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Predicting Significant Hyperbilirubinemia in ABO Incompatibility: Is Cord Direct Antiglobulin Test Useful?


To study the prevalence of direct antiglobulin test (DAT) positivity and outcomes in babies with ABO incompatibility and the role of DAT in predicting need for phototherapy. This was an analytical retrospective cohort study conducted in a tertiary care hospital in South India. DAT was performed routinely in cord blood of all neonates born to O positive mothers. The case records of neonates ≥ 35 weeks of gestation and birth weight > 2000 gm with ABO setting born between January 2019 and December 2020 were reviewed and outcomes were analyzed. Among 2484 live births, there were 426 eligible ABO incompatible births and DAT was positive in 68(15.9%). DAT positive neonates had significantly higher peak mean bilirubin [16.02 mg/dL vs. 13.68 mg/dL, p = 0.00], need for phototherapy in first 24 h [23(33.8%) vs. 32(8.9%), p = 0.00], need for exchange transfusion [2(2.9%) vs. 0(0%), p = 0.025] and immunoglobulin [6(8.8%) vs. 0(0%), p = 0.00]. Cord DAT showed 29.9% sensitivity, 96.9% specificity, 89.7% positive predictive value and 60.1% negative predictive value for predicting need for phototherapy. DAT positivity occurs in a significant proportion of ABO incompatible births and a “selective” cord blood DAT in neonates born to O positive mothers can identify those neonates at risk of significant hyperbilirubinemia with high diagnostic accuracy.

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  1. Zahed Pasha Y, Alizadeh-Tabari S, Zahed Pasha E, Zamani M (2020) Etiology and therapeutic management of neonatal jaundice in Iran: a systematic review and meta-analysis. World J Pediatr 16:480–493

    Article  Google Scholar 

  2. Herschel M, Karrison T, Wen M, Caldarelli L, Baron B (2002) Isoimmunization is unlikely to be the cause of hemolysis in ABO-incompatible but direct antiglobulin test-negative neonates. Pediatrics 110:127–130

    Article  Google Scholar 

  3. Shahid R, Graba S (2012) Outcome and cost analysis of implementing selective Coombs testing in the newborn nursery. J Perinatol 32:966–969

    CAS  Article  Google Scholar 

  4. Dinesh D (2005) Review of positive direct antiglobulin tests found on cord blood sampling. J Paediatr Child Health 41:504–507

    Article  Google Scholar 

  5. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia (2004) Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 114:297–316

    Article  Google Scholar 

  6. Bhat YR, Kumar CGP (2012) Morbidity of ABO haemolytic disease in the newborn. Paediatr Int Child Health 32:93–96

    CAS  Article  Google Scholar 

  7. Das S, Shastry S, Chakravarthy PK, Baliga PB (2021) Clinical implication of immunohaematological tests in ABO haemolytic disease of newborn: revisiting an old disease. Transfus Med 31:30–35

    Article  Google Scholar 

  8. Shash HA, Alkhater SA (2021) Maternal blood group and routine direct antiglobulin testing in neonates: is there a role for selective neonatal testing? Children (Basel) 8:426

    Google Scholar 

  9. Alwar V, Devi AMS, Sitalakshmi S, Karuna RK (2012) Evaluation of the use of gel card system for assessment of direct coombs test: weighing the pros and cons. Indian J Hematol Blood Transfus 28:15–18

    Article  Google Scholar 

  10. Courtney JE, Vincent JL, Indrikovs AJ (2001) Tube and column agglutination technology for autocontrol testing. Immunohematology 17:50–52

    CAS  Article  Google Scholar 

  11. Mullon CJ, Langer R (1987) Determination of conjugated and total bilirubin in serum of neonates, with use of bilirubin oxidase. Clin Chem 33:1822–1825

    CAS  Article  Google Scholar 

  12. Madan A, Huntsinger K, Burgos A, Benitz WE (2004) Readmission for newborn jaundice: the value of the Coombs’ test in predicting the need for phototherapy. Clin Pediatr (Phila) 43:63–68

    Article  Google Scholar 

  13. Mir SE, van der Geest BAM, Been JV (2019) Management of neonatal jaundice in low- and lower-middle-income countries. BMJ Paediatr Open 3:e000408

    Article  Google Scholar 

  14. Toy PT, Reid ME, Papenfus L, Yeap HH, Black D (1988) Prevalence of ABO maternal-infant incompatibility in Asians, Blacks. Hisp Cauc Vox Sang 54:181–183

    CAS  Article  Google Scholar 

  15. Matteocci A, De Rosa A, Buffone E, Pierelli L (2019) Retrospective analysis of HDFN due to ABO incompatibility in a single institution over 6 years. Transfus Med 29:197–201

    CAS  Article  Google Scholar 

  16. Bel Comos J, Ribera Crusafont A, Natal Pujol A, Coroleu Lletget W, Pujol Posch N (1991) Prats Viñas [Value of the Coombs test in ABO incompatibility]. J An Esp Pediatr 35:248–250

    CAS  Google Scholar 

  17. Özgönenel B, Kukreja G, O’Malley B, Bluth MH (2015) Neonatal BO incompatibility is associated with a positive cord blood direct antiglobulin test in infants of black ethnicity. J Pediatr Hematol Oncol 37:e453-457

    Article  Google Scholar 

  18. Novaretti MCZ, Jens E, Pagliarini T, Bonifacio SL, Dorlhiac-Llacer PE, Chamone DAF (2004) Comparison of conventional tube test technique and gel microcolumn assay for direct antiglobulin test: a large study. J Clin Lab Anal 18:255–258

    CAS  Article  Google Scholar 

  19. Jaiprakash M, Gupta PK, Kumar H (2006) Role of gel based technique for Coomb’s test. Indian J Pathol Microbiol 49:370–372

    CAS  PubMed  Google Scholar 

  20. Valsami S, Politou M, Boutsikou Τ, Briana D, Papatesta M, Malamitsi-Puchner A (2015) Importance of direct antiglobulin test (DAT) in cord blood: causes of DAT (+) in a cohort study. Pediatr Neonatol 56:256–260

    Article  Google Scholar 

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Correspondence to Sethuraman Giridhar.

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Chowdhary, S., Devi, U. & Giridhar, S. Predicting Significant Hyperbilirubinemia in ABO Incompatibility: Is Cord Direct Antiglobulin Test Useful?. Indian J Hematol Blood Transfus 38, 591–595 (2022).

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  • Direct antiglobulin test
  • Neonatal jaundice
  • Phototherapy
  • Exchange transfusion