新生兒黃疸neonataljaundice

1、Neonatal Jaundice,Dezhi Mu MD/PhDDepartment of Pediatrics, West China Second University Hospital, Sichuan University,Introduction,Jaundice is quite common (5mg/dl). Full term infants: at least 50% Preterm infants:

2、 over 80% Elevated blood bilirubin levels: 97%,Introduction continued,When? in the first week of life Where? skin , mucosa and white of eye How many? blood bilirubin concentrations is ≥5-7mg/d

3、l.,,Introduction continued,,,Producing Excreting,,,Why Jaundice occurred?,,,,Bilirubin Metabolism:,1. RBC: Heme bilirubin (UCB) 2. Blood: carried by bound to albumin3. Liver: uptaken : Y protein, Z protein

4、 conjugated: UDPGT excreted： to the biliary system 4. Intestine: stercobilins ?-glucuronidase enterohepatic circulation,The

5、metabolic characteristics of bilirubin in newborns:,1. Bilirubin production 8.8mg/Kg/d in newborns3.8mg/Kg/d in adults 2. Bilirubin-albumin complex formation a. preterm infant; b. acidosis,,,3. Bilir

6、ubin metabolism of hepatocyte a. Hepatic uptake of bilirubin b. Bilirubin conjugation: UDPGT (uridine diphosphate glucoronyl transferase) c. Defective bilirubin

7、excretion ability to bile system 4. Enterohepatic circulation,The metabolic characteristics of bilirubin continued,,,Bilirubin toxicity,1. Conjugated bilirubin water-soluble 2. Unconjugated bilirubi

8、n lipid-soluble bilirubin-encephalopathy （kernicterus）,,Clinical Manifestations,Jaundice appears When: at any time during the neonatal period Where: from face chest

9、 abdomen feet,,,,,Evaluation of jaundice :1. By eyes: face, 5mg/dl ( 85μmol/L ); abdomen, 10-15mg/dl; feet, 15-20mg/dl ;2. By transcutaneous measurement :

10、 used for screening3. By serum levels : standard,Manifestations continue,Classification: Physiological Jaundice Pathological Jaundice,Manifestations continue,Physiological jaundice : 1. General state is well

11、2. Appears 2-3days (>24h of age) peaks < 12.9mg/dl (full term infants) <15mg/dl (preterm infants) fades <2 week (term infants) <4 weeks (preterm infants)

12、 3. Accumulates <5mg/dl/d 4. Direct bilirubin <2mg/dl,Manifestations continue,Pathological Jaundice 1. Appears earlier (first 24 hours of life)2. Peaks >12.9mg/dl (full term infants) >15m

13、g/dl (preterm infants) Fades >2 weeks (term infants) >4 weeks (preterm infants)3. Accumulates >5mg/dl/d4. Direct bilirubin >2mg/dl5.Jaundice recurrent,Manifestations contin

14、ue,Common causes of pathological jaundice,1. Unconjugated bilirubinemia: a. hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice,2. Conjugated bilirubinemia: a

15、. Neonatal hepatitisb. Biliary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. Congenital metabolic diseases α-1 antitrypsin deficiency,Causes of pathological

16、 jaundice continue,Hemolytic disease of newborn,Hemolytic disease: ABO: 85.3%Rh : 14.6%MN : 0.1%,Hemolytic disease of newborn continued,ABO incompatibility the mother: type O the infant: type

17、 A or B Rh incompatibility the mother： Rh（-） the infant: Rh（+）D,E,C,d,e,c,Pathogenesis,Pathophysiology,Red blood cell breakdown,Hyperbilirubinemia,Jaundice,Kernicterus,Seizures

18、 etc.,Anemia,Liver SpleenHeart, other organsHydrops,,,,,,,Clinical Manifestations:,ABO Rh1.Jaundice : mild severe 1-2 day 24 h2.Anemia: mild severe

19、 (3-6 weeks) heart failure3.Hepato- rare commonsplenomegaly,,,Complication,Kernicterus: Phase 1: decreased alertnessHypotoniaPoor feeding Phase 2:Hypertonia,

20、 Retrocollis, opisthotonus Phase 3:Hypotonia,1. Blood type incompatibility 2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests 1). Hemoglobin level : low 2). Retic

21、ulocytes:10–15% 3). Nucleated RBC,Laboratory tests:,,Antibody test1). Direct Coombs test (+) confirm 2). Antibody release test (+) confirm3). Free antibody test (+) judge,Laboratory te

22、sts continued,1). Phototherapy 2). Exchange transfusion3). Internal Medicine,Treatments,During pregnancy 1. Intrauterine blood transfusion 2. Early delivery,Treatments continued,After birth 1. Ph

23、ototherapy Principle : photon of light Three photochemical reactions: 1). Structure isomer 2). Geometric isomer 3). Photo-oxidationPhotoproducts excretion: w/o conjugation,Treatme

24、nts continued,,Indications of phototherapy :Unconjugated bilirubinemia Bilirubin level >12mg/dl Light source: Spectral outputs 420 to 500nm,Treatments continued,Side effects of phototherapy : a. diarrh

25、ea b. fever c. skin rash d. bronze baby syndrome (conjugated bilirubin>4mg/dl),Treatments continued,,,2. Exchange Transfusions: a. Severe hemolytic disease b. Refractory to phot

26、otherapy,Treatments continued,Aims of transfusions:a. Remove antibodiesb. Remove bilirubinc. Correct anemia,Treatments continued,Indication of transfusions: one of the follows20mg/dl (340 μmol/L)>4mg/d

27、l,Hgb<120g/L, edema 0.7mg/dl/hKernicterus,Treatments continued,Source of the blood mother newbornsFor Rh: Rh ABOincompatibility For

28、 ABO: “AB” plasma “O” cells incompatibility packed RBC,Treatments exchange transfusions,,,,Potential complications:a. Infectionb. Necrotizing enterocolitis NECc. Thromboembolic complicatio

29、ns,Treatments exchange transfusions,3. Pharmacological agents:a. Phenobarbital Effects: Uptake, Conjugation Excretionb. Albuminc. IVIG,Treatments continued,Preventions,For ABO incompati

30、bility: NoFor Rh incompatibility 300 μg of human anti-D globulin within 72 h of delivery.,1.Unconjugated bilirubinemia:,a. Hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency;

31、 c. Breast milk jaundice,1.Unconjugated bilirubinemia:,b. G-6-PD deficiency; male, jaundice, enzyme activityc. Breast milk jaundice causes: unclear, ?-glucuronidase follows physiologic jaundice: 4-7 d

32、 breast feeding persist for several weeks.,Conjugated bilirubinemia:,2.Conjugated bilirubinemia: a. neonatal hepatitis b. biliary obstruction (cholestatic jaundice) biliary atresia, co

33、mmon bile duct stenosis c. congenital metabolic diseases α-1 antitrypsin deficiency,Case analysis :,24 old male infant, gravida1,para 1. Apgar scores: 8 at 1 minMother: blood type “O”PE: icterus appeared

34、on face and trunk skin liver edge 1cm palpable spleen tip,Case analysis continued,Lab tests:Hgb:13g/dl, reticulocyte count : 7%Blood smear: nucleated RBCBlood type: A, Rh-positiveSerum bilirubin