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Hemorrhagic Disease of Newborn(HDN).pptx
1. Addis Ababa university college of health science department of
nursing and midwifery post graduate program
Course Title: introduction to maternity and neonatal nursing
Topic: Hemorrhagic Disease in Newborn (HDN)
By
Mulugeta Abeneh Mulu…………..GSR/4375/16
Sumitted to
DR.RAJALAKSHMI(PHD)
TAHISSAS 2016 E.C
ETHIOPIA (A.A)
3/13/2024
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2. Acknowledgements
First of all, we would like to thank almightily God’s for
his kindness, love and helping us for everything that
couldn‘t be done beyond him.
Next, we gratefully acknowledge to our dear instructors:
DR.Rajalakshmi(phd) for her necessary guidance to do
and present this case.
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5. HDN…
Introduction
Hemorrhagic disease is a bleeding disorder in a baby during
the first few day of life
The normal range of the newborn PT and PTT extend above
than those for a healthy adult
The formation of a strong clot induced by activated platelets
and fibrinogen aims to stop bleeding.
Bleeding disorders are scarcely reported in the overall neonatal
population, but, as commonly observed among hospitalized
neonates, they pose a great challenge to the treating physician.
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6. HDN…
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Introduction…
Studies have shown an incidence of 0.3% for bleeding
disturbances in neonatal life .
Even though thrombocytopenia is the most common cause of
disorders pertained to primary hemostasis, bleeding intension is
equally observed at hemostasis dys-regulation other than low
platelet count (PLT).
Major or minor bleeding occurs in hospitalized neonates, mostly
secondary due to acquired rather than congenital disorders in
hemostasis.
Thrombocytopenia is the most common cause of disorders pertained
to primary hemostasis, bleeding intension is equally observed at
hemostasis dys-regulation other than low platelet count
7. HDN…
Neonatal hemostatic system
The hemostatic system is a complex protective pathway
against bleeding that begins as soon as an endothelial injury
occurs and tissue factor (TF) is released.
The formation of a strong clot induced by activated platelets
and fibrinogen aims to stop bleeding
The fact that hemostasis in newborns is still immature and
differs significantly from that of older children and adults
complicates the differential diagnosis
Otherwise, the hemostatic system prevents both bleeding and
thromboembolic events in a complex well-balanced way
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11. HDN
Hemophilia
Hemophilia A and B (HA and HB) are the most common
congenital bleeding disorders that occur in the neonatal period.
Hemophilia is an inherited bleeding disorder.
• Newborn with hemophilia cant stop bleeding b/c they don’t
have enough clotting factor in blood
There are many blood clotting factor involve in forming of clot
to stop bleeding
Two common factors that affect blood clotting are F8 AND F9
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12. Hemophilia
The 3 main forms of hemophilia are:
Hemophilia A
Caused by a lack of the blood clotting factor 8.
Hemophilia B
Caused by a deficiency of factor 9
Hemophilia C
Cause by lack of factor 11
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13. Hemophilia ….
Cause of hemophilia in newborn
Hemophilia type A and B are inherited disease
They are passed from parents to children through a gene
on the X chromosome
When a hemophilia carrier female is pregnant there is a
50/50 chance that hemophilia gene will be passed on to
the baby
If the gene is passed on to a son ,he will have the disease
but if the gene is passed on to a daughter ,she will be a
carrier
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14. Hemophilia …
The sign and symptom of hemophilia
Bleeding into the joints
Bleeding into the skin
Muscle and soft tissue
Bleeding of the mouth, nose and gums
Bleeding that is hard to stop after losing a tooth.
Blood found in the urine or stool.
Hemophilia C usually doesn’t cause problem, but may
have increased bleeding after surgery.
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15. Hemophilia …
Diagnosis of hemophilia
History and a physical exam
Blood tests include
CBC.RBC,WBC,platlet and hematocrit
Level of each clotting factor
Bleeding times
DNA testing for abnormal gene
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16. Hemophilia …
Hemophilia management
Treatment for hemophilia is aimed to preventing bleeding
complication(mainly head and joint bleeds,)
Bleeding in the joint may need surgery or immobilization
Blood transfusions may be needed if major blood loss has
occurred.
Self –infused factor 8 or 9 can allow the newborn with
hemophilia to lead a near normal lifestyle
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17. Hemophilia …
Hemophilia complication
Hemorthrosis
Inflammation and long term joint problem
Tumor enlargements
Development of antibody against clotting factor
Infection from transfusion
Hematoma
Spontaneous nosebleed
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18. Von Willebrand disease(VWD)
Von Willebrand disease (VWD) is a relatively common inherited
bleeding disorder, with 1.3% frequency in mixed population, due
to quantitative or qualitative abnormalities of the VWF
VWD is a genetic disorder caused by missing of defective VWF,
a clotting protein
VWF bind factor 8, a key clotting protein and platelets in blood
vessel wall, which help from a platelets plug during the clotting
process
VWD is the most common inherited bleeding disorder
It is carried on chromosome 12 and occur equally in men and
women.
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19. VWD…
Sign and symptom of VWD
Bleeding from the gums
Easy bruising
Prolonged bleeding after cuts or bloodworm
Frequent and prolonged nosebleeds.
Blood in the tool or urine
Babies with VWD rarely bleed at birth
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24. Liver disease
Liver disease
Pro- and anticoagulant proteins, as well as thrombopoietin, are
synthesized in the liver, with the exception of FVIII and VWF.
Disruption of liver function results in dys-regulation of the
coagulation system, which in turn leads to bleeding or thrombotic
diathesis
Biliary obstruction impaired VIT K absorption decrease synthesis
F2,F8,F9and F10
Severe hepatocellular disease, reduced F5,fibrinogen and
plasminogen activator
Dysfunctional fibrinogen
Low thrombopoietin
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25. Liver disease …
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Probable causes of liver disease :
Inborn errors of metabolism
Bacterial or viral sepsis
Hematologic disorders
Hypoxic-ischemic injury (e.g., due to perinatal
asphyxia) and
Fetal-maternal hemorrhage that can lead to
intrauterine insult and multi-organ failure
Hemophagocytic lymphohistiocytosis.
26. Liver disease …
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Liver disease cannot easily be distinguished from DIC, as
overlapping conditions may occur.
Liver failure counter to DIC presents itself with PLT that
is usually stable in low levels, D-dimers that are mildly
increased and stable FXIII levels.
It manifests clinically with fever, hepatosplenomegaly and
bleeding occur at any site.
27. Liver disease …
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Laboratory finding
Increased serum ferritin
Abnormal liver function tests,
Increased triglyceride levels
Increased PT, aPTT and D-dimers
Decreased fibrinogen and cytopenia
Decreased fibrinogen activity and platelet
28. Liver disease …
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Treatment
Identifying the underline cause were important
Symptomatic management
Blood transfusion if necessary
Clotting factor replacing
Surgery dealing to obstruction
29. Disseminated intravascular coagulation(DIC)
DIC is globally defined as a disorder pertaining to
thrombotic and hemorrhagic irregularity, which affects the
coagulation system’s integrity.
DIC is an acquired syndrome characterized by excessive
systemic activation of coagulation resulting in both
hemorrhagic and thrombosis
DIC can progress rapidly into life –threating multi organ
failure
DIC always occurs as secondary event, and a number of
prenatal and neonatal problems are associated
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30. DIC…
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DIC is an over-activation condition of pro-coagulant
proteins and fibrinolysis while being consumptive for
coagulopathy inhibitors presenting clinical and
biochemical evidence of end-organ failure.
Although data clearly reporting DIC incidence among
term and preterm infants are lacking, its prevalence is
worrisome among NICU hospitalized patients.
Therefore, DIC manifests itself as a secondary event
associated with many perinatal and neonatal
complications.
32. DIC…
Laboratory diagnosis of DIC
DIC diagnosis is challenging
Typical pattern of reduced platelets, PT,APTT with or
with out thrombin clotting time
Reduced fibrinogen
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33. DIC..
Manifestation of DIC in neonate
Bleeding
Bruising
Low blood pressure and shortness of breath
Confusion
Management
Treatment by underlying cause
FFP(10-15ml/kg) can be used to replace hemostatic protein
Cryoprecipitate(5-10ml/kg) is a better source of fibrinogen
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34. In neonate it is traditionally defined as a platelet count
<150000/mcl
Over all incidence of neonatal thrombocytopenia
is(0.7%-0.9%)
In NICU it is very high 22%-35%
Classification
Mild (pc=100000-150000/mcl)
Moderate (pc=50000-99000/mcl)
Severe (pv<50000/mlc)
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Neonatal thrombocytopenia…
43. Vitamin k deficiency
Babies are normally born with low levels of vitamin K, an
essential factor in blood clotting.
A deficiency in vitamin K is the main cause of
hemorrhagic disease in newborn babies..
As a result of vitamin K deficiency, there is a decreased
activity of vitamin K dependent coagulation factors II,
VII, IX, X, protein C and protein S.
vitamin K converts inactive clotting factors into an active
state
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44. VKDB…
Vitamin K is a fat-soluble vitamin mainly synthesized in
adults by gut bacteria.
Newborns, however, have minimal vitamin K reserves in
their liver during the time of delivery and are not able to
synthesize vitamin K due to a sterile gut.
Deficiency leads to the inadequate activity of these
clotting factors, which results in bleeding.
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45. VKDB…
Classification
VKDB can be categorized into three groups based on age of
onset.
I. Early: Occurs within the first 24 hours of birth, can also
occur in-utero or during delivery.
Incidence :rare
Site :cephalohematoma,subgaleal,intracranial
,gastrointestinal,umblicus,intra-abdominal
Ethology…..maternal drug
Risk factor :inherited coagulopathy
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46. VKDB…
2 .Classical: 1 week of neonatal life
Incidence 2% if infant not given vitamin k
Site :gastrointestinal ,ears-nose-throat –
mucosal,intracranial,circumcision,injection sites.
Etiology: vitamin k deficiency ,breast feeding
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47. VKDB…
3 .Late: From 8 days to up to 6-12 months
Incidence: dependent on primary disease.
Site: intracranial, gastrointestinal, ears-throat-mucosal,
injection site and thoracic
Ethology :malabsorption of vitamin k(billary atresia,
cystic fibrosis, hepatitis
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49. VKDB…
Investigation :
Complete blood count
Prothrombin time (PT) will be increased due to decreased
activity of factor 7
Partial thromboplastic time (PTT) will also be increased
due to decreased activity of factors 2,9 and 10
Fibrinogen levels will remain normal
Chest X-ray
Computed tomography (CT)
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50. VKDB…
Treatment / Management
Administration of vitamin K to the infant a single
intramuscular (IM) dose of 1 mg of vitamin.
In cases of severe life-threatening bleeding, immediate
blood transfusions
Surgical evacuation or intracranial shunting to relieve
increased intracranial pressure and associated symptoms.
Physiotherapy can be advised to retain/strengthen neural
function
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52. REFERENCE
1. Kher P, Verma RP. Hemorrhagic disease of
newborn. 2020.
2. Netseho K.Gigjga university college of medicine
and health science graduate study:2021
3. Neonatal bleeding disorders. A practical diagnostic
approach
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