Koumail Yassine

5thYear Doz 3

Case 1
A full-term boy has the 1st birth from the 3rd pregnancy mother with group blood B(III) by
Rhesus-negative; during the primary inspection   jaundice, pastiness, hepatosplenomegaly were
noted. In the anamnesis mother: 2 medical abortions. Analysis result umbilical cord blood: group
blood O(I) Rh-positive, general bilirubin 80 μmol /l at the expense indirect fractions . What is the
examination method allows to confirm diagnosis: hemolytic disease of the newborn, rhesus
conflict ?

Testing of the baby's umbilical cord blood for blood group, Rh factor, red blood cell count, and
antibodies
1. Your previous diagnosis. Justify your opinion and outline the leading syndromes
The mother being rh- indicates that it has rh antibodies in her serum which can attack the RBCs
of the fetus which carry the rh antigen being rh+ causing the hemolysis of the RBCs and leading
to hemolytic diseases in the child. The symptoms evident in this case appear to be the liver
related ones, be jaundice and hepatomegaly when the liver is unable to handle the rate if RBCs
breakdown and the resulting high levels of bilirubin.

2. What factors could contribute to the development of the disease in this case?
In a first pregnancy, Rh sensitization is not likely. So, this being the 3rd pregnancy increases the
chance of this happening. The core cause of this problem is mainly genetic due to the rh
incompatibility between the mother and the fetus. HDN most frequently occurs when an Rh-
negative mother has a baby with an Rh positive father. When the baby's Rh factor is positive,
like the father's, problems can develop if the baby's red blood cells cross to the Rh-negative
mother. This usually happens at delivery when the placenta detaches. However, it may also
happen anytime blood cells of the two circulations mix, such as during a miscarriage or abortion,
with a fall, or during an invasive prenatal testing procedure. The mother's immune system sees
the baby's Rh positive red blood cells as "foreign." Just as when bacteria invade the body, the
immune system responds by developing antibodies to fight and destroy these foreign cells. The
mother's immune system then keeps the antibodies in case the foreign cells appear again, even in
a future pregnancy. Which what happened in this case. This means that the mother has been Rh
sensitized in the previous miscarriage pregnancies.

3. Evaluate the results of the additional examination.

The results indicate a great damage to the fetus liver due to the high degree of RBCs hemolysis
and the large amount of resulting bilirubin as shown in the placental blood analysis and evident
by the enlarged liver.

4. Does the child need additional examination? If so, which one?

Definitely, the child needs a liver function test to assess the severity of liver damage, he needs a
CBC to assess his anemia level due to the hemolysis and to look for any sign of inflammation.
An ultrasound can be done to measure the level of his hepatomegaly and also evaluate the
situation of his spleen. Amniocentesis can be done to measure the amount of bilirubin in the
amniotic fluid and testing the fetus blood for bilirubin as well. Also something that is not looked
for enough is testing of the baby's umbilical cord blood for blood group, Rh factor, red blood cell
count, and antibodies, although not urgent as the previous test.
5. With what conditions or diseases it is necessary to make a differential diagnosis?
Other etiologies of jaundice and hyperbilirubinemia in the newborn include physiologic
jaundice, prematurity, breast milk, and breastfeeding jaundice, G6PD deficiency, thalassemia,
sepsis, birth trauma, Gilbert's syndrome, and hypothyroidism. The history and physical as well as
simple laboratory evaluation, as described above, can help differentiate these causes.

6. Assign the child treatment.

According to the further analysis and lab test, the treatment should include:
 Blood transfusions (for severe anemia)
 Intravenous fluids (for low blood pressure)
 Phototherapy for reducing the hyperbilirubinemia
 Help for respiratory distress using oxygen, surfactant, or a mechanical breathing machine
 Exchange transfusion to replace the baby's damaged blood with fresh blood.
 Intravenous immunoglobin (IVIG).

Case 2

The boy is 3 days in the ward with a diagnosis of "intestinal bleeding".

Mother is 17 years old. The pregnancy was threatened with termination at 32-34
weeks. Childbirth at 38 weeks, massatila - 2950 g, Apgar score 7 - 8 points.

The condition at birth is moderate due to neurological symptoms. On the 3rd

day there was a single vomiting with traces of blood, ground.

On examination, the condition is moderate due to moderate neurological

symptoms in the form of symptoms of depression. Grounding continues. Total blood
analysis: Hb - 180 g / l, RBC -5.2 T / l, CI 0.94, WBC- 12.7 G / l, Pl.- 310 G / l. The
duration of Duke's bleeding is 2 minutes, the coagulation time of Lee-White blood is
the beginning of 3.5 minutes, the end of 7 minutes.

Task:
1. Your previous diagnosis.
Vitamin K deficiency clotting disorder

2. What is the basis of the identified symptoms?

The unhealing bleeding with long clotting times as the tests have shown, despite normal platelet
count.

3. What factors could contribute to the development of the disease in this case?
Factors include: not receiving vitamin K shot at birth, maternal use of some medications such as
isoniazid to treat seizures, GIT problems not allowing vitamin K absorption

4. Evaluate the results of the additional examination.

Blood test looks fine however dukes bleeding test is a bit long and the same goes for Lee-White
blood coagulation time

5. Does the child need additional examination? If so, which one?

Yes, PT and PTT to accurately assess the severity of clotting, and response to vitamin K
injection
6. With what conditions or diseases it is necessary to make a differential diagnosis?
Hemophilia, DIC, hepatic failure and thrombocytopenia

7. Assign the child treatment.

slow IV infusion of 1-5 mg of vitamin K1