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

Abstract

Background and objectives Guidelines 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 methods In 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. Results The 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. Conclusion Exchange 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.

Neonatal sepsis in alloimmune hemolytic disease of the fetus and newborn: A retrospective cohort study of 260 neonates

“…5 Bloodstream infections such as CLABSI, are a major cause of morbidity and mortality in neonatal intensive care units (NICU) worldwide, leading to prolonged hospital stays and increased health-care expenditures. 6 Despite the numerous outcomes studied among neonates with HDFN including hematological and cardiorespiratory complications, long-term neurodevelopmental outcome, and mortality, 5,[7][8][9][10][11] the incidence of cultureproven early-onset (EOS) and late-onset (LOS) sepsis, including CLABSI, is not well described. Moreover, in the context of an existing inherently low risk of infection, equivocal evidence regarding potential risk factors for sepsis evaluation and clinical indication for antibiotic therapy remains absent.…”

Use of prophylactic phototherapy for RhD neonatal disease in a referral service

“…in the 20-year experience (2000-2020) of ET in infants with gestational age equal to or greater than 35 weeks with HDN by Rh at the Leiden University Medical Center. 15 …”

History and current standard of postnatal management in hemolytic disease of the fetus and newborn

“…Inherent to invasive nature of the procedure and the use of central lines, exchange transfusions are not without risk. Although in experienced hands the mortality rate of exchange transfusions may be as low as 0-0.3% in (near-) term neonates with increasing rates at a lower gestational age, complications associated with exchange transfusions should be considered [80][81][82][83]. Frequently occurring complications are thrombocytopenia < 100•10 9 /L (31≥90%) [81,84], hypocalcemia (1-47%) [81,82,84], leukocytopenia < 5•10 9 /L (33%) and sepsis related to the procedure (10%) [81].…”

“…Although in experienced hands the mortality rate of exchange transfusions may be as low as 0-0.3% in (near-) term neonates with increasing rates at a lower gestational age, complications associated with exchange transfusions should be considered [80][81][82][83]. Frequently occurring complications are thrombocytopenia < 100•10 9 /L (31≥90%) [81,84], hypocalcemia (1-47%) [81,82,84], leukocytopenia < 5•10 9 /L (33%) and sepsis related to the procedure (10%) [81]. In a study by Jansen et al, it was found that neonates with HDFN with a central line had a higher risk for lateonset sepsis (RR 1.11, 95% CI: 1.04-1.20).…”