13                                                Trauma and                                                bleeding      ...
242   NEWBORN CARE13-4 What is caput?                                 13-7 What is a subaponeurotic                       ...
TRAUMA AND BLEEDING        243which has been lost into the subaponeurotic             to the normal side. Fortunately the ...
244   NEWBORN CAREspontaneous recovery if the arm is not better       If the humerus or femur is fractured, the limbby 6 w...
TRAUMA AND BLEEDING     245BLEEDING                                          umbilical vein and arteries. Bleeding from a ...
246   NEWBORN CARE13-20 When does abnormal platelet                      4. Disseminated intravascular coagulopathyfunctio...
TRAUMA AND BLEEDING         247 Haemorrhagic disease is caused by low concen-            Haemorrhagic disease usually pres...
248   NEWBORN CARE1. Maternal blood, swallowed at delivery or         and is a lifelong problem. However, individual   fro...
TRAUMA AND BLEEDING     249had a subaponeurotic haemorrhage. This was             2. How would you confirm this diagnosis?...
250   NEWBORN CARE3. What is thrombocytopaenia?                      2. Why does this infant have blood in the            ...
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Newborn Care: Trauma and bleeding


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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Newborn Care: Trauma and bleeding

  1. 1. 13 Trauma and bleeding 13-2 Which infants are at an increased risk Objectives of trauma? 1. Preterm infants who have delicate tissues When you have completed this unit you that are easily damaged. 2. Large infants where there is difficulty should be able to: delivering the head and shoulders. • Name the important forms of trauma 3. Malpresentations, e.g. breech delivery that occur during delivery. where the infant has to be manipulated. • Manage infants with birth trauma. 4. Forceps or vacuum delivery where traction • Name the important causes of bleeding. or suction is applied to the head. • Understand haemorrhagic disease of the 5. Unassisted deliveries where the infant may fall after delivery. newborn. 6. Precipitous deliveries when the infant is • Treat the different causes of bleeding. delivered very fast. 13-3 What are the major types of trauma?TRAUMA 1. Caput (i.e. caput succedaneum) 2. Cephalhaematoma 3. Subaponeurotic haemorrhage13-1 What is trauma? 4. Facial palsy 5. Brachial palsyTrauma means damage or injury. During 6. Bruisingdelivery the infant may be damaged by 7. Fracturespressure on the body as it passes down the 8. Lacerationsbirth canal. The infant may also be damagedby the person conducting the delivery, eitherduring a vaginal birth or caesarean section.
  2. 2. 242 NEWBORN CARE13-4 What is caput? 13-7 What is a subaponeurotic haemorrhage?Caput (or caput succedaneum) is oedemaof the presenting part caused by pressure on A subaponeurotic haemorrhage is a collectionthe presenting part during a vaginal delivery. of blood under the aponeurosis of the scalp.It is usually of no clinical importance and The aponeurosis is a sheet of fibrous tissuedisappears during the first 48 hours after connecting the muscle over the forehead withdelivery. You should explain this to the parents that over the occiput (back of the head). Theespecially if the caput is large. subaponeurotic space is large and can contain a lot of blood. Fortunately a subaponeuroticMore severe caput, often with damage to the haemorrhage is not common.skin, may be present on the infant’s head after avacuum extraction (when it is called a chignon) A subaponeurotic haemorrhage results fromor on the buttocks after a breech delivery. The trauma to blood vessels crossing this spacecaput is caused by the suction cup. from the skull to the overlying scalp. It is almost always caused by a forceps delivery or13-5 What is a cephalhaematoma? vacuum extraction.A cephalhaematoma is a collection of blood A subaponeurotic haemorrhage presents with:under the periosteum of the parietal bone of 1. Shock and pallor. Shock presents withthe skull. It is common, may be unilateral or tachycardia, a low blood pressure andbilateral, and appears within hours of delivery delayed capillary filling time. Withinas a soft, fluctuant swelling on the side of the 30 minutes of the haemorrhage thehead. A cephalhaematoma never extends haemoglobin and packed cell volume startbeyond the edges of the bone and, therefore, to fall rapidly. There is a great danger thatnever crosses suture lines. the infant will die of blood loss.Bleeding is caused by damage to capillaries 2. A boggy (soft) swelling of the head. As theunder the periosteum of the parietal bone. This subaponeurotic space crosses the sutures,may occur during a normal vaginal delivery, the blood is able to track over the wholebut is more common with cephalopelvic head. A subaponeurotic haemorrhagedisproportion or an assisted delivery. gives a diffuse swelling of the head in contrast to the localised swelling in a13-6 What is the treatment of a cephal- cephalhaematoma. Sutures usually are nothaematoma? palpable. The amount of blood under the scalp is far more than is estimated. WithinCephalhaematomas are usually small and need 48 hours the blood tracks between theno treatment. The reabsorption of blood may fibres of the occipital and frontal musclescause jaundice, however, which may require causing bruising behind the ears, along thetreatment by phototherapy. It can take up posterior hair line and around the eyes.to 3 months before the cephalhaematomadisappears. A bony ridge may form at theedge of the healing haematoma but this also It is important to differentiate between caput,eventually disappears without treatment. a cephalhaematoma and a subaponeuroticNever aspirate or drain a cephalhaematoma as haemorrhagethis may introduce infection. 13-8 What is the treatment of a Never aspirate or drain a cephalhaematoma subaponeurotic haemorrhage? The treatment consists of transfusing the infant with blood to replace the blood
  3. 3. TRAUMA AND BLEEDING 243which has been lost into the subaponeurotic to the normal side. Fortunately the weaknessspace. While waiting for the donor blood usually recovers spontaneously in a few daysto arrive, transfuse with normal saline (or or weeks and no treatment is needed.stabilised human serum or fresh frozenplasma or Haemaccel) to correct the shock.Give Konakion 1 mg by intramuscular or Facial palsies usually recover spontaneouslyintravenous injection to assist the liver to within days of deliveryreplace clotting factors which are lost with thehaemorrhage. Infants with a subaponeurotic NOTE The asymmetric crying face syndromehaemorrhage may die of blood loss if there is mimics a facial palsy but the infant is able to close the eye on the weak side. Usually the weaknessany delay in resuscitation and treatment. of the lower face is only seen when the infant cries and the mouth is pulled to the normal side. A subaponeurotic haemorrhage requires The weakness is due to congenital absence of the muscles on one side of the face and does not emergency treatment to replace the blood loss improve with time. NOTE A subdural haemorrhage is a collection of 13-10 What is a brachial palsy? blood in the subdural space. Severe moulding and marked traction on the head during delivery Brachial palsy (or Erb’s palsy) is usually causes a tear in the large veins and sinuses caused by excessive traction on the head and draining blood from the brain. These vessels neck during a difficult vertex delivery. The then bleed into the subdural space. A subdural infant is usually large and born at term with haemorrhage is uncommon and is usually seen after a difficult forceps delivery or vacuum difficulty in delivering the shoulders. Brachial extraction in a woman with cephalopelvic palsy may also complicate a poorly managed disproportion. This form of trauma should be breech delivery. By stretching the neck, prevented. the brachial plexus of nerves in the neck is stretched and damaged. A subdural haemorrhage presents with: • Shock and/or anaemia due to blood loss. Immediately after birth it is noticed that the • Neurological signs due to brain compression, infant does not move one arm due to weakness e.g. convulsions, apnoea, a dilated pupil or a at the shoulder and elbow. The arm is fully depressed level of consciousness. extended, rotated inwards and held beside • A full fontanelle and splayed sutures due to the body (the ‘porter’s tip’ position). The raised intracranial pressure. infant will not be able to flex the elbow but The infant may die of blood loss or brain movement of the hand and fingers is normal. compression. Management consists of replacing The infant also has a markedly asymmetrical the blood lost and transferring the infant urgently Moro reflex. Unless there is an associated to the nearest level 2 or 3 hospital where the fracture, there is no tenderness, pain or subdural haemorrhage may need to be drained. swelling of the arm.13-9 What is a facial palsy? 13-11 What is the treatment of brachialFacial palsy is muscle weakness of one side of palsy?the face due to trauma to the facial nerve. This Usually the weakness is much better by a weekis almost always caused by pressure from a and full movement and power return. If theforceps blade on the facial nerve just in front nerves in the neck have been torn, however,of the ear. the infant will still not be able to flex theThe affected side of the face droops and the elbow after a week and some weakness willinfant is unable to close the eye tightly on that remain permanently. There is little hope ofside. When crying the mouth is pulled across
  4. 4. 244 NEWBORN CAREspontaneous recovery if the arm is not better If the humerus or femur is fractured, the limbby 6 weeks. is usually swollen, tender and bruised. If the clavicle or humerus is broken, the infant willSplints and keeping the arm above the head not move that arm, and will cry if the arm iswill not help recovery. Every time the nappy moved. An asymmetric Moro reflex due to ais changed, however, the arm should be put fractured clavicle or humerus may mimic athrough a full range of movements to prevent brachial palsy. Fracture of a femur may causethe development of contractures. If weakness shock due to blood loss. The clinical diagnosisremains by 6 weeks, the infant must be of a fracture can be confirmed by X-ray.referred to a level 3 hospital for investigationand possible surgery to repair the torn nerves. Rarely the skull can be indented in a depressed fracture after a difficult delivery. A brachial palsy may result in permanent 13-14 How are fractures treated? weakness of the arm Fracture of the clavicle needs no treatment and heals well.13-12 What causes bruising? With fracture of the humerus, the upper armBruising is common after difficult deliveries, should be immobilised to lessen the pain byespecially breech delivery in a preterm infant. strapping it to the side of the chest.The bruise is due to bleeding into the skin and A fractured femur is treated with gallowsmuscle caused by the rupture of small blood traction after the infant has been resuscitated.vessels. A tight umbilical cord around the Paracetamol (Panado syrup 2.5 ml everyneck commonly causes severe congestion and 6 hours) can be given in all fractures if painbruising of the face. relief is needed.The bruise is present at or within hours of If a depressed fracture of the skull does notdelivery and usually does not cause problems correct spontaneously in 24 hours, or if thealthough the area may be tender for a few infant develops neurological signs, it must bedays. The bruise fades after a week or two and referred urgently for the skull to be surgicallyneeds no treatment. The reabsorbed blood elevated.is converted into bilirubin and may causejaundice, requiring phototherapy. 13-15 What is the management ofBruising appearing after the first day is serious lacerations?and suggests a bleeding problem or intentional(non-accidental) trauma (battering). Lacerations (cuts) are usually made during a caesarean section, when the infant is cut by mistake as the uterus is opened. The infant13-13 What fractures are seen in the may also bleed after a fetal scalp blood samplenewborn infant? has been taken. Small cuts can be held closedThe clavicle is the bone most commonly with strapping. Large cuts must be sutured asfractured at birth. Fractures of the humerus, soon as possible after delivery.femur and skull are fortunately uncommon.Fractures are usually caused by very difficultand traumatic deliveries. The fracture may beheard during delivery and bony crepitus (agrating feeling) may be felt after birth whenthe bone is palpated.
  5. 5. TRAUMA AND BLEEDING 245BLEEDING umbilical vein and arteries. Bleeding from a large blood vessel can be stopped by clamping or tying off the vessel. A transfusion of whole13-16 What makes a wound stop bleeding? blood is needed if the infant is shocked. After a big haemorrhage the packed cell volume andNormally bleeding from a wound stops haemoglobin concentration may be normal forspontaneously because: the first hour, before starting to fall. Therefore,1. Arteries go into spasm. This is particularly a normal haemoglobin concentration or important when bleeding is from the packed cell volume immediately after a big umbilical cord or severe lacerations. bleed does not exclude severe blood loss.2. The blood contains platelets which pack together and block the hole in the blood 13-19 When does a decreased number of vessel. platelets cause bleeding?3. The blood contains clotting factors which The number of platelets in the blood is are proteins that cause the blood to clot. normally more than 100 000 per mm3 Many of these proteins are produced in (100 × 109/l) in both preterm and term the liver and most require vitamin K for infants. A platelet concentration of less than their production. Each clotting factor acts 100 000 per mm3 is abnormal and is called on another in a chain reaction to produce thrombocytopaenia (thrombocyte = platelet; the clot. If one or more is missing then the paenia = deficiency in the blood). blood will not clot.13-17 What causes excessive bleeding? Thrombocytopaenia is an abnormally lowThere are 4 main causes of excessive bleeding number of platelets in the bloodin a newborn infant: A decreased number of platelets may be1. Damage to blood vessels caused by:2. Too few platelets3. Abnormal function of platelets 1. A decreased production of platelets by the4. Decreased amount of clotting factors bone marrow as a result of: • Septicaemia. • Syphilis.13-18 When does damage to the blood 2. An increased destruction of platelets in thevessels cause bleeding? blood stream as a result of:Damage to capillaries causes bruising or • Disseminated intravascular coagulationpurpura (small pin-point pink or blue bruises) (DIC), when problems such as hypoxia,especially in preterm infants that have very hypothermia or infection cause excessivedelicate vessels in the skin. The bruising is clotting within the blood stream. Thisusually localised and due to rough handling at results in the using up (consumption)delivery or a tight umbilical cord around the of large numbers of platelets and largeneck. amounts of clotting factors.The commonest site of haemorrhage from a • Antibodies against platelets crossinglarge vessel is the umbilical cord. If the cord the placenta from the mother to theclamp or ligature slips after the cord is cut, fetus (immune thrombocytopaenia).a serious or fatal haemorrhage may result.Haemorrhage from the umbilical vein can Infection may cause both a decreased productionalso occur if an intravenous umbilical vein and an increased destruction of plateletscatheter is displaced. If the cord snaps at resulting in thrombocytopaeniadelivery, haemorrhage occurs from both the
  6. 6. 246 NEWBORN CARE13-20 When does abnormal platelet 4. Disseminated intravascular coagulopathyfunction cause bleeding? (DIC) 5. Liver diseaseThe concentration of platelets may be normal 6. Maternal warfarin treatment. If thisbut their function may be abnormal. The anticoagulant drug is given to the mothercommonest cause of decreased platelet during pregnancy it will cross the placentafunction is the maternal ingestion of large and may cause severe bleeding in theamounts of aspirin during pregnancy. Aspirin infant at delivery. Heparin does not crosscrosses the placenta and may interfere with the the placenta and therefore does not causenormal function of the fetal platelets. These bleeding in the fetus and newborn infant.infants commonly are born with generalisedpurpura. Therefore, aspirin should not be Except for disseminated intravascular coagulo-taken in large amounts during pregnancy. pathy (DIC), all these conditions result in NOTE Rarely, an inherited abnormality of platelets a decreased production of clotting factors can cause abnormal platelet function. by the liver. In disseminated intravascular coagulopathy (DIC) clotting factors are used up (consumed) too fast.13-21 How does a decreased plateletnumber or abnormal platelet function Bleeding due to decreased clotting factors ispresent clinically? managed by removing the cause, if possible, and replacing the missing factor with freshBoth too few platelets and an abnormality frozen plasma and/or factor 8 concentrate.of platelet function present with generalisedpurpura (also called petechiae). This is a rashof small pink or blue spots over the whole 13-23 What is haemorrhagic disease of thebody, but especially areas where the infant is newborn?handled, such as the arms and legs. Localised Vitamin K is needed by the liver to producepurpura (purpura of one part of the body most of the clotting factors. In adults, bacteriaonly) is usually due to trauma (e.g. cord in the gut produce vitamin K while vitamin Karound the neck). is also available in a balanced adult diet.Bleeding due to a decreased number of platelets The fetus receives very little vitamin K fromis managed by removing the cause, if possible, the mother during pregnancy and there isand transfusing packs of platelet, if indicated. not much vitamin K in breast milk. At birth the infant, therefore, has very limited stores Generalised purpura suggests too few platelets or of vitamin K for the production of clotting factors. If added vitamin K is not given at abnormal platelet function birth, the levels of some clotting factors start to fall and usually reach their lowest levels by day13-22 When does a decrease in clotting 4. Thereafter they slowly return to normal asfactors cause bleeding? bacteria colonise the gut and start to produce vitamin K. The fall in clotting factors is mostThere are many separate clotting factors marked and the recovery slowest in preterm(numbered 1 to 13) which are needed for the infants as they have an immature liver.normal clotting of blood. If one or more ismissing, blood will not clot normally. Clotting Between days 4 and 7 after delivery, when thefactors are decreased in: concentration of some clotting factors is low, the infant may present with bleeding. This is1. Haemorrhagic disease of the newborn called haemorrhagic disease of the newborn.2. Inherited deficiencies of a single clotting factor, e.g. haemophilia3. Preterm infants
  7. 7. TRAUMA AND BLEEDING 247 Haemorrhagic disease is caused by low concen- Haemorrhagic disease usually presents with trations of some clotting factors during the first vomiting blood or blood in the stool week of life A decrease in clotting factors due to causes other than haemorrhagic disease also presents13-24 How do you prevent haemorrhagic with generalised bruising, bleeding intodisease of the newborn? internal organs and bleeding from lacerations,All newborn infants must be given 1 mg needle prick sites or operation sites.vitamin K1 (0.5ml Konakion) within 1 hourafter birth by intramuscular injection. This is Bleeding from many sites is usually caused by abest given into the lateral thigh (not into the decreased concentration of one or more clottingbuttock). It is preferable to give the vitamin K factorswhen the infant reaches the nursery or wardrather than in the labour ward or theatre as NOTE Infants with haemorrhagic disease of thethe infant may in error be given oxytocin or newborn have an abnormal partial thromboplastinergometrine prescribed for the mother. Giving time (PTT) and an abnormal prothrombin time ororal Konakion is not recommended as it has international normalised ratio (INR).to be repeated once or more, especially inbreastfed infants, to be effective. 13-26 How should you treat haemorrhagic disease of the newborn? All babies must be given intramuscular Konakion 1. Give the infant 1 mg vitamin K1 (Konakion) after delivery intravenously. An intramuscular injection may cause a haematoma. NOTE Giving Konakion will not cause or aggravate 2. Start an intravenous infusion with neonatal jaundice. Ergometrine, given in error to Neonatalyte. the infant, causes severe apnoea lasting a few days. 3. Treat shock with fresh frozen plasma, stabilised human serum, Haemaccel or13-25 What is the clinical presentation of normal saline. Fresh frozen plasma ishaemorrhagic disease of the newborn? preferable as it will also replace some of theInfants with haemorrhagic disease present missing clotting factors.with bleeding in the first week of life. At the 4. Cross-match fresh blood and transfuse ifstart of the bleeding they appear generally well necessary.but later they may become pale and shocked 5. Monitor the haemoglobin concentration ordue to blood loss. They will not have received packed cell volume.vitamin K1 at delivery. Bleeding usually starts 6. Watch for further bleeding or signs ofin the gut and presents as haematemesis shock.(vomiting blood) or melaena (blood in the NOTE Konakion will correct the deficit of clottingstools). Infants may also develop generalised factors in haemorrhagic disease within a fewbruising or bleed from the umbilical cord. hours. Fresh frozen plasma will replace factors 2,They may also bleed excessively from a heel 7, 9, 10 (vitamin K-dependent factors) which areprick, needle punctures or circumcision very low in haemorrhagic disease.wound. If the delivery was traumatic, theymay develop a subaponeurotic haemorrhage. 13-27 How do you differentiate betweenRarely they may bleed into the brain. Unless maternal and infant blood?treated, they may die of blood loss. Vomited blood or blood in the stool may be either:
  8. 8. 248 NEWBORN CARE1. Maternal blood, swallowed at delivery or and is a lifelong problem. However, individual from a bleeding nipple. bleeds can be controlled with factor 8 infusions.2. Infant blood from a bleed in the mouth, NOTE Infants with haemophilia have an abnormal upper airways or gastrointestinal tract. partial thromboplastin time (PTT) but a normalIt is essential to differentiate between maternal prothrombin time or international normalised ratio (INR).and infant blood as swallowed maternal bloodcauses few problems while bleeding by theinfant requires urgent management. 13-29 How can you diagnose the cause of the bleeding?Fresh (red) blood can be identified as maternalor infant blood using the Apt (sodium 1. The cause of bleeding due to a severehydroxide) test: laceration is obvious. 2. Localised bruising or purpura is usually1. Add the sample of blood (vomitus or stool) due to trauma. to some water in a test tube and shake 3. Infants with generalised purpura well to give a pink solution. If the solution who are otherwise well usually have is brown and not pink the Apt cannot be thrombocytopaenia, or abnormal platelet done. To do an Apt test the blood must be function due to maternal aspirin ingestion. red and the solution pink. 4. Infants with generalised purpura, blood in2. If the pink solution is not clear, centrifuge the stools or vomitus, or excessive bleeding the sample and then transfer the clear from the cord, lacerations, needle prick solution to another test tube. sites or operation wounds usually have a3. Add 5 ml of the pink solution to 1 ml of deficiency of one or more clotting factors. 1% sodium hydroxide in a second test tube 5. Bleeding in infants who have not been and shake well. given routine Konakion is probably due to4. Examine the colour of the mixture at haemorrhagic disease. 1 minute. If the mixture stays pink then the 6. Generally sick infants usually have a blood is from the infant. However, if the disseminated intravascular coagulopathy as mixture turns brown the blood is maternal. the cause of bleeding. If the test is read after 1 minute an 7. Male infants who are generally well but incorrect result may be obtained as infant bleed excessively may have haemophilia. blood will eventually also turn brown. All infants with bleeding problems must be13-28 What is haemophilia? referred urgently to a level 2 or 3 hospital for measurements of platelets and clotting factors.Occasionally infants bleed because they aremissing a single clotting factor. This is aninherited abnormality and the commonest CASE STUDY 1example is haemophilia, caused by the lack ofclotting factor 8. Haemophilia is seen almost An infant is delivered by difficult vacuumalways in boys and may present as excessive extraction. A few hours after delivery the infantbleeding after circumcision. A family history appears pale, has a heart rate of 180 beats perof bleeding in boys may be obtained. Girls minute and is noticed to have a boggy swellingare usually not affected by haemophilia but of the whole scalp. The packed cell volume andmay pass the clotting abnormality on to their haemoglobin concentration are low.sons. Factor 8 deficiency cannot be correctedby giving vitamin K. All these infants must bereferred urgently to a haematology unit in a 1. What is the diagnosis?level 2 or 3 hospital where they can be treated The swelling of the whole scalp, the tachycardiawith factor 8. Haemophilia cannot be cured and the anaemia indicate that the infant has
  9. 9. TRAUMA AND BLEEDING 249had a subaponeurotic haemorrhage. This was 2. How would you confirm this diagnosis?probably caused by the vacuum extraction. The infant will have weakness of the shoulder and elbow and will be unable to lift her arm2. Why is this not a cephalhaematoma? off the bed or flex the elbow against gravity.A cephalhaematoma is usually unilateral and Movement and power in the hand will benever extends over the whole scalp. Neither is normal. Unless there is a fracture, there shouldit large enough to cause anaemia and shock. be no tenderness.3. What is the correct treatment of a 3. Will the weakness recover?subaponeurotic haemorrhage? Usually the weakness is much improved by aA subaponeurotic haemorrhage is an week. If not, then full recovery may not takeemergency as the infant can easily die of blood place.loss. Blood must be cross-matched urgently.While waiting for the blood, give fresh frozen 4. What is the correct treatment?plasma, stabilised human serum or Haemaccel No treatment is needed. However, the motherto treat the shock. Fresh frozen plasma will should flex the elbow and shoulder a few timesalso provide clotting factors. Also give 1 mg a day to prevent contractures developing. Ifof Konakion to help the liver to replace the weakness remains at 6 weeks the infant mustclotting factors lost in the haemorrhage. be referred to a level 3 hospital for further investigation.4. Why are infants with a subaponeurotichaemorrhage not always anaemic? 5. Why do infants bruise easily?The haemoglobin concentration and packed Because the small blood vessels in the skincell volume may remain normal immediately are easily damaged. Bruising is usually due toafter the onset of a large subaponeurotic a difficult delivery. A tight cord around thehaemorrhage as it may take an hour for the neck may cause bruising of the face. Extensivetests to become abnormal. Therefore a normal bruising may result in jaundice.Hb or PCV does not excude a bleed.CASE STUDY 2 CASE STUDY 3 A term infant is noticed to have extensiveAn infant weighing 5 kg is born in a level 2 purpura over the trunk and limbs soon after ahospital. The shoulders are delivered with normal vaginal delivery. The infant is clinicallygreat difficulty. After birth it is noticed that the well and breastfeeds.infant does not move her right arm much andhas an asymmetrical Moro reflex. The infant isalso very bruised. 1. What is purpura? Purpura (or petechiae) are small pink or blue1. What do you think is wrong with her arm? spots (bruises) cause by bleeding into the skin.She probably has a brachial palsy (Erb’s palsy)caused by excessive downward traction on 2. What are the causes of generalisedthe neck during the difficult delivery of the purpura?shoulders. Either too few platelets or an abnormality of the platelets.
  10. 10. 250 NEWBORN CARE3. What is thrombocytopaenia? 2. Why does this infant have blood in the vomitus and stool?Too few platelets, i.e. less than 100 000 permm3 (100 × 109/l). The infant probably has haemorrhagic disease of the newborn due to lack of vitamin K. This4. What are the common causes of is commoner in preterm than in term infants.thrombocytopaenia in a newborn infant? 3. What is the correct management of this1. A decreased production of platelets, e.g. infant? septicaemia or syphilis2. An increased destruction of platelets, e.g. Start an intravenous infusion with Neonatalyte DIC or maternal antibodies against the and cross-match blood urgently. Give 1 mg infant’s platelets Konakion intravenously. An intramuscular injection may cause a large haematoma. Give5. What is a common cause of abnormal fresh frozen plasma followed by blood if theplatelet function? infant is shocked.Aspirin which the mother has taken during 4. Is haemorrhagic disease of the newbornthe last few days of pregnancy. preventable? Yes. This condition should not be seen ifCASE STUDY 4 Konakion is given routinely after birth to all infants.A preterm infant weighing 1500 g is born athome. The infant is transferred to hospital but 5. What diagnosis must always be thoughtthe staff forget to give Konakion. On day 5 the of if bleeding presents in a male infant whoinfant passes a lot of fresh blood in the stool, is otherwise well?has a small dark brown vomit and appears pale. Haemophilia.1. What is Konakion? 6. What is a common cause of bleeding in aVitamin K1. This must be given to all infants severely ill infant?after birth by intramuscular injection into Disseminated intravascular coagulopathythe thigh. Oral vitamin K should not be used (DIC) due to septicaemia or hypoxia.as it has to be given repeatedly, especially inbreastfed infants.