新生儿黄疸(英文)课件.ppt

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1、Neonatal Jaundice,(Hyperbilirubinemia),Neonatal Jaundice(Hyperbilir,Introduction,All babies develop elevated serum bilirubin (SBR) levels, to a greater or lesser degree, in the first week of life. This is due to: increased production (accelerated RBC breakdown); decreased removal (liver enzyme insuf

2、ficiency) Increased reabsorption (enterohepatic circulation).,Introduction All babies deve,Introduction,60% of infants become clinically jaundiced in 1st wk Bili levels peak at 35 days in full term infants 1/6 of formula fed infants have bili levels over 12 1/3 of breast fed infants have bili levels

3、 over 12 Over 80% of all infants with bili levels12.9 mg/dl in the first four days of life are breast fed,Introduction 60% of infants b,Bilirubin Metabolism,derived from the catabolism of proteins that contain heme the most important source is the breakdown of Hb from RBC native bilirubin is relativ

4、ely insoluble in water at physiologic pH, but it is very lipid soluble bilirubin circulates bound to albumin in equilibrium with its unbound or free fractionthe unbound fraction that readily crosses the blood-brain barrier and results in neurotoxicity,Bilirubin Metabolism derived f,Bilirubin Metabol

5、ism,Bilirubin is made more water-soluble in the liver by conjugation with glucuronic acid to form conjugated or direct-reacting bilirubin, then cleared through the bile into the intestines and out through the feces. Phototherapy works by producing photoisomers of bilirubin that are more water solubl

6、e, and that can be cleared directly in bile or urine without conjugation in the liver.“enterohepatic circulation”: b-glucuronidase in the gut hydrolysis the conjugated bilirubin into unconjugated bilirubin, and reabsorbed into liver,Bilirubin Metabolism Bilirubin,Characteristics of Neonatal Bilirubi

7、n Metabolism,Increased bilirubin production 8.8mg/kg daily vs 3.8mg/kg in adults Insufficiency of bilirubin transportation acidosis, hypoalbuminemia Immature of liver function lower ingestion (y, z protein); lower UDPGT activity Increased “enterohepatic circulation” lower in gut bacteria; higher b-g

8、lucuronidase activity,Characteristics of Neonatal Bi,“Physiological” Jaundice,Seen in 60% of term infants and over 80% of preterm Serum values reaches maximum at 6mg/dl on 45d in term and 1012mg/dl on 57d in premature infants Jaundice declines gradually, reaching normal values within 2 wks in term,

9、and 34w (12m) in preterm Causes no damage in term infants Up limit for abnormal? Undefined(Term 12mg/dl, or term13, preterm15mg/dl),“Physiological” Jaundice Seen,Factors likely to make “physiological jaundice” worse,prematurity bruising cephalohematoma polycythaemia delayed passage of meconium breas

10、t feeding certain ethnic groups, esp Chinese,Factors likely to make “physio,Characteristics of Pathological Jaundice,Jaundice appears within 24 hrs of life Severe jaundice: SBR1215mg/dl, or 5mg/dl/day Sustained jaundice (term2w, preterm4w ) Recurrence of jaundice Increased serum conjugated bilirubin

11、 (1.52mg/dl),Characteristics of Pathologica,Pathological Jaundice,Infectious diseasesNeonatal hepatitis (Torch infection)Neonatal septicemia Non-infectious diseasesHemolytic diseasesBiliary atresiaBreast milk jaundiceGenetic metabolic diseases: G6PD, a1-antitrypsin, CFDrugs induced: Vitamin K3, K4,P

12、athological Jaundice Infectio,Breast Milk Jaundice,Occurs infrequently (1%), peaks in 23wk, may persist at moderately high levels for 3-4 weeks before declining slowly It is a diagnosis of exclusionIn an otherwise well infant, it is considered a benign condition. If breast feeding stopped, the serum

13、 bilirubin usually fallsThe potential harms of stopping breast feeding would outweigh any risks of a mild or moderate hyperbilirubinaemiaAetiology is unknown, some hormonal in the milk may acting on the infants hepatic metabolism, or enzyme (lipase) facilitating intestinal absorption of bilirubin.,B

14、reast Milk JaundiceOccurs inf,Breast-feeding Jaundice,increased bilirubin levels seen during the first week of life in infants who are breast feddue to both caloric deprivation (mostly) and some fluid deprivation (a small part) during the first few days of lifeThe more frequently breast feeding occu

15、rs during the first few days, the lower are subsequent bili levelscan be prevented by teaching effective breast-feeding practices and support policies,Breast-feeding Jaundice increa,Clinical Investigation: Kramers Rule,Cephalocaudal Progression of Jaundice,Clinical Investigation: Kramer,Clinical Inv

16、estigation,Total SBR conjugated SBR full blood count - may reveal spherocytes or septic Group & Direct Coombs test hemolytic jaundice high TSH & low T4 - suspect thyroid disease G6PD screen - male and appropriate ethnic group sepsis screen if indicated galactosaemia,Clinical Investigation Total S,Rh

17、esus isoimmunisation,Rh antigen: C, D, E, c, d, e most common type is RhD Rh (-) refers to D- Rare in un-transfused 1st pregnancy In severe cases fetal anaemia develops, causing congestive cardiac failure (hydrops fetalis) The fetus is protected with placental removal of bilirubin, following rapidly

18、 rising SBR after birth,Rhesus isoimmunisation Rh anti,ABO Incompatibility,Most often seen in the setting of mother being group O and the baby being groups A or B Milder that Rhesus disease, rarely affects the fetus Jaundice that becomes apparent on day 1 or 2 Diagnosis with blood groups and direct

19、Coombs Test Responds well to phototherapy Rarely requires exchange transfusion,1/5 for ABO, 1/20 for Rh incompatibility will becoming hemolytic,ABO Incompatibility Most often,Clinical Manifestation,Jaundice: within 24h in 77% of Rh, 28% in ABO Anemia Hepatosplenomegaly Bilirubin encephalopathy (Kern

20、icterus)Early (27d): more in preterm, includes hypertonia, lethargy, feeding difficulty, seizures, 1/3 death, bilirubin staining of the basal gangiaLate: Survivors may go on to develop sensorineural hearing loss and cerebral palsy, often with ataxia and choreoathetosis; disorders in eye movement; en

21、amel hypoplasia,Clinical Manifestation Jaundic,Diagnosis,Family history: still birth, abortion, jaundice Parents ABO/Rh typing, antibody Ultrasound for hydrops fetalis Postnatal: jaundice, anemia, neurological symptom Blood type and antibody,Direct Coombs, Antibody release, & Free antibody Test,Diag

22、nosis Family history: stil,Management,Prenatal: Rh (-), monitoring antibody, bilirubin, etcTerminate pregnancy when lungs are maturedPlasma transfusion to remove antibodyIntrauterine blood transfusionMaternal use of phenobarbitone to induce enzyme,Management Prenatal:,Phototherapy,Isomerisation of u

23、nconjugated bilirubin Wave length: 427475nm (blue), 510530nm (green)Blue light, green light/day lightProtection of eyes/gonadInvisible water lossSide effects: skin rash, fever, diarrheaBeware of conjugated hyperbilirubinemia (bronze baby),PhototherapyIsomerisation of u,Phototherapy,Phototherapy,Exch

24、ange Transfusion,Prenatal diagnosed, Hb12 mmol/L/hr (0.75mg/dl)SBR 342 mmol/L (20mg/dl)Preterm/Rh history/Hypoxia/Acidosis/SepsisFor Rh: Rh same as mother, ABO same as infantFor ABO: AB/plasma and O/RBS; or type OVolume: 150180ml/kg via umbilical vein catheter,Exchange TransfusionPrenatal d,Other In

25、tervention,Albumin (1g/kg), plasma (25ml)Correct acidosisPhenobarbitone (5mg/kg) to induce enzymesIntravenous immunoglubulin (1g/kg) Prevent hypoxia/hypothermia/hypoglycemiaAnti RhD IgG (300mg, im) for Rh (-) mother after delivered a Rh (+) baby (within 72h) Good perinatal care,Other InterventionAlbumin (1g/,Sleep well,Baby!,Sleep well,