2014 JOURNAL OF MEDICAL RESEARCHVol.1 No.1Vol.1Jul.–Dec. 2014ERA’S JOURNAL OF MEDICAL RESEARCHJul.–Dec. No.1ERA’S
NEoN ATAl AND oBSTETRIC TRANSFUSIoN
Prof. S. Riaz Mehdi1, Dr. Fiza Mustaqueem2 Dr. Nishi Tandon2,
Professor1, Assistant Professor2, Department of Pathology
Era’s Lucknow Medical College, Lucknow
Address for Correspondence
Up to four weeks of birth a newborn is considered a neonate. Most often, these neonates are in Prof. S. Riaz Mehdi
need of blood or one of its components. The naturally occurring ABO antibodies are not fully 505, Dilkash Apartment, 3–River
developed in neonates and the presence of Wharton’s jelly poses problems in routine grouping Bank Colony,
and cross matching procedures. Indications and the guidelines for transfusion are different in No. :Lucknow–226018Ph. 09506942129, E–mail :
cases of neonates. Extra precautions are recommended. The proper choice of component is of firstname.lastname@example.org
utmost importance. Hemolytic Disease of Newborn (HDN) is a frequently encountered disorder,
occasionally requiring exchange transfusion. The indications, procedure and the complications
of Exchange Transfusion have to be understood properly by the pediatricians before employing
the procedure, especially in low birth weight babies.
The transfusion in obstetric cases and in post partum hemorrhage (PPH) too requires guidelines, which have to be followed.
Most of the deaths in obstetrics take place due to PPH which is preventable if the obstetricians take precautions and start the
transfusion timely. Beside PPH, perioperative hemorrhage is often an indication for transfusion. All pregnant women must be
monitored regularly for iron deficiency anaemia , hemoglobinopathies and alloantibodies during their antenatal period.
Neonates quite often require blood transfusion and their requirements are different and unique. A normal neonate has
approximately 85 ml/kg of blood volume. Frequent blood collection for laboratory investigations leads to iatrogenic blood loss
and need for transfusion.
Key Words : Transfusion, Neonatal, Obstetrics
Blo oD GRoUPING oF NEWBoRN’S oR procedure for the blood grouping and DAT is similar to that
CoRD BlooDemployed in cases of adults. (1, 2, 3)
ABo Grou pingCoombs’ (AHG) Test
The ABO antigens are not fully developed on the red cells of The DAT is strongly positive in HDN. If the DAT is positive
a newborn. The naturally occurring complete antibodies are and the maternal serum is negative for antibody screen,
also not present. Whatever alloantibodies are present in the there is a strong possibility of ABO HDN or HDN due to
cord blood are of maternal origin.low incidence antigen. In case of low incidence antigen HDN
The reverse grouping is not recommended on newborn’s theconfirmation, eluate should mother’s be tested serum against against the father’s father’s cells red should cells. For be
blood. The cord blood contains Wharton’s jelly, which may tested. (4)
lead to error unless the cord cells are thoroughly washed 3–4
times in saline.CRoSS MATCHING IN NEoNATES
Rh GroupingIf antibody screen is negative and the neonate has been
In a normal neonate the routine Rh grouping poses no transfusedthen compatibility with O negative testing can or be ABO omitted. compatible If unexpected blood
problem, unless the neonatal red cells are heavily coated by antibodies are detected in neonate’s or mother’s serum then
IgG antibodies. The contamination by Wharton’s jelly may compatibility testing must be carried out. If the neonate is to
also lead to inaccurate result. In case of Rh Hemolytic Disease receive RBC concentrate of an ABO group incompatible with
of Newborn (HDN_ the neonatal red cells may be fully mother’s serum, it is necessary to cross match the RBC with
saturated with maternal anti–D leading to “blocked D”. The neonate’s serum.
anti–D reagent may notEJMR react with the unavailable antigen
leading to a false negative result. The forward ABO blood Procedure
grouping and Rh–D can also be performed by the gel card
technique. The card has 6 microtubes. The sixth microtube 1. D etermine the ABO and Rh (D) grouping of the neonate
carries Anti Human Globulin (AHG) reagent and used for by forward grouping only.
Direct Antiglobulin Test (DAT). The requirements and 2. Perform DAT on the neonate’s red cells for Haemolytic
Disease of Newborn (HDN).
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3. S creen the maternal serum for any alloantibody.– To remove the infants’ affected red blood cells and
4. When DAT on neonate’s cells and the Indirect circulating maternal antibodies to reduce red cell
Antiglobulin Test (IAT) on mother’s serum are negative, destruction;
cross match the group specific donor cells with the – To correct anaemia and treat any potential for heart
neonate’s serum.failure whilst maintaining euvolaemia. (14, 20)
5. If the antibody screening on mother’s serum is positive The indications for exchange transfusion are
or the DAT on neonate’s cells is positive (HDN), the
Haemolytic disease of newborn (HDN)
donor’s cells must be cross matched with the maternal •
Sickle cell anaemia
6. If group O blood is to be given to group A or B
Cord Hb < 12 mg/dl and/or cord Serum Bilrubin (SBR)
recipient then RBC concentrate and not whole blood is •
recommended. (1, 5, 6, 7, 8, 9)> 80: ( immediate exchange transfusion)
2 Exchange transfusion if rate of rise in SBR is such that
CoMPoNENTS TRANSFUSIoN IN •
NEoNATESSBR is likely to reach 300 micromol/L ( aim to keep SBR
below 340 micromol/L) (15)
Red Cell Concentrate
Cross Matching for Exchange Transfusion
The neonates require small amounts of blood transfusion.
Many aliquots can be prepared from a single unit of blood or The serum or plasma of either mother or neonate can be used
small amount of blood may be collected from a donor after for cross matching with the donor’s RBC. (16, 17)
adjusting the blood and anticoagulant ratio. A single unit of Techniques
blood can provide 12 aliquots of 20 ml each and a unit of
Fresh Frozen Plasma (FFP). Units containing 30–60 ml of An exchange transfusion equal to twice the newborn’s blood
whole blood (WB) can also be collected. A unit intended for volume is recommended. The blood volume of a full term
WB should be collected in a double bag. The unit intended newborn is approximately 85 ml/Kg of body weight. Volume
for component preparation of RBC, FFP and Platelet of whole blood required for two volume exchange transfusion
Concentrate (PC) should be collected in a set of quadruple is calculated as ; Weight of newborn in Kg × 85 × 2 Two
bags. (10, 11, 15)catheters of identical size are required for isovolumetric
method. The umbilical artery is used for withdrawal and
Criteria for RBC Concentrate Transfusion inumbilical vein for infusion. A maximum of 5 ml/kg is used
Neonatesfor each with drawal and infusion. (18,19)
1. Hb. < 13 gm/dl with severe pulmonary disease.GUIDElINESWEIGHT INFANTS FoR BASEDEXCHANGE oN AGE TRANSFUSIoN IN loW BIRTH
2. Hb. < 10 gm/dl with moderate pulmonary disease.
3. Hb. < 13 gm/dl with severe cardiac disease.HoursSBR(micro–SBR(micromol/L)SBR(micromol/L)
4. Hb. < 8 gm /dl with symptomatic anaemia.mol/L)<24 >170–255>255>270–310
Criteria for FFP Transfusion in Neonates24–48 >170–255>255>270–310
The criteria for FFP transfusion in neonates are slightly >72 >255>290>310–340
different from adults.
Complications of Exchange Transfusion
1. Reconstitution of RBC concentrates to simulate whole
The most commonly reported adverse events during
blood for use in exchange transfusion.•
or soon after exchange transfusion: Catheter related
2. Hemorrhage secondary to vitamin K deficiency.complications; air emboli; thrombosis; haemorrhage
3. Disseminated intravascular coagulation (DIC) with •
bleeding. (11)Haemodynamichypo or hypertension, (related to excess removal of blood):
4. Bleeding in congenital coagulation factor deficiency. (12)•
Intraventricular haemorrhage (preterm)
EXCHANGE BlooD TRANSFUSIoN•
Hypo or hyperglycaemia
In exchange transfusion the blood volume is replaced by •
fresh blood. This is one genuine reason for use of fresh blood, Hypocalcaemia,complications related hyperkalaemia, to exchange transfusion:EJMRacidaemia Potential
where blood no more than 5 days old is recommended. (13)
The aim of Exchange transfusion is;
– To lower the serum bilirubin level and reduce the risk of •
Neutropenia, dilutional coagulopathy
brain damage (kernicterus);•
2223 2014 JOURNAL OF MEDICAL RESEARCHVol.1 No.1Vol.1Jul.–Dec. 2014ERA’S JOURNAL OF MEDICAL RESEARCHJul.–Dec. No.1ERA’S
• Septicaemia, blood born infectionCriteria for obstetric Transfusion
• Hypo or hyperthermiaThe aim of these guidelines is to offer guidance about the
• Thrombocytopeniaappropriate use of blood in obstetric cases as well as to
minimize blood loss.
Anaemia should be treated first. If the haemoglobin
Intrauterine transfusion can be performed after 24th week of level is less than 10.5 gm/dl in the antennal period,
gestation.iron deficiency anaemia should be considered, once the
The procedure is performed under radiographic monitoring. haemoglobinopathies have been ruled out.
A needle is passed through the mother’s abdomen and 2. All pregnant women should have their blood group and
uterine wall into the fetal abdominal cavity. The transfused antibodies status checked at 28 weeks of gestation.
red cells enter the fetal circulation by absorption from the 3. Patient blood samples used for cross matching of RBC
lymphatic channels. An intrauterine exchange transfusion, should be no more than 7 days old.
under ultrasound guidance can also be performed through
the umbilical vein.4. Preferably, a Kell– negative blood should be used for
transfusion to avoid HDN.
The high levels of bile pigments in the amniotic fluid , a
sign of fetal haemolysis in cases of impending HDN, is an 5. Theon haematological decision to perform and transfusion clinical profile should of be patient. based
indication for intrauterine transfusion.Transfusion is rarely indicated in a stable patient with
Cytomegalovirus InfectionHb greater than 10gm/ dl and always indicated when
Cytomegalovirus (CMV) infection may occur in perinatal less than 6 gm/dl.
period or can be harboured from mother’s breast feed 6. The red cells and platelets concentrate for transfusion
or nursery personnel. CMV is also transmitted by blood should be Cytomegalovirus (CMV) seronegative.
transfusion which can be and should be avoided. The CMV is 7. Blood salvage is recommended in patients where
carried by leukocytes. The premature and under weight babies intraoperative blood loss is expected to be greater than
requiring multiple transfusions are at a higher risk of CMV 1500 ml.
infection. The washing of red cells and leukocyte depleted red
cells diminish the chances of acquired CMV infection.8. pregnancy.Predeposit autologous transfusion is not an option in
oBS TETRICAl TRANSFUSIoN PRACTICE9. In cases of DIC or a total blood loss of almost 1
Massive perioperative or periparturitional bleeding volume of blood, a combination of platelets, FFP and
occasionally occurs in obstetric and gynaecologic patients. cryoprecipitate is recommended.
Placenta previa, uterine atony, ectopic pregnancy and 10. Fibrinogen level should be maintained above 1.0gm
post partum haemorrhage are just a few examples of many (21,22)
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