Bleeding neonate
Dr.Sandip Gupta
PGT,PEDIATRICS
B.S.M.C.H.
Introduction
•

Neonates are susceptible to bleeding for
various reasons
Immaturity of the haemostatic system
because of q...
Clinical presentation
•

Bleeding in neonates may present with
Oozing from the umbilical stump
Cephalhaematoma
Bruising , ...
Etiology
A.Deficiency of clotting factors:
1.Transitory deficienciesDeficiency of vitamin K dependent
C.F- II, VII, IX, X...
Causes:
a. Total parenteral nutrition or antibiotics
b. Lack of administration of vitamin K .
c. Drug intake in pregnancy
...
• The incidence among babies born to mothers
on these drugs have varied between 6-12%*.
In a recent series on children bor...
2. Disturbances of clotting
- Related to DIC due to
infection, shock, anoxia, NEC, renal vein
thrombosis, use of IV canula...
b. Autosomal dominant diseases:
i. Von Willebrand disease – Deficiency of
VWF which is a carrier of factor VIII & as a
pla...
iii. VWD Type III

B. Platelet problems:
1. Qualitative disorders:

- Glanzman’s thrombasthenia.
- Bernard-Soulier syndrom...
2. Quantitive disorders:
- Immune thrombocytopenia
- Matrnal Preeclampsia, HELLP syndrome
or severe uteroplacental insuffu...
- Congenital leukemia
- Inherited thrombocytopenia syndromes
: gray platelet syndrome
- Macrothrombocytopenias : MayHeggli...
C. Vascular origin:
- Pulmonary haemorrhage
- A-V malformations
- CNS haemorrhage
- Hemangiomas.
Diagnostic workup
• HISTORY: A detailed history and examination
essential in the assessment of bleeding neonate
History in...
B. Examination:
First diagnose whether the infant is Sick or Well
1. Sick infant:
- DIC
- Bacterial/ viral infections.
2. ...
3. Patchiae, ecchymosis, mucosal
bleeding: Platelet problem
4. Large bruises: DIC, C.F
deficiencies, liver diseases
5. Enl...
C. Laboratory tests:
1. Apt test :
- To rule out maternal blood in infant’s
GIT
- Done in otherwise well infant with
only ...
3. PT
4. APTT
5. D-Dimer assays: Measure fibrin
degradation products in DIC & Liver
diseases causing defective clearing of...
Laboratory findings
Laboratory Studies

Other useful tests

DIC

Platelets PT

Likely Diagnosis

Fibrinogen, FDP, Sepsis
s...
Laboratory Studies
Platelets PT

Likely Diagnosis

Other useful tests

Immune thrombocytopenia
Bone marrow hypoplasia

Mat...
Treatment Of Bleeding
A. Inj Vitamin K1 (Aquaminophyton)
- 1 mg IV or IM if not given at birth.
- Infants on TPN
- Infants...
B. FFP:
- 10ml/kg IV for active bleeding
- Repeated 8-12 hrly as needed.
- Replaces C.F. immediately.
C. Platelets:
- 1 Un...
D. Fresh whole blood:
- 10ml/kg
- Can be repeated after 6-8 hrs as needed.
E. Clotting factor concetrates
- Severe VWD :
-...
F. Disorders due to problems other than hemostatic
proteins :
- Rule out the underlying possibilities
- eg. Infection, Liv...
- Platelets/ FFP to keep platelet counts > 50,000/ml
and to stop bleeding.
- If bleeding persists,
i. Exchange transfusion...
VKDB
•
•
•
•

Early , Classic, and Late forms
Early VKDB – in first day
Severe bleeding – GI and ICH
Cause – Maternal drug...
VKDB
Classical form: 2-7 days of age
• 0.25-1.7% of all babies
• Cause – not received prophylaxis
on breast feeds, sterile...
Management of VKDB
• Prolonged PT , APTT (if severe)
• Normal platelets and fibrinogen

• Factor assays of vit K dependent...
Prophylaxis of VKDB
• Early VKDB- single IM inj of vit K at
birth and oral Vit K to mother for
last 4 weeks
• Classical an...
Hemophilia in the Newborn
• Factor VIII or XI deficiency
– A good family history goes a long way
Hemophilia A
Most common inherited clotting factor def
X linked recessive, 1 in 4000 males
1/3rd of cases present in newbo...
Hemophilia B
•
•
•
•
•
•

XLR
Deficiency of Factor IX
Less common than the classical form
Prolonged APTT and low Factor IX...
Thrombocytopenia
•
•
•
•
•

Less than 150,000/uL
Incidence in newborns: 1-5%
Incidence in NICU – 15-30%
In VLBW and preter...
Causes of thrombocytopenia
• Immune-mediated
• Associated with infection - Bacterial or Nonbacterial
• Drug-Related
• Incr...
Early thrombocytopenia
•
•
•
•
•
•
•

Placental insufficiency (PIH, IUGR,DM)
NAITP
Birth asphyxia
Perinatal infection
Mate...
Late Thrombocytopenia
•
•
•
•

Late onset sepsis and NEC
Congenital infection
Maternal ITP, SLE
Congenital / Inherited con...
Immune Thrombocytopenia
• Neonatal allo-immune thrombocytopenia
(NAIT)
• Incidental thrombocytopenia of
pregnancy or Gesta...
Neonatal allo-immune
thrombocytopenia (NAIT )
•
•
•
•
•
•

Incompatibility between mother and baby
Similar to Rh disease
A...
NAIT
• Management – fetal blood sampling and
platelet transfusion or maternal IVIG
• If previous sibling had a significant...
Congenital causes
•
•
•
•
•

TAR , Fanconis anemia,
Congenital amegakaryocytic anemia
Trisomy 21, 18,13
Wiskott Aldrich sy...
TAR (Thrombocytopenia & Absent
Radii)
• Congenital
• Findings
–
–
–
–
–

Thrombocytopenia
Absent radii bilaterally
Small s...
PT and APTT
• PT: measures extrinsic pathway
• VII, X, II, V
• Normal range : preterm:(14-22S)
term
: (13-20s)
• APTT: Mea...
Thank You…
Bleedingneonate sandip1
Upcoming SlideShare
Loading in …5
×

Bleedingneonate sandip1

1,554 views

Published on

APROACH TO BLEEDING IN NEONATES

Published in: Health & Medicine, Technology
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,554
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
124
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Bleedingneonate sandip1

  1. 1. Bleeding neonate Dr.Sandip Gupta PGT,PEDIATRICS B.S.M.C.H.
  2. 2. Introduction • Neonates are susceptible to bleeding for various reasons Immaturity of the haemostatic system because of quantitative and qualitative deficiency of coagulation factors Maternal disease and drugs Birth trauma Other conditions - sepsis and asphyxia
  3. 3. Clinical presentation • Bleeding in neonates may present with Oozing from the umbilical stump Cephalhaematoma Bruising , Petechiae Bleeding from peripheral venipuncture or procedure sites Bleeding following circumcision Intracranial haemorrhage Bleeding from mucous membranes Unexplained anemia and hypotension
  4. 4. Etiology 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.
  5. 5. Causes: a. Total parenteral nutrition or antibiotics b. 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
  6. 6. • 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*.
  7. 7. 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 diseasesi. Hemophilia-A : Factor VIII deficiency. ii. Hemophilia-B : Factor IX deficiency.
  8. 8. 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 surgery/trauma.
  9. 9. iii. VWD Type III B. Platelet problems: 1. Qualitative disorders: - Glanzman’s thrombasthenia. - Bernard-Soulier syndrome - Platelet type VWD
  10. 10. 2. Quantitive disorders: - Immune thrombocytopenia - Matrnal Preeclampsia, HELLP syndrome or severe uteroplacental insuffuciency. - DIC due to infection or asphyxia. - Inherited marrow failure syndromes : Fanconi anemia & congenital amegakaryocytic thrombocytopenia
  11. 11. - Congenital leukemia - Inherited thrombocytopenia syndromes : gray platelet syndrome - Macrothrombocytopenias : MayHegglin syndr. - Platelet consumption in clots/ vascular disorders eg. Vascular malformations, NEC.
  12. 12. C. Vascular origin: - Pulmonary haemorrhage - A-V malformations - CNS haemorrhage - Hemangiomas.
  13. 13. Diagnostic workup • HISTORY: A detailed history and examination essential in the assessment of bleeding neonate History includes • Maternal diseases as ITP, preeclampsia . • Maternal exposure to drugs as aspirin, anticonvulsants, rifampicin and isoniazid • Family history of bleeding disorders • Previous affected sibling
  14. 14. B. Examination: First diagnose whether the infant is Sick or Well 1. Sick infant: - DIC - Bacterial/ viral infections. 2. Well infant: - Vit K deficiency - Isolated C.F. deficiencies - Immune thrombocytopenia - Maternal blood in infant’s GIT.
  15. 15. 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.
  16. 16. 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 – large platelets.
  17. 17. 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.
  18. 18. Laboratory findings Laboratory Studies Other useful tests DIC Platelets PT Likely Diagnosis Fibrinogen, FDP, Sepsis screen Platelet consumption (NEC, Renal vein thrombosis, marrow infiltration, Sepsis) LFT, Albumin APTT SICK INFANTS N N Liver disease N N N N Compromised vascular integrity (hypoxia, prematurity, acidosis)
  19. 19. Laboratory Studies Platelets PT Likely Diagnosis Other useful tests Immune thrombocytopenia Bone marrow hypoplasia Maternal platelet count, Platelet antigen typing, Bone marrow, Fibrinogen, FDP, Factor VII & IX assays APTT HEALTHY INFANTS N N N N N Vitamin K Deficiency N Heriditory C.F. deficiencies N Bleeding d/t local factors, Plt function anomalies, Factor XIII deficiency(rare) N Platelet aggregometry Urea clot solubility
  20. 20. 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.
  21. 21. 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 50,000-100,000/mm3 in a 3kg newborn. - Platelet count slowly decreases if stores 3-5 days.
  22. 22. 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
  23. 23. 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.
  24. 24. - 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 (10ml/kg)
  25. 25. VKDB • • • • Early , Classic, and Late forms Early VKDB – in first day Severe bleeding – GI and ICH Cause – Maternal drug intake Phenytoin, phenobarb, ATT, warfarin
  26. 26. VKDB Classical form: 2-7 days of age • 0.25-1.7% of all babies • Cause – not received prophylaxis on breast feeds, sterile gut, lack of placental transfer Late form : 2-8 weeks of age • Boys > girls, 5-10/1 lac • Well , breastfed, term baby • Liver disease • Malabsorption
  27. 27. Management of VKDB • Prolonged PT , APTT (if severe) • Normal platelets and fibrinogen • Factor assays of vit K dependent factors • Treatment – 1mg iv or sc • FFP in severe cases
  28. 28. Prophylaxis of VKDB • Early VKDB- single IM inj of vit K at birth and oral Vit K to mother for last 4 weeks • Classical and Late forms – IM Vit K at birth oral Vit K at 0 , 4 days and 4 weeks In preterms – Weekly iv Vit K
  29. 29. Hemophilia in the Newborn • Factor VIII or XI deficiency – A good family history goes a long way
  30. 30. Hemophilia A Most common inherited clotting factor def X linked recessive, 1 in 4000 males 1/3rd of cases present in newborn period ICH(25%), cephalhematoma(10-15%) Post circumcision bleed is characteristic Family history – absent in 30% Inv – prolonged APTT, normal PT, normal platelets. • Factor VIIIc assay level <2% severe, 2-10% moderate, >10% mild • • • • • • •
  31. 31. Hemophilia B • • • • • • XLR Deficiency of Factor IX Less common than the classical form Prolonged APTT and low Factor IX Rx- 100u/k iv OD , to raise levels to 100% Avoid lumbar punctures, IM injections
  32. 32. Thrombocytopenia • • • • • Less than 150,000/uL Incidence in newborns: 1-5% Incidence in NICU – 15-30% In VLBW and preterms – 50% Causes of thrombocytopenia in newborn: Neonatal megakaryocytes are smaller Inadequate production of thrombopoietin
  33. 33. Causes of thrombocytopenia • Immune-mediated • Associated with infection - Bacterial or Nonbacterial • Drug-Related • Increased peripheral consumption of platelets – Disseminated Intravascular Coagulation, Necrotizing enterocolitis, hypersplenism • Genetic and Congenital Anomalies • Miscellaneous – asphyxia, IUGR, PIH, GDM
  34. 34. Early thrombocytopenia • • • • • • • Placental insufficiency (PIH, IUGR,DM) NAITP Birth asphyxia Perinatal infection Maternal autoimmune causes( ITP, SLE) Congenital infection Inherited – TAR, Wiskott- Aldrich
  35. 35. Late Thrombocytopenia • • • • Late onset sepsis and NEC Congenital infection Maternal ITP, SLE Congenital / Inherited conditions
  36. 36. Immune Thrombocytopenia • Neonatal allo-immune thrombocytopenia (NAIT) • Incidental thrombocytopenia of pregnancy or Gestational thrombocytopenia • Autoimmune thrombocytopenic purpura
  37. 37. Neonatal allo-immune thrombocytopenia (NAIT ) • • • • • • Incompatibility between mother and baby Similar to Rh disease Antibodies against HPA – 1 (most common) In utero bleed can occur Manifests with first pregnancy in 50% Postnatal : petechiae, purpura ICH in 10% with sequelae
  38. 38. NAIT • Management – fetal blood sampling and platelet transfusion or maternal IVIG • If previous sibling had a significant bleed • Caesarian section • In newborn – maternal platelets or HPA compatible platelets • IVIG 1gm/k for 2 days or 0.5g/k for 4 days
  39. 39. Congenital causes • • • • • TAR , Fanconis anemia, Congenital amegakaryocytic anemia Trisomy 21, 18,13 Wiskott Aldrich syndrome Noonan’s and Apert’s Syndromes
  40. 40. TAR (Thrombocytopenia & Absent Radii) • Congenital • Findings – – – – – Thrombocytopenia Absent radii bilaterally Small shoulders Abnormal knees Malabsorption • History – Platelets stabilize – ? Leukemia
  41. 41. PT and APTT • PT: measures extrinsic pathway • VII, X, II, V • Normal range : preterm:(14-22S) term : (13-20s) • APTT: Measures intrinsic pathway • VIII, IX,XI,XII, X,II, V • Uses a contact activator like kaolin , silica • Normal values: Term-(30s-45s) Preterm – ( 35 – 55s)
  42. 42. Thank You…

×