A recent study published in Best Practice & Research: Clinical Obstetrics & Gynaecology outlines the current recommendations and challenges associated with managing hemolytic disease of the fetus and newborn (HDFN).
In their review, the authors sought to compile the best practices for treating newborns with HDFN to assist clinicians in the decision-making process.
Patients may be diagnosed with HDFN either during pregnancy or after birth. “Prenatally identified infants can be managed early to prevent severe hyperbilirubinemia, whereas postnatally identified infants require prompt interventions focused on treating severe hyperbilirubinemia and preventing complications,” the authors explained.
What is bilirubin?
Bilirubin is a molecular byproduct of the breakdown of hemoglobin, the protein responsible for holding the oxygen transported in red blood cells. It is normally transported to the liver, where it undergoes a transformation called conjugation, and is then excreted from the body through the intestines. Jaundice is caused by the accumulation of bilirubin in the blood, which is known as hyperbilirubinemia.
Read more about HDFN treatment and care
In patients who are diagnosed prenatally, delivery should usually occur at around 36 to 37 weeks gestation, the authors wrote. Blood should be taken from the umbilical cord for testing, and cord clamping can be delayed for 30 to 60 seconds after birth. Phototherapy is also recommended within one hour of birth for those with severe hyperbilirubinemia.
Infants who were not diagnosed with HDFN before birth are usually diagnosed through a positive direct antiglobulin test or the onset of severe jaundice. For these individuals, careful monitoring is key to improving outcomes.
After birth, HDFN management is centered around treating and preventing complications of hyperbilirubinemia. Phototherapy is typically recommended to newborns to help lower bilirubin levels.
Although its routine use is not currently recommended, intravenous immunoglobulin can be administered to infants to prevent the breakdown of red blood cells when bilirubin levels remain high following phototherapy. Exchange transfusions can also be used to replace the baby’s blood with a donor’s blood, although this procedure can be risky.
Researchers are investigating experimental therapies, including metalloporphyrin, phenobarbital and albumin, to manage hyperbilirubinemia in HDFN. However, data on their effectiveness is very limited at this time.
Elevated bilirubin levels can also cause cholestasis, a buildup of bile in the liver. Patients with a younger gestational age at birth, those with a history of intrauterine transfusions and infants with anti-D HDFN are at the highest risk for cholestasis. Usually, this condition will resolve on its own with the help of tube feeding.
Anemia is another potential complication of HDFN, the authors said. Transfusions may be needed in some cases, depending on the infant’s age and hemoglobin level.
Additionally, iron overload, which occurs when the body stores too much iron, can arise in patients with HDFN, especially those who received an intrauterine transfusion. Iron overload can cause liver, heart and endocrine disorders if not treated. Parents should take care to limit their babies’ iron intake, and chelation therapy can be used to help remove iron from the body if necessary.
“Despite the effectiveness of current therapies, ongoing research and careful management are essential to address potential risks and improve outcomes for infants affected by [HDFN],” the authors concluded.
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