|Year : 2019 | Volume
| Issue : 1 | Page : 51-54
Association of ABO neo-maternal incompatibility and neonatal jaundice in Nguru, Nigeria
Hadiza Tikau Idi1, Sani Awwalu2, Usman Abjah3, Ahmadu Aliyu Babadoko2, Abdulaziz Hassan2, Baba M Mohammed4, Ishaku Ibrahim4
1 Department of Haematology, Federal Medical Centre, Nguru, Yobe State, Nigeria
2 Department of Haematology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Haematology, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
4 Department of Paediatrics, Federal Medical Centre, Nguru, Yobe State, Nigeria
|Date of Web Publication||5-Mar-2019|
Dr. Hadiza Tikau Idi
Department of Haematology, Federal Medical Centre, Nguru, Yobe State
Source of Support: None, Conflict of Interest: None
Context: ABO blood group antigens are inherited and specific to an individual. In pregnancy, active immunisation occurs when the foetus is of a different ABO blood group from the mother and may result in neonatal jaundice (NNJ). Therefore, monitoring and evaluation of mothers at booking and throughout pregnancy and the postpartum period is important in management. Aim: The aim of this study is to determine the prevalence of neo-maternal ABO blood group incompatibility and to assess any relationship with NNJ among mother-neonate pairs in Nguru, Northeast Nigeria. Subjects and Methods: This was a cross-sectional descriptive study of 200 pregnant women at Federal Medical Centre, Nguru, Yobe State, Nigeria in 2015. ABO blood group antigens of both mothers and neonates were determined while direct Coomb's test (DCT), full blood counts, reticulocyte counts and bilirubin assays were determined for neonates of ABO-incompatible neo-maternal pairs. Data were analysed using SPSS Version 20, and a P ≤ 0.05 was considered as statistically significant. Results: The mean age of the mothers was 26.4 ± 6.2 years. Blood group O had the highest frequencies among mothers and neonates 58% and 57.5%, respectively. Although 28% of the mother-neonate pairs were ABO blood group incompatible, only 12.5% of the incompatible neonates had a positive cord blood DCT, and only 6% of the neonates developed jaundice. There was a strong and positive association between ABO neo-maternal blood group incompatibility and NNJ P = 0.007 (Fishers' exact test), odds ratio = 8.52, 95% confidence interval; 1.665, 43.591. Conclusion: ABO neo-maternal incompatibility is common, and it has a strong positive association with NNJ. There is a need for routine neonatal ABO screening, especially where jaundice exists.
Keywords: ABO blood group, ABO neo-maternal incompatibility, neonatal jaundice
|How to cite this article:|
Idi HT, Awwalu S, Abjah U, Babadoko AA, Hassan A, Mohammed BM, Ibrahim I. Association of ABO neo-maternal incompatibility and neonatal jaundice in Nguru, Nigeria. Niger J Basic Clin Sci 2019;16:51-4
|How to cite this URL:|
Idi HT, Awwalu S, Abjah U, Babadoko AA, Hassan A, Mohammed BM, Ibrahim I. Association of ABO neo-maternal incompatibility and neonatal jaundice in Nguru, Nigeria. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 Oct 23];16:51-4. Available from: http://www.njbcs.net/text.asp?2019/16/1/51/253407
| Introduction|| |
Neonatal jaundice (NNJ) is a paediatric emergency associated with morbidity and mortality if not treated early. It affects about 1.1 million neonates globally with the majority being in sub-Saharan Africa and South Asia. It is the fourth cause of neonatal admission after prematurity, birth asphyxia and sepsis in Nigeria. When severe, it may affect the brain more especially the basal ganglia resulting in either acute or chronic bilirubin encephalopathy. About 50% of term and 60%–80% of pre-term babies develop jaundice in their 1st week of life which resolves spontaneously after 1–2 weeks. Jaundice can be physiological when it occurs on the 2nd–4th day of neonatal life. However, jaundice occurring in the first 24 h of life is most likely pathological.,
The most common cause of NNJ is the haemolytic disease of the foetus and new-born due to either rhesus (Rh), ABO or other minor blood group incompatibilities. Intrauterine viral or bacterial infections, malaria and glucose-6-phosphate dehydrogenase deficiency, have also been implicated. Jaundice becomes clinically visible when serum bilirubin levels exceed 5 mg/dl and affected neonates produce bilirubin at the rate of 6–8 mg/kg/day.
In pregnancy, active immunisation may occur during labour when the foetus is of a different ABO blood group from the mother and NNJ may result due to this incompatibility., This is not a common cause of NNJ relative to Rh incompatibility. The incidence of ABO incompatibility is higher in people of African lineage than among Caucasians., ABO haemolytic disease of the new-born is caused by immune Immunoglobulin G maternal antibodies which can cross the placental barrier. The presence of A and B antigens on cells and body fluids results in the high titre maternal immune antibodies being neutralised, hence babies do not develop jaundice in most cases. However, those developing jaundice do so when sensitised red cells are destroyed by macrophages in foetal spleen resulting to hyperbilirubinaemia. This most often results in mild jaundice but no anaemia. However, few cases may be severe to require either phototherapy or exchange transfusion.
Neonates are usually examined by Kramer's dermal staining of bilirubin which gives a guide to the level of bilirubin. The dermal staining in the new-born occurs in a cephalocaudal direction under bright daylight. Clinical examination is, however, unreliable more especially in blacks. Therefore, laboratory investigations are the best assessment tools in assessing jaundice.
Published data on the relationship between ABO incompatibility and NNJ are not readily available, especially from the North East of Nigeria. Therefore monitoring and evaluation of any intervention program will be defective due to the absence of baseline data. This study was to determine the prevalence of mother-neonate ABO blood group incompatibility and to assess any relationship with NNJ.
| Subjects and Methods|| |
This was a cross-sectional descriptive study of 200 pregnant women and their neonates at the delivery suite of Federal Medical Centre, Nguru, Yobe State, Nigeria in 2015. Institutional Ethical and Scientific approval was obtained. All mothers (booked and un-booked) and their neonates (full term or preterm), who presented to the labour ward for delivery irrespective of the mode of delivery, were enrolled as they present after obtaining consent. Mothers with haemoglobin SS, positive serology for HIV, hepatitis B virus, and venereal disease research laboratory and those with a history of fever were excluded from the study. Maternal peripheral blood and neonatal cord blood were obtained; complete blood count was determined by automated haematology analyser (Shenzhen Mindray B-3200), ABO blood groups for mother-neonate pairs were determined using tile method and cord blood serum bilirubin was also analysed by Cobt c111 spectrophotometer auto-analyser. Thereafter neonates that were ABO incompatible with their mothers had cord blood direct Coomb's test (DCT) performed. Post-treatment haematological variables were also determined for neonates who developed jaundice.
Data were analysed using SPSS version 20.0. Chigaco (SPSS Inc., Chicago, IL, USA). Qualitative variables were reported as percentages and charts. Quantitative variables were summarised as means ± standard deviations. Fishers' exact test (FET) was used to determine relationship between neo-maternal ABO incompatibility and development of NNJ. The risk of developing NNJ was assessed using odds ratio (OR) with 95% confidence limits. Median pre-and post-treatment haematological variables and bilirubin levels of neonates who developed jaundice were compared using Wilcoxon–Signed Rank Tests. Levels of significance were set at P ≤ 0.05.
| Results|| |
The mean age of the mothers was 26.4 ± 6.2 years. Blood Group O had the highest frequencies among mothers and neonates; 116 (58.0%) and 115 (57.5%), respectively [Figure 1]. Only 8/200 (4.0%) of the neonates developed jaundice. Although 56 (28.0%) of the mother-neonate pairs were ABO blood group incompatible, only 7/56 (12.5%) of the incompatible neonates had positive cord blood DCT results. More neonates with neo-maternal ABO incompatibility developed jaundice compared to those who were compatible (6/8 [75.0%] vs. 2/8 [25.0%], Z = 3.266, P = 0.001).
|Figure 1: Maternal and neonatal ABO blood Groups among 200 mother-neonate pairs|
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There was a strong and positive association between ABO neo-maternal blood group incompatibility and NNJ P = 0.007 (FET), OR = 8.52, 95% confidence interval; 1.665, 43.591. The eight neonates who developed jaundice were subsequently followed up. One neonate died while on admission and three left against medical advice. Only four were followed up to discharge, their bilirubin levels and haematological parameters were compared before and after treatment [Table 1] and [Table 2].
|Table 1: Comparison of bilirubin levels of jaundiced neonates before and after treatment (n=4)|
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|Table 2: Comparison of haematological parameters of jaundiced neonates before and after treatment (n=4)|
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| Discussion|| |
The neonatal blood group in this study showed a predominance of blood Group O whereas AB is the least. This is comparable to the studies done by Nwauche et al. (2012) and Omotade et al. in Ibadan. Similarly, the mothers showed a predominance of blood Group O similar to the reports of Babadoko et al. in Nguru; it is also similar to the study by Nwauche et al. (2012) in Port Harcourt. The similarities with other studies may be attributed to the same nationality.
Twenty-eight percent of neo-maternal pairs were ABO incompatible which was higher than the findings by Ella et al. in Zaria but lower than the reports of Oseni andAkomolafe in Osogbo. Although, blood Group O was the most frequent among both the mothers and neonates; however, ABO incompatibility still exist as was seen in other parts of the country. Thus, NNJ occurs in neonates that were incompatible with their mothers.
DCT positivity was seen in 12.5% of the ABO-incompatible neonates and this was lower than the finding of Ella et al. in Zaria. This suggests that even neonates that were incompatible may not have a positive DCT or NNJ due to reasons other than ABO incompatibility like differences in the titre of the immunoglobulins, the epitopes on the red cell membrane and the sensitivity of the AHG reagents.
There was a positive association between ABO incompatibility and the presence of NNJ in this study which was similar to the works of Zabeen et al. in Bangladesh. This showed that the risk assessment of ABO incompatibility is higher. Also, the OR ‘a measure of association between an exposure and an outcome’ showed there was a strong positive association between NNJ and ABO incompatibility.
Although our data suggest that there was no statistically significant difference between the levels of unconjugated bilirubin before or after treatment, this should be interpreted with caution as it may be due to the small sample size involved. This is because point estimates reveal reductions in all pre-treatment bilirubin fractions following treatment with clinical improvement of neonates. This buttresses the need to differentiate statistically significance from clinical significance and the importance of evaluating measures of effect sizes. The formation of unconjugated bilirubin in ABO incompatibility is not as severe as in Rhesus incompatibility. Thus, it rarely causes kernicterus.
Similarly, the lack of significant difference between the pack cell volume before and after treatment is similar to the finding of Patel et al. in Vadodara India. Anaemia is not a common finding in ABO incompatibility as compared to Rhesus incompatibility as the level of haemolysis is mild because ABO antigens are present on the tissues other than the RBCs, allowing neutralisation and also ABO antigens are not fully developed on neonatal RBCs.
Small sample size, as well as testing for other blood group types (Rhesus, Kell and Kidd) which are also responsible for NNJ. Further studies should include larger sample size as well as use of all compatible neonates as control.
| Conclusion|| |
ABO neo-maternal incompatibility is common and it has a strong, positive association with NNJ. There is a need for instituting preventive measures by a policy requiring mandatory screening of all mother-neonate pair as well as health education of mothers on the dangers of NNJ.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhutani VK, Zipursky A, Blencowe H, Khanna R, Sgro M, Ebbesen F, et al.
Neonatal hyperbilirubinemia and rhesus disease of the newborn: Incidence and impairment estimates for 2010 at regional and global levels. Pediatr Res 2013;74 Suppl 1:86-100.
Olusanya BO, Ezeaka CV, Ajayi-Obe EK, Mukhtar-Yola M, Ofovwe GE. Paediatricians' perspectives on global health priorities for newborn care in a developing country: A national survey from Nigeria. BMC Int Health Hum Rights 2012;12:9.
Martin CR, Cloherty JP. Neonatal hyperbilirubinaemia. In: Cloherty JP, Eichenwald EC, Stark AR, editors. Manual of Neonatal Care. 6th
ed. Wolters Kluwer Lippincott Williams and Wilkins; 2008. p. 182-212.
Luke AJ, Paul W. Neonatal jaundice. Am Fam Physician 2012;85:824-85.
Kavitha VK, Bollipo S, Varahala AM. Clinical study of pathological jaundice in newborns. IOSR J Dent Med Sci 2016;15:58-63.
Porter ML, Dennis BL. Hyperbilirubinemia in the term newborn. Am Fam Physician 2002;65:599-606.
Annagur A, Altunhan H, Konak M, Koc H, Örs R. Role of subgroup incompatibility in newborn jaundice requiring exchange transfusion. Eur J Gen Med 2014;11:66-70.
Ogundare O, Omale O. The management of neonatal jaundice in Nigeria. IFEMED J 2008;14:18-23.
Shinton NK. Blood groups. In: Desk Reference for Haematology. 2nd
ed. Bocan Raton: CRC; 1998. p. 128-30.
Klein HG, Anstee DJ. Blood group system. In: Mollison's Blood Transfusion in Clinical Medicine. 12th
ed. USA: Wiley Blackwell; 2014. p. 136-66.
Vos GH, Adhikari M, Coovadia HM. A study of ABO incompatibility and neonatal jaundice in black South African newborn infants. Transfusion 1981;21:744-9.
Bucher KA, Patterson AM Jr., Elston RC, Jones CA, Kirkman HN Jr. Racial difference in incidence of ABO hemolytic disease. Am J Public Health 1976;66:854-8.
Akanmu AS, Oyedeji OA, Adeyemo TA, Ogbenna AA. Estimating the risk of ABO hemolytic disease of the newborn in Lagos. J Blood Transfus 2015;2015:560738.
Hadley AG. Laboratory assays for predicting the severity of haemolytic disease of the fetus and newborn. Transpl Immunol 2002;10:191-8.
Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Am J Dis Child 1969;118:454-8.
Cashore WJ. Bilirubin and jaundice in the micropremie. Clin Perinatol 2000;27:171-9, vii.
Nwauche CA, Eneh AU, Pughikumo CO, Chijioke-Nwauche IN. ABO and Rhesus blood groups in mothers and their newborns in Port Harcourt, Nigeria. Port Harcourt Med J 2012;4:455-59.
Omotade OO, Adeyemo AA, Kayode CM, Falade SL, Ikpeme S. Gene frequencies of ABO and Rh (D) blood group alleles in a healthy infant population in Ibadan, Nigeria. West Afr J Med 1999;18:294-7.
Babadoko AA, Takai IU, Kawuwa MB. Distribution of ABO, Rh D blood groups and haemoglobin phenotypes among ante-natal clinic attendees in federal medical centre Nguru, Nigeria. Borno Med J 2014;11:86-90.
Ella EE, Garba SA, Ogala WN. ABO incompatibility and its role in neonatal jaundice in Zaria, Kaduna state of Nigeria. Int J Eng Sci 2013;2:17-23.
Oseni BS, Akomolafe OF. The frequency of ABO blood group maternal-fetal incompatibility, maternal iso-agglutinins, and immune agglutinins quantitation in Osogbo, Osun state, South-West of Nigeria. Asian J Transfus Sci 2011;5:46-8.
] [Full text]
Zabeen B, Nahar J, Nabi N, Baki A, Tayyeb S, Azad K, et al
. Risk factors and outcome of neonatal jaundice in a tertiary hospital. Ibrahim Med Coll J 2010;4:70-3.
Szumilas M. Explaining odds ratios. J Can Acad Child Adolesc Psychiatry 2010;19:227-9.
Page P. Beyond statistical significance: Clinical interpretation of rehabilitation research literature. Int J Sports Phys Ther 2014;9:726-36.
Patel AS, Desai DA, Patel AR. Association of ABO and Rh incompatibility with neonatal hyperbilirubinaemia. Int J Reprod Contracept Obstet Gynaecol 2017;6:1368-75.
Reid EM, Westboff CM. Human blood group antigens. In: Hoffman R, Benz EJ, Shattil SJ, Furie B, Silberstein LE, McGlave P, et al.
, editors. Hematology Basic Principles and Practice. 5th
ed. Philadelphia: Elsevier; 2009. p. 2163-77.
[Table 1], [Table 2]