Hemorrhagic disease of the newborn (HDN) is a rare bleeding condition often resulting from vitamin K deficiency, critical for blood clotting, leading to potentially life-threatening hemorrhages. It can be categorized into early, classic, and late onset based on the timing of symptoms, with various risk factors related to maternal medication and breast milk vitamin K levels. Prevention strategies include administering vitamin K shots to newborns at birth, especially for those born to mothers on specific medications.

1. HEMORRHAGIC DISEASE OF
THE NEWBORN
(HDN)

2. HEMORRHAGIC DISEASE OF THE NEWBORN
• Hemorrhagic disease of the newborn is a rare bleeding
problem that can occur after birth. Hemorrhaging
(excessive bleeding) is a potentially life-threatening
condition.
• It is often called vitamin K deficiency bleeding, or
VKDB; since Vitamin K plays a key role in blood clotting,
and most babies are born with low stores of the vitamin
in their system.
• vitamin K deficiency there is an impaired production of
coagulation factors II, VII, IX, X by the liver. The
hemorrhaging is a potentially life-threatening.

3. CATEGORIES OF HDN
VKDB is categorized according to the timing of first
symptoms:
– early onset (within 24 hours), which is very rare -
Results of low levels of prothrombin and other
vitamin K dependent clotting factors, (Factors II,
VII, IX and X) caused by vitamin K deficiency
– classic onset (two to seven days), which is also
very rare
– late onset (two weeks to six months) – Immaturity
of liver affects production of clotting factors

4. Abnormal bleeding

5. Causes of HDN
• Newborns have low vitamin K stores at birth
• Vitamin K passes the placenta poorly
• The levels of vitamin K in breast milk are low
• The gut flora as not yet been developed (vitamin K is
normally produced by bacteria in the intestines).

6. 1) Vit. K deficiency
• Essential for production of active forms of
factors II, VII, IX, X and anticoagulants such as
protein C & S
• Def d/t
– Inadequate intake
– Malabsorption ( coeliac dz, cystic fibrosis,
obstructive jaundice)
– Vit K antagonists (eg. Warfarin)

7. 2) Liver Disease
• Billiary obstruction impaired vit K absorption l/t
decrease synthesis FII,FVII,FIX and X.
• Severe hepatocellular disease, reduced FV,
fibrinogen & plasminogen activator.
• Dysfunctional fibrinogen (dysfibrinogenaemia)
• Low thrombopoietin production l/t
thrombocytopenia
• Hypersplenism associated with portal HTN l/t
thrombocytopenia

8. Diagnosis
• The diagnostic criteria for vitamin K deficiency
bleeding include:
• Prolonged prothrombin time (PT)/Elevated international
normalized ratio (INR) (gold standard)
• Prolonged activated partial thromboplastin time (aPTT)
• Fibrinogen levels and a platelet count within in normal range for
newborns
• The diagnosis is confirmed if the INR normalizes
after administration of vitamin K and the
bleeding is stopped.

9. Why Is It Done?
• The prothrombin time (PT) and international normalized ratio
(INR) are measures of the extrinsic pathway of coagulation
( INR is a calculation made to standardize prothrombin time.
INR is based on the ratio of the patient's prothrombin time and
the normal mean prothrombin time)
• PT measures factors I (fibrinogen), II (thrombin), V, VII, and X.
• Prothrombin, or factor II, made by the liver. Vitamin K is
needed to make it & other clotting factors.
The prothrombin time can be prolonged as a result of deficiencies
in vitamin K, warfarin therapy, malabsorption, or lack of
intestinal colonization by bacteria (such as in newborns). In
addition, poor factor VII synthesis (due to liver disease) or
increased consumption (in disseminated intravascular
coagulation) may prolong the PT.

10. Tests and Exams
• Significant bleeding in neonates should prompt clinical
evaluation.
• ‘Initial empirical therapy consists of platelet and/or
factor supplementation, which is often administered
while diagnostic studies are under way’
• Laboratory evaluation of the hemorrhage in newborns
should include
Sepsis evaluation
determination of the ( Blood clotting tests) platelet
count, PT, aPTT, TT, and fibrinogen concentration.

11. Risk factors
Vitamin K deficiency causes VKDB. A baby’s risks vary,
depending upon when symptoms occur.
Early-Onset
Early-onset of VKDB occurs within the first 24 hours after
birth. Risk factors include:
• mother taking anti-seizure drugs that interfere with
vitamin K metabolism (phenytoin, phenobarbital,
caramezepine, or primidone)
• mother taking blood thinning medication such as
Coumadin or aspirin
• mother taking antibiotics, such as cephalosporins

12. Late-Onset
Late-onset is seen in babies up to 2 months old. Risk
factors include:
• low levels of vitamin K in breast milk
• biliary atresia (slow bile flow)
• cystic fibrosis
• celiac disease
• chronic diarrhea
• hepatitis
• A1-antitrypsin deficiency (may cause lung and liver
disease)

13. Clinical presentation of HDN
The disease causes an increased risk of excessive
bleeding. The most common sites of bleeding are
the;
– umbilicus
– mucous membranes
– gastrointestinal tract
– circumcision
– Venipunctures (puncture in the vein for
therapeutic purpose e.g IV)
– Intracranial bleeding can cause brain damage or
death.

14. prevention

15. Prevention
• Many newborns- deficient in vit. K, whether measured in cord blood or
indirectly by measuring the levels of vitamin K–dependent coagulation
proteins. Recommends giving every baby a shot of vitamin K immediately
after birth. This practice has helped prevent the condition.
• The early onset form of the disease may be prevented by giving vitamin K
shots to pregnant women who take anti-seizure medications.(mechanisms
by which anticonvulsant drug l/t vit. K deficiency bleeding in neonates
:not clearly understood)
• Most infants born to well-nourished mothers have adequate
vitamin stores at birth
– Vitamin K is naturally produced by intestinal bacteria which newborn’s lack
resulting in the deficiency
– Suppression of intestinal bacteria by various antibiotics is responsible for this
deficiency
– Infants receive Vitamin K either orally or intramuscularly

17. The End