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‘ROLE OF IVIG IN THE MANAGEMENT OF
NEONATAL ISOIMMUNE HEMOLYTIC
JAUNDICE’
MEETA SACHDEV
G.MALINI, P.N.AGRAWAL, S.M.DEWANGAN
DEPTT. OF PEDIATRICS
JLN HOSPITAL & RESEARCH CENTRE
BHILAI
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INTRODUCTION
 Neonatal jaundice: Common in 1st wk of life
 60% of term & 80% of preterm infants.
 Clinical jaundice: Bilirubin >7 mg/dl.
 Mostly physiologic
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NONPHYSIOLOGIC JAUNDICE IN
WELL INFANT
 Hemolytic disease of newborn (ABO/Rh)
 Incidence of ABO incompatibility : 25%
significant jaundice : 2.5%
 Incidence of Rh incompatibility : 4.8%
significant jaundice : 0.17 – 0.31%
Gupte et al. Natl Med J India 1994; 7: 65-66
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WHY WORRY
 Clinically indistinguishable
 Bilirubin rises to toxic levels
 Acute bilirubin
encephalopathy
 Left with sequelae-
KERNICTERUS
 Athetosis, sensorineural
deafness, intellectual deficits
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CONVENTIONAL MANAGEMENT
 Intensive phototherapy
(excretion by alternative
pathways)
 Maintain hydration &
increase feeds
(decreases enterohepatic
circulation)
 Exchange transfusion
(mechanical removal)
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EXCHANGE TRANSFUSION
Prerequisites
 Invasive procedure
 Trained personnel
 Well-equipped setup
 Sepsis screen & blood culture
 Parentral fluids &
prophylactic antibiotics
 Near- fatal complications(5%)
& mortality (1%)
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COMPLICATIONS OF EXCHANGE
TRANSFUSION
 RISK OF EXPOSURE TO BLOOD
 COMPLICATIONS OF UVC
 Hypocalcaemia , hypomagnesaemia, hyperkalemia
 Hypoglycemia, acid-base disturbances
 Cardiovascular, apnea, seizures
 Bleeding, hemolysis
 Infection
 Misc- hypo/hyperthermia, NEC. Etc.
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IVIG IN HDN -AAP GUIDELINES
(Pediatrics 2004;114:297-316)
 Indication: Hemolytic disease of newborn with significant
hyperbilirubinemia
 Dose: 0.5-1gm/kg
 Mode of administration: Infusion given over 2-4 hrs.
 Monitoring: For adverse reactions
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Y
Y
Y
Y
YY
Y
Maternal
Y
Fetal RBC Antibodies
MECHANISM OF IVIG
Blockade
Y
Y RE cell
IVIG
Y
Y
Fc
Immunoglobulin Lysis of RBC
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WHY THIS STUDY
 After publication of AAP guidelines,
IVIG is being used more frequently in HDN.
 Is IVIG useful only to bring down the bilirubin level ?
 Are there any more advantages?
 What is our experience?
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AIMS & OBJECTIVES
 To evaluate the efficacy of IVIG in HDN
 To compare the stay, cost of treatment
& complications between IVIG & Exchange group
 Which is safer?
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MATERIAL & METHODS
 TYPE OF STUDY : OBSERVATIONAL
 TIME FRAME : JAN 2010 – DEC 2011
 NO. OF SUBJECTS : 16(16)
 INCLUSION CRITERIA : Healthy neonates (>35wks), HDN
& significant hyperbilirubinemia
 EXCLUSION CRITERIA : Sick neonates & gestation <35 wks.
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MATERIAL & METHODS
 Blood grouping of infants whose mother’s blood
group is O/Rh negative
 Close monitoring for clinical jaundice
 Measurement of serum bilirubin levels
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MATERIAL & METHODS
 INTENSIVE PHOTOTHERAPY & Maintain hydration
 INTRAVENOUS IMMUNOGLOBULIN INFUSION :
Rising bilirubin level despite intensive phototherapy
OR
bilirubin levels were within 2-3 mg % of exchange levels
 EXCHANGE TRANSFUSION :
Bilrubin level >5mg% of exchange threshold
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AAP GUIDELINES FOR PHOTOTHERAPY
(Pediatrics 2004;114:297-316)
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AAP GUIDELINES FOR EXCHANGE
TRANSFUSION
(Pediatrics 2004;114:297-316)
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OBSERVATIONS
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SEX DISTRIBUTION
Female : male = 1.28: 1
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GESTATION
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WEIGHT
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INCOMPATIBILITY
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BIRTH ORDER
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H/O JAUNDICE IN SIBLING
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SERUM BILIRUBIN LEVELS
Peak bilirubin
After After After
Mean value
24 hrs 48 hrs 72 hrs
(Age in days)
16.31 13.16 9.95
19.53
IVIG
(2.5 Days)
p < 0.005 p< 0.001 p < 0.001
Significant Highly significant Highly significant
18.82 13.23 9.68
Exchange 25.09
transfusion (3.75 Days)
p < 0.001 p < 0.001 p < 0.001
Highly significant Highly significant Highly significant
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CULTURE-POSITIVE SEPSIS
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PARENTRAL FLUIDS & ANTIBIOTICS
ANCILLARY EXCHANGE
IVIG
TREATMENT TRANSFUSION
IV FLUIDS 3 (19%) 16 (100%)
First line 3 (19%) 0
ANTIBIOTICS Broad spectrum 2 (13%) 9 (56%)
Extended spectrum 0 7 (44%)
2-5 D 5 (31%) 4 (25%)
DURATION OF
6-10 D 0 4 (25%)
ANTIBIOTICS
11-14 D
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0 8 (50%)

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DURATION & COST OF T/T
Blood exchange p value
MEAN VALUES IVIG group
group (Unpaired T test)
Significance
DURATION OF
5.5 Days 4.5 Days
PHOTOTHERAPY p > 0.05
Not significant
HOSPITAL STAY 7.2 Days 9.6 Days p < 0.05
Significant
COST ( Rs) 13,500 22,200 p < 0.005
Highly significant
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ADVERSE EFFECTS IN
EXCHANGE TRANSFUSION
100%
80%
% of patients
60%
44%
40%
25%
19% 19%
20% 13%
0%
0%
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CONCLUSION
 Predicting the risk of severe jaundice, close monitoring &
follow-up is crucial in ABO & Rh incompatibility
 Early intervention with intensive phototherapy & IVIG is
helpful in averting exchange transfusion, its associated
risks & complications significantly
 Duration of stay & cost of treatment is significantly
reduced
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REFERENCES
 Alcock GS, Liley H. Immunoglobulin infusion for isoimmune hemolytic
jaundice in neonates (review). Cochrane Database Syst Rev 2001;(4)
 Vinayaka G et al. role of intravenous immunoglobulin in the management
of hemolytic disease of newborn. Pediatrics Today Vol XII No. 6,2009
 Alpay F et al. High dose intravenous immunoglobulin therapy in neonatal
immune hemolytic jaundice. Acta Pediatr 1999;88:216-119
 Patra K. Adverse effects associated with neonatal exchange transfusion in
the 1990s. J Pediatr 2004;144:626-31
 Mukhopadhyay K et al.Intravenous immunoglobuin in rhesus hemolytic
disease. Indian J Pediatr 2003;70:697-9
 Miqdad AM et al. IVIG therapy for significant hyperbilirubinemia in ABO
hemolytic background from www.awesomebackgrounds.com Matern Fetal Neonatal Med 2004;16:163-6
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disease of newborn. J

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HOUR-SPECIFIC BILIRUBIN NOMOGRAM
(Bhutani VK, et al.Pediatrics 1999;103:6-14)
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TIMING OF FOLLOW-UP
(Pediatrics 2004;114:297-316)
Infant discharged follow-up by
Before age 24 h 72 h
Between 24 & 48 h 96 h
Between 48 & 72 h 120 h
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THANK YOU
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