrs old, day 3),

Double lights continued Bloods taken @ 0615 hrs (45 hrs old, day 3), SBR: 158/9 Phototherapy ceased Bloods repeated 12 hrs later, SBR: 168/11 Remained out of lights Bloods repeated 24 hrs later (69 hrs old), SBR: 171/12, Hb: 12. 7 CASE STUDY 3

 Mum suppressed lactation Discharged home day 4, bottle feeding Followed up by DOM

Mum suppressed lactation Discharged home day 4, bottle feeding Followed up by DOM service No further issues CASE STUDY 3

 Would you call this a physiological or a pathological jaundice? What is your

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

Would you take this baby out of the isolette for breastfeeds? Nappy on or off? Why day? would bloods be repeated again the same 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

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? QUESTIONS

 What is that an abbreviation for? Why is it significant when we talk

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? G 6 pd

 Does it affect men or women more? Which nationalities are more commonly affected?

Does it affect men or women more? Which nationalities are more commonly affected? Is it hereditary? G 6 pd

 G 1 P 1, PPROM (4 days prior to birth), 33 wks, received

G 1 P 1, PPROM (4 days prior to birth), 33 wks, received oral then IV antibiotics O+ve blood group, GBS+ve, normal USS Hospitalised after ROM’s Unexpected, precipitate, breech vaginal birth in ward Obstetric response called Paed team arrived as male infant born CASE STUDY 4

 Required IPPV with air and then oxygen for over first 5 mins of

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 [email protected] min and [email protected] mins. Admitted to SCN; BW: 2230 g CASE STUDY 4

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

IV bung inserted, bloods taken for CRP, cultures & FBE, surface swabs taken and gastric aspirate taken Significant malodour noted from baby Moved to isolette commenced on IV 10% dextrose @ 60 m. L/kg Antibiotics 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 neg Hb: 16. 9 Other bloods NAD, gastric aspirate

Baby B +ve, DAT neg Hb: 16. 9 Other bloods NAD, gastric aspirate grew ureaplasma urealyticum (associated with PROM’s) SBR taken @ 47 hrs of age 219/8; phototherapy commenced SBR 166/7 @ 73 hrs of age; ptx ceased SBR 173/11 @ 97 hrs of age; remained out of ptx CASE STUDY 4

 Is this a pathological or physiological jaundice? What are this babies risks factors

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 QUESTIONS