新生儿黄疸(Neonatal-Jaundice)课件

Neonatal JaundiceDezhi Mu MD/PhDDepartment of Pediatrics,West China Second University Hospital,Sichuan UniversityNeonatal JaundiceDezhi Mu MD/PIntroduction Jaundice is quite common(5mg/dl).Full term infants:at least 50%Preterm infants:over 80%Elevated blood bilirubin levels:97%Introduction Jaundice is quiteIntroduction continued When?in the first week of life Where?skin,mucosa and white of eye How many?blood bilirubin concentrations is 5-7mg/dl.Introduction continued WhenIntroduction continuedIntroduction continuedProducing Excreting Why Jaundice occurred?Producing Why Jaundice occu新生儿黄疸(Neonatal-Jaundice)课件Bilirubin Metabolism:1.RBC:Heme bilirubin(UCB)2.Blood:carried by bound to albumin3.Liver:uptaken:Y protein,Z protein conjugated:UDPGT excreted：to the biliary system 4.Intestine:stercobilins -glucuronidase enterohepaticcirculationBilirubin Metabolism:1.RBC:HThe metabolic characteristics of bilirubin in newborns:1.Bilirubin production 8.8mg/Kg/d in newborns3.8mg/Kg/d in adults 2.Bilirubin-albumin complex formation a.preterm infant;b.acidosis The metabolic characteristics 3.Bilirubin metabolism of hepatocyte a.Hepatic uptake of bilirubin b.Bilirubin conjugation:UDPGT(uridine diphosphate glucoronyl transferase)c.Defective bilirubin excretion ability to bile system 4.Enterohepatic circulation The metabolic characteristics of bilirubin continued 3.Bilirubin metabolism of hBilirubin toxicity 1.Conjugated bilirubin water-soluble 2.Unconjugated bilirubin lipid-soluble bilirubin-encephalopathy （kernicterus）Bilirubin toxicity 1.ConjugatClinical Manifestations Jaundice appears When:at any time during the neonatal period Where:from face chest abdomen feetClinical Manifestations JaundiEvaluation of jaundice:1.By eyes:face,5mg/dl(85mol/L);abdomen,10-15mg/dl;feet,15-20mg/dl;2.By transcutaneous measurement:used for screening3.By serum levels:standardManifestations continueEvaluation of jaundice:Manife Classification:Physiological Jaundice Pathological Jaundice Manifestations continue Classification:Manifestatio Physiological jaundice:1.General state is well 2.Appears 2-3days (24h of age)peaks 12.9mg/dl(full term infants)15mg/dl (preterm infants)fades 2 week (term infants)4 weeks (preterm infants)3.Accumulates 5mg/dl/d 4.Direct bilirubin 12.9mg/dl (full term infants)15mg/dl (preterm infants)Fades 2 weeks (term infants)4 weeks (preterm infants)3.Accumulates 5mg/dl/d4.Direct bilirubin 2mg/dl5.Jaundice recurrent Manifestations continue Pathological Jaundice ManifesCommon causes of pathological jaundice1.Unconjugated bilirubinemia:a.hemolytic diseases:ABO,Rh incompatibility b.G-6-PD deficiency;c.Breast milk jaundice Common causes of pathological 2.Conjugated bilirubinemia:a.Neonatal hepatitisb.Biliary obstruction(cholestatic jaundice)biliary atresia,common bile duct stenosis c.Congenital metabolic diseases -1 antitrypsin deficiencyCauses of pathological jaundice continue2.Conjugated bilirubinemia:CHemolytic disease of newbornHemolytic disease:ABO:85.3%Rh :14.6%MN :0.1%Hemolytic disease of newbornHeHemolytic disease of newborn continuedABO incompatibility the mother:type O the infant:type A or B Rh incompatibility the mother：Rh（-）the infant:Rh（+）D,E,C,d,e,cHemolytic disease of newborn PathogenesisPathogenesisPathophysiologyRed blood cell breakdownHyperbilirubinemiaJaundiceKernicterus Seizures etc.Anemia1.Liver 2.Spleen3.Heart,other organs4.Hydrops PathophysiologyRed blood cell Clinical Manifestations:ABO Rh1.Jaundice:mild severe 1-2 day 24 h2.Anemia:mild severe (3-6 weeks)heart failure3.Hepato-rare commonsplenomegaly Clinical Manifestations:ABComplicationKernicterus:Phase 1:decreased alertnessHypotoniaPoor feeding Phase 2:Hypertonia,Retrocollis,opisthotonus Phase 3:HypotoniaComplicationKernicterus:1.Blood type incompatibility 2.Hyperbilirubinemia:Unconjugated bilirubin level 3.Hemolytic tests 1).Hemoglobin level:low 2).Reticulocytes:1015%3).Nucleated RBCLaboratory tests:1.Blood type incompatibility Antibody test1).Direct Coombs test (+)confirm 2).Antibody release test (+)confirm3).Free antibody test (+)judgeLaboratory tests continued Antibody testLaboratory tes1).Phototherapy 2).Exchange transfusion3).Internal MedicineTreatments1).Phototherapy Treatmen During pregnancy 1.Intrauterine blood transfusion 2.Early deliveryTreatments continued During pregnancyTreatments c After birth 1.Phototherapy Principle:photon of light Three photochemical reactions:1).Structure isomer 2).Geometric isomer 3).Photo-oxidationPhotoproducts excretion:w/o conjugation Treatments continued After birthTreatments continuIndications of phototherapy:Unconjugated bilirubinemia Bilirubin level 12mg/dl Light source:Spectral outputs 420 to 500nmTreatments continuedIndications of phototherapy:TSide effects of phototherapy:a.diarrhea b.fever c.skin rash d.bronze baby syndrome (conjugated bilirubin4mg/dl)Treatments continuedSide effects of phototherapy:新生儿黄疸(Neonatal-Jaundice)课件新生儿黄疸(Neonatal-Jaundice)课件2.Exchange Transfusions:a.Severe hemolytic disease b.Refractory to phototherapy Treatments continued2.Exchange Transfusions:TreatAims of transfusions:a.Remove antibodiesb.Remove bilirubinc.Correct anemiaTreatments continuedAims of transfusions:TreatmentIndication of transfusions:one of the followsa.20mg/dl(340 mol/L)b.4mg/dl,Hgb120g/L,edema c.0.7mg/dl/hd.KernicterusTreatments continuedIndication of transfusions:TrSource of the blood mother newbornsFor Rh:Rh ABOincompatibility For ABO:“AB”plasma “O”cells incompatibility packed RBC Treatments exchange transfusionsSource of the bloodTreatments Potential complications:a.Infectionb.Necrotizing enterocolitis NECc.Thromboembolic complicationsTreatments exchange transfusionsPotential complications:Treatm3.Pharmacological agents:a.Phenobarbital Effects:Uptake,Conjugation Excretionb.Albuminc.IVIGTreatments continued3.Pharmacological agents:TreaPreventionsFor ABO incompatibility:NoFor Rh incompatibility 300 g of human anti-D globulin within 72 h of delivery.PreventionsFor ABO incompatibi1.Unconjugated bilirubinemia:a.Hemolytic diseases:ABO,Rh incompatibility b.G-6-PD deficiency;c.Breast milk jaundice1.Unconjugated bilirubinemia:1.Unconjugated bilirubinemia:b.G-6-PD deficiency;male,jaundice,enzyme activityc.Breast milk jaundice causes:unclear,-glucuronidase follows physiologic jaundice:4-7 d breast feeding persist for several weeks.1.Unconjugated bilirubinemia:bConjugated bilirubinemia:2.Conjugated bilirubinemia:a.neonatal hepatitis b.biliary obstruction(cholestatic jaundice)biliary atresia,common bile duct stenosis c.congenital metabolic diseases -1 antitrypsin deficiencyConjugated bilirubinemia:2.ConCase analysis:24 old male infant,gravida1,para 1.Apgar scores:8 at 1 minMother:blood type“O”PE:icterus appeared on face and trunk skin liver edge 1cm palpable spleen tipCase analysis:24 old male infCase analysis continuedLab tests:Hgb:13g/dl,reticulocyte count:7%Blood smear:nucleated RBCBlood type:A,Rh-positiveSerum bilirubin:12.9mg/mlDirect Coombs test:weakly positiveQuestion:whats the risk factor?Case analysis continuedLab tesThank you!Questions？Department of Pediatrics Thank you!Questions？Departmen