After Birth Interventions
It is important to talk with your hospital before you give birth to make sure that they can treat your baby accordingly. Not all hospitals are able to do exchange transfusions, or IVIG. Make sure that the hospital you will be delivering at is ready and able to do these on your baby.
All interventions carry risk, not intervening also carries risk. Talk with your doctor about all of your options. If you feel your baby's needs aren't being met, ask to speak with a supervisor, NICU doctor, pediatric hematologist, patient advocate, or start calling other hospitals. You've got a baby with Hemolytic Disease of the Newborn if you've got a positive coomb's test, and they need to get appropriate care. Wait and see, not checking labs until x hours after birth, and ignoring the AAP guidelines for phototherapy and exchange transfusions are not indicators of appropriate care.
After Birth Interventions
Phototherapy - Bili Light
Bilirubin tends to peak around days 4-6 with ISO babies. You need to watch out for rebounding jaundice. ISO babies tend to have a decrease in bilirubin when on lights, but rapidly increase when the lights are removed. This can occur up to 3-4 days after removal from lights, so keep checking the bilirubin levels even after treatment has ended. Below is the AAP's recommendation for phototherapy graph. By having an iso baby, you will need to be looking at the medium or high risk lines depending on how many weeks you were when you gave birth. If your baby falls on or above the lines, you'll want to get him on a bilirubin light.
These lights emit a certain wavelength of light that helps remove the bilirubin from the baby's system. Their risk is minimal. The two main complications are dehydration and if the light isn't done correctly, sunburn like burns. You can still touch your baby when he's under lights, and you can still breastfeed. This can be done by pointing the lights at you, using a bili blanket, or only removing baby for 10-15 minutes to feed, and then putting right back under lights. You want the baby under the lights with as much exposed skin as possible, so expect him to be naked except for a diaper and goggles unless you're using a hospital biliblanket. Home biliblankets should not be used because they're not effective enough with iso.
Lights are most effective when left on for a period of time. What you do not want is baby on lights for 12 hours, off overnight, and then back on in the morning. You want to keep the lights on until the bilirubin is at a safe level and declining regularly. Remove them 1 light at a time, and test for rebounds. If baby rebounds, expect to go back under lights. Once baby isn't rebounding, and bilirubin is decreasing on it's own, you're usually good to go.
The following are images of infants receiving phototherapy. There may be other things shown in the photo as well, but the blue light is the phototherapy light.
There are a few kinds of blood transfusions. You can have a platelet transfusion, a red blood cell transfusion (sometimes called a top up), or an exchange transfusion. Some transfusions may affect your baby receiving non live vaccinations for up to 4 months afterwards. Make sure you talk with a pediatric hematologist, not a regular doctor, about what vaccines are safe for your child when. Blood products, such as platelets, exchange transfusions, and IVIG, contain significant amounts of antibodies to infectious agents. These products are made from other people's blood, and therefore contain their antibodies in adult amounts. These antibodies are present because of natural or vaccine induced immunity. Because there's so many antibodies in the blood products, it can interfere with the baby's immune response to vaccines. The baby's body won't make enough antibodies because it already sees all the adult antibodies.(51).
Platelet transfusions are useful for thrombocytopenia. They're just the packed platelets, nothing else.
Red blood cell transfusions are useful for anemia. These are generally done later with iso babies, at a few weeks old. This kind of transfusion will not remove the antibodies, but will put new blood that is antigen negative into the baby. For example, if you've got anti-Kell, your baby needs Kell negative blood. The risks of a RBC transfusion are lower than with an exchange transfusion, and are generally done later, once the bilirubin is taken care of. Think of it as topping off the baby so that they've got enough blood.
Exchange transfusions carry more risk. In this transfusion, they remove all of the baby's blood and replace it with donor blood. This is usually done twice, in what's called a double volume exchange. It is very helpful when treating HDN, but it does carry risk.
This is the transfusion graph. First determine your risk. If you are having a sensitized pregnancy, you are either medium or high risk. Then determine your baby's age and plot their numbers. The exception to this graph is with the cord blood. If at birth your cord bili levels are already over 4.5 (5), an exchange transfusion should be considered. At the very least, IVIG should be administered while prepping blood for baby.
The following are indications for exchange transfusion:
Severe anemia (Hb < 10 g/dL)
Cord bilirubin > 4 mg/dL.
Rate of bilirubin rises more than 0.5 mg/dL despite intensive phototherapy
Serum bilirubin-to-albumin ratio exceeding levels that are considered safe (5)
IVIG has been shown to reduce the need for an exchange transfusion.
These are pictures and descriptions of what care for an isoimmunized pregnancy and a baby with hemolytic disease of the newborn looks like. The photos might seem scary at first, but remember, knowledge is power. It's much better to have an idea of what things might look like, than to be shocked when your medical team first does something. It should also be reassuring the number of babies who have gone through this before and are now perfectly healthy, normal children. The infants below are receiving transfusions. It should be noted that the head is one of the least painful places to receive a transfusion which is why so many of the babies have IVs in their heads.
IVIG stands for intravenous immunoglobulin. It is a product made from human blood plasma. The AAP recommends IVIG if the total bilirubin is rising despite intensive phototherapy or if the level is within 2-3 mg/dL of the exchange level. If necessary, this dose can be repeated in 12 hours(49). IVIG has been shown to reduce the need for exchange transfusions in hemolytic disease of the newborn.
One of the problems with IVIG is that it can affect vaccines. You need to wait 11 months for live vaccines after IVIG. If your child has had a live virus vaccine within 14 days before receiving IVIG, the dose will need to be repeated after the wait period is up (50). Most doctors will not know this. That is why it's important to talk with a pediatric hematologist, and do your research.
The routinely used live vaccines are:
1. MMR (measles, mumps and rubella)
2. Varicella (chicken pox)
3. Flumist Live Attenuated Influenza Vaccine(LAIV) which is the influenza vaccine given as a intranasal spray. You can ask for a non-live version that is a shot.
5. Oral polio vaccine (OPV). This vaccine is no longer used in the U.S.
6. Shingles (Herpes Zoster)
7. BCG(Vaccine against TB-Tuberculosis) This is no longer a routinely used vaccine in the US, but is used under many circumstances. It is still used, especially in countries where TB is prevalent.
Live vaccines that are used in special circumstances such as during travel to a foreign country or during an epidemic are: Oral Typhoid Vaccine and the Yellow Fever Vaccine.
Blood products, such as platelets, exchange transfusions, and IVIG, contain significant amounts of antibodies to infectious agents. These products are made from other people's blood, and therefore contain their antibodies in adult amounts. These antibodies are present because of natural or vaccine induced immunity. Because there's so many antibodies in the blood products, it can interfere with the baby's immune response to vaccines. The baby's body won't make enough antibodies because it already sees all the adult antibodies. (51)
Note:Some babies have an allergic reaction to the IVIG. If this is the case, talk with your doctor about trying a different brand.
These are pictures and descriptions of what care for an isoimmunized pregnancy and a baby with hemolytic disease of the newborn looks like. The photos might seem scary at first, but remember, knowledge is power. It's much better to have an idea of what things might look like, than to be shocked when your medical team first does something. It should also be reassuring the number of babies who have gone through this before and are now perfectly healthy, normal children. The infants below are receiving IVIG through an IV or an umbilical line.