Polycythemia in newborns is defined as an increased total red blood cell mass with a hematocrit greater than 65%. This can lead to hyperviscosity or increased blood viscosity. Polycythemia occurs in 1-5% of term newborns, often due to placental transfusion or insufficiency. Symptoms include poor feeding, lethargy, and hypotension due to regional hypoxia from hyperviscosity. Treatment involves partial exchange transfusion for symptomatic infants or increased fluids and monitoring for asymptomatic infants with hematocrits between 70-65%. The prognosis is generally good but partial exchange transfusion may increase risks of gastrointestinal disorders.

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.