polycythemia definition,c/f and management

1. POLYCYTHEMIA IN NEWBORN
KANCHAN GAWADE

2. Definition
 Polycythemia ( polyglobulia)
 is increased total RBC mass
 Central venous hematocrit > 65%
 the hemoglobin is greater than 22 mg/dL
 Hct initially rises after birth due to placental transfer
of blood and decrease to baseline at 24 hrs
 Hyperviscosity is increased viscosity of the blood
more than 2 SD of mean resulting from
increased numbers of RBCs

3.  Blood viscosity is ratio of shear stress to shear
rate and is dependent on pressure gradient along
the vessel,radius,length of vessel and velocity of
flow of blood.
 Viscosity is directly prop to Hct and plasma
viscosity whereas inversely proportional to
deformability of RBCs
 Relation between Hct and viscosity is linear till
Hct is 60 % after that viscosity increases
exponentially

4. Oxygen delivery vs.
Hematocrit
0
20
40
60
80
100
120
140
160
180
0 20 40 60 80
Hct
OxygenTransport

5. Incidence
 1-5% of term newborns
 It is increased in IUGR, SGA and post term
 Half of these are symptomatic
 Hyperviscosity occurs in 25% of infants with
hematocrit 60-64%
 Hyperviscosity without polycythmia occurs in 1%
(nonpolycythemic hyperviscosity)

6. Pathophysiology
 Clinical signs result from regional effects of
hyperviscosity and from the formation of
microthrombi
 Tissue hypoxia
 Acidosis
 Hypoglycemia
 Organs affected – CNS, kidneys, adrenals,
cardiopulmonary system, GI tract

7. Pathophysiology of
Polycythemia

8. Causes
 Placental red cell transfusion --
-- Delayed cord clamping – at 1 min blood
volume of baby is 80 ml / kg.
-- At 2 min – blood vol of infant is 90 ml/kg
-- In newborn with polycythemia blood
volume
is inversly proportional to birth weight.

9. Causes
 Placental red cell transfusion --
--Holding baby below the mother at delivery
-- Maternal to fetal transfusion – diagnosed with
K-B test
--Twin to twin trasfusion
--forceful uterine contraction before cord
clamping

10. Causes
 Placental insufficiency
--Increased fetal erytropoesis d/t chronic
hypoxia
--SGA and IUGR
--Maternal hypertension like preeclampsia
--Post term
--Mothers with chronic hypoxia
(heart dis ,pulmonary dis)
--Pregnancy at hihg altitude ,maternal smoking

11. Other conditions
 Diabetic mother – raised erythropoiesis
 LGA
 CAH,
 patau syndrome,
 edward syndrome ,
 downs syndrome (PED)
 Maternal use of propranolol
 sepsis

12. Clinical features
 Mostly asymtomatic
 CNS – poor feeding ,lethargy,hypotonia, apnea,
tremers ,jitteriness,seizures, cerebral venous
thrombosis.
 CVS- cynosis, tachypnea, heart murmur, CHF,
cardiomegaly , increased pulmonary vascular
resisance,prominent vascular markings.

13. Clinical features
 RENAL- decreased GFR ,decrease sodium
excretion, renal vein thrombosis, Hematuria ,
proteinurea
 OTHERS – thrombosis ,thrombocytopenia,
poor feeding, decrease in calcium, NEC ,testicular
infracts, priapism, DIC

15. Screening
WHOME TO SCREEN
 IUGR babies
 LGA babies
 Infant of diabetic mother
 Lager of the twins

16. SCREENING
 Not routinly done in all term babies
 high-risk neonates screened at 2 hours of age
 If Hematocrit value >65% at 2 hours of age
 repeat screening at 12 and 24 hours.

17. SCREENIG IS DONE IN ALL SYMPTOMATIC
CASES
If HCT more than 65%
Then again at 12 & 24 hrs
High risk infants
Screened at 2 hrs of life

18. Diagnosis
 Central venous hematocrit > 65%
 ALWAYS draw a central venous sample if the
capillary hematocrit is > 65%
 Warmed capillary hematrocrit > 65% only suggestive
of polycythemia
 BLOOD VISCOSITY – may be measured where
facility available

19. Management
 Asymptomatic infants
 HCT 60 -70 % increase fluid intake and repeat
HCT after 4 to 6 hr
 central venous hematocrit >70%
(consider partial exchange transfusion)

20. Management
 Symptomatic infants
with peripheral HCT > 65%
 Partial exchange transfusion is advisable.
 For exchange can use normal saline, 5% albumin, or
FFP
 Volume exchanged =
(Weight (kg) x blood volume) x (observed hct -
desired hct)
/observed hct
Blood volume is 80-90 ml/kg in term and 90-100 ml/kg
in pre term
 In exchange blood from umbilical vein and normal saline
infused in peripheral vein

21. Polycythemia
Asymtomatic
Hct <70
Give addit
fluid @ 20 MKD
Hct >70
Partial
exc.transfusion
Symptomatic
Hct >65
Partial
exc.transfusion

22. AIIMS PROTOCOL
 SYMTOMATIC – Partial exchange
transfusion(PET)
 ASYMTOMATIC-
1. Hct >75% - transfusion
2. Hct 75 – 70 % - extra fluid alliquote @20 mkd
3. Hct <70 % - monitor Hct
 The Cochrane review – with exchange
transfusion there
is no difference in morbidity of patient

23. Other labs to check
 Serum glucose
 Hypoglycemia is common with polycythemia
 Serum bilirubin
 Increased bili due to increased RBC turnover
 Serum sodium, BUN, urine specific gravity
 Usually high if baby is deyhdrated
 Blood gas to rule-out inadequate oxygenation
as cause of symptoms
 Platelets, as thyrombocytopenia can be present
 Serum calcium b/c hypocalcemia can be seen

24. Prognosis
 Increased risk of GI disorders and NEC with
partial exchange transfusion (PET)
 PET is controversial!
 Infants with asymptomatic polycythemia have an
increased risk for neurologic sequelae.