Bleeding neonate

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  • 1. Bleeding neonateDr. Abhijeet

2. EtiologyA.Deficiency of clotting factors:1.Transitory deficiencies-Deficiency of vitamin K dependentC.F- II, VII, IX, X. Deficiency of anticoagulant proteinsC & S. 3. 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. 4. The incidence among babies born to motherson these drugs have varied between 6-12%*. In a recent series on children born to motherson anticonvulsants, abnormal PT wasdocumented in 14 out of 105 babies (13%), no overt bleeding was observed*. 5. 2. Disturbances of clotting- Related to DIC due to infection, shock,anoxia, NEC, renal vein thrombosis, useof 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. 6. b. Autosomal dominant diseases:i. Von Willebrand disease Deficiency ofVWF which is a carrier of factor VIII & as aplatelet aggregation agent.c. Autosomal recessive diseases:i. Severe factor VII & factor XIII deficiency intracranial hemorrhage in neonates ii. Factor XI deficiency unpredictable bleeding duringsurgery/trauma. 7. iii. VWD Type IIIB. Platelet problems:1. Qualitative disorders:- Glanzmans thrombasthenia.- Bernard-Soulier syndrome- Platelet type VWD 8. 2. Quantitive disorders:- Immune thrombocytipenia- Matrnal Preeclampsia, HELLP syndromeor severe uteroplacental insuffuciency.- DIC due to infection or asphyxia.- Inherited marrow failure syndromes :Fanconi anemia & congenitalamegakaryocytic thrombocytopenia 9. - Congenital leukemia- Inherited thrombocytopenia syndromes: gray platelet syndrome- Macrothrombocytopenias : May-Hegglin syndr.- Platelet consumption in clots/ vasculardisorders eg. Vascular malformations,NEC. 10. C. Vascular origin:- Pulmonary haemorrhage- A-V malformations- CNS haemorrhage- Hemangiomas. 11. Diagnostic workupA.History- Family h/o bleeding disorders- Maternal medications- Pregnancy & birth history- Maternal h/o infant with bleeding disorder- Any medications, procedures, anomalies ininfant 12. 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 infants GIT. 13. 3. Patchiae, ecchymosis, mucosalbleeding: Platelet problem4. Large bruises: DIC, C.F deficiencies,liver diseases5. Enlarged spleen : Possible congenitalinfections or erythroblastosis.6. Jaundice : Sepsis, liver diseases,resorption of large hematoma. 14. C. Laboratory tests:1. Apt test : - To rule out maternal blood in infants GIT - Done in otherwise well infant with only GI bleeding.2. PBS :- DIC- fragmented RBCs- Congenital macrothrombocytopenias large platelets. 15. 3. PT4. APTT5. D-Dimer assays: Measure fibrindegradation products in DIC & Liverdiseases causing defective clearing offibrin split products.6. Specific factor assays & VonWillebrand assay: For patients with +ve family h/o. 16. Laboratory findings Laboratory StudiesLikely Diagnosis Other useful testsPlatelets PT APTTSICK INFANTS DIC, sepsis, hypoxia, acidosis, cold Fibrinogen, FDP, Sepsis stress screen Platelet consumption LFT, Albumin (NEC, Renal vein thrombosis, N N marrow infiltration, Sepsis) Liver disease N Compromised vascular integrity N N N (hypoxia, prematurity, acidosis) 17. Laboratory StudiesLikely Diagnosis Other useful testsPlatelets PT APTTHEALTHY INFANTS Immune thrombocytopeniaMaternal platelet count, N N Bone marrow hypoplasia Platelet antigen typing,Bone marrow, Fibrinogen,FDP, Factor VII & IX assays N Vitamin K Deficiency N N Heriditory C.F. deficiencies B.T. Bleeding d/t local factors,Platelet aggregometry N N N Plt function anomalies,Urea clot solubility Factor XIII deficiency(rare) 18. Treatment Of BleedingA. 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. 19. 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 by50,000-10,000/mm3.- Platelet count slowly decreases if stores3-5 days. 20. 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 VIIIconcetrate.- Known deficiency of factor VIII or IX :Recombinent DNA derived factor VIII andIX concetrate 21. 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. 22. - Platelets/ FFP to keep platelet counts > 50,000/mland to stop bleeding.- If bleeding persists, i. Exchange transfusion with fresh whole blood/Packed RBC/Platelets/FFPii. Continuous transfusion with platelets, packedRBCs or FFP as needed. iii. For hypofibrinogenemia : Cryoprecipitate(10ml/kg) 23. 2. Haemorrhagic disease of newborn- Incidance is 1:200 neonates (Not given Vit-K).- For active bleeding : 10ml/kg FFP & InjVitamin K 1mg IV .- If mother is on t/t with Phenytoin, primidone, Methoximide or Phenobarbital, the infantmay be deficient in vit K .Inj Vit K 10mg IM 24 hours before delivery . Newborn is monitored for signs of bleeding,PT, APTT. 24. 3. Delayed Hemorrhagic disease ofnewborn:- Occurs at 4-12 weeks of age- Not very common in infants who received VitK 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 3months of life. 25. Referances*. Sutor AH, von Kries R, Marlies Conelissen EA,Mcninch, Andrew M. VitaminK DeficiencyBleeding (VKDB) in infancy.Thrombosis andHaemostasis 1999;81: 456-461.* Narang A. Hemorrhagic Disease of Newborn.Indian Pediatr 1989, 26:523-524. 4. von KriesR, Hanawa Y. Neonatal vitamin Kprophylaxis.Thrombosis and Haemostasis1993, 69:293-295. 26. Thank You