View source for Medicine:Hemolytic disease of the newborn (anti-RhE)

{{Infobox medical condition (new)
| name            = HDN due to anti-RhE alloimmunization
|
| synonyms        = anti-RhE
  | symptoms        =
| complications   =
| onset           =
| duration        =
| types           =
| causes          =
| risks           =
| diagnosis       =
| differential    =
| prevention      =
| treatment       =
| medication      =
| prognosis       =
| frequency       =
| deaths          =
}}
'''Hemolytic disease of the newborn''' ('''anti-RhE''') is caused by the anti-RhE antibody of the [[Medicine:Rh blood group system|Rh blood group system]]. The anti-RhE [[Biology:Antibody|antibody]] can be naturally occurring, or arise following [[Biology:Immune system|immune]] sensitization after a [[Medicine:Blood transfusion|blood transfusion]] or pregnancy.

The anti-RhE antibody is quite common especially in the Rh genotype CDe/CDe; it usually only causes a mild hemolytic disease, but can cause a severe condition in the newborn.  It can occur with other antibodies, usually the anti-Rhc antibody, which can also cause a severe hemolytic disease.<ref name=emedicine273995>{{EMedicine|article|273995|Erythrocyte Alloimmunization and Pregnancy}}</ref>

One study done by Moran et al., found that titers are not reliable for anti-E. Their most severe case of [[Medicine:Hemolytic disease of the newborn|hemolytic disease of the newborn]] occurred with titers 1:2. Moran states that it would be unwise routinely to dismiss anti-E as being of little clinical consequence.<ref name=pmid11117776>{{cite journal |doi=10.1111/j.1471-0528.2000.tb11662.x |pmid=11117776 |title=Anti-E in pregnancy |journal=BJOG |volume=107 |issue=11 |pages=1436–8 |year=2000 |last1=Moran |first1=P. |last2=Robson |first2=S. C. |last3=Reid |first3=M. M. |s2cid=1240358 }}</ref>

==Presentation==
===Complications===
* High at birth or rapidly rising [[Chemistry:Bilirubin|bilirubin]]<ref name=pmid17337672/>
* Prolonged hyperbilirubinemia<ref name=pmid17337672/>
* Bilirubin-induced neurological dysfunction<ref>{{cite journal |doi=10.1038/sj.jp.7211157 |pmid=15578034 |title=Definition of the Clinical Spectrum of Kernicterus and Bilirubin-Induced Neurologic Dysfunction (BIND) |journal=Journal of Perinatology |volume=25 |issue=1 |pages=54–9 |year=2004 |last1=Shapiro |first1=Steven M |s2cid=19663259 }}</ref>
* [[Medicine:Cerebral palsy|Cerebral palsy]]<ref>{{cite journal |doi=10.1016/j.siny.2005.10.010 |pmid=16338186 |title=Epidemiology of cerebral palsy |journal=Seminars in Fetal and Neonatal Medicine |volume=11 |issue=2 |pages=117–25 |year=2006 |last1=Blair |first1=Eve |last2=Watson |first2=Linda }}</ref>
* [[Medicine:Kernicterus|Kernicterus]]<ref>{{cite journal |doi=10.1016/S0022-3476(48)80225-8 |pmid=18866937 |title=Clinical signs and development of survivors of kernicterus due to Rh sensitization |journal=The Journal of Pediatrics |volume=32 |issue=6 |pages=693–705 |year=1948 |last1=Lande |first1=Lottie }}</ref><ref name=pmid2494315/><ref name=pmid14413526/>
* [[Medicine:Thrombocytopenia|Thrombocytopenia]]<ref name=pmid2494315/>
* Hemolytic anemia – must ''not'' be treated with iron<ref name=pmid23802744/>
* Late onset [[Medicine:Anemia|anemia]] – must ''not'' be treated with iron. Can persist up to 12 weeks after birth.<ref>{{cite journal |pmid=20212966 |pmc=2828194 |year=1999 |last1=Mitchell |first1=S |title=Severe late anemia of hemolytic disease of the newborn |journal=Paediatrics & Child Health |volume=4 |issue=3 |pages=201–3 |last2=James |first2=A |doi=10.1093/pch/4.3.201}}</ref><ref>{{cite journal |pmid=10379500 |year=1999 |last1=Al-Alaiyan |first1=S |title=Late hyporegenerative anemia in neonates with rhesus hemolytic disease |journal=Journal of Perinatal Medicine |volume=27 |issue=2 |pages=112–5 |last2=Al Omran |first2=A |s2cid=32155893 |doi=10.1515/JPM.1999.014 }}</ref>

==Mechanism==
Hemolytic disease of the fetus and newborn (HDN) is a condition where the passage of maternal antibodies results in the hemolysis of fetal/neonatal red cells. The antibodies can be naturally occurring such as anti-A, and anti-B, or immune antibodies developed following a sensitizing event.<ref name=pmid21572705>{{cite journal |doi=10.4103/0973-6247.75963 |pmid=21572705 |pmc=3082712 |title=Hemolytic disease of the fetus and newborn: Current trends and perspectives |journal=Asian Journal of Transfusion Science |volume=5 |issue=1 |pages=3–7 |year=2011 |last1=Basu |first1=Sabita |last2=Kaur |first2=Ravneet |last3=Kaur |first3=Gagandeep |doi-access=free }}</ref> Isoimmunization occurs when the maternal immune system is sensitized to red blood cell surface antigens. The most common causes of isoimmunization are blood transfusion, and fetal-maternal hemorrhage.<ref name=pmid22439037>{{cite journal |pmid=22439037 |pmc=3279102 |year=2009 |last1=Cacciatore |first1=A |title=Obstetric management in Rh alloimmunizated pregnancy |journal=Journal of Prenatal Medicine |volume=3 |issue=2 |pages=25–7 |last2=Rapiti |first2=S |last3=Carrara |first3=S |last4=Cavaliere |first4=A |last5=Ermito |first5=S |last6=Dinatale |first6=A |last7=Imbruglia |first7=L |last8=Recupero |first8=S |last9=La Galia |first9=T |last10=Pappalardo |first10=E. M. |last11=Accardi |first11=M. C. }}</ref> The hemolytic process can result in anemia, hyperbilirubinemia, neonatal thrombocytopenia, and neonatal neutropenia.<ref name=pmid2494315>{{cite journal |pmid=2494315 |year=1989 |last1=Koenig |first1=J. M. |title=Neutropenia and thrombocytopenia in infants with Rh hemolytic disease |journal=The Journal of Pediatrics |volume=114 |issue=4 Pt 1 |pages=625–31 |last2=Christensen |first2=R. D. |doi=10.1016/s0022-3476(89)80709-7}}</ref> With the use of RhD Immunoprophylaxis, (commonly called Rhogam), the incidence of anti-D has decreased dramatically and other alloantibodies are now a major cause of HDN.<ref name=pmid21572705/>

===Antibody specific===
One study done by Moran et al., found that titers are not reliable for anti-E. Their most severe case of [[Medicine:Hemolytic disease of the newborn|hemolytic disease of the newborn]] occurred with titers 1:2. Moran states that it would be unwise routinely to dismiss anti-E as being of little clinical consequence.<ref name=pmid11117776/>

In the case of anti-E, the woman should be checked around 28 weeks to see if she has developed anti-c as well.{{citation needed|date=February 2017}}

==Testing==
Testing for HDN involves blood work from both mother and father, and may also include assessment with amniocentesis and Middle Cerebral Artery scans.{{cn|date=November 2021}}

===Mother===
Blood testing for the mother is called an indirect [[Medicine:Coombs test|Coombs test]] (ICT) or an indirect agglutination test (IAT). This test tells whether there are antibodies in the maternal plasma. If positive, the antibody is identified and given a titer. Critical titers are associated with significant risk of fetal anemia and hydrops.<ref name=emedicine273995/> Titers of 1:8 or higher is considered critical for Kell. Titers of 1:16 or higher are considered critical for all other antibodies. After critical titer is reached, care is based on MCA scans. If antibodies are low and have a sudden jump later in pregnancy, an MCA scan is warranted. If the titer undergoes a 4 fold increase, it should be considered significant regardless of if the critical value has been reached. Maternal titers are not useful in predicting fetal anemia after the first affected gestation and should not be used for the basis of care.<ref name=emedicne974349treatment>{{EMedicine|article|974349|Hemolytic Disease of Newborn|treatment}}</ref> Titers are tested monthly until 24 weeks, after which they are done every 2 weeks.<ref name=pmid22439037/>

"In only 2 situations are patients not monitored identically to patients who are Rh sensitized. The first is that of alloimmunization to the c, E, or, C antigens. Some concern exists that hemolysis may occur in these patients with a lower than 1:16 titer. Thus, if the initial titer is 1:4 and stable but increases at 26 weeks' gestation to 1:8, assessment with MCA Doppler velocity at that point is reasonable. However, if the patient presents in the first trimester with a 1:8 titer that remains stable at 1:8 throughout the second trimester, continued serial antibody titers are appropriate.
The second situation in which patients should not be treated identically to patients who are Rh D sensitized is that of Kell isoimmunization because several cases of severe fetal hemolysis with anti-Kell antibodies have occurred in the setting of low titers."<ref name=emedicine273995/>

In the case of a positive ICT, the woman must carry a medical alert card or bracelet for life because of the risk of a transfusion reaction.{{cn|date=November 2021}}

===Father===
Blood is generally drawn from the father to help determine fetal antigen status.<ref>{{cite journal |doi=10.1111/j.1471-0528.2011.03028.x |pmid=21668766 |title=Noninvasive fetal blood group genotyping of rhesus D, c, E and of K in alloimmunised pregnant women: Evaluation of a 7-year clinical experience |journal=BJOG: An International Journal of Obstetrics & Gynaecology |volume=118 |issue=11 |pages=1340–8 |year=2011 |last1=Scheffer |first1=PG |last2=Van Der Schoot |first2=CE |last3=Page-Christiaens |first3=Gcml |last4=De Haas |first4=M |s2cid=32946225 }}</ref> If he is homozygous for the antigen, there is a 100% chance of all offspring in the pairing to be positive for the antigen and at risk for HDN. If he is heterozygous, there is a 50% chance of offspring to be positive for the antigen.<ref>Transfusion Medicine and Hemostasis: Clinical and Laboratory Aspects {{ISBN|978-0-08-092230-0}}{{page needed|date=February 2017}}{{full citation needed|date=February 2017}}</ref> This test can help with knowledge for the current baby, as well as aid in the decision about future pregnancies. With RhD, the test is called the RhD genotype. With RhCE, and Kell antigen it is called an antigen phenotype.{{cn|date=November 2021}}

===Fetus===
There are three possible ways to test the fetal antigen status. Free cell DNA, amniocentesis, and chorionic villus sampling (CVS). Of the three, CVS is no longer used due to risk of worsening the maternal antibody response. Once antigen status has been determined, assessment may be done with MCA scans.{{citation needed|date=February 2017}}
* Cell-free DNA can be run on certain antigens. Blood is taken from the mother, and using PCR, can detect the K, C, c, D, and E alleles of fetal DNA. This blood test is non-invasive to the fetus and is an easy way of checking antigen status and risk of HDN. Testing has proven very accurate and is routinely done in the UK at the International Blood Group Reference Laboratory in Bristol.<ref>{{cite journal |doi=10.1111/j.1537-2995.2007.01437.x |pmid=17958542 |title=Fetal genotyping for the K (Kell) and Rh C, c, and E blood groups on cell-free fetal DNA in maternal plasma |journal=Transfusion |volume=47 |issue=11 |pages=2126–33 |year=2007 |last1=Finning |first1=Kirstin |last2=Martin |first2=Peter |last3=Summers |first3=Joanna |last4=Daniels |first4=Geoff |s2cid=8292568 }}</ref> Sanequin laboratory in Amsterdam, Netherlands also performs this test. For US patients, blood may be sent to either of the labs. In the US, Sensigene is done by Sequenome to determine fetal D status. Sequenome does not accept insurance in the US, but US and Canadian patients have had insurance cover the testing done overseas.{{citation needed|date=February 2017}}
* Amniocentesis is another recommended method for testing antigen status and risk for HDN. Fetal antigen status can be tested as early as 15 weeks by PCR of fetal cells.<ref name=pmid22439037/>
* CVS is possible as well to test fetal antigen status but is not recommended. CVS carries a higher risk of fetal maternal hemorrhage and can raise antibody titers, potentially worsening the antibody effect.<ref name=pmid22439037/>

===MCA scans===
Middle cerebral artery – peak systolic velocity is changing the way sensitized pregnancies are managed.<ref name=pmid10620643>{{cite journal |doi=10.1056/NEJM200001063420102 |pmid=10620643 |title=Noninvasive Diagnosis by Doppler Ultrasonography of Fetal Anemia Due to Maternal Red-Cell Alloimmunization |journal=New England Journal of Medicine |volume=342 |issue=1 |pages=9–14 |year=2000 |last1=Mari |first1=Giancarlo |last2=Deter |first2=Russell L. |last3=Carpenter |first3=Robert L. |last4=Rahman |first4=Feryal |last5=Zimmerman |first5=Roland |last6=Moise |first6=Kenneth J. |last7=Dorman |first7=Karen F. |last8=Ludomirsky |first8=Avi |last9=Gonzalez |first9=Rogelio |last10=Gomez |first10=Ricardo |last11=Oz |first11=Utku |last12=Detti |first12=Laura |last13=Copel |first13=Joshua A. |last14=Bahado-Singh |first14=Ray |last15=Berry |first15=Stanley |last16=Martinez-Poyer |first16=Juan |last17=Blackwell |first17=Sean C. |doi-access=free }}</ref> This test is done noninvasively with ultrasound. By measuring the peak velocity of blood flow in the middle cerebral artery, a MoM (multiple of the median) score can be calculated. MoM of 1.5 or greater indicates severe anemia and should be treated with IUT.<ref>{{cite journal |doi=10.1002/uog.1882 |pmid=15789353 |title=Middle cerebral artery peak systolic velocity for the diagnosis of fetal anemia: The untold story |journal=Ultrasound in Obstetrics and Gynecology |volume=25 |issue=4 |pages=323–30 |year=2005 |last1=Mari |first1=G. |s2cid=12342034 }}</ref><ref name=pmid10620643/>

==Intervention==
There are several intervention options available in early, mid and late pregnancies.{{citation needed|date=February 2017}}

===Early pregnancy===
* IVIG – IVIG stands for intravenous immunoglobulin. It is used in cases of previous loss, high maternal titers, known aggressive antibodies, and in cases where religion prevents blood transfusion. Ivig can be more effective than IUT alone.<ref>{{cite journal |pmid=9085208 |year=1997 |last1=Voto |first1=L. S. |title=High-dose gammaglobulin (IVIG) followed by intrauterine transfusions (IUTs): A new alternative for the treatment of severe fetal hemolytic disease |journal=Journal of Perinatal Medicine |volume=25 |issue=1 |pages=85–8 |last2=Mathet |first2=E. R. |last3=Zapaterio |first3=J. L. |last4=Orti |first4=J |last5=Lede |first5=R. L. |last6=Margulies |first6=M |s2cid=22822621 |doi=10.1515/jpme.1997.25.1.85}}</ref> Fetal mortality was reduced by 36% in the IVIG and IUT group than in the IUT alone group. IVIG and plasmapheresis together can reduce or eliminate the need for an IUT.<ref>{{cite journal |pmid=19003884 |year=2008 |last1=Novak |first1=D. J. |title=Plasmapheresis and intravenous immune globulin for the treatment of D alloimmunization in pregnancy |journal=Journal of Clinical Apheresis |volume=23 |issue=6 |pages=183–5 |last2=Tyler |first2=L. N. |last3=Reddy |first3=R. L. |last4=Barsoom |first4=M. J. |doi=10.1002/jca.20180 |s2cid=206013087 }}</ref>
* [[Medicine:Plasmapheresis|Plasmapheresis]] – Plasmapheresis aims to decrease the maternal titer by direct plasma replacement.<ref name=pmid25722586>{{cite journal |doi=10.4103/0973-6247.150968 |pmid=25722586 |pmc=4339947 |title=Maternal anti-M induced hemolytic disease of newborn followed by prolonged anemia in newborn twins |journal=Asian Journal of Transfusion Science |volume=9 |issue=1 |pages=98–101 |year=2015 |last1=Arora |first1=Satyam |last2=Doda |first2=Veena |last3=Maria |first3=Arti |last4=Kotwal |first4=Urvershi |last5=Goyal |first5=Saurabh |doi-access=free }}</ref> Plasmapheresis and IVIG together can even be used on women with previously hydropic fetuses and losses.<ref>{{cite journal |pmid=17045529 |year=2006 |last1=Palfi |first1=M |title=A case of severe Rh (D) alloimmunization treated by intensive plasma exchange and high-dose intravenous immunoglobulin |journal=Transfusion and Apheresis Science |volume=35 |issue=2 |pages=131–6 |last2=Hildén |first2=J. O. |last3=Matthiesen |first3=L |last4=Selbing |first4=A |last5=Berlin |first5=G |doi=10.1016/j.transci.2006.07.002 }}</ref><ref>{{cite journal |pmid=17306655 |year=2007 |last1=Ruma |first1=M. S. |title=Combined plasmapheresis and intravenous immune globulin for the treatment of severe maternal red cell alloimmunization |journal=American Journal of Obstetrics and Gynecology |volume=196 |issue=2 |pages=138.e1–6 |last2=Moise Jr |first2=K. J. |last3=Kim |first3=E |last4=Murtha |first4=A. P. |last5=Prutsman |first5=W. J. |last6=Hassan |first6=S. S. |last7=Lubarsky |first7=S. L. |doi=10.1016/j.ajog.2006.10.890 }}</ref>

===Mid to late pregnancy===
* IUT – intrauterine transfusion (IUT) is done either by intraperitoneal transfusion (IPT) or intravenous transfusion (IVT).<ref>{{cite journal |doi=10.1007/s40556-016-0072-4 |pmid=26811110 |title=Intrauterine Transfusion |journal=Journal of Fetal Medicine |volume=27 |issue=3 |pages=13–17 |year=2016 |last1=Deka |first1=Dipika |s2cid=42005756 |doi-access=free }}</ref> IVT is preferred over IPT.<ref name=emedicine273995/> IUTs are only done until 35 weeks. After that, the risk of an IUT is greater than the risk from post birth transfusion.<ref name="uptodate IFTR">{{Cite web|url=https://www.uptodate.com/contents/intrauterine-fetal-transfusion-of-red-cells%7B%7Bfull+citation+needed%7Cdate=February+2017%7D%7D|title=UpToDate|website=www.uptodate.com}}</ref>
* Steroids – steroids are sometimes given to the mother before IUTs and early delivery to mature the fetal lungs.<ref name="uptodate IFTR"/><ref name=emedicne974349treatment/>
* [[Chemistry:Phenobarbital|Phenobarbital]] – Phenobarbital is sometimes given to the mother to help mature the fetal liver and reduce hyperbilirubinemia.<ref name=emedicne974349treatment/><ref>https://www.mombaby.org/wp-content/uploads/2016/03/UNC-Isoimmunization-Detection-Prevention.pdf{{full citation needed|date=February 2017}}{{Dead link|date=January 2020 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>
* Early delivery – delivery can occur anytime after the age of viability.<ref name=emedicine273995/> Emergency delivery due to failed IUT is possible, along with induction of labor at 35–38 weeks.<ref name="uptodate IFTR"/><ref>{{cite journal |doi=10.1002/uog.2837 |pmid=16941575 |title=Management of Kell isoimmunization — evaluation of a Doppler-guided approach |journal=Ultrasound in Obstetrics and Gynecology |volume=28 |issue=6 |pages=814–20 |year=2006 |last1=Rimon |first1=E. |last2=Peltz |first2=R. |last3=Gamzu |first3=R. |last4=Yagel |first4=S. |last5=Feldman |first5=B. |last6=Chayen |first6=B. |last7=Achiron |first7=R. |last8=Lipitz |first8=S. |s2cid=19672347 |doi-access= }}</ref>

==After birth==
===Testing===
* Coombs – after birth the baby will have a direct Coombs test run to confirm antibodies attached to the infant's red blood cells. This test is run from [[Biology:Cord blood|cord blood]].<ref name=pmid17337672>{{cite journal |doi=10.1136/adc.2005.076794 |pmid=17337672 |pmc=2675453 |title=Haemolytic disease of the newborn |journal=Archives of Disease in Childhood: Fetal and Neonatal Edition |volume=92 |issue=2 |pages=F83–8 |year=2007 |last1=Murray |first1=N. A |last2=Roberts |first2=I. A G }}</ref>
In some cases, the direct Coombs will be negative but severe, even fatal HDN can occur.<ref>{{cite journal |pmid=7655573 |year=1995 |last1=Heddle |first1=N. M. |title=Three examples of Rh haemolytic disease of the newborn with a negative direct antiglobulin test |journal=Transfusion Medicine (Oxford, England) |volume=5 |issue=2 |pages=113–6 |last2=Wentworth |first2=P |last3=Anderson |first3=D. R. |last4=Emmerson |first4=D |last5=Kelton |first5=J. G. |last6=Blajchman |first6=M. A. |doi=10.1111/j.1365-3148.1995.tb00197.x|s2cid=21936425 }}</ref> An indirect Coombs needs to be run in cases of anti-C,<ref name=emedicne974349workup>{{EMedicine|article|974349|Hemolytic Disease of Newborn|workup}}</ref> anti-c,<ref name=emedicne974349workup/> and anti-M. Anti-M also recommends antigen testing to rule out the presence of HDN.<ref name=pmid25722586/>
* Hgb – the infant's [[Biology:Hemoglobin|hemoglobin]] should be tested from cord blood.<ref name=pmid17337672/>
* [[Biology:Reticulocyte|Reticulocyte]] count – Reticulocytes are elevated when the infant is producing more blood to combat anemia.<ref name=pmid17337672/>  A rise in the retic count can mean that an infant may not need additional transfusions.<ref>{{Cite web |url=https://www.ucsfbenioffchildrens.org/pdf/manuals/42_Hemol.pdf |title=Archived copy |access-date=2017-02-15 |archive-date=2021-03-09 |archive-url=https://web.archive.org/web/20210309053500/https://www.ucsfbenioffchildrens.org/pdf/manuals/42_Hemol.pdf |url-status=dead }}{{full citation needed|date=February 2017}}</ref> Low retic is observed in infants treated with IUT and in those with HDN from anti-Kell<ref name=emedicne974349workup/>
* [[Biology:Neutrophil|Neutrophil]]s – as [[Medicine:Neutropenia|neutropenia]] is one of the complications of HDN, the neutrophil count should be checked.<ref name=pmid2494315/><ref name=pmid14413526>{{cite journal |pmid=14413526 |year=1960 |last1=Lalezari |first1=P |title=Neonatal neutropenia due to maternal isoimmunization |journal=Blood |volume=15 |pages=236–43 |last2=Nussbaum |first2=M |last3=Gelman |first3=S |last4=Spaet |first4=T. H. |issue = 2|doi = 10.1182/blood.V15.2.236.236|doi-access=free }}</ref>
* Thrombocytes – as thrombocytopenia is one of the complications of HDN, the thrombocyte count should be checked.<ref name=pmid2494315/>
* Bilirubin should be tested from cord blood.<ref name=pmid17337672/>
* [[Biology:Ferritin|Ferritin]] – because most infants affected by HDN have iron overload, a ferritin must be run before giving the infant any additional iron.<ref name=pmid23802744>{{cite journal |pmid=23802744 |year=2013 |last1=Rath |first1=M. E. |title=Iron status in infants with alloimmune haemolytic disease in the first three months of life |journal=Vox Sanguinis |volume=105 |issue=4 |pages=328–33 |last2=Smits-Wintjens |first2=V. E. |last3=Oepkes |first3=D |last4=Walther |first4=F. J. |last5=Lopriore |first5=E |doi=10.1111/vox.12061 |s2cid=24789324 }}</ref>
* Newborn screening tests – transfusion with donor blood during pregnancy or shortly after birth can affect the results of the newborn screening tests. It is recommended to wait and retest 10–12 months after last transfusion. In some cases, DNA testing from saliva can be used to rule out certain conditions.{{cn|date=November 2021}}

==Treatment==
* Phototherapy – Phototherapy is used for cord bilirubin of 3 or higher. Some doctors use it at lower levels while awaiting lab results.<ref name=pmid15231951>{{cite journal |pmid=15231951 |url=http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=15231951 |year=2004 |author1=American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. |title=Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation |journal=Pediatrics |volume=114 |issue=1 |pages=297–316 |doi=10.1542/peds.114.1.297|doi-access= }}</ref>
* IVIG – IVIG has been used to successfully treat many cases of HDN. It has been used not only on anti-D, but on anti-E as well.<ref>{{cite journal |pmid=20092394 |year=2010 |last1=Onesimo |first1=R |title=Intravenous Immunoglobulin therapy for anti-E hemolytic disease in the newborn |journal=The Journal of Maternal-Fetal & Neonatal Medicine |volume=23 |issue=9 |pages=1059–61 |last2=Rizzo |first2=D |last3=Ruggiero |first3=A |last4=Valentini |first4=P |s2cid=25144401 |doi=10.3109/14767050903544751 }}</ref> IVIG can be used to reduce the need for exchange transfusion and to shorten the length of phototherapy.<ref>{{cite journal |doi=10.1136/fn.88.1.F6 |pmid=12496219 |pmc=1755998 |title=Systematic review of intravenous immunoglobulin in haemolytic disease of the newborn |journal=Archives of Disease in Childhood: Fetal and Neonatal Edition |volume=88 |issue=1 |pages=F6–10 |year=2003 |last1=Gottstein |first1=R }}</ref> The AAP recommends "In isoimmune hemolytic disease, administration of intravenousγ-globulin (0.5–1 g/kg over 2 hours) is recommended if the TSB is rising despite intensive phototherapy or the TSB level is within 2 to 3 mg/dL (34–51 μmol/L) of the exchange level. If necessary, this dose can be repeated in 12 hours (evidence quality B: benefits exceed harms). Intravenous γ-globulin has been shown to reduce the need for exchange transfusions in Rh and ABO hemolytic disease."<ref name=pmid15231951/>
* Exchange transfusion – exchange transfusion is used when bilirubin reaches either the high or medium risk lines on the nonogram provided by the American Academy of Pediatrics (Figure 4).<ref name=pmid15231951/> Cord bilirubin >4 is also indicative of the need for exchange transfusion.<ref name=emedicne974349followup>{{EMedicine|article|974349|Hemolytic Disease of Newborn|followup}}</ref>

==Transfusion reactions==
Once a woman has antibodies, she is at high risk for a transfusion reaction.<ref>{{cite journal |doi=10.1159/000154811 |pmid=21512623 |pmc=3076326 |title=Hemolytic Transfusion Reactions |journal=Transfusion Medicine and Hemotherapy |volume=35 |issue=5 |pages=346–353 |year=2008 |last1=Strobel |first1=Erwin }}</ref> For this reason, she must carry a medical alert card at all times and inform all doctors of her antibody status.{{citation needed|date=July 2020}}

"Acute hemolytic transfusion reactions may be either immune-mediated or nonimmune-mediated. Immune-mediated hemolytic transfusion reactions caused by immunoglobulin M (IgM) anti-A, anti-B, or anti-A,B typically result in severe, potentially fatal complement-mediated intravascular hemolysis. Immune-mediated hemolytic reactions caused by IgG, Rh, Kell, Duffy, or other non-ABO antibodies typically result in extravascular sequestration, shortened survival of transfused red cells, and relatively mild clinical reactions. Acute hemolytic transfusion reactions due to immune hemolysis may occur in patients who have no antibodies detectable by routine laboratory procedures."<ref>{{EMedicine|article|206885|Transfusion Reactions}}</ref>

Summary of transfusion reactions in the US:<ref>https://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/ucm302847.htm{{full citation needed|date=February 2017}}</ref>

==See also==
* [[Medicine:Coombs test|Coombs test]]
* [[Medicine:Hematology|Hematology]]
* Hemolytic anemia
* [[Medicine:Hemolytic disease of the newborn|Hemolytic disease of the newborn]]

==References==
{{Reflist}}

==Further reading==
* Antenatal & neonatal screening (second edition). Chapter 12: Rhesus and other haemolytic diseases,  by E.A. Letsky, I. Leck, J.M. Bowman. 2000. Oxford University Press. {{ISBN|0-19-262826-7}}.

== External links ==
{{Medical resources
|   ICD10       = {{ICD10|P|55|8|p|50}}
|   ICD9        = {{ICD9|773.2}}
}}


{{DEFAULTSORT:Hemolytic Disease Of The Newborn (Anti-Rhe)}}
[[Category:Transfusion medicine]]

ru:Гемолитическая желтуха новорождённых

{{Sourceattribution|Hemolytic disease of the newborn (anti-RhE)}}