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Transcript of 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.
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
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.
A.History- Family h/o bleeding disorders- Maternal medications- Pregnancy & birth history- Maternal h/o infant with bleeding disorder- Any medications, procedures, anomalies in
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 –
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
Platelet consumption(NEC, Renal vein thrombosis, marrow infiltration, Sepsis)
N Liver disease
N N NCompromised vascular integrity(hypoxia, prematurity, acidosis)
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
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
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
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,
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.
*. 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.