Neonatal Transfusion Research Articles

Benefits of lower neonatal platelet transfusion thresholds

Degree of thrombocytopenia is not a predictor of bleeding risk in neonates, yet most platelet transfusions are given prophylactically in non-bleeding premature infants. Recent data support a lower platelet transfusion threshold of 25 × 109 /L in non-bleeding premature neonates and indicate that higher transfusion thresholds may be associated with harm including increased risk of death and bleeding. The mechanism of increased adverse events with higher platelet transfusion threshold is unknown, but considerations include adult platelets disrupting the neonatal hemostatic balance of hypoactive platelets in a hypercoagulable and fragile environment and having a pro-inflammatory effect.

Implementation of a neonatal platelet transfusion guideline to reduce non-indicated transfusions using a quality improvement framework.

ObjectiveVariation exists in neonatal platelet transfusion practices. Recent studies found potential harm in liberal platelet transfusion practices, supporting the use of lower transfusion thresholds. Our aim was to reduce non-indicated platelet transfusions through implementation of a restrictive platelet transfusion guideline.Study designPlatelet transfusions from January 2017 to December 2019 were classified as indicated or non-indicated using the new guideline. Interventions included guideline implementation and staff education. Outcomes were evaluated using statistical process control charts. Major bleeding was the balancing measure.ResultDuring study, 438 platelet transfusions were administered to 105 neonates. The mean number of non-indicated platelet transfusions/month decreased from 7.3 to 1.6. The rate of non-indicated platelet transfusions per 100 patient admissions decreased from 12.5 to 2.9. Rates of major bleeding remained stable.ConclusionsImplementation of a restrictive neonatal platelet transfusion guideline significantly reduced potentially harmful platelet transfusions in our NICU without a change in major bleeding.

Exchange transfusions in severe Rh-mediated alloimmune haemolytic disease of the foetus and newborn: a 20-year overview on the incidence, associated risks and outcome.

Background and objectivesGuidelines and indications for exchange transfusion in haemolytic disease of the foetus and newborn (HDFN) have changed drastically in the past decades, causing a decline in exchange transfusion rate. This study aims to evaluate the incidence of exchange transfusions (ETs) in neonates with Rh‐mediated HDFN over the past 20 years at our centre, and report potentially ET‐related complications as well as indicators for bilirubin encephalopathy.Material and methodsIn this observational study, 438 neonates were included with HDFN, born ≥ 35 weeks gestational age at the Leiden University Medical Centre between January 2000 and July 2020. The incidence of ET and procedure‐related complications were assessed in three consecutive time periods determined by changes in guidelines and indications for ET.ResultsThe incidence of ET in our centre declined from (104/156) 67% (time period 2000–2005), to (39/181) 22% (2006–2015) and to (10/101) 10% (2015–2020, p < 0·001). The maximum bilirubin levels in neonates after birth increased from 13·6 mg/dL (or 233 μmol/L), to 15·0 mg/dL (257 μmol/L) and to 15·3 mg/dL (263 μmol/L). The incidence of complications associated with the use of ET (including sepsis, haematologic disorders and respiratory failure) remained stable throughout the years, and no neonates died during the study period.ConclusionExchange transfusion incidence declined significantly over the past two decades. Decrease in ET incidence, and concomitant decrease in exposure and expertise, was not associated with an increase in procedure‐related complications.

Are fetal bilirubin levels associated with the need for neonatal exchange transfusions in hemolytic disease of the fetus and newborn?

Fetal bilirubin is routinely measured at our center when taking a pretransfusion blood sample at intrauterine transfusions in hemolytic disease of the fetus and newborn. However, the clinical value of fetal bilirubin assessment is not well known, and the information is rarely used. We speculated that there could be a role for this measurement in predicting the need for neonatal exchange transfusion. This study aimed to evaluate the predictive value of fetal bilirubin for exchange transfusions in severe hemolytic disease of the fetus and newborn. A total of 186 infants with Rh alloantibody-mediated hemolytic disease of the fetus and newborn treated with one or more intrauterine transfusions at the Leiden University Medical Center between January 2006 and June 2020 were included in this observational study. Antenatal and postnatal factors were compared between infants with and without exchange transfusion treatments. The primary outcome was the fetal bilirubin levels before the last intrauterine transfusion in relation to the need for exchange transfusion. In a multivariate logistic regression analysis, the fetal bilirubin level before the last intrauterine transfusions (odds ratio, 1.32; 95% confidence interval, 1.09-1.61 per 1 mg/dL) and the total number of intrauterine transfusions (odds ratio, 0.63; 95% confidence interval, 0.44-0.91 per intrauterine transfusion) were independently associated with the need for exchange transfusion. The area under the curve was determined at 0.71. A Youden index was calculated at 0.43. The corresponding fetal bilirubin level was 5 mg/dL and had a sensitivity of 79% and a specificity of 64%. A high fetal bilirubin level before the last intrauterine transfusion was associated with a high likelihood of neonatal exchange transfusion.

931 Maternal and neonatal outcomes associated with vasa previa resolution during the antepartum period

In recent years, the phenomenon of “resolved” vasa previa has been increasingly described when vasa previa (VP) is detected on ultrasound in the midtrimester with a resolution rate as high as 20-26%. There is little information on the obstetrical outcomes associated with resolved VP. Our objective was to describe obstetrical and neonatal outcomes in women with resolved VP and compare them to women who have persistent VP. This was a multi-center descriptive and retrospective cohort study of patients diagnosed prenatally with VP on transvaginal ultrasound in the NYC MFM Research Consortium centers between 2012 and 2018. The primary outcome was gestational age (GA) at delivery. Other outcomes evaluated included mode of delivery, birthweight, NICU admission, and preterm birth. Data were analyzed using Mann-Whitney U test and Fisher exact test with p<0.05 defined as significance. 165 pregnancies with VP were included, of which 16 were twin gestations. 43 VP cases (26.1%) including one twin gestation were noted to resolve on subsequent ultrasound, of which 6 were lost to follow up. Pregnancies with resolved VP had a higher median GA at delivery, lower rate of preterm birth <37 weeks, and lower rate of cesarean delivery. There was no difference in rate of preterm birth <32 weeks (Table 1). Neonatal data was available on 131 newborns. In cases of resolved VP, neonates had a higher median birthweight and lower rate of NICU admission. There were no significant differences in rates of neonatal blood transfusion or neonatal death (Table 2). Resolved VP is associated with later GA at delivery, lower rate of cesarean delivery, and improved neonatal outcomes. However, it is not associated with a reduction in preterm birth prior to 32 weeks. The observed preterm birth rate in the resolved group of 16% raises concern that resolved VP may be a risk factor for preterm birth and merits further investigation. Once VP is diagnosed, surveillance for VP resolution should be performed as resolution has important implications for obstetrical and neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

635 Neonatal morbidity associated with pregnancies complicated by vasa previa: a comparative study

Vasa previa (VP) affects 2.5 per 1000 deliveries. Neonatal complications of VP are thought to result from peripartum fetal hemorrhage from ruptured vessels and/or sequelae of iatrogenic prematurity, but there is scarce data on the post-natal course. This study aims to better characterize post-natal complications which may occur in pregnancies affected by VP. This is a retrospective cohort study of subjects with VP identified on ultrasound at a single tertiary care University center from 2011-2020. VP cohort was matched 2:1 with gestational-age-matched and birthweight-matched control group delivered after spontaneous preterm labor (SPB). Primary outcome was the difference in early neonatal morbidity between groups. Secondary outcomes included differences in neonatal intensive care unit (NICU) length of stay (LOS) and neonatal transfusion rates. Outcomes were evaluated with descriptive statistics, Mann-Whitney-U tests, and T-tests. There were 23 subjects (19 singleton, 3 dichorionic, 1 monochorionic twins) with VP and 46 singleton controls. Descriptive characteristics shown in Table 1. Completion of antenatal steroids (ANC) course was significantly more common in VP group (78.3% vs 42.9%, p<0.01). Neonatal transfusion rates were elevated in VP group (17.4% VP versus 4.7% SPB, p=0.08) and mean neonatal hematocrit was significantly lower (42.6% VP versus 47.5% SPB, p<0.01) (Table 1). Immediate assisted ventilation and prolonged assisted ventilation (>6hrs) were significantly higher in the VP cohort (Table 1). NICU LOS was significantly longer in neonates with VP (median 13 days (IQR 9-24) versus 5 days (IQR 0-13); p<0.01) and this persisted when stratified by gestational age (Figure 1). Neonates of pregnancies complicated by VP had significantly higher ventilatory requirements, despite higher rates of ANC completion. In addition, neonates had a longer NICU LOS implying more complex post-natal course. Neonatal transfusion rates were also 4 times higher in VP, but this did not reach statistical significance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Closing the evidence to practice gap in neonatal transfusion medicine

Significant resources are directed towards world-class research projects, but the findings are not necessarily translated into better healthcare outcomes, either at all or in a sustained way. There is a clear need to dedicate further resources to understanding how to promote the uptake of evidence and effectively change neonatal transfusion practice to improve outcomes. Approaching blood transfusion behaviour change more systematically, and working across disciplines and involving families, holds the potential to increase the rate of uptake of emerging evidence in clinical practice. This approach holds the potential to save costs, conserve resources, and improve clinical outcomes. Our paper focuses on the use of quality improvement to bridge the gap between evidence-based knowledge and transfusion practice in neonatal units around the world.

Effects of blood sampling stewardship and erythropoietin administration in extremely low birth weight infants-a quality improvement non-controlled before-and-after retrospective study.

The majority of extremely low birth weight (ELBW) neonates receive red blood cell (RBC) transfusions; at least 50% receive multiple transfusions. Anemia care bundles could be the most effective approach to reduce transfusion rates. We conducted a quality improvement non-controlled before-and-after retrospective study involving 345 ELBW infants admitted over a 5-year period in two consecutive epochs before and after implementation of an anemia care bundle in January 2017. Bundle components included (a) prophylactic subcutaneous erythropoietin twice each week (600 IU/kg/week) from day 7 through 8 weeks of age and (b) blood sampling stewardship in the first five postnatal weeks. Early postnatal blood sampling losses were significantly reduced following the implementation of the care bundle (21.2 ml/kg vs 25 ml/kg, P < 0.001). We found a 50% reduction in the rate of multiple RBC transfusions (adjusted RR 0.45, 95% CI: 0.34-0.59) and a reduced odds of necrotizing enterocolitis (NEC) (4% vs 10%, adjusted OR 0.38 (95% CI: 0.15-0.78)) among infants that received the anemia care bundle (n = 182 infants). The overall transfusion rate, number and volume of transfusions, and multiple donor exposures were also significantly reduced.Conclusion: The combination of extended subcutaneous erythropoietin administration and reduced early postnatal blood sampling was associated with a significant reduction in the rate of multiple erythrocyte transfusions and NEC in ELBW neonates. What is known: • The majority of extremely low birth weight neonates continue to require blood transfusions despite advances in standardized transfusion practices; at least 50% require multiple transfusions. • Anemia care bundles, employing a combination of anemia prevention strategies, can effectively reduce the RBC transfusion rates in ELBW infants. What is new: • A combination of extended subcutaneous erythropoietin supplementation and blood sampling stewardship practices reduced the rate of multiple RBC transfusions in ELBW neonates by 50%. • Implementation of the anemia care bundle was associated with a significant reduction in the rates of necrotizing enterocolitis.

Pattern of serum bilirubin changes following double volume exchange blood transfusion in neonates at a tertiary health facility in Nigeria.

Introductionexchange blood transfusion (EBT) is a form of massive transfusion useful in rapidly reducing serum bilirubin levels, but serum bilirubin levels frequently rebound within hours of completing the procedure, due to equilibration of extravascular bilirubin as well as on-going hemolysis. The study was carried out to determine the pattern of reduction in serum bilirubin levels following EBT among neonates with severe hyperbilirubinemia, as well as the factors contributing to this pattern, so as to establish evidence-based expectations following EBT.Methodsa retrospective descriptive study covering a two-year period in a Nigerian tertiary hospital. Details of the EBT procedures, including serial serum bilirubin levels, were obtained from the hospital records of all newborn babies who had double volume EBT done for severe hyperbilirubinaemia during the study period. Data was analyzed using the statistical software SPSS version 21.0.Resultsthe mean total serum bilirubin (TSB) before EBT in the 36 babies was 17.9 ± 6.3 mg/dl. The mean percentage decrease in TSB immediately following EBT was 44.3 ± 10.2%. Six hours after EBT, TSB levels had increased from the immediate post-EBT values by an average of 57.5 ± 32.2%. Twenty-four hours after the procedure, TSB values in most (87.1%) cases were still higher than the immediate post-EBT values, but lower than the pre-EBT values. Post-EBT anemia was recorded among 33.3% of the babies.ConclusionEBT is effective in rapidly reducing serum bilirubin levels and preventing acute bilirubin encephalopathy in neonates with severe hyperbilirubinemia, despite the rebound increase that occurs in TSB values after the procedure.

Immunization against αIIbβ3 and αvβ3 in Glanzmann thrombasthenia patients carrying the French Gypsy mutation

Unlabelled Box AbstractBackgroundGlanzmann thrombasthenia (GT) is a rare bleeding disorder caused by the absence or the dysfunction of the platelet αIIbβ3 integrin. A founder mutation in the ITGA2B gene was previously identified in French Gypsy patients. Interestingly, this mutation was strongly linked to the human platelet antigen‐1b (HPA‐1b). The HPA‐1bb Gypsy patients are at risk of isoimmunization against αIIbβ3, as this complex is not expressed at their platelet surface. Tentatively, they would, however, not have an increased risk of developing anti‐HPA‐1a alloantibodies by exposure of αIIbβ3 on platelets from random platelet transfusions. However, the β3 chain can also associate with the αv subunit expressed at the platelet surface. Because Gypsy GT patients express normal αvβ3 carrying HPA‐1b epitopes, these patients might develop anti‐HPA‐1a alloantibodies reacting with αvβ3 and/or β3. Objectives/Patients/MethodsTo demonstrate this hypothesis, sera from HPA‐1bb (n = 5) and HPA‐1ab (n = 1) Gypsy GT patients were investigated by modified antigen capture assay using platelets or stable transfected cells. Furthermore, stable transfected cells expressing either αIIbβ3 or αvβ3 together with soluble monomeric chimeric β3 (as absorbent) were used to differentiate anti‐β3 and anti‐αvβ3 reactivity. ResultsOnly HPA‐1bb patients developed alloantibodies reacting with HPA‐1a cells. Further analysis showed that HPA‐1bb patients developed anti‐HPA‐1a alloantibodies reacting with β3 and/or αvβ3. ConclusionIn this study, we found that HPA‐1bb patients who failed to express αIIbβ3 on the platelet surface can develop alloantibodies against HPA‐1a reacting with β3 as well as αvβ3. This is of particular importance as anti‐HPA‐1a alloantibodies might cause fetal neonatal alloimmune thrombocytopenia and/or platelet transfusion refractoriness.

Influence of evening/night-time birth on maternal/perinatal outcomes in a low-risk population

Objective:To compare maternal and perinatal outcomes between day-time and evening/night-time births in a low-risk population.Material and Methods:The present study had a retrospective and cross-sectional design. The study recruited 421 pregnant women admitted for spontaneous or induced labor, with singleton, full-term pregnancy, without comorbidities, and with birthweight between 2,500 and 4,499 g. Maternal data, including severe bleeding, need for blood transfusion, puerperal infection, and admission to the intensive care unit, and neonatal data including birthweight, Apgar scores at first and fifth minute, oxygen administration, resuscitation, admission to the neonatal care unit, infection, and blood transfusion, were evaluated. Univariate and multivariate analysis and calculation of the prevalence ratio (PR) were performed with a 95% confidence interval (CI).Results:There were no differences in factors of maternal morbidity between delivery times. Newborns delivered during the evening/night-time had a higher prevalence of infection (15.3% vs 7.9%, p=0.019, PR: 2.11, CI 95% 1.13-3.93) and hospitalization in the neonatal care unit (25.8% vs 10.4%, p<0.001, PR: 2.99, CI 95% 1.76-5.10). There was no difference in other perinatal morbidities examined.Conclusion:Evening/night-time births were associated with a higher prevalence of infection and the need for admission to an intensive care unit.

The effect of concomitant histologic chorioamnionitis in pregnancies complicated by fetal growth restriction

IntroductionWe aimed to investigate the effect of placental histologic chorioamnionitis (HC) on neonatal outcomes in pregnancies complicated by fetal growth restriction (FGR). Methods- The computerized medical files of all pregnancies diagnosed with FGR (birthweight <10th percentile) at 24–42 weeks of gestation between 2008 and 2019 were reviewed. Maternal and neonatal outcomes were compared between FGR with and without evidence of placental HC.Placental lesions were classified according to “Amsterdam” criteria. Composite adverse neonatal outcome-included any of the following complications: neurological morbidity, neonatal respiratory assistance, RDS, NEC, sepsis, blood transfusion, phototherapy, hypoglycemia, or neonatal death. Composite severe adverse neonatal outcome included any of the following complications – neurological morbidity, blood transfusion, NEC, sepsis, RDS, neonatal death. Results- Compared to FGR without HC (n = 446), FGR with HC (n = 57) was characterized by more advanced gestational age at delivery 39.2 (38.3–39.9) vs. 38.2 (36.9–39.2), weeks respectively, p < 0.001), higher rate of nulliparity (73.7% vs. 45.1%, p < 0.001), less vascular lesions of MVM (1.8% vs.11.2%, p = 0.02), higher rate of Apgar scores at 5 min <7 (10.5% vs. 2%, p = 0.004), increased neonatal death (7.0% vs. 0.9%, p = 0.007), higher rates of both composite adverse neonatal outcome (31.1% vs. 17.3% p = 0.02), and composite severe adverse neonatal outcome (16.3% vs. 8.2% p = 0.04).By multivariate regression analysis HC was found to be independently associated with composite adverse neonatal outcome (aOR = 1.21, 95% CI 1.08–2.38) and with severe composite adverse neonatal outcome (aOR = 1.39, 95% CI 1.16–3.76). ConclusionsPregnancies complicated by FGR with concomitant HC were associated with higher rates of adverse neonatal outcomes.

Changes in the Use of Fresh-Frozen Plasma Transfusions in Preterm Neonates: A Single Center Experience.

The aim of this study was to evaluate changes in the use of fresh-frozen plasma (FFP) transfusions and the use of clotting tests in preterm neonates in our center over the past two decades. In this retrospective cohort analysis, we included all consecutive neonates with a gestational age at birth between 24 + 0 and 31 + 6 weeks admitted to our neonatal intensive care unit (NICU) between 2004 and 2019. We divided all included neonates into three consecutive time epochs according to date of birth: January 2004 to April 2009, May 2009 to August 2014 and September 2014 to December 2019. The main outcomes were the use of FFP transfusion, coagulation testing and the indications for FFP transfusion. The percentage of preterm neonates receiving FFP transfusion decreased from 5.7% (47/824) to 3.7% (30/901) to 2.0% (17/852) from the first epoch to the last epoch (p < 0.001). Additionally, the rate of neonates undergoing coagulation testing decreased from 24.3% (200/824) to 14.5% (131/901) to 8% (68/852) over the epochs (p < 0.001). Most FFP transfusions were prescribed prophylactically based on prolongation of activated partial thromboplastin time (aPTT) or prothrombin time (PT) (56%). In conclusion, both the use of FFP transfusions and the use of coagulation tests decreased significantly over the years. The majority of the FFP transfusions were administrated prophylactically for abnormal coagulation tests.

British Society for Haematology Guidelines on transfusion for fetuses, neonates and older children (Br J Haematol. 2016;175:784-828). Addendum August 2020.

Following publication of the British Society for Haematology (BSH) transfusion guidelines for fetuses, neonates and older children,1 there have been a number of changes requiring this addendum, prior to full revision of the guideline. For each update in the addendum, the relevant section number in the main guideline is given. The PlaNeT-2/MATISSE study was a multicentre randomised controlled trial of prophylactic platelet transfusions in preterm neonates (660 babies, <34 weeks’ gestation). The results showed that babies with severe thrombocytopenia randomised to receive platelet transfusions to maintain a platelet count threshold of 50 × 109/l had a significantly higher rate of mortality or major bleeding within 28 days of randomisation than those transfused to maintain a platelet count threshold of 25 × 109/l.2 The possible reasons for this evidence of harm of platelet transfusions are not clear and are the subject of further investigation.3 The PlaNeT-2/MATISSE results support strengthening the current BSH guideline restrictive recommendation on prophylactic platelet transfusion thresholds. New additional wording is shown in italics: For preterm neonates with very severe thrombocytopenia (platelet count below 25 × 109/l) platelet transfusions should be administered in addition to treating the underlying cause of the thrombocytopenia (2C). For non-bleeding neonates platelet transfusions should not be routinely administered if platelet count is ≥25 × 109/l (1B). Suggested threshold counts for platelet transfusions in different situations are given in Table 2 (2C). The requirement to import plasma for treatment of individuals born on or after 1 January 1996 or with TTP was introduced in 2004 in the UK, as part of variant Creuzfeldt–Jacob disease (vCJD) risk reduction measures. In September 2019, the Department of Health and Social Care withdrew this requirement and approved the use of UK-sourced plasma and pooled platelets for these individuals (https://www.parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2019-09-09/HCWS1821/). This followed publication of advice and a comprehensive updated assessment of the vCJD risk by the Advisory Committee for the Safety of Blood, Tissues and Organs (SaBTO) (https://www.gov.uk/government/publications/risk-reduction-measures-for-variant-creutzfeldt-jakob-disease-pcwg-report). For details on the use of plasma for treatment of patients with TTP also refer to the relevant BSH guideline.4 The Joint UK Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC) subsequently agreed that UK plasma for those born on or after 1 January 1996 does not need to be pathogen inactivated, similar to UK plasma for all other age groups (Oct 2019, https://www.transfusionguidelines.org/about/minutes-of-jpac-meetings). Helen V. New and Simon J. Stanworth wrote the initial manuscript, all authors critically reviewed it and approved the final version. We gratefully acknowledge the comments of the BSH Transfusion Task Force and review by paediatric haematology and neonatology expert colleagues.

Maternal Red Blood Cell Alloimmunization Managed with Intrauterine Blood Transfusion: Predictors of Poor Outcome

Background: The rhesus (Rh) and Kell blood group systems are the most common of over 50 different antigens capable of causing maternal red blood cell (RBC) alloimmunization and severe fetal hemolytic disease. Anti-K and anti-D are responsible for a significant proportion of fetal anemia requiring intrauterine transfusion (IUT). Whilst IUT of packed RBCs improves neonatal survival and morbidity, clinical prognostic indicators are lacking. Our primary objective was to identify predictors of adverse outcome. Methods: We conducted a retrospective single-center study at Mount Sinai Hospital (MSH), Toronto, Canada. All pregnant patients alloimmunized with anti-K and anti-D as a single antibody, between 1991 and 2018 were included. Data were obtained from patient medical records, ultrasound reports and information from the transfusion medicine laboratory. Data included maternal demographics, antibody titers, pregnancy history, number of IUTs, hemoglobin (HB) concentration at the beginning and end of all IUTs. Neonatal outcomes included survival, mode of delivery, gestational age at delivery, birth weight, HB at birth and need for neonatal transfusion, phototherapy or intravenous immunoglobulins (IVIG). Our primary outcome was the composite outcome of stillbirth or neonatal death (SB/NND). We also constructed a secondary outcome consisting of top-up neonatal transfusion, exchange transfusion, phototherapy, or use of IVIG. Medians and interquartile ranges (IQR) or mean±SD were used as summary statistics and compared by Mann-Whitney or t-test; p&amp;lt;0.05 was statistically significant. Outcome predictors were identified using multivariable logistic or linear regression analysis; accounting for patient level clustering by marginal Generalized Estimating Equation did not significantly affect variables. Data were analyzed using SPSS. Results: 116 women with 128 pregnancies and 425 IUTs with anti-K or anti-D as a single antibody were identified. Median maternal age was 31 years (27.0-35.0) for anti-K and 32 years (23.6-40.6) for anti-D. The gestational age at 1st IUT differed significantly between anti-K and anti-D (24.3 vs 28.7 weeks respectively, p=0.004). Women with anti-K antibodies required more IUTs than women with anti-D (3.84 vs 3.12 IUTs, p=0.036) and HB at 1st IUT was significantly lower in the anti-K group (5.10 vs 7.05 g/dL, p=0.001) (Table 1). Following initiation of IUT, the time from 1st IUT to delivery was 69.6 days in the anti-K group and 54.6 in the anti-D group (p=0.06). The daily decrease of HB between 1st and 2nd IUT (as a marker of disease severity), development of fetal hydrops and severe preterm birth did not differ significantly between the two groups. Mean gestation age at delivery was 35.0 weeks in the anti-K and 36.0 weeks in the anti-D group (p=0.28), with 87.1% and 93.9% survival (p=0.37), respectively. The proportion of neonates requiring phototherapy, IVIG and exchange/top-up transfusion was comparable across the two antibody groups (Table 1). Regression analysis showed that delivery occurred sooner if HB dropped more rapidly between the first two IUTs (p=0.01). Each additional transfusion gained on average 22.5 days in utero (Table 2). In multivariable analysis, gestational age at 1st IUT was the only predictor of a SB/NND outcome (adjusted OR 0.79 [95%CI 0.67-0.93]; p=0.006). With 1st IUT at 23 weeks, the risk of SB/NND was 8%, but only 2.5% at 28 weeks and &amp;lt;0.01% at 36 weeks (Table 3). Gestational age at delivery (adjusted OR 1.11 [95%CI 1.00 to 1.23]; p=0.046) and HB at 1st IUT (adjusted OR 0.84 [95%CI 0.72 to 0.99]; p=0.038) were the only predictors of a composite adverse blood product requirement/intervention outcome (Table 4). The odds of blood product requirement/intervention postnatally at 1st IUT (median HB at 1st IUT of 6.6g/dL) at 28 weeks were 43% and increased by a further 38% for delivery at 34 weeks. Conclusion: The earlier in gestation that IUTs are implemented, the higher the odds of a SB/NND; however the later the gestation at delivery, the greater the odds of the neonate requiring blood products post-partum. The greater the HB drop between the 1st and 2nd IUT, the shorter the 'time between the first IUT and delivery', which increases the odds of a SB/NND outcome. Disclosures Garbowski: Vifor Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Imara: Consultancy. Shehata:Ferring: Honoraria.

Exchange blood transfusion in neonates with severe hyperbilirubinemia in a lower-middle-income country: can we minimise the incidence?

Our descriptive study examines the clinical profile of referred neonates who underwent exchange blood transfusion (EBT) and identifies possible interventions at peripheral hospitals to decrease their severe hyperbilirubinemia. Among the 38 neonates enrolled, the following were identified as potential clinical gaps in management: early discharge within 24 h of birth (57%); non-availability of ABORh blood grouping (43%); lack of anti-D immunoprophylaxis (75%); pathological weight loss because of inadequate breastfeeding (42%); and low usage of phototherapy. Because of late recognition, the mean age at admission was 5.4 ± 3.3 days, levels of total serum bilirubin (TSB) were 516.4 ± 123.1 µmol/L, and acute bilirubin encephalopathy (ABE) was seen in 45% of neonates. Rh iso-immunisation (39.5%), ABO iso-immunisation (21%) and sepsis (8%) were major risk factors for severe hyperbilirubinaemia. Quality prenatal screening identifying at-risk newborns, preventing early discharge after birth, a bilirubin nomogram risk assignment before discharge and assuring early recognition of hyperbiliubinaemia by parents may well minimise the incidence of EBT.

Outcome of neonatal jaundice in term neonates with ABO incompatibility at tertiary level center

Background: Neonatal jaundice is extremely common as almost every new-born develops an unconjugated serum bilirubin level of more than 1.8 mg/dl during the first seven days of life. ABO incompatibility is associated in about 20% of all pregnancies but manifestations of ABO haemolytic disease of new-born occurs in &lt;10% of these cases. True incidence of ABO incompatibility, particularly in developing countries like Nepal, is not understood sufficiently. Furthermore, the confirmation of severe ABO incompatibility cannot be made accurately using only a single test. Hence, this study was done to know the outcome of jaundice in ABO incompatibility patients.Methods: This was a descriptive cross-sectional study done at Department of Paediatrics, between August 2018 to July 2019. All term neonates born to ‘O’ positive mother, with blood group A or B positive, and fulfilling the selection criteria were included in the study. Sample size was calculated to be 114 with confidence level at 95% and prevalence of ABO haemolytic disease as 11.4% with margin of error 5%.Results: Severe ABO incompatibility as evident by presence of jaundice within 24 hours of life, a positive result on direct coomb’s test and haemolytic picture on peripheral blood smear was observed in 12% of the total enrolled 200 neonates. Modalities of treatment showed significant relation with severe ABO incompatibility indicating increased need for double volume exchange transfusion in neonates with severe ABO incompatibility.Conclusions: Phototherapy was found to be effective in the management of most of the cases of neonatal jaundice in term ABO incompatible neonates but some cases, requiring exchange transfusion can occur, mostly in presence of positive result on direct Coomb’s test.

The role of Albumin infusion before exchange transfusion in term neonates with hyperbilirubinemia

The role of Albumin infusion before exchange transfusion in term neonates with hyperbilirubinemia

Blood Component Transfusion in Tertiary Care Neonatal Intensive Care Unit and Neonatal Intermediate Care Unit: An Audit.

BackgroundNeonates admitted in a tertiary neonatal intensive care unit (NICU) require multiple blood transfusions because of extended NICU stay and repeated sampling. The rookie organ systems and miniature blood volumes in the neonate call for regular audits in neonatal blood transfusion practice. Sharing component usage data with the blood bank will prepare them to store components according to demand, thus limiting wastage of components as well as make banks ready to face a shortage in case of ramped up requirements.ObjectiveAuditing neonatal blood transfusion indications and identifying the most commonly used component.MethodologyThis retrospective cohort study was conducted by the department of pediatrics over 22 months from February 20, 2017, to December 30, 2018. Any preterm and term neonates admitted to the NICU and Neonatal Intermediate Care Unit (NIMC) and receiving any transfusion, i.e., fresh frozen plasma (FFP), red cell concentrate (RCC), platelets, and exchange transfusion were included in our study. We collected data from the medical records of NICU and NIMC admitted patients receiving blood component transfusions from 2011 to 2016. Patients were categorized according to the classification of neonatal conditions by the International Classification of Diseases 11th Revision (ICD-11). There were no exclusion criteria. A descriptive statistical analysis was done, and a Chi-square test was applied.ResultsOut of 340 neonates, 249 (73.2%) were low birth weight, 139 (40.9%) were small for gestational age (SGA), and 277 (81.5%) neonates required transfusion during the first week of life. The majority of neonates require multiple transfusions. Fourteen(4.12%) neonates required up to 10 transfusions, two neonates required up to 22 transfusions, and 58 neonates required more than five blood transfusions. The majority required transfusion due to neonatal sepsis, Disseminated intravascular coagulopathy, low birth weight, respiratory distress syndrome, and unconjugated hyperbilirubinemia. Thirty-seven point eighty-two percent (37.82%) transfusions were fresh frozen plasma, 31.34% transfusions were red cell concentrate, 28.14% transfusions were platelet concentrate, and 2.70% were whole blood. Out of 340 neonates, 317 survived and were discharged.ConclusionThe most commonly transfused component was fresh frozen plasma, the indication was neonatal sepsis, and the group was preterm. Whole blood is still being used and needs to be stopped.

Warming blood products for transfusion to neonates: In vitro assessments

Blood products may be transfused into neonates at temperatures at or below room temperature. The benefits and risks of warming blood to 37°C are not defined in this population or with the equipment used in neonates. Physiologic warming might enhance product effectiveness or decrease transfusion-associated hypothermia. We utilized an in vitro model of neonatal transfusions, with a syringe pump, blood tubing, and 24-gauge catheter and compared current practice (cold products) vs an inline blood warmer. Transfusions were performed rapidly (30 minutes) and slower (120 minutes) to model emergent vs routine situations. We tested red blood cells, fresh-frozen plasma, apheresis platelets (PLTs), and cold-stored low-titer group O whole blood. We used infrared detectors and inline probes to measure temperatures at the origin and at the simulated patient. We assessed warmer-induced damage by measuring plasma hemoglobin and hematocrit (seeking hemolysis), fibrinogen (seeking activation of coagulation), and PLT count and TEG-MA (seeking PLT destruction or dysfunction). The cold-stored products were 4.2 ± 1.0°C (mean ± SD) at the origin and 21.5 ± 0.1°C at the patient. With the inline warmer, products were 37.8 ± 0.6°C at the warmer and 32.6 ± 1.7°C at the patient during a 30-minute infusion, but were 34.5 ± 2.1 with a foil sheath covering the terminal tubing. We found no warmer-induced damage using any metric. In simulated neonatal intensive care unit (NICU) transfusions, an inline blood warmer can deliver blood products at near-physiologic temperatures with no detected damage. We suggest in vivo testing of warmed NICU transfusions, assessing product effectiveness and hypothermia risk reduction.