Neonatal Jaundice
and Hemolysis
bhzhou@shmu.edu.cn
Jaundice 黄疸
Bilirubin 胆红素
Hyperbilirubinemia 高胆红素血症
Jaundice is a common neonatal
problem,Sixty-five percent of
newborns develop clinical
jaundice with a bilirubin level
above 5 mg/dl during the first
week of life.
Metabolism of bilirubin
production ?：
1 g hemoglobin 34 mg bilirubin
Adult 3.8 mg / kg.d，
Neonatal 8.5mg / kg.d，
cleaning ?:
Protein Y and Z ? (in liver cell )
UDPGT?（ glucuronyl transferase - 葡萄糖醛酸转移酶）
the enterohepatic circulation of bilirubin
breakdown
Maisels in 1981
? Clincial jaundice appears in 24 hour after born
? Total bilirubin level rises >5 mg / dl per day
? Peak bilirubin level > 12.9mg / dl (term baby) or
>15 mg / dl ( premature baby)
? Conjugated bilirubin level >1.5--2.0 mg / dl
? Clincial jaundice is not resolved by 1 week in term
infant or 2 week in preterm infant
Etiology of jaundice secondary
to unconjugated hyperbilirubemia
Overproduction of bilirubin
? Increased rate of hemolysis
? Patient with a positive Coombs test
? Rh incompatibility
? ABO blood group incompatibility
? Patient with negative Coombs test
? Abnormal red cell shapes
? Red cell enzyme abnormalities G-6-PD
? Patient with bacterial or viral sepsis
? Nonhemolytic causes of increased biliurbin load
? Extravascular hemorrhage
? Polycythemia (红细胞增多症）
? Exaggerated enterohepatic circulation（ 肠肝循环） of biliurbin
Etiology of jaundice secondary
to unconjugated hyperbilirubemia
Decreased rate of conjugation
Physiologic jaundice (生理性黄疸）
Crigler-Najjar syndrome
Gillbert syndrome
breast jaundice
? Reported by Arias in 1960
? 60th 1％～ 2％
80th 20％（ De Angelis,1982）
82％（ Lascair,1986）
? Maisels in1986 1250 baby 97％ 12.5mg/dl
breast feeding 15.7mg/dl
Breast jaundice
?Manifestation,
jaundice,general condition is good
?diagnosis：
the presence of moderate unconjugated
hyperbilirubinemia for 6 ~ 8 weeks in a thriving
infant without evidence for hemolysis,
hypothyroidism,or other disease strongly suggests
this breast jaundice.
Hemolytic disease
?Hemolytic of the newborn
Rh erythrocatalysis
ABO erythrocatalysis
?Hemolytic in the newborn
G－ 6－ PD 红细胞葡萄糖－ 6－磷酸脱氢酶缺陷病
Pathogensis：
Mother Rh D (－ ),Fetal Rh (＋ )
Fetal RBC Maternal circulation IgM
Fetal RBC placenta IgG
First time
Rarely occurs during a first pregnancy
After abortion,or delivery of an Rh-positive infant
Mother Neonatal infant
dCcEe DCcEe
DCcee DCcEe
DccEe DCcEe
Rh D (－ ) Rh D (＋ )
Rh E (－ ) Rh E (＋ )
Rh C (－ ) Rh C (＋ )
Clinic manifestations
Edema of fetal
Jaundice,early,fast and severe
Anemia,severe
Enlargement of liver and spleen
Diagnosis：
Antenatal diagnosis
Postnatal diagnosis
?History,previous transfusions,abortion or pregnancy
?Blood routine test,reticulocytes may be increased to 10~15%
?ABO blood group and Rh type
?Coombs’ test,direct
?Serum bilirubin level
Coombs test (抗人球蛋白试验 )
?直接法
病人血球＋抗人体球蛋白血清 凝集 (+)
不凝 (-)
?间接法
病人血清＋标准 RBC＋ 抗人体球蛋白血清
凝集 (+)
不凝 (-)
ABO blood group incompatibility
Mothe, type O Fetal type A or B
Fetal RBC Maternal circulation IgM
Maternal circulation IgG
Clinic manifestation
Most case are mild
Jaundice,pallor,enlargement liver and spleen
Diagnosis
Test blood type
Coombs’ Test
bilirubin encephalopathy 胆红素脑病
Kernicterus 核 黄 疸
Bilirubin encephalopathy
Clincial manifestation
Early symptoms
Lethargy（ 嗜睡 ）,hypotonia （ 肌张力低下 ）,poor
sfeeding,Progressing to hypertonia,Opisthotonos
（ 角弓反张） high-pitched cry,convulsion
Long-term sequelae
Athetoid cerebral palsy(脑瘫）,sensorineural
deafness（ 耳聋）,limitation of upward gaze,dental
dysplasia
Treatment of medicine
?Protoporphyrins
Inhibitors of heme oxygenase(血红素加氧酶 )）
Sn-pp,Zinc protoporphyrin or mesoporphyrin
（ 原卟啉） （中卟啉）
?Albumin,1g Albumin 15 mg biliurbin
?Enzyme inductor,Lumina
?Intravenous immune globulin ( IVIG )
Treatment of jaundice and hemolytic disease
of neonatal infant
Exchange transfusions
The main goals
To prevent intrauterine or extrauterine death from
severe anemia and hypoxia
To avoid neurotoxicity from hyperbilirubinemia
Exchange transfusions
? Rh type as the mother,ABO blood group
as the infant
? Type O blood cells,type AB plasma
? Double-volume exchange transfusion
Treatment of jaundice and hemolytic
disease of neonatal infant
Infections of neonate
Intrauterine infection
septicemia
purulent meningitis
Intrauterine infection
TORCH
T - Toxoplama (弓型虫）
O - Others
R – Rubella （ 风疹）
C – Cytomegalic virus (巨细胞病毒 CMV)
H – Hepatiatis B
Herpes simplex virus（ 疱疹病毒）
neonatal septicemia
? 1~10%,1000~1500G 164‰
? Bacteriemia:
30 ~ 40 s GAS (A组链球菌 )
50 ~ 60 s E,coli （ 大肠杆菌 ）
70s GBS（ B组链球菌 ）
now,USA,staphylococcus (葡萄球菌 ）
China:E coli and staphylococcus aureus
（ 金黄色葡萄球菌 ）
Etiology
? Both the cellular and humoral immune is
low
? E coli and staphylococcus aureus
Clinical findings
? Early- onset
respiratory distress,unexplained low Apgar
scores without fetal distress（ 胎儿窘迫）,poor
perfusion（ 低灌注 ）,hypotension (低血压）
? Late – onset
poor feeding,lethargy (嗜睡 ）,hypotonia（ 张
力低 ）,temperature instability （ 体温不稳定 ）
? Jaundice
? Fever and hypothermia
? Enlargement of liver and spleen
? Hemorrhagic shock
? others,necrotizing enterocolitis ( NEC ),
Meningitis
Diagnosis
? Blood culture
? Blood count (CBC)
? CRP( C反应蛋白 )
? others：
Neonatal purulent meningitis
Incidence, live births 0.2 ~ 1 ‰,
premature infants 3 ‰
Diagnosis, CSF protein >150mg/dl,glucose
<30mg/dl,leukocytes >25/uL,Gram stain
Other,CT,Ultrasound
Treatment
Antibiotics
? Early, ampicillin plus and aminoglycoside
? Late,vancomycin
Others
intravenous immine globulin,IVIG
humab granulocyte colony-stimulating factor G-csf
(集落刺激因子）
and Hemolysis
bhzhou@shmu.edu.cn
Jaundice 黄疸
Bilirubin 胆红素
Hyperbilirubinemia 高胆红素血症
Jaundice is a common neonatal
problem,Sixty-five percent of
newborns develop clinical
jaundice with a bilirubin level
above 5 mg/dl during the first
week of life.
Metabolism of bilirubin
production ?：
1 g hemoglobin 34 mg bilirubin
Adult 3.8 mg / kg.d，
Neonatal 8.5mg / kg.d，
cleaning ?:
Protein Y and Z ? (in liver cell )
UDPGT?（ glucuronyl transferase - 葡萄糖醛酸转移酶）
the enterohepatic circulation of bilirubin
breakdown
Maisels in 1981
? Clincial jaundice appears in 24 hour after born
? Total bilirubin level rises >5 mg / dl per day
? Peak bilirubin level > 12.9mg / dl (term baby) or
>15 mg / dl ( premature baby)
? Conjugated bilirubin level >1.5--2.0 mg / dl
? Clincial jaundice is not resolved by 1 week in term
infant or 2 week in preterm infant
Etiology of jaundice secondary
to unconjugated hyperbilirubemia
Overproduction of bilirubin
? Increased rate of hemolysis
? Patient with a positive Coombs test
? Rh incompatibility
? ABO blood group incompatibility
? Patient with negative Coombs test
? Abnormal red cell shapes
? Red cell enzyme abnormalities G-6-PD
? Patient with bacterial or viral sepsis
? Nonhemolytic causes of increased biliurbin load
? Extravascular hemorrhage
? Polycythemia (红细胞增多症）
? Exaggerated enterohepatic circulation（ 肠肝循环） of biliurbin
Etiology of jaundice secondary
to unconjugated hyperbilirubemia
Decreased rate of conjugation
Physiologic jaundice (生理性黄疸）
Crigler-Najjar syndrome
Gillbert syndrome
breast jaundice
? Reported by Arias in 1960
? 60th 1％～ 2％
80th 20％（ De Angelis,1982）
82％（ Lascair,1986）
? Maisels in1986 1250 baby 97％ 12.5mg/dl
breast feeding 15.7mg/dl
Breast jaundice
?Manifestation,
jaundice,general condition is good
?diagnosis：
the presence of moderate unconjugated
hyperbilirubinemia for 6 ~ 8 weeks in a thriving
infant without evidence for hemolysis,
hypothyroidism,or other disease strongly suggests
this breast jaundice.
Hemolytic disease
?Hemolytic of the newborn
Rh erythrocatalysis
ABO erythrocatalysis
?Hemolytic in the newborn
G－ 6－ PD 红细胞葡萄糖－ 6－磷酸脱氢酶缺陷病
Pathogensis：
Mother Rh D (－ ),Fetal Rh (＋ )
Fetal RBC Maternal circulation IgM
Fetal RBC placenta IgG
First time
Rarely occurs during a first pregnancy
After abortion,or delivery of an Rh-positive infant
Mother Neonatal infant
dCcEe DCcEe
DCcee DCcEe
DccEe DCcEe
Rh D (－ ) Rh D (＋ )
Rh E (－ ) Rh E (＋ )
Rh C (－ ) Rh C (＋ )
Clinic manifestations
Edema of fetal
Jaundice,early,fast and severe
Anemia,severe
Enlargement of liver and spleen
Diagnosis：
Antenatal diagnosis
Postnatal diagnosis
?History,previous transfusions,abortion or pregnancy
?Blood routine test,reticulocytes may be increased to 10~15%
?ABO blood group and Rh type
?Coombs’ test,direct
?Serum bilirubin level
Coombs test (抗人球蛋白试验 )
?直接法
病人血球＋抗人体球蛋白血清 凝集 (+)
不凝 (-)
?间接法
病人血清＋标准 RBC＋ 抗人体球蛋白血清
凝集 (+)
不凝 (-)
ABO blood group incompatibility
Mothe, type O Fetal type A or B
Fetal RBC Maternal circulation IgM
Maternal circulation IgG
Clinic manifestation
Most case are mild
Jaundice,pallor,enlargement liver and spleen
Diagnosis
Test blood type
Coombs’ Test
bilirubin encephalopathy 胆红素脑病
Kernicterus 核 黄 疸
Bilirubin encephalopathy
Clincial manifestation
Early symptoms
Lethargy（ 嗜睡 ）,hypotonia （ 肌张力低下 ）,poor
sfeeding,Progressing to hypertonia,Opisthotonos
（ 角弓反张） high-pitched cry,convulsion
Long-term sequelae
Athetoid cerebral palsy(脑瘫）,sensorineural
deafness（ 耳聋）,limitation of upward gaze,dental
dysplasia
Treatment of medicine
?Protoporphyrins
Inhibitors of heme oxygenase(血红素加氧酶 )）
Sn-pp,Zinc protoporphyrin or mesoporphyrin
（ 原卟啉） （中卟啉）
?Albumin,1g Albumin 15 mg biliurbin
?Enzyme inductor,Lumina
?Intravenous immune globulin ( IVIG )
Treatment of jaundice and hemolytic disease
of neonatal infant
Exchange transfusions
The main goals
To prevent intrauterine or extrauterine death from
severe anemia and hypoxia
To avoid neurotoxicity from hyperbilirubinemia
Exchange transfusions
? Rh type as the mother,ABO blood group
as the infant
? Type O blood cells,type AB plasma
? Double-volume exchange transfusion
Treatment of jaundice and hemolytic
disease of neonatal infant
Infections of neonate
Intrauterine infection
septicemia
purulent meningitis
Intrauterine infection
TORCH
T - Toxoplama (弓型虫）
O - Others
R – Rubella （ 风疹）
C – Cytomegalic virus (巨细胞病毒 CMV)
H – Hepatiatis B
Herpes simplex virus（ 疱疹病毒）
neonatal septicemia
? 1~10%,1000~1500G 164‰
? Bacteriemia:
30 ~ 40 s GAS (A组链球菌 )
50 ~ 60 s E,coli （ 大肠杆菌 ）
70s GBS（ B组链球菌 ）
now,USA,staphylococcus (葡萄球菌 ）
China:E coli and staphylococcus aureus
（ 金黄色葡萄球菌 ）
Etiology
? Both the cellular and humoral immune is
low
? E coli and staphylococcus aureus
Clinical findings
? Early- onset
respiratory distress,unexplained low Apgar
scores without fetal distress（ 胎儿窘迫）,poor
perfusion（ 低灌注 ）,hypotension (低血压）
? Late – onset
poor feeding,lethargy (嗜睡 ）,hypotonia（ 张
力低 ）,temperature instability （ 体温不稳定 ）
? Jaundice
? Fever and hypothermia
? Enlargement of liver and spleen
? Hemorrhagic shock
? others,necrotizing enterocolitis ( NEC ),
Meningitis
Diagnosis
? Blood culture
? Blood count (CBC)
? CRP( C反应蛋白 )
? others：
Neonatal purulent meningitis
Incidence, live births 0.2 ~ 1 ‰,
premature infants 3 ‰
Diagnosis, CSF protein >150mg/dl,glucose
<30mg/dl,leukocytes >25/uL,Gram stain
Other,CT,Ultrasound
Treatment
Antibiotics
? Early, ampicillin plus and aminoglycoside
? Late,vancomycin
Others
intravenous immine globulin,IVIG
humab granulocyte colony-stimulating factor G-csf
(集落刺激因子）
