Hyperbilirubinemia

Definition:
Hyperbilirubinemia is excessive accumulation of bilirubin in the blood (normal levels of 5 mg / dl in normal babies) that cause jaundice, yellow color is clearly visible on the skin, mucosa, sclera and urine.


Etiology:
Hyperbilirubinemia can be caused by a variety of circumstances. The most common cause of hemolysis found here is caused by ABO blood group incompatibility or G6PD enzyme deficiency. Hemolysis may also arise because of the bleeding closed (sefal hematoma, bleeding subaponeoratik) or Rh blood group inkompatabilitas. The infection also plays an important role in the occurrence of hyperbilirubinemia: the situation is especially true in patients with sepsis and gastroenteritis. Several other factors are also a cause of hyperbilirubinemia is hypoxia / anoksia, dehydration and acidosis, hypoglycemia and polycythemia.

Pathophysiology
Increased bilirubin levels of the body can occur in some circumstances. Genesis is often found when there is the addition of bilirubin load on liver cells that are too excessive. It can be found when there is increased destruction of erythrocytes, polycythemia, shortened erythrocyte age fetus / infant, increased bilirubin from other sources, or the presence of increased enterohepatic circulation.

Impaired uptake of plasma bilirubin can also cause elevated levels of bilirubin body. This can happen if a Y-protein content is reduced or the state of protein-protein-Y and Z are bound by other anions, for example in infants with acidosis or to hypoxia / anoksia. Other circumstances which show elevated levels of bilirubin are found gagguan if hepatic conjugation (enszim glukoronil transferase deficiency) or infants who suffer from disorders of excretion, such as neonatal hepatitis or bile duct blockage intra / extra hepatic.

In some degree, this bilirubin will be toxic and tissue damage. Toxicity was mainly found in indirect bilirubin that are difficult to dissolve in water but soluble in fat. This property allows the occurrence of pathological effects on brain cells when bilirubin was able to penetrate the blood brain barrier. Abnormalities that occur in the brain called the nucleus jaundice or biliary encephalopathy. Generally considered that the abnormalities in the central nervous sususnan might arise if the indirect bilirubin levels over 20 mg / dl. Easy least bilirubin through the blood brain barrier was not only depends on the high levels of bilirubin, but depends also on the state of their own neonates. Indirect bilirubin will easily through the blood brain barrier in infants if there are circumstances immaturity, low birth weight, hypoxia, hypercarbia, hypoglycemia, and central nervous system disorders resulting from trauma or infection.

Assessment

1. Family history and pregnancy:
- Parents or siblings with neonatal jaundice or liver disease
- Prenatal care
- DM in the mother
- Infections such as toxoplasmosis, spilis, hepatitis, rubella, cytomegalovirus and herves which cross keplasenta transmitted during pregnancy
- Abuse of drugs in the elderly
- Mother with Rh negative and Rh positive father
- History Rh positive transfusion in Rh-negative mother
- History of abortion with the baby's Rh positive
- The drugs during pregnancy, such as sulfonamides, nitrofurantoin and anti-malaria
- Induction of oxytocin during childbirth
- The use of vacuum extraction
- The use of phenobarbital in pregnant 1-2 months before delivery

2. Status of infants at birth:
- Prematurity or small gestational
- Apgar score indicating asphyxia
- Trauma with hematoma or injury
- Neonatal Sepsis, a liquid that smells
- Hepatosplenomegaly

3. Cardiovascular
- General edema, or decreased blood volume, leading to heart failure on hydro fetalis

4. Gastrointestinal
- Oral feeding poor
- Losing weight to 5% for 24 hours caused by low calorie intake
- Hepatosplenomegaly

5. Integumentary
- Jaundice during the first 24 hours (pathological type), after 24 hours of the first (physiologic type) or after 1 month with a given breast milk
- Heat is caused by anemia due to RBC hemolysis

6. Neurologic
- Hipotoni
- Tremor, no moro reflex and sucking reflex, tendon reflexes minimal
- Irritability, elbow flexion, muscle weakness, opistotonis
- Seizures

7. Pulmonary
- Apnu, cyanosis, dyspnea after the incident nuclear jaundice
- Aspiksia, pulmonary effusion

8. Supporting Data
- Blood type and Rh factor in the mother and infant to determine the risk of Incompatibilities, Rh father also checked if Rh negative mothers (test performed during prenatal)
- Amniocentesis with amniotic fluid analysis, Coombs test with negative results indicate an increased titer of anti-D antibodies, bilirubin levels in amniotic fluid increases to more than 0.28 mg / dl had an abnormal value (indicates the need for transfusion in the fetus).
- Coombs test (direct) in cord blood after childbirth, positive when antibodies are formed in infants.
- Coombs test (indirect) in cord blood, positive if the antibody present in maternal blood.
- Serial total bilirubin level, greater than or equal to 0.5 mg / h till 20 mg / dl indicates the risk of exchange transfusion kernikterus and needs depending on the baby's weight and gestational age.
- Direct bilirubin levels, increases in the event of infection or disruption of Rh hemolytic
- Calculate the reticulocyte, an increase in hemolysis
- Hb and HCT
- Total protein, determining the decrease in binding sites
- Calculate the leukocytes, decreased to below 5000/mm3, indicating the occurrence of infection
- Urinalsis, to detect glucose and acetone, pH and urobilinogen, creatinine level