Bleeding neonate

Dr. Abhijeet

Etiology

A.Deficiency of clotting factors:1.Transitory deficiencies-Deficiency of vitamin K dependent

C.F- II, VII, IX, X. Deficiency of anticoagulant proteins

C & S.

Causes:a. Total parenteral nutrition or antibioticsb. Lack of administration of vitamin K .c. Drug intake in pregnancy eg.i. Phenytoin, Phenobarbital, Salicylates . (Interferes with the synthesis of vit. K

dependent c.f. ) ii. Calmodulin compounds : interfare

with synthesis of vit K dependeat C.F.

• The incidence among babies born to mothers on these drugs have varied between 6-12%*.

In a recent series on children born to mothers on anticonvulsants, abnormal PT was documented in 14 out of 105 babies (13%) , no overt bleeding was observed*.

2. Disturbances of clotting- Related to DIC due to infection, shock,

anoxia, NEC, renal vein thrombosis, use of IV canula.

3. Inherited abnormalities of C.F. a. X-Linked recessive diseases- i. Hemophilia-A : Factor VIII deficiency. ii. Hemophilia-B : Factor IX deficiency.

b. Autosomal dominant diseases: i. Von Willebrand disease – Deficiency of

VWF which is a carrier of factor VIII & as a platelet aggregation agent.

c. Autosomal recessive diseases: i. Severe factor VII & factor XIII deficiency –

intracranial hemorrhage in neonates ii. Factor XI deficiency – unpredictable bleeding during

surgery/trauma.

iii. VWD Type III

B. Platelet problems:1. Qualitative disorders:- Glanzman’s thrombasthenia.- Bernard-Soulier syndrome- Platelet type VWD

2. Quantitive disorders:- Immune thrombocytipenia- Matrnal Preeclampsia, HELLP syndrome

or severe uteroplacental insuffuciency.- DIC due to infection or asphyxia.- Inherited marrow failure syndromes :

Fanconi anemia & congenital amegakaryocytic thrombocytopenia

- Congenital leukemia- Inherited thrombocytopenia

syndromes : gray platelet syndrome- Macrothrombocytopenias : May-Hegglin

syndr.- Platelet consumption in clots/ vascular

disorders eg. Vascular malformations, NEC.

C. Vascular origin:- Pulmonary haemorrhage- A-V malformations- CNS haemorrhage- Hemangiomas.

Diagnostic workup

A.History- Family h/o bleeding disorders- Maternal medications- Pregnancy & birth history- Maternal h/o infant with bleeding disorder- Any medications, procedures, anomalies in

infant

B. Examination:First diagnose whether the infant is Sick or Well1. Sick infant: - DIC - Bacterial/ viral infections.2. Well infant:- Vit K deficiency- Isolated C.F. deficiencies- Immune thrombocytopenia- Maternal blood in infant’s GIT.

3. Patchiae, ecchymosis, mucosal bleeding: Platelet problem

4. Large bruises: DIC, C.F deficiencies, liver diseases

5. Enlarged spleen : Possible congenital infections or erythroblastosis.

6. Jaundice : Sepsis, liver diseases, resorption of large hematoma.

C. Laboratory tests: 1. Apt test : - To rule out maternal blood in infant’s

GIT - Done in otherwise well infant with only

GI bleeding.2. PBS : - DIC- fragmented RBCs - Congenital macrothrombocytopenias –

large platelets.

3. PT 4. APTT 5. D-Dimer assays: Measure fibrin

degradation products in DIC & Liver diseases causing defective clearing of fibrin split products.

6. Specific factor assays & Von Willebrand assay: For patients with + ve family h/o.

Laboratory findings Laboratory Studies Likely Diagnosis Other useful tests

Platelets PT APTT

SICK INFANTS DIC, sepsis, hypoxia, acidosis, cold

stressFibrinogen, FDP, Sepsis screen

N N

Platelet consumption(NEC, Renal vein thrombosis, marrow infiltration, Sepsis)

LFT, Albumin

N Liver disease

N N NCompromised vascular integrity(hypoxia, prematurity, acidosis)

Laboratory Studies Likely Diagnosis Other useful tests

Platelets PT APTT

HEALTHY INFANTS

N NImmune thrombocytopeniaBone marrow hypoplasia

Maternal platelet count,Platelet antigen typing, Bone marrow, Fibrinogen, FDP, Factor VII & IX assays

N Vitamin K Deficiency

N N Heriditory C.F. deficiencies B.T.

N N NBleeding d/t local factors, Plt function anomalies,Factor XIII deficiency(rare)

Platelet aggregometryUrea clot solubility

Treatment Of Bleeding

A. Inj Vitamin K1 (Aquaminophyton)- 1 mg IV or IM if not given at birth.- Infants on TPN- Infants on Antibiotics > 2 weeks: at

least 0.5mg Vit K weekly.- Preferred rather than FFP for prolonged

PT & PTT, FFP should be reserved for emergencies.

B. FFP:- 10ml/kg IV for active bleeding - Repeated 8-12 hrly as needed.- Replaces C.F. immediately.C. Platelets:- 1 Unit of platelet raises count by

50,000-10,000/mm3.- Platelet count slowly decreases if stores

3-5 days.

D. Fresh whole blood:- 10ml/kg- Can be repeated after 6-8 hrs as needed.E. Clotting factor concetrates- Severe VWD : - VWF containing plasma derived factor VIII

concetrate.- Known deficiency of factor VIII or IX :

Recombinent DNA derived factor VIII and IX concetrate

F. Disorders due to problems other than hemostatic proteins :

- Rule out the underlying possibilities- eg. Infection, Liver rupture, catheter, NEC.

G. T/t of specific disorders :1. DIC :- Treat the underlying cause i.e. sepsis, NEC- Make sure that Vit K1 has been given.

- Platelets/ FFP to keep platelet counts > 50,000/ml and to stop bleeding.

- If bleeding persists, i. Exchange transfusion with fresh whole blood

/Packed RBC/Platelets/FFP ii. Continuous transfusion with platelets, packed

RBCs or FFP as needed. iii. For hypofibrinogenemia : Cryoprecipitate

(10ml/kg)

2. Haemorrhagic disease of newborn- Incidance is 1:200 neonates (Not given Vit-K).- For active bleeding : 10ml/kg FFP & Inj

Vitamin K 1mg IV .- If mother is on t/t with Phenytoin, primidone, Methoximide or Phenobarbital, the infant

may be deficient in vit K .Inj Vit K 10mg IM 24 hours before delivery . Newborn is monitored for signs of bleeding,

PT, APTT.

3. Delayed Hemorrhagic disease of newborn:

- Occurs at 4-12 weeks of age- Not very common in infants who received Vit

K at birth. - Exclusively breast feeding infant- Infant on t/t with broad spectrum antibiotics- Infant with malabsorption T/t: Vitamin K1- 1mg/week orally for first 3

months of life.

Referances

*. Sutor AH, von Kries R, Marlies Conelissen EA, Mcninch, Andrew M. VitaminK Deficiency Bleeding (VKDB) in infancy.Thrombosis and Haemostasis 1999;81: 456-461.

* Narang A. Hemorrhagic Disease of Newborn. Indian Pediatr 1989, 26:523-524. 4. von Kries R, Hanawa Y. Neonatal vitamin K prophylaxis.Thrombosis and Haemostasis 1993, 69:293-295.

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