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Hemolytic disease of the fetus and newborn

Last updated: August 27, 2020

Summary

Hemolytic disease of the fetus and newborn (HDFN) is a condition characterized by the destruction of fetal red blood cells (RBC) and subsequent anemia. It is commonly caused by a Rhesus (Rh) or ABO incompatibility between the mother and fetus, although other blood incompatibilities (e.g., Kell blood group incompatibility) can also cause HDFN. In Rh incompatibility, maternal IgG antibodies form after maternal exposure to fetal Rh-positive blood during birth or pregnancy-related complications (e.g., fetomaternal hemorrhage). The initial pregnancy is not affected; however, subsequent pregnancies are at risk of fetal hemolysis and, in severe cases, intrauterine hydrops fetalis. ABO incompatibility, on the other hand, may lead to fetal hemolysis in the first pregnancy because of preexisting antibodies in the mother, and it usually has a milder course of disease. Newborns may present with pallor, jaundice, and hepatosplenomegaly. Diagnosis of HDFN involves clinical and laboratory assessment for evidence of antibody-mediated hemolysis (e.g., Coombs test). Prenatal imaging may be used to exclude hydrops fetalis. Treatment includes iron supplementation and, in the case of severe jaundice, phototherapy. In rare cases, extremely low hemoglobin (Hb) levels require transfusion of red cell concentrates. Since Rh incompatibility may be fatal, anti-D immunoglobulin prophylaxis is administered to Rh-negative pregnant women. ABO incompatibility, on the other hand, rarely presents with complications and does not require immunoglobulin prophylaxis.

Definition

HDFN is a condition characterized by blood group incompatibility between the mother and fetus that leads to the destruction of fetal erythrocytes by maternal antibodies.

Etiology

References:[2][3]

Pathophysiology

ABO incompatibility

Rh incompatibility

References:[2]

Clinical features

Prenatal

Postnatal

ABO incompatibility usually has a significantly milder course of disease than Rh incompatibility.

Anemia may conceal cyanosis.

References:[3]

Diagnostics

The diagnosis of HDFN requires evidence of hemolysis in the presence of fetomaternal blood incompatibility.

Prenatal diagnosis

Postnatal diagnosis

References:[3][4][5]

Differential diagnoses

ABO vs. Rh incompatibility

ABO incompatibility

Rh incompatibility

Incidence
  • Frequent
  • Rare
Disease during the first pregnancy
  • Frequent
  • Rare

Clinical findings

  • Generally normal to mild; may be asymptomatic
  • Mild to severe

Coombs test (direct or indirect)

  • Weak positive or negative
  • Positive
Spherocytosis
  • Present
  • Rare

References:[3]

The differential diagnoses listed here are not exhaustive.

Treatment

References:[3][6]

Prevention

Screening

Anti-D immunoglobulin (RhoGAM)

References:[2][3][8][9][10]

References

  1. Benrubi GI. Handbook of Obstetric and Gynecologic Emergencies. Lippincott Williams & Wilkins ; 2010
  2. Basu S, Kaur R, Kaur G. Hemolytic disease of the fetus and newborn: current trends and perspectives. Asian J Transfus Sci. 2011; 5 (1): p.3-7. doi: 10.4103/0973-6247.75963 . | Open in Read by QxMD
  3. Wagle S. Hemolytic Disease of Newborn. In: Rosenkrantz T, Hemolytic Disease of Newborn. New York, NY: WebMD. http://emedicine.medscape.com/article/974349. Updated: January 2, 2016. Accessed: May 11, 2017.
  4. Moise KJ. Intrauterine Fetal Transfusion of Red Cells. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/intrauterine-fetal-transfusion-of-red-cells.Last updated: April 11, 2017. Accessed: May 11, 2017.
  5. Calhoun DA. Postnatal Diagnosis and Management of Hemolytic Disease of the Fetus and Newborn. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/postnatal-diagnosis-and-management-of-hemolytic-disease-of-the-fetus-and-newborn.Last updated: July 25, 2016. Accessed: May 11, 2017.
  6. Kirpalani H, Whyte RK, Andersen C, et al.. The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr. 2006; 149 (3): p.301-307. doi: 10.1016/j.jpeds.2006.05.011 . | Open in Read by QxMD
  7. Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 181. Obstetrics & Gynecology. 2017; 130 (2): p.e57-e70. doi: 10.1097/aog.0000000000002232 . | Open in Read by QxMD
  8. Fischer C. Master the Boards USMLE Step 2 CK. Kaplan Publishing ; 2015
  9. Moise KJ. Prevention of Rhesus (D) Alloimmunization in Pregnancy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/prevention-of-rhesus-d-alloimmunization-in-pregnancy.Last updated: August 28, 2016. Accessed: May 11, 2017.
  10. Kleihauer Betke Test.
  11. Strutz J, Mann W, Schumacher K. Praxis der HNO-Heilkunde, Kopf- und Halschirurgie. Thieme Verlag (2009) ; 2009