Double Volume Exchange Transfusion Research Articles

Clinico-etiological profile of neonates with neonatal hyperbilirubinmemia treated with double volume exchange transfusion

Clinico-etiological profile of neonates with neonatal hyperbilirubinmemia treated with double volume exchange transfusion

Efficacy and safety of short- vs. standard-course antibiotics for culture-negative neonatal sepsis: a systematic review and meta-analysis.

To conduct a systematic review and meta-analysis of evidence from randomized controlled trials (RCTs) comparing a short course of antibiotics (2-4 days), to a standard course (5-7 days), for the treatment of culture-negative neonatal sepsis. Relevant databases were searched for RCTs comparing short- vs. standard-course of antibiotics for culture-negative sepsis. The primary outcomes were mortality and treatment failure, defined as the reappearance of clinical signs suggestive of sepsis within 7 days of stoppage of antibiotics. Secondary outcomes included neurological impairment, duration of hospital stay, need for oxygen, respiratory support and double-volume exchange transfusion (DVET). Seven RCTs were included in the review with 729 neonates >30 weeks gestational age at birth. No mortality occurred in either of the groups (2 studies; 276 neonates). Treatment failure rates were similar in the short- and standard-course antibiotic groups [7 studies; 729 neonates; risk ratio(RR) = 1.01; 95% confidence interval (CI), 0.55 to 1.86; very low certainty]. The short course of antibiotics resulted in a shorter hospital stay [3 studies; 293 neonates; mean difference (MD), -2.46 days; 95% CI, -3.16 to -1.75]. There was no difference in the need for oxygen supplementation (2 studies; 258 neonates; RR, 1.40; 95% CI, 0.40 to 4.91), any respiratory support (2 studies; 258 neonates; RR, 1.04; 95% CI, 0.92 to 1.17) or DVET (2 studies; 258 neonates; RR, 1.29; 95% CI, 0.56 to 2.95). Very-low certainty evidence suggests that a short antibiotic course, compared to a standard course, does not affect treatment failure rates in culture-negative neonatal sepsis. There is a need for well-designed RCTs powered enough to assess critical outcomes such as mortality and neurological sequelae to generate stronger evidence and inform guidelines. CRD42023437199.

Erythrokinetic mechanism(s) causing the "late anemia" of hemolytic disease of the fetus and newborn.

A transfusion-requiring "late anemia" can complicate the management of neonates convalescing from hemolytic disease of the fetus and newborn (HDFN). This anemia can occur in any neonate after HDFN but is particularly prominent in those who received intrauterine transfusions and/or double-volume exchange transfusions. Various reports describe this condition as occurring based on ongoing hemolysis, either due to passive transfer of alloantibody through breast milk or persistence of antibody not removed by exchange transfusion. However, other reports describe this condition as the result of inadequate erythrocyte production. Both hypotheses might have merit, because perhaps; (1) some cases are primarily due to continued hemolysis, (2) others are primarily hypoproductive, and (3) yet others result from a mixture of these two mechanisms. We propose prospective collaborative studies that will resolve this issue by serially quantifying end-tidal carbon monoxide. Doing this will better inform the assessment and treatment of neonates recovering from HDFN.

Effect of Low-volume Exchange Transfusion on Neonatal Hyperbilirubinaemia: A Retrospective Cohort Study

Introduction: A double volume exchange transfusion for hyperbilirubinaemia often requires more than one pack of compatible blood to fulfil the calculated volume. This is often unavailable, necessitating exchange transfusion using less than the calculated double-volume. During practice, the authors found that many patients had a positive therapeutic response even when the exchange blood volume was reduced. Aim: To study the effect of the reduced volume of blood used for exchange transfusion in neonates with hyperbilirubinaemia. Materials and Methods: A retrospective cohort study was conducted in the Neonatal Intensive Care Unit (NICU), Malankara Orthodox Syrian Church Medical College (tertiary level), Kerala, India, between January 2015 and December 2020. Total 116 patients who underwent exchange transfusion for hyperbilirubinaemia, regardless of gestational age, were included. Pre- and postexchange details, blood chemistry and haemogram were collected from the records and analysed. The patients were grouped into group 1 (80-≤120 mL/kg) and group 2 (>120-≤160 mL/kg) based on the volume of blood used for exchange transfusion. The correlation of exchange blood volume with the percentage drop in bilirubin, rebound rise of bilirubin at six hours, duration of phototherapy, and duration of admission was studied using Pearson’s/ Spearman’s correlation. Data were statistically analysed using Independent samples t-test, Paired sample t-test, and Chi-square test to determine, if there was a significant difference between the groups. Results: Out of 116 patients, group 1 had 67 (57.78%) patients, and group 2 had 49 (42.24%) patients. The mean±Standard Deviation (SD) gestational age was 37.6±1.57 weeks, and 59 (50.86%) were males. The mean±SD postexchange bilirubin was 13.12±3.85 mg/ dL in group 1 and 10.26±2.78 mg/dL in group 2, resulting in a bilirubin reduction of 40.74±12.81% and 53.81±11.67%, respectively. The rebound bilirubin at six hours (13.15±4.32 mg/dL vs 11.23±2.30 mg/dL) made no clinical difference in the management of the patient. The median duration of phototherapy was 48 hours, and the median duration of admission was five days in both groups. Conclusion: Exchange transfusion with a lower volume of blood, followed by phototherapy, can lead to a clinically acceptable reduction in serum bilirubin. Non availability of the exact 160 mL/kg of blood for exchange is not an adequate reason to delay exchange transfusion.

Early Onset Portal Hypertension Due to Silent Extensive Portal Vein Thrombosis Following Umbilical Vein Catheterization

Background: Umbilical vein catheterization is a routine procedure in neonatal intensive care units. This invasive procedure, though easy and useful, can result in disastrous complications. Clinical Description: A 28 day old baby boy presented with umbilical sepsis along with multiple skin abscesses. He had a history of double volume exchange transfusion for Glucose 6 Phosphate deficiency induced hyperbilirubinemia, during the postnatal period. Ultrasound whole abdomen done to look for intra-abdominal abscesses revealed extensive portal vein thrombosis including the main portal vein and its branches with cavernoma formation. Upper gastrointestinal endoscopy revealed Grade II esophageal varices suggestive of the development of portal hypertension. Management and Outcome: Baby was started on subcutaneous enoxaparin which continued for 3 months. Follow up ultrasound showed complete obliteration of portal vein, replaced by cavernomas with development of grade II esophageal varices seen on upper gastrointestinal endoscopy. Conclusion: This case highlights how umbilical vein catheterization in the neonatal period can lead to catastrophic complications such as obliteration of the entire main portal vein and its branches, formation of portal cavernoma, portal hypertension, and esophageal varices, all of which can develop silently, at a very early age.

Hemolytic Disease of Newborn Following Anti-C and Anti-S Alloimmunization

Background: Non-Rhesus D antigen non-ABO, minor blood group alloimmunization in pregnant women is being increasingly recognized as a significant contributor to the development of the hemolytic disease of the fetus and newborn (HDFN). We report severe HDFN in a neonate born to an Rh-positive mother with sickle cell disease, following anti-C and anti-S alloimmunization. Clinical Description: A male baby born to a repeatedly transfused mother with sickle cell disease developed severe jaundice at 22 h of life. The baby was found to have severe anemia and indirect hyperbilirubinemia, but no encephalopathy, hepatosplenomegaly, or features of sepsis. Management and Outcome: His blood group was O positive and the direct Coombs test was 4+. Minor blood group typing showed the presence of anti-C and anti-S antibodies. The baby improved after receiving a double-volume exchange transfusion with matched blood and phototherapy. Conclusion: Severe hemolytic disease of the newborn (HDN) may be caused by minor blood group alloimmunization, especially seen in mothers with a history of multiple transfusions. Antenatal screening for alloimmunization in high-risk mothers can ensure timely diagnosis and treatment of HDN and prevent the harmful effects of neonatal hyperbilirubinemia.

Case report: Pyruvate kinase deficiency in an infant

Pyruvate kinase deficiency is a rare cause of hemolytic anaemia. We report a case of Non-spherocytic hemolytic anaemia due to a deficiency of the red cell Pyruvate kinase enzyme due to a homozygous type of autosomal recessive inheritance. The child underwent a double volume Exchange Transfusion and received blood transfusions for Rapid Hemolysis on the first day of life. In this report, we stress the need for consideration of Red cell Pyruvate kinase enzyme deficiency as one of the differentials of Non-immune hemolytic anaemia. The study will help human geneticists and paediatricians with early identification or screening.

Little known and less understood: the benefits of a lower hematocrit (~40%) in reconstituted blood for double volume exchange transfusion.

A double volume exchange transfusion (DVET) is an important, if infrequently performed, intervention to acutely lessen the total serum bilirubin (TSB) and reduce the extravascular CNS bilirubin exposure when neonatal hyperbilirubinemia poses a neurotoxicity risk. The current analysis based on the seminal works of Valaes, and Sproul and Smith, predicts that a DVET blood product of lower hematocrit (~40%) via its greater plasma volume and corresponding higher albumin content optimizes the benefits of an DVET in several ways. First, by augmenting bilirubin clearance from the extravascular space and thereby further reducing the CNS bilirubin exposure, second, by favorably positioning the intravascular albumin-bilirubin binding capacity at DVET completion to accommodate additional bilirubin equilibration and rebound hyperbilirubinemia post-exchange, and third by correcting anemia if present.

A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Abstract Background Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant. Purpose The primary aim of our study is to report a case of NALF with successful liver transplant. Method We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation. Result(s) This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29. Conclusion(s) Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared MICROBIOME & MICROBIAL THERAPY

Novel device for automating exchange transfusions through umbilical venous route in neonates.

Our prototype of a novel device can safely automate a DVET. Further trials of this device are warranted. •Double volume exchange transfusion is often performed manually, but this is time-consuming and error-prone. •Previous attempts at automation were not widely adopted because they involved inserting two catheters and did not have mechanisms to prevent embolism. •This novel device fully automates double volume exchange transfusions through a single-lumen umbilical venous catheter. •It prevents air and clot embolism and has a screen for input and output parameters and alarms.

Severe Hereditary Spherocytosis Presenting with Non-Immune Fetal Hydrops

Background: Hereditary spherocytosis (HS) is characterized by spherocytes on the peripheral smear and heterogeneous clinical presentation (mild, moderate, moderate/severe, and severe) depending upon the severity of hemolytic anemia, jaundice, and splenomegaly. The underlying cause is defects in various red blood cell membrane proteins due to pathogenic mutations. Genotype-phenotype correlation is known. Clinical Description: We report a consanguineous family with a healthy daughter, multiple pregnancy losses due to fetal hydrops, and the current daughter. She was diagnosed with fetal anemia at 22 weeks gestation, developed fetal hydrops, was born premature and developed respiratory distress, severe anemia, severe jaundice, and postnatal hemolysis. Management: The case was managed since intrauterine life till date by multispecialty coordination. Intrauterine transfusions were given during pregnancy. In the neonatal period, she received surfactant for respiratory distress syndrome, double volume exchange transfusion and phototherapy for the jaundice, and repeated blood transfusions for the hemolytic anemia, that is still continuing. Rational and sequential investigations were planned and a systematic approach used. She was diagnosed with severe HS due to a homozygous likely pathogenic variant in the SPTA1 gene (affecting formation of spectrin), and heterozygous variant of uncertain significance in the ANK1 gene (that encodes ankyrin). At 3 years she has transfusion dependent hemolytic anemia, moderate splenomegaly, and age appropriate growth and development. Conclusions: HS is a rare but manageable (albeit challenging) cause of nonimmune hydrops fetalis. Genetic diagnosis allows precise management and family counselling.

Association of Antenatal Corticosteroid use with Hypoglycaemia and Hyperbilirubinemia in Preterm Neonates Admitted in a Tertiary Hospital of Kolkata: A Longitudinal Study

AbstractBackground: Timely use of antenatal corticosteroids in a mother of preterm labour decreases the rates ofperinatal death, respiratory distress syndrome, intra-ventricular hemorrhage, necrotizing enterocolitis inthe new borns. However it is reported to have a causative role in neonatal hypoglycemia and hyperbilirubinemia.So the present study attempts to determine the association between the use of antenatal corticosteroids withhypoglycaemiaand hyperbilirubinemia in newborns with less than 35 weeks of gestational age.Methods: A prospective observational study was conducted during a time period of 24 months from January 2020to December 2021 in a tertiary care hospital of Kolkata on 99 preterm neonates of less than 35 weeks of gestationalage. Antenatal history of corticosteroid use, neonatal glucose level and bilirubin level were measured amongothers. Data were analyzed using MS-EXCEL.Results: Majority of neonates’ mothers (71.7%) had received antenatal corticosteroids. Only 4.0% of the cases hadhypoglycaemia at birth. But there was no cases of hypoglycaemia at 12 hour and 24 hour after birth. In 58.6% ofthe cases bilirubin level was in the phototherapy range and double surface photo therapy was required. In 14.1%of the cases double volume exchange transfusion was required.Conclusion: Antenatal corticosteroid administration is not associated with neonatal hypoglycaemia but it issignificantly related to neonatal hyperbilirubinemia.

Efficacy of single-and double-volume exchange transfusion for neonatal hyperbilirubinemia.

To investigate the efficacy and safety of singleand double-volume exchange transfusion for neonatal hyperbilirubinemia (HB) and compare their effects on the internal environment of newborns. The clinical data of 96 HB newborns admitted to and treated in our hospitals from January 2016 to October 2021 were retrospectively analyzed. Then, these newborns were divided into single volume group (80-110 mL/kg, n=48) and double volume group (150-180 mL/kg, n=48) by the exchange volume per unit body mass. The hematological indicators total serum bilirubin (TSB), peripheral blood red blood cell (RBC) count, white blood cell (WBC) count, platelet (PLT) count, serum albumin (ALB), prothrombin time (PT) and activated partial thromboplastin time (APTT), and changes in inner-environment indexes (blood gas, blood glucose, acid-base and electrolyte levels) were compared between the two groups of newborns before treatment and after once treatment. Additionally, the adverse reactions of exchange transfusion in the two groups of newborns were recorded.

Impact of National Clinical Practice Guidelines on Exchange Transfusion for Severe Neonatal Hyperbilirubinemia in Singapore

Aims: To review the incidence of double volume exchange transfusion for severe neonatal hyperbilirubinemia in infants ≥35 weeks’ gestational age before and after implementation of National Clinical Practice Guidelines (NCPGNJ), analyze etiologies for severe hyperbilirubinemia, readmission rates for phototherapy and neurodevelopmental outcomes up to 2 years.
 Study Design: Retrospective study
 Place and Duration of Study: KK Women’s and Children’s Hospital, Singapore, between January 2016 and December 2021.
 Methodology: National Clinical Practice Guidelines on Evaluation and Management of Neonatal Jaundice (NCPGNJ) was implemented in January 2019. We retrospectively reviewed the medical records of neonates in our center who underwent double volume exchange transfusion for severe neonatal hyperbilirubinemia before and after implementation of the national clinical practice guidelines.
 Results: Overall, 56 infants underwent double volume exchange transfusion for severe hyperbilirubinemia during the study period. There was a decline in the incidence of exchange transfusion from 107 per 100 000 live births in epoch 1 (2016-2018) to 61 per 100 000 live births in epoch 2 (2019-2021). There was a steady decline in overall phototherapy rates (p=0.06), readmission rates for phototherapy (p=0.04) and number of neonates needing exchange transfusion (p=0.25). ABO-hemolytic disease of the newborn was the most common etiology. One infant had delayed presentation of severe hyperbilirubinemia and eventually developed cerebral palsy. The rest of the infants had normal neurodevelopmental and audiological assessments at follow-up.
 Conclusion: The evidence-based National Clinical Practice Guidelines (NCPGNJ) has reduced the incidence of exchange transfusion. It provides a unified framework for all healthcare professionals who manage neonates with hyperbilirubinemia in different healthcare settings.

Severe neonatal hyperbilirubinemia secondary to combined RhC hemolytic disease, congenital hypothyroidism and large adrenal hematoma: a case report

BackgroundABO blood group incompatibility, neonatal sepsis, G-6-PD deficiency, thyroid dysfunction, and hereditary spherocytosis are all probable causes of neonatal hyperbilirubinemia. However, the etiology of some hyperbilirubinemia is extremely complicated, which may be caused by multiple factors, resulting in severe jaundice. We report a case of severe jaundice due to three causes, showing the significance for the investigation of the etiology of neonatal hyperbilirubinemia.Case presentationAt 96 h of life, a full-term and vaginal delivery male infant with yellowish discoloration of body was transferred to our hospital. When he entered neonatal intensive care unit on the fourth day after birth, he developed jaundice and the transcutaneous bilirubin was 28 mg/dl. Total bilirubin was 540.2 μmol/L, while the indirect bilirubin was 516.7 μmol/L. Both parents and the baby’s blood types were O Rh(D +), and direct coomb’s test was negative. But mother’s indirect coomb’s test was positive. Investigating for minor blood group revealed that the father’s blood type of Rh was CCDee, the mather’s was ccDEE, and CcDEe for the baby. After intensive phototherapy and double volume exchange transfusion, the total bilirubin remained at 303 μmol/L. At day 10, the bilirubin level was 303.5 μmol/L, intensive phototherapy was continued, and intravenous immunoglobulin was used again. The test for thyroid hormones at day 10, the TSH was 13.334mIU/L. And the screening for congenital hypothyroidism showed the TSH was 33mIU/L. Because of the palpable abdominal mass, ultrasound and MRI was done, showed a huge mass in the right adrenal gland. Brainstem auditory evoked potential was performed at day 7, which indicated hearing impairment (65db for left ear and 70db for the right). Euthyrox and intermittent phototherapy were given as following treatment. The jaundice did not subside until the 12th day.ConclusionEven if their parents' ABO blood group and Rh (d) are consistent, a Coomb test is required for newborns with hyperbilirubinemia since they may have minor blood group incompatibilities. When bilirubin rises rapidly or the clinical treatment effect is inadequate, additional causes should be aggressively screened. Adrenal ultrasound should be performed on newborns with palpable abdominal mass, anemia and jaundice to determine whether there is adrenal hemorrhage.

Variable manifestations of minor blood group incompatibility

In settings with adequate coverage of anti-D immunoglobulin, minor blood group incompatibility has become an important cause of hemolytic disease of the newborn (HDN). We presented a series of cases of HDN of varying severities caused due to presence of anti-E and anti-C antibodies. Two neonates with anti-E antibodies developed jaundice requiring intensive phototherapy, while the course of the third neonate born to mother with Rh D isoimmunization was complicated by presence of anti-C antibodies, who needed double volume exchange transfusions for jaundice and packed red cell transfusions for anemia. Hearing screening and neurological examination at discharge were normal for all three neonates. These cases highlighted the need for appropriate testing for minor blood group incompatibility in unusual cases of HDN to initiate timely therapy and prevent neonatal morbidity and mortality.

D or anti-D!!! Unblocking the dilemma of blocking-D phenomenon using acid elution

Maternal IgG antibodies directed against fetal red cells can cause hemolytic disease in fetus and newborn manifesting as anemia and jaundice. Sometimes, these antibodies are so strong that they encapsulate the antigens on neonatal red blood cells and result in erroneous laboratory findings when tested. A requisition for double volume exchange transfusion was received for a term,3.1 kg female baby with neonatal jaundice at day 2 of life, born to a multiparous woman. The neonate was typed as AB RhD negative and the mother as A Rh D negative. The maternal sample tested positive for Indirect antiglobulin testing showing presence of Anti-D with IgG titer of 128. The direct antiglobulin testing for baby was strongly (4 +) positive. The strong DAT result with negative RhD typing for the neonate indicated towards the Blocking-D phenomenon. We attempted to resolve the Blocked-D case using acid elution, which revealed the presence of D antigen on the eluted neonate's red cells. The report emphasizes the importance of appropriate blood typing for neonates to provide prompt adequate care as a team by the departments of Neonatology and Transfusion Medicine.

A Male Infant with Cholestatic Jaundice, Hemolytic Anemia, and Thrombocytopenia.

A Male Infant with Cholestatic Jaundice, Hemolytic Anemia, and Thrombocytopenia.

Efficacy of Double Volume Exchange Transfusion in Term Neonates with Hyperbilirubinemia Due to Abo Incompatibility

Objectives: To determine the efficacy of double volume exchange transfusion in term neonates with hyperbilirubinemia due to ABO incompatibility. Materials and Methods: This was a descriptive case series study conducted in the Neonatal Unit, Department of Pediatrics, Sheikh Zayed Hospital, Rahim Yar Khan from 30-09-2016 to 29-12-2017. Results: Total cases were 87, out of which 47 (54.02%) were males with a mean age of 4.32±1.51 days. The efficacy of double exchange transfusion was seen in 28 (32.18%) cases. Conclusion: The efficacy of double volume exchange is seen in 28 (32.18%) out of 87 cases and it is significantly high in cases when the exchange is done within the first 3 days of birth (p= 0.01). Keywords: ABO incompatibility, hyperbilirubinemia, double volume exchange transfusion.

Irregular erythrocyte antibodies among antenatal women and their neonatal outcome at a tertiary care hospital in Northern India.

Red blood cell alloimmunisation during the pregnancy is a significant cause for neonatal mortality and morbidity. This study was planned to determine the prevalence and specificity of irregular erythrocyte antibodies in antenatal mothers and their neonatal outcome. In this observational study, blood grouping and red cell antibody screening of mothers were performed at first visit and after 28 weeks of gestation and positive cases were identified and followed up monthly till delivery by repeating antibody titre and middle cerebral artery-peak systolic velocity. After delivery of alloimmunised mothers, cord blood haemoglobin, bilirubin and direct antiglobulin tests (DAT) were analysed and further outcome of neonate was recorded. Among 652 registered antenatal cases, 18 multigravida women were found to be alloimmunised, accounting to prevalence of 2.8%. Most common alloantibody identified was anti D (>70%) followed by anti-Lea, anti-C, anti-Leb, anti-E and anti-Jka. Only 47.7% Rh D negative women received anti-D prophylaxis during previous pregnancies or whenever indicated. DAT was positive in 56.2% of neonates. Among nine DAT positive neonates, two early neonatal deaths due to severe anaemia were observed following birth resuscitation. Four antenatal mothers required intrauterine transfusion in view of fetal anaemia while three neonates received double volume exchange transfusion and top up transfusions after birth. This study emphasises importance of red cell antibody screening for all multigravida antenatal women at registration of pregnancy and additionally at 28 weeks or later in high-risk cases irrespective of RhD status.