Bleeding neonate

of 28 /28
Bleeding neonate Dr. Abhijeet

Embed Size (px)

Transcript of Bleeding neonate

Page 1: Bleeding neonate

Bleeding neonate

Dr. Abhijeet

Page 2: Bleeding neonate


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.

Page 3: Bleeding neonate

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.

Page 4: Bleeding neonate

• 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*.

Page 5: Bleeding neonate

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.

Page 6: Bleeding neonate

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


Page 7: Bleeding neonate

iii. VWD Type III

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

Page 8: Bleeding neonate

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

Page 9: Bleeding neonate

- Congenital leukemia- Inherited thrombocytopenia

syndromes : gray platelet syndrome- Macrothrombocytopenias : May-Hegglin

syndr.- Platelet consumption in clots/ vascular

disorders eg. Vascular malformations, NEC.

Page 10: Bleeding neonate

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

Page 11: Bleeding neonate

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


Page 12: Bleeding neonate

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.

Page 13: Bleeding neonate

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.

Page 14: Bleeding neonate

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.

Page 15: Bleeding neonate

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.

Page 16: Bleeding neonate
Page 17: Bleeding neonate
Page 18: Bleeding neonate

Laboratory findings Laboratory Studies Likely Diagnosis Other useful tests

Platelets PT APTT

SICK INFANTS DIC, sepsis, hypoxia, acidosis, cold

stressFibrinogen, FDP, Sepsis screen


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

LFT, Albumin

N Liver disease

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

Page 19: Bleeding neonate

Laboratory Studies Likely Diagnosis Other useful tests

Platelets PT APTT


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

Page 20: Bleeding neonate

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.

Page 21: Bleeding neonate

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.

Page 22: Bleeding neonate

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

Page 23: Bleeding neonate

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.

Page 24: Bleeding neonate

- 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


Page 25: Bleeding neonate

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,


Page 26: Bleeding neonate

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.

Page 27: Bleeding neonate


*. 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.

Page 28: Bleeding neonate

Thank You…