hemorrhagic disease of newborn

1. Intracranial Hemorrhage
of the Newborn
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2. Aims
• To be familiar with etiology and
pathogenesis
• To understand the clinical signs
and main points of diagnosis and
treatment
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3. Etiology
• Delivery Trauma.
This condition occurs mostly in fullterm
infants.
• Anoxia.
This condition occurs mostly in
premature infants.
• Deficiency of vitamin K.
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4. Pathology
• Subdural hemorrhage (SDH)
• Subarachnoid hemorrhage (SAH)
• Intracerebral hemorrhage (ICH)
• Periventricular or Intraventricular
hemorrhage (PVH / IVH)
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5. • In the premature infant,
it originates in the
capillaries of the
germinal matrix,
usually over the body
of the caudate nucleus.
It lead to
periventricular or
intraventricular
hemorrhage(PVH/IVH).
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6. • With increasing
maturation the
germinal matrix
involutes, so that
in the term infant
the choroid plexus
becomes the
principal site of the
hemorrhage.
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7. Choroid Plexus
• It produces the cerebrospinal fluid (CSF)
which is found within the ventricles of the
brain and in the subarachnoid space
around the brain and spinal cord.
• It is comprised of a rich capillary bed,
piamater, and choroid epithelial cells.
• It is located in certain parts of the
ventricular system of the brain.
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8. The predisposition of
the premature infant
to PVH / IVH may in
part be due to the
presence of a highly
vascularized germinal
matrix, to which a
major portion of the
blood supply of the
immature cerebrum is
directed.
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9. PVH-IVH
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10. • Furthermore,
the capillaries of the premature infant
have less basement membrane than
those of the mature brain.
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11. Finally,
abnormalities in the autoregulation of
arterioles in premature infants and
distressed term infants impair their
response to hypoxia and hypercarbia
and thus permit the transmission of
arterial pressure fluctuations to the
fragile periventricular capillary bed.
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12. On the basis of CT or ultrasonography,
periventricular and intraventricular
hemorrhages have been classified into
four grades of severity.
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13. • Ⅰ Periventricular hemorrhage with
minimal or no intraventricular
hemorrhage.
• Ⅱ Periventricular hemorrhage into
ventricle, but lateral ventricle isn’t
enlarge.
• Ⅲ Intraventricular hemorrhage with
both lateral ventricle enlarge.
• Ⅳ Intraventricular hemorrhage and
accompany hematoma in the
substance of brain.
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14. I PVH with minimal or no IVH.
Four Grades of Severity
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15. II PVH into ventricle, but lateral ventricle
isn’t enlarge.
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16. III IVH with both lateral ventricle enlarge.
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17. IV IVH and accompany hematoma in the
substance of brain.
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18. Intracerebral Hemorrhage
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19. Clinical Manifestations
• It may go clinically unnoted in more than
half of the infants affected.
• In the remainder, there may be a sudden,
sometimes catastrophic deterioration.
• highlighted by alterations in
consciousness.
• Deterioration may continue over several
hours then stop, only to resume hours or
days later.
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20. • Conscious disturbance (意识障碍)
Excitement
Lethargy (嗜睡)
Coma (昏迷)
• Abnormal eye movements
Gaze (凝视)
Poor light reflex (对光反射迟钝)
• Respiratory irregularities
Apnea (呼吸暂停)
Cyanosis (发绀)
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21. • Increased intracranial pressure
Enlarging head circumference
Bulging fontanel.
(The presence of a full fontanel, which is
noted in a significant proportion of infants.
It may be the consequence of
Massive intracranial hemorrhage,
Cerebral edema
Acute subdural hemorrhage. )
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22. • Muscular tension（肌张力）
Increase---decrease
• Primary reflex（原始反射）
Weak or absent
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23. Diagnosis
1.History of Trauma and anoxia
and clinical signs give the clues
of diagnosis.
2.Ultrasonography and CT
scanning can diagnose the
presence and the extent of an
intracranial hemorrhage.
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24. 3.Spinal puncture
Performed only in the
presence of convulsion or
bulging anterior fontanel
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25. Treatment
1.Support Therapy
–Oxygen
–Quiet environment of the nursery
–Keep the body temperature, blood
pressure
–Fluid controlled in 50-60ml/kg/d
–Caloric
–Correct acidosis
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26. 2.Stop bleeding
–Vit k15-10mg im, and fresh blood
or serum 10ml/kg iv drip， once
a day
–Ethamsylate(止血敏), Reptilase(立
止血) etc.
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27. 3.Control Convulsion
Phenobarbital 20mg/kg, If it doesn’t
work, 10mg/kg 1hr after. Maintains
dosage is 5mg/kg.d.
4.Decrease Brain Pressure
Furosemide(呋塞米)0.5~1mg/kg/time
Dexamethasone0.5~1.0mg/kg/d
Mannitol 0.25~0.5/kg per 4~6hr
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28. 5.Waterhead(hydrocephlaus)
• Acetazolamide( 乙 酰 唑 胺 ) reduce the
fluid produce. 50-100mg/kg/d tid or qid
• For subdural hemorrhage. Serial lumber
puncture, ventricular puncture can be
done.
6.Surgery Treatment
Control hydrocephalus:
Ventricle to abdomen shunt.
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29. Prognosis
• It is not easy to determine. It mainly
determines according to the bleeding
causes, amount, position, and other
factors.
Generally for full term infant, small
amount, acute bleeding, the prognosis
is better and for premature, chronic,
huge bleeding and in the substance of
brain, it is worse.
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30. • Recovery is likely when
symptoms clear up within a
week.
• Survivors of catastrophic
symptoms in the first 48 hours
may recover completely.
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31. • Sequelae are likely to occur
–When irritability or poor
sucking response persists
beyond 1 or 2 weeks
–Cerebral palsy or mental
retardation
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32. Thanks!
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