Intravenous immunoglobulin (IVIG) treatment has been reported to decrease requirements for exchange transfusion, phototherapy, and to shorten hospitalization time for patients with Rh hemolytic disease of the newborn(1-3). It was shown that IVIG is also effective in prevention of repeated exchange transfusions when used after the first exchange transfusion(4). Here we report four cases of hemolytic disease in which exchange transfusion was indicated, but the patients were initially treated with IVIG.

Case 1 was a male infant. At birth, the infant did not show marked icterus but mild skin edema and hepatosplenomegaly were noted. The cord blood hemoglobin (Hb) level was 10.3 g/dL, and the total bilirubin level was 4.4 mg/dL. IVIG was administered. Four hours later, the patient’s Hb and total bilirubin levels were 11.2 g/dL and 5.3 mg/dL, respectively.

Table I Summary of the Characteristics and Laboratory Findings for the Four Cases.

Case 2 was a boy. On admission to our hospital at 26 hours after birth, the patient was icteric and his liver was palpable 4 cm below the costal margin. The serum Hb was 12 g/dL, the total bilirubin level was 19 mg/dL. He was given IVIG and phototherapy was initiated. Six hours later, the baby’s Hb level was 13 g/dL and his total bilirubin had dropped to 14 g/dL.

Case 3 was a female. On admission to our hospital 10 hours after birth, the infant was icteric and both her liver and spleen were enlarged. The serum Hb level was 11 g/dL, total bilirubin was 10.5 mg/dL. The baby was given IVIG and started on phototherapy. Four hours later, her Hb level was 11.5 g/dL and her total bilirubin had fallen to 9 mg/dL.

Case 4 was a girl. Physical examination at birth revealed hepatosplenomegaly. She was given phototherapy in the first 24 hours of life. On admission to our hospital at 24 hours after delivery, the patient’s serum Hb was 10 g/dL, and total bilirubin was 18 mg/dL. The baby was given IVIG. Six hours later, her Hb had risen to 12 g/dL, and her total bilirubin level was 16 mg/dL.

The four patients in this report developed hemolytic disease due to Rh-incompatibility. Exchange transfusion was indicated but was withheld, and treatment with 0.5 g/kg IVIG significantly reduced the rate of hemolysis in all cases. Only one of the four patients required subsequent red cell transfusions.

The exact mechanism of action of IVIG in hemolytic disease of newborn is unknown. It is hypothesised that the anti-D sensitised neonatal erythrocytes are destroyed by antibody dependent cellular cytotoxic effects mediated by the Fc receptor on the cells of the reticuloendothelial system. IVIG would occupy the Fc receptor sites, thus competing with the anti-D sensitised neonatal erythro-cytes and preventing hemolysis(5). This mechanism explained the abrupt block in hemolysis and arrest in rising bilirubin levels with adjuvant phototherapy in these four cases, but this observation needs to be validated by other studies as well.

We think that delaying exchange trans-fusion by 4-6 hours, until the results of IVIG treatment are known, may at least partially reduce the need for these transfusions. Another important consideration is that IVIG therapy can be administered quickly. This may gain some valuable time for the patient, as it take may take hours to prepare for an exchange transfusion.

Tarcan Aylin,
Gürakan Berkan,
Department of Pediatrics,
Baskent University Faculty of Medicine,
Turkey.
Correspondence to:
Dr. Aylin Tarcan,
Konutkent 1 Safir sok,
D35/3 Çayyolu Ankara 06530,
Turkey
E-mail: [email protected] 

1. Rübo J, Albrecht K, Lasch P, Laüfkötter E, Leititis J, Marsan D, et al. High-dose intravenous immune globulin therapy for hyperbilirubinemia caused by Rh hemolytic disease. J Pediatr 1992; 121: 93-97.

2. Dagoglu T, Ovali F, Samanci N, Bengisu E. High-dose intravenous immunoglobulin therapy for rhesus hemolytic diseases. J Int Med Res 1995; 23: 264-271.

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4. Aggarwal R, Seth R, Paul VK, Deorari AK. High dose Intravenous Immunoglobulin therapy in the treatment of Rhesus Hemolytic Disease. J Tropical Ped 2002; 48: 116-117.

5. Urbaniak SJ. ADCC (K cell) lysis of human erythrocytes sensitised with Rhesus allo-antibodies. II. Investigation into mechanism of lysis. Br J Haematol 1979; 42: 315-328.