新生儿黄疸NeonatalJaundice.ppt

Neonatal Jaundice,Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University,Introduction,Jaundice is quite common (5mg/dl). Full term infants: at least 50% Preterm infants: 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/dl.,Introduction continued,Producing Excreting,Why Jaundice occurred?,Bilirubin Metabolism:,1. RBC: Heme bilirubin (UCB) 2. Blood: carried by bound to albumin 3. Liver: uptaken : Y protein, Z protein conjugated: UDPGT excreted： to the biliary system 4. Intestine: stercobilins -glucuronidase enterohepatic circulation,The metabolic characteristics of bilirubin in newborns:,1. Bilirubin production 8.8mg/Kg/d in newborns 3.8mg/Kg/d in adults 2. Bilirubin-albumin complex formation a. preterm infant; b. acidosis,3. Bilirubin metabolism of hepatocyte a. Hepatic uptake of bilirubin b. Bilirubin conjugation: UDPGT (uridine diphosphate glucoronyl transferase) c. Defective bilirubin excretion ability to bile system 4. Enterohepatic circulation,The metabolic characteristics of bilirubin continued,Bilirubin toxicity,1. Conjugated bilirubin water-soluble 2. Unconjugated bilirubin lipid-soluble bilirubin-encephalopathy （kernicterus）,Clinical Manifestations,Jaundice appears When: at any time during the neonatal period Where: from face chest abdomen feet,Evaluation of jaundice : 1. By eyes: face, 5mg/dl ( 85mol/L ); abdomen, 10-15mg/dl; feet, 15-20mg/dl ; 2. By transcutaneous measurement : used for screening 3. By serum levels : standard,Manifestations continue,Classification: Physiological Jaundice Pathological Jaundice,Manifestations continue,Physiological jaundice : 1. General state is well 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) 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) 15mg/dl (preterm infants) Fades 2 weeks (term infants) 4 weeks (preterm infants) 3. Accumulates 5mg/dl/d 4. Direct bilirubin 2mg/dl 5.Jaundice recurrent,Manifestations continue,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. Neonatal hepatitis b. Biliary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. Congenital metabolic diseases -1 antitrypsin deficiency,Causes of pathological 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 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 etc.,Anemia,Liver Spleen Heart, other organs Hydrops,Clinical Manifestations:,ABO Rh 1.Jaundice : mild severe 1-2 day 24 h 2.Anemia: mild severe (3-6 weeks) heart failure 3.Hepato- rare common splenomegaly,Complication,Kernicterus: Phase 1: decreased alertness Hypotonia Poor feeding Phase 2: Hypertonia, Retrocollis, opisthotonus Phase 3: Hypotonia,1. Blood type incompatibility 2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests 1). Hemoglobin level : low 2). Reticulocytes:1015% 3). Nucleated RBC,Laboratory tests:,Antibody test 1). Direct Coombs test (+) confirm 2). Antibody release test (+) confirm 3). Free antibody test (+) judge,Laboratory tests continued,1). Phototherapy 2). Exchange transfusion 3). Internal Medicine,Treatments,During pregnancy 1. Intrauterine blood transfusion 2. Early delivery,Treatments continued,After birth 1. Phototherapy Principle : photon of light Three photochemical reactions: 1). Structure isomer 2). Geometric isomer 3). Photo-oxidation Photoproducts excretion: w/o conjugation,Treatments continued,Indications of phototherapy : Unconjugated bilirubinemia Bilirubin level 12mg/dl Light source: Spectral outputs 420 to 500nm,Treatments continued,Side effects of phototherapy : a. diarrhea b. fever c. skin rash d. bronze baby syndrome (conjugated bilirubin4mg/dl),Treatments continued,2. Exchange Transfusions: a. Severe hemolytic disease b. Refractory to phototherapy,Treatments continued,Aims of transfusions: a. Remove antibodies b. Remove bilirubin c. Correct anemia,Treatments continued,Indication of transfusions: one of the follows 20mg/dl (340 mol/L) 4mg/dl,Hgb120g/L, edema 0.7mg/dl/h Kernicterus,Treatments continued,Source of the blood mother newborns For Rh: Rh ABO incompatibility For ABO: “AB” plasma “O” cells incompatibility packed RBC,Treatments exchange transfusions,Potential complications: a. Infection b. Necrotizing enterocolitis NEC c. Thromboembolic complications,Treatments exchange transfusions,3. Pharmacological agents: a. Phenobarbital Effects: Uptake, Conjugation Excretion b. Albumin c. IVIG,Treatments continued,Preventions,For ABO incompatibility: No For Rh incompatibility 300 g of human anti-D globulin within 72 h of delivery.,1.Unconjugated bilirubinemia:,a. Hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice,1.Unconjugated bilirubinemia:,b. G-6-PD deficiency; male, jaundice, enzyme activity c. Breast milk jaundice causes: unclear, -glucuronidase follows physiologic jaundice: 4-7 d breast feeding persist for several weeks.,Conjugated bilirubinemia:,2.Conjugated bili