Podcast
Questions and Answers
What process is essential for the body to eliminate bilirubin?
What process is essential for the body to eliminate bilirubin?
- Reabsorption of bilirubin in the intestines.
- Storing bilirubin within the red blood cells for later use.
- Conjugating bilirubin in the liver, then excreting it in bile, urine, and stool. (correct)
- Directly excreting unconjugated bilirubin via urine.
Which enzyme is responsible for the detoxification of bilirubin in the liver?
Which enzyme is responsible for the detoxification of bilirubin in the liver?
- Amylase
- Lipase
- Lactase
- Glucuronyl transferase (correct)
What happens to conjugated bilirubin after it enters the intestines?
What happens to conjugated bilirubin after it enters the intestines?
- It is directly excreted in the urine.
- Bacterial action reduces it to urobilinogen. (correct)
- It is converted back to unconjugated bilirubin.
- It is absorbed into the bloodstream unchanged.
What is the initial form of bilirubin that is produced as a result of hemoglobin breakdown?
What is the initial form of bilirubin that is produced as a result of hemoglobin breakdown?
What is the primary cause of jaundice (icterus) in newborns?
What is the primary cause of jaundice (icterus) in newborns?
Which symptom is an early sign of bilirubin encephalopathy in infants?
Which symptom is an early sign of bilirubin encephalopathy in infants?
What is a late-stage neurological sign associated with bilirubin encephalopathy?
What is a late-stage neurological sign associated with bilirubin encephalopathy?
A newborn's body produces more bilirubin than an adult due to which of these factors?
A newborn's body produces more bilirubin than an adult due to which of these factors?
What is a primary reason for reduced bilirubin conjugation in newborn livers?
What is a primary reason for reduced bilirubin conjugation in newborn livers?
Why is enterohepatic circulation accentuated in newborns?
Why is enterohepatic circulation accentuated in newborns?
What is a long-term effect of severe bilirubin encephalopathy in a child?
What is a long-term effect of severe bilirubin encephalopathy in a child?
Which statement best describes physiologic jaundice in newborns?
Which statement best describes physiologic jaundice in newborns?
Which factor contributes to the reduced plasma-binding capacity for bilirubin in newborns?
Which factor contributes to the reduced plasma-binding capacity for bilirubin in newborns?
What is the primary mechanism by which feeding aids in reducing bilirubin levels in newborns?
What is the primary mechanism by which feeding aids in reducing bilirubin levels in newborns?
Which of the following best describes the role of bacteria introduced by feeding in bilirubin metabolism?
Which of the following best describes the role of bacteria introduced by feeding in bilirubin metabolism?
What is a key reason that early breastfeeding can lead to breastfeeding-associated jaundice?
What is a key reason that early breastfeeding can lead to breastfeeding-associated jaundice?
Why are supplemental fluids like glucose water or water not recommended to enhance bilirubin excretion?
Why are supplemental fluids like glucose water or water not recommended to enhance bilirubin excretion?
What typically causes prolonged jaundice starting around the fourth day in breastfed infants?
What typically causes prolonged jaundice starting around the fourth day in breastfed infants?
Which of the following factors found in breast milk may play a role to cause jaundice in some infants?
Which of the following factors found in breast milk may play a role to cause jaundice in some infants?
Jaundice presenting within the first 24 hours is most likely caused by:
Jaundice presenting within the first 24 hours is most likely caused by:
When does physiological jaundice typically peak in newborns?
When does physiological jaundice typically peak in newborns?
In ABO incompatibility, what causes the destruction of fetal red blood cells?
In ABO incompatibility, what causes the destruction of fetal red blood cells?
Which maternal blood type poses the highest risk for ABO incompatibility in a neonate?
Which maternal blood type poses the highest risk for ABO incompatibility in a neonate?
How does ABO incompatibility typically differ from Rh incompatibility in its initial presentation?
How does ABO incompatibility typically differ from Rh incompatibility in its initial presentation?
What is the immediate cause of jaundice in a newborn with HDN?
What is the immediate cause of jaundice in a newborn with HDN?
When is hydrops most likely to be evident in a newborn with HDN?
When is hydrops most likely to be evident in a newborn with HDN?
What is the purpose of a maternal antibody titer (indirect Coombs test) early in prenatal care?
What is the purpose of a maternal antibody titer (indirect Coombs test) early in prenatal care?
Besides fetal blood type, what additional information can be obtained using amniocentesis with polymerase chain reaction in a woman with a positive antibody screen?
Besides fetal blood type, what additional information can be obtained using amniocentesis with polymerase chain reaction in a woman with a positive antibody screen?
What is the main reason for testing paternal zygosity at the Rh gene locus?
What is the main reason for testing paternal zygosity at the Rh gene locus?
What is the primary purpose of detecting cell-free fetal DNA in the maternal plasma of Rh-negative women?
What is the primary purpose of detecting cell-free fetal DNA in the maternal plasma of Rh-negative women?
Serial Doppler ultrasound of the fetal middle cerebral artery peak velocity is considered the gold standard for:
Serial Doppler ultrasound of the fetal middle cerebral artery peak velocity is considered the gold standard for:
Which of the following methods is used to assess erythroblastosis fetalis by evaluating the amniotic fluid?
Which of the following methods is used to assess erythroblastosis fetalis by evaluating the amniotic fluid?
The direct Coombs test on a newborn is used to detect:
The direct Coombs test on a newborn is used to detect:
Which of the following findings is most indicative of ABO incompatibility in a newborn?
Which of the following findings is most indicative of ABO incompatibility in a newborn?
Why might the direct Coombs test be less conclusive in cases of ABO incompatibility compared to Rh incompatibility?
Why might the direct Coombs test be less conclusive in cases of ABO incompatibility compared to Rh incompatibility?
What is the primary aim in the therapeutic management of isoimmunization?
What is the primary aim in the therapeutic management of isoimmunization?
Which of these scenarios would most likely indicate the need for an exchange transfusion in a newborn with isoimmunization?
Which of these scenarios would most likely indicate the need for an exchange transfusion in a newborn with isoimmunization?
What is the primary purpose of an exchange transfusion in neonates?
What is the primary purpose of an exchange transfusion in neonates?
What is the expected duration of an exchange transfusion procedure?
What is the expected duration of an exchange transfusion procedure?
Which complication is NOT associated with exchange transfusion?
Which complication is NOT associated with exchange transfusion?
How much donor blood is typically used during a double-volume exchange transfusion?
How much donor blood is typically used during a double-volume exchange transfusion?
What is monitored in the neonate during the exchange transfusion procedure?
What is monitored in the neonate during the exchange transfusion procedure?
What could happen if there is inadequate replacement of blood during the exchange transfusion?
What could happen if there is inadequate replacement of blood during the exchange transfusion?
Which of the following is an important pre-procedure laboratory study for exchange transfusion?
Which of the following is an important pre-procedure laboratory study for exchange transfusion?
What medication is commonly used to treat hypocalcemia during the exchange transfusion?
What medication is commonly used to treat hypocalcemia during the exchange transfusion?
Flashcards
Hyperbilirubinemia
Hyperbilirubinemia
An excessive level of bilirubin in the blood, causing yellowing of the skin and other organs. It's common in newborns, but extreme levels can signify a serious problem.
Bilirubin
Bilirubin
The breakdown product of hemoglobin from red blood cell destruction. It exists in two forms: unconjugated (insoluble) and conjugated (soluble).
Conjugation
Conjugation
The process of converting unconjugated bilirubin into conjugated bilirubin. This makes it soluble and excretable.
Excretion
Excretion
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Liver
Liver
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Physiologic Jaundice
Physiologic Jaundice
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Bilirubin Encephalopathy
Bilirubin Encephalopathy
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Higher RBC turnover in newborns
Higher RBC turnover in newborns
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Reduced Glucuronyl Transferase activity in newborns
Reduced Glucuronyl Transferase activity in newborns
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Enterohepatic Circulation
Enterohepatic Circulation
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Athetoid Cerebral Palsy
Athetoid Cerebral Palsy
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Long-term consequences of Bilirubin Encephalopathy
Long-term consequences of Bilirubin Encephalopathy
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ABO Incompatibility
ABO Incompatibility
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Hemolysis
Hemolysis
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Hydrops fetalis
Hydrops fetalis
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Bilirubin Conjugation
Bilirubin Conjugation
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Bilirubin Excretion
Bilirubin Excretion
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Maternal Antibody Titer
Maternal Antibody Titer
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How feeding helps reduce bilirubin
How feeding helps reduce bilirubin
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Colostrum's role in reducing bilirubin
Colostrum's role in reducing bilirubin
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What causes Breastfeeding Associated Jaundice?
What causes Breastfeeding Associated Jaundice?
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How does low caloric intake affect bilirubin?
How does low caloric intake affect bilirubin?
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What is the primary cause of Breastfeeding Associated Jaundice?
What is the primary cause of Breastfeeding Associated Jaundice?
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Should supplemental fluids be given for breastfeeding-associated jaundice?
Should supplemental fluids be given for breastfeeding-associated jaundice?
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What is Breast Milk Jaundice?
What is Breast Milk Jaundice?
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How to differentiate jaundice types
How to differentiate jaundice types
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Direct Coombs Test
Direct Coombs Test
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Indirect Coombs Test
Indirect Coombs Test
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Erythroblastosis fetalis
Erythroblastosis fetalis
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Amniotic fluid
Amniotic fluid
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Amniocentesis
Amniocentesis
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Phototherapy
Phototherapy
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Exchange transfusion
Exchange transfusion
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Sensitized Erythrocytes
Sensitized Erythrocytes
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Hypocalcemia
Hypocalcemia
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Inferior Vena Cava
Inferior Vena Cava
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UVC Placement
UVC Placement
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Severe Hyperbilirubinemia
Severe Hyperbilirubinemia
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Clot Formation
Clot Formation
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Study Notes
Neonatal Jaundice (NNJ)
- NNJ, also known as hyperbilirubinemia, is an excessive buildup of bilirubin in the blood, leading to a yellowish discoloration of the skin and organs (jaundice or icterus).
Lecture Objectives
- Describe bilirubin metabolism.
- Understand the clinical significance of hyperbilirubinemia.
- Learn the diagnostic approach and further work-up.
- Differentiate between indirect and direct hyperbilirubinemia.
- Develop differential diagnoses for each type.
- Understand management options for each type.
Hyperbilirubinemia
- Caused by an imbalance in bilirubin production and elimination.
- Bilirubin must be conjugated in the liver to be cleared from the body.
- Conjugated bilirubin is excreted in bile and eliminated through urine and stool.
Bilirubin Metabolism
- Results from red blood cell (RBC) destruction.
- Hemoglobin breaks down into heme and globin.
- Heme is converted to unconjugated bilirubin, an insoluble substance bound to albumin.
- In the liver, bilirubin detaches from albumin and is conjugated with glucuronic acid, forming a soluble substance (conjugated bilirubin glucuronide) that's excreted in bile.
- In the intestine, bacteria convert conjugated bilirubin to urobilinogen, which gives feces its color.
- Most bilirubin is excreted in the feces.
Definition of Hyperbilirubinemia
- Refers to an excessive level of accumulated bilirubin in the blood.
- Characterized by a yellowish discoloration of skin and organs (jaundice or icterus).
- Usually benign in newborns but can indicate a pathologic state in extreme cases.
Pathophysiology of NNJ
- Bilirubin is a byproduct of RBC breakdown.
- Unconjugated bilirubin is insoluble and bound to albumin.
- The liver conjugates bilirubin, making it soluble and excretable.
- The intestines further process bilirubin for excretion.
Possible Causes of Hyperbilirubinemia in Newborns
- Physiological factors (immaturity, increased bilirubin load from RBC breakdown, enterohepatic shunting).
- Breastfeeding (decreased milk intake, increased enterohepatic circulation).
- Breast milk jaundice (factors in breast milk that prevent bilirubin conjugation).
- Hemolytic disease (blood incompatibility).
- Other conditions (e.g., G6PD deficiency, hypothyroidism, galactosemia).
- Genetic predisposition to increased production.
Types of Hyperbilirubinemia
- Indirect/unconjugated: Fat-soluble; more common in newborns.
- Direct/conjugated: Water-soluble.
Types of Newborn Jaundice
- Physiological jaundice (common, benign). Onset: 24 hours (longer in pre-term infants); peaks on day 2-5, resolving by day 7-10.
- Breast-feeding jaundice (early onset). Onset : day 3-4; peaks 3-5 days
- Breast milk jaundice (late onset). Onset: day 4; peaks day 10-15.
- Hemolytic disease. Onset: First 24 hours; peaks variable; duration depends on treatment.
- Other causes.
Therapy for Physiologic Jaundice
- Increase feeding frequency to stimulate bowel movements.
- Avoid supplements (water, dextrose water, formula).
- Monitor bilirubin levels (TcB or TSB).
- Perform risk assessment.
- Use phototherapy for significantly elevated bilirubin levels.
Therapy for Breastfeeding Jaundice
- Frequent breastfeeding is key.
- Supplements are not usually recommended.
- Evaluate stooling pattern, and perform risk assessment.
- Consider temporary cessation of breastfeeding (with medical advice) if phototherapy is necessary.
Therapy for Breast Milk Jaundice
- Continue frequent breastfeeding.
- Avoid supplements.
- Evaluate benefits and harm before temporarily discontinuing breastfeeding.
- The goal is to encourage frequent breastfeeding.
Therapy for Hemolytic Disease
- Monitor bilirubin levels.
- Administer phototherapy.
- Consider intravenous immunoglobulin (IVIG).
- Perform exchange transfusion if severe.
Complications
- Bilirubin encephalopathy (kernicterus) is a serious complication of severe hyperbilirubinemia, causing brain damage.
- Symptoms range from subtle to severe and can lead to permanent neurological problems.
Risk Assessment for Pathological Hyperbilirubinemia
- Jaundice appearing within 24 hours of birth.
- Elevated serum bilirubin level (or transcutaneous bilirubin).
- Blood group incompatibility (positive Direct Coombs test).
- Hereditary hemolytic disease (e.g., G6PD deficiency).
- Premature infants (gestational age 35-36 weeks).
- East Asian or Asian-American race.
- Cephalhematoma or bruising.
- Exclusive breastfeeding (especially infants with feeding difficulty or significant weight loss).
- Family history of hyperbilirubinemia.
- Unrecognized hemolysis, UDP glucoronyl transferase deficiency
Diagnostic Evaluation for NNJ
- Bilirubin level (TSB or TcB).
- History (pregnancy and delivery, family history, feeding method).
- Physical exam (bruising, hydration).
- Risk assessment.
- Further studies may include blood type, Coombs test, complete blood count (CBC), reticulocyte count, albumin levels, liver function tests (LFTs), thyroid function tests (TFTs), and imaging.
Jaundice Assessment Tools
- Visual assessment of jaundice (Kramer's Index): based on the progression of jaundice from head to toe (higher numbers indicate more severe jaundice).
Treatment for Neonatal Hyperbilirubinemia
- Maintain serum bilirubin levels below the high-risk zone on the hour-specific bilirubin nomogram.
Treatment for Hemolytic Disease
- Phototherapy.
- Exchange transfusion.
Medications for Hyperbilirubinemia
- Phenobarbital (promotes bilirubin conjugation).
- Heme oxygenase inhibitors (reduce bilirubin production).
- Intravenous immunoglobulin (IVIG)
Intrauterine Transfusion
- Infusion of blood into the umbilical vein of the fetus.
- Used when severe fetal anemia is diagnosed via serial Doppler assessments.
- Helps raise the fetal hematocrit.
Exchange Transfusion
- Standard therapy for severe hyperbilirubinemia unresponsive to phototherapy.
- Removes affected blood cells and bilirubin.
- Replacement with donor blood.
Risk/Complications of Exchange Transfusion
- Cardiac and respiratory disturbances.
- Shock.
- Electrolyte imbalances (hypo/hyperkalemia, hypo/hypermagnesemia, hypoglycemia/hyperglycemia hypocalcemia).
- Infections.
- Clot formation, air embolism, portal hypertension
Management of Breastfeeding Jaundice
- Encourage frequent breastfeeding.
Nursing Care Management
- Evaluate jaundice regularly and use Kramer's Index.
- Assess hydration, feedings and avoid water supplementation.
Prevention of Rh Isoimmunization
- Administration of Rh immunoglobulin (RhoGAM) to Rh-negative women within 72 hours (or up to 3-4 weeks) of childbirth, miscarriage, abortion, or any event that could expose the mother to fetal red blood cells.
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