Hemolytic Disease of Newborn Workup

  • Author: Sameer Wagle, MBBS, MD; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: May 18, 2011
 

Laboratory Studies

The following findings may be noted in hemolytic disease of the newborn (HDN):

Hemolytic disease of the newborn is characterized by one or more of the following clinical presentations:[23]

  • Rapidly progressive severe hyperbilirubinemia or prolonged hyperbilirubinemia
  • Positive maternal antenatal antibody findings and/or diagnosis of anemia or fetal hydrops
  • Positive neonatal direct Coombs test (direct antiglobulin test)
  • Hemolysis on blood film findings

The severity of hematologic abnormalities is directly proportional to the severity of hemolysis and the extent of hematopoiesis. The following abnormalities are observed on CBC count findings:

  • Anemia: Measurements are more accurate using central venous or arterial samples rather than capillary blood.
  • Increased nucleated RBCs, reticulocytosis, polychromasia, anisocytosis, spherocytes, and cell fragmentation
    • The reticulocyte count can be as high as 40% in patients without intrauterine intervention.
    • The nucleated RBC count is elevated and falsely elevates the leukocyte count, reflecting a state of erythropoiesis.
    • Spherocytes (< 40%) are more commonly observed in cases of ABO incompatibility. Glucose does not correct the autohemolysis in ABO incompatibility unlike hereditary spherocytosis.
    • In severe hemolytic disease, schistocytes and burr cells may be observed, reflecting ongoing disseminated intravascular coagulation.
    • A low reticulocyte count is observed in fetuses provided with intravascular transfusion in utero and with Kell alloimmunization.
    • Abnormally elevated mean cell hemoglobin concentration (MCHC) and red cell distribution width (RDW) values should prompt a diagnosis of hereditary spherocytosis.[24]
  • Neutropenia: This condition seems to be secondary to stimulation of erythropoiesis in favor of myelopoiesis. However, neutrophilia can be observed after intrauterine transfusion because of an increase in circulating cytokines (granulocyte-macrophage colony-stimulating factor).
  • Thrombocytopenia: This condition is common, especially after intrauterine or exchange transfusions because of platelet-poor blood product and suppression of platelet production in favor of erythropoiesis.

Hypoglycemia is common and is due to islet cell hyperplasia and hyperinsulinism[25] . The abnormality is thought to be secondary to release of metabolic byproducts such as glutathione from lysed RBCs. Hypokalemia, hyperkalemia, and hypocalcemia are commonly observed during and after exchange transfusion.

Serologic test findings include the following:

  • Indirect Coombs test and direct antibody test results are positive in the mother and affected newborn. Unlike Rh alloimmunization, direct antibody test results are positive in only 20-40% of infants with ABO incompatibility.[26] In a recent study,[27] positive direct antibody test findings have a positive predictive value of only 23% and a sensitivity of only 86% in predicting significant hemolysis and need for phototherapy, unless the findings are strongly positive (4+). This is because fetal RBCs have less surface expression of type-specific antigen compared with adult cells. A prospective study has shown that the titers of maternal immunoglobulin G (IgG) anti-A or anti-B may be more helpful in predicting severe hemolysis and hyperbilirubinemia. The sensitivity and specificity of IgG titers of 512 or higher in predicting need for invasive intervention was 90% and 73%, respectively.[28]
  • Although the indirect Coombs test result (neonate's serum with adult A or B RBCs) is more commonly positive in neonates with ABO incompatibility, it also has poor predictive value for hemolysis. This is because of the differences in binding of IgG subtypes to the Fc receptor of phagocytic cells and, in turn, in their ability to cause hemolysis.
  • IgG2 is more commonly found in maternal serum but has weak lytic activity, which leads to the observation of little or no hemolysis with a positive direct antibody test result. On the other hand, significant hemolysis is associated with a negative direct antibody test result when IgG1 and IgG3 are predominant antibodies, which are in low concentration but have strong lytic activity, crossing to neonatal circulation.
  • In newborns with hemolytic disease due to anti-c or anti-C antibodies, direct antibody test results may be negative, and the diagnosis is established after indirect Coombs testing.

Table. Comparison of Rh and ABO Incompatibility (Open Table in a new window)

CharacteristicsRhABO
Clinical aspectsFirst born5%50%
Later pregnanciesMore severeNo increased severity
Stillborn/hydropsFrequentRare
Severe anemiaFrequentRare
JaundiceModerate to severe, frequentMild
Late anemiaFrequentRare
Laboratory findingsDirect antibody testPositiveWeakly positive
Indirect Coombs testPositiveUsually positive
SpherocytosisRareFrequent
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Imaging Studies

High-resolution ultrasonography has been a major advance in detection of early hydrops and has also reduced the fetal trauma and morbidity rate to less than 2% during percutaneous umbilical blood sampling (PUBS) and placental trauma during amniocentesis. High-resolution ultrasonography has been extremely helpful in directing the needle with intraperitoneal transfusion (IPT) and intravascular transfusion (IVT) in fetal location.

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Contributor Information and Disclosures
Author

Sameer Wagle, MBBS, MD  Consulting Staff, Division of Neonatology, Northwest Medical Center of Washington County

Sameer Wagle, MBBS, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Prashant G Deshpande, MD  Attending Pediatrician, Department of Pediatrics, Christ Hospital Medical Center and Hope Children's Hospital, Oak Lawn, Illinois; Assistant Clinical Professor of Pediatrics, Midwestern University, Downers Grove, IL

Prashant G Deshpande, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and American Telemedicine Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Oussama Itani, MD, FAAP, FACN  Clinical Associate Professor of Pediatrics and Human Development, Michigan State University; Medical Director, Department of Neonatology, Borgess Medical Center

Oussama Itani, MD, FAAP, FACN is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, and American Heart Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

David A Clark, MD  Chairman, Professor, Department of Pediatrics, Albany Medical College

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Carol L Wagner, MD  Professor of Pediatrics, Medical University of South Carolina

Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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Liley curve. This graph illustrates an example of amniotic fluid spectrophotometric reading of 0.206, which when plotted at 35 weeks' gestation falls into zone 3, indicating severe hemolytic disease.
Modified Liley curve for gestation of less than 24 weeks showing that bilirubin levels in amniotic fluid peak at 23-24 weeks' gestation.
Queenan Curve: Modified Liley curve that shows delta-OD 450 values at 14-40 weeks' gestation.
Slopes for peak systolic velocity in middle cerebral artery (MCA) for normal fetuses (dotted line), mildly anemic fetuses (thin line), and severely anemia fetuses (thick line).
Management of first affected pregnancy.
Management of pregnant women with previously affected fetus.
Table. Comparison of Rh and ABO Incompatibility
CharacteristicsRhABO
Clinical aspectsFirst born5%50%
Later pregnanciesMore severeNo increased severity
Stillborn/hydropsFrequentRare
Severe anemiaFrequentRare
JaundiceModerate to severe, frequentMild
Late anemiaFrequentRare
Laboratory findingsDirect antibody testPositiveWeakly positive
Indirect Coombs testPositiveUsually positive
SpherocytosisRareFrequent
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