A Green-Colored Neonate

A male infant is born at 39 weeks’ gestational age to a 36-year-old woman. This is her second pregnancy and she has a healthy daughter at home with the same partner. This pregnancy has been complicated by advanced maternal age and anti-c antibodies in her serum that cause her indirect Coombs test result to be positive. Her blood type is O Rhesus factor positive and she has antibodies to rubella; she is negative for human immunodeficiency virus (HIV) type 1 and 2 antibodies, hepatitis B surface antigen, and rapid plasma reagin; and she is not colonized with group B Streptococcus . She is followed by the maternal fetal medicine obstetricians. Prenatal ultrasonography reveals a middle cerebral artery velocity of 1.37 multiples of median 3 days before the delivery. She does not require any per umbilical blood sampling or fetal intrauterine red cell transfusion during the pregnancy. The father’s blood type is O with Cc antigens on his red cells. The infant is born via the vaginal route, requires no resuscitation in the delivery room, and has Apgar scores of 9 and 9 at 1 and 5 minutes of age, respectively. His birthweight is 3,200 g (38th percentile), length is 50 cm (45th percentile), and occipitofrontal circumference is 34 cm (36th percentile). His physical examination findings are normal and he has no pallor, jaundice, edema, or hepatosplenomegaly. His blood type is O Rhesus factor positive and direct Coombs test result is positive. Anti-c antibody is eluted from his serum. He is noted to have jaundice at 6 hours of age and his total bilirubin is 12.4 mg/dL (212 µmol/L). Intense phototherapy is started as per the American Academy of Pediatrics (AAP) guidelines. His bilirubin increases progressively and reaches 14 mg/dL (239 µmol/L) at 24 hours of age despite the intense phototherapy …