Hyperbilirubinemia in the Newborn
Presentation:
Patient J.C. is a preterm baby who was delivered by elective cesarean section at 36 weeks due to the finding of Rh sensitivity. Mom has a 2 year old at home who also has Rh+ blood and mom received RhoGAM® after delivery for that baby. Baby J.C. was found on ultrasound at 20 weeks to have fetal hydrops prompting six intrauterine transfusions at 20, 22, 23, 26, 28, and 30 weeks gestation. An intrauterine transfusion involves giving blood via the umbilical vein to the fetus to make up for the blood that is being destroyed due to the anti-Rh antibodies from mom.
J.C. was admitted directly to the NICU for observation, hydration, respiratory support, and possible phototherapy and/or exchange transfusion. Patient was placed on respiratory support due to initial oxygen saturation of 60%. D10 was started for blood sugar of 29 and because patient was ordered NPO in case of need for exchange transfusion. Initial labs were sent to check for Hyperbilirubinemia (Total and Direct Bilirubin, T&D Bili)*. An umbilical artery catheter (UAC) and an umbilical venous catheter (UVC) were placed for preparation for exchange transfusion and for internal blood pressure monitoring.
Treatment:
At 5 hours of life, patient was noted to have yellowing of the skin and sclera. Labs were sent and the Total Bilirubin had doubled, so triple bank phototherapy was started (triple bank = a bili blanket + an overhead light turned on to the double setting). The patient remained on phototherapy for 56 hours at which point the doctors felt the bilirubin was stable enough to try her off the phototherapy. The patient was taken off of phototherapy and the rebound check was within normal limits (checking the rebound T&D Bili is an important assessment tool to see if the patient needs to go back under phototherapy). The patient remained stable and never required an extra-uterine exchange transfusion.
Outcome:
This patient had an uncomplicated course and went home from the NICU after one week. She will need to have a repeat type and screen and newborn metabolic screen at 3 months of age due to all of the intrauterine exchange transfusions that her mom had to have. She had two major risk factors for newborn Hyperbilirubinemia which were Rh incompatibility as well as prematurity. Premature babies have immature livers that have a harder time conjugating bilirubin in order to have the body excrete it. Additional risk factors include sepsis, bruising from forceps/vacuum at birth, ABO incompatibility, glucose‐6‐phosphate dehydrogenase deficiency, and feeding problems. Treatment includes keeping the patient well hydrated, phototherapy, and exchange transfusion.
The reason why T&D Bili is so closely monitored in the newborn period is because if left untreated, it can cause kernicterus which will result in mental retardation, speech, hearing, and neuromotor problems. All of these problems are completely preventable if elevated bilirubin levels are detected and treated early. As per JCAHO standards, any baby with a Total Bilirubin greater than 30 mg/dL is considered a sentinel event.
Case created by Joanna Casey, 2010.