Vitamin K deficiency bleeding Hemorrhagic disease of Newborn

1. Vitamin K Deficiency Bleeding
HEMORRHAGIC DISEASE OF NEWBORN
Prof. Imran Iqbal
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Multan, Pakistan

3. It contains estimated 200 Billion Stars, the sun lies roughly 27,000 light-years
from the centre of the galaxy. And there are estimated minimum
100 Billion Galaxies in the Universe.

4. Vitamin K Deficiency Bleeding
Hemorrhagic Disease of Newborn
is the name given to infants presenting
with bleeding in first few days of life

5. Vitamin K Deficiency Bleeding
Vitamin K
Glutamic acid -co-glutamic acid
Clotting factors II, VII, IX, X
Ca ++ Activation

6. Vascular Cell
K
K
K
K
Vitamin K is an essential factor to a hepatic gamma-glutamyl carboxylase
that adds a carboxyl group to glutamic acid residues on factors II, VII, IX
and X, as well as Protein S, Protein C and Protein Z. The main role of
protein Z appears to be the degradation of factor Xa. This is done
by protein Z-related protease inhibitor (ZPI), but the reaction is accelerated
1000-fold by the presence of protein Z
K
K
Platelets
Vascular Cells
Advances in Vascular Medicine 8 September 2014, Article ID 542034, 4 pages
http://dx.doi.org/10.1155/2014/542034 and wikipedia.org/coagulation

7. SOURCES OF VITAMIN K
• K1 (Phytomenadione) – diet (plants origin)
• K2 (menaquinone) - Intestinal Flora
Vitamin K2

8. Vitamin K Deficiency results in
• Deficiency of Factor II,VII,IX,X
• Impaired blood clotting
• Bleeding.

9. Vitamin K Deficiency
can present as
• Purpura
• Mucosal bleeds
• Hemetemesis
• Melena
• Hematuria
• Umbilical bleed
• Intracranial hemorrhage

10. Neonatal Vit K deficiency
 Vitamin K not easily transported across the
placenta
 Prothrombin synthesis in the liver is an
immature process in newborns
 The neonatal gut is sterile, lacking the
bacteria that is necessary in menaquinone
synthesis.
 Breast milk is not a good source of vitamin K

11. Vit K deficiency
can occour due to
• Exclusive breastfeeding
• Liver disease
• Biliary atresia
• Lipid malabsorption
• Prolonged Antibiotic use

12. Case Scenario of
Vit K deficiency

13. Case Scenario
• Baby AS was born on 17th may 2019. Parents
were very happy.
• Baby was started on exclusive mother feeds.
• When he was 26 days old, mother noticed
that since today morning baby is less
interested in feeds and is lethargic. There
were no other symptoms
• What could have happened ?

14. Lethargy in 26 days old newborn
• Meningitis
• Encephalitis
• Metabolic disorder
• Encephalopathy
• Intracranial Hemorrhage
• Accidental poisoning

15. What happened ?
• Mother took the baby to the local
doctor who examined the baby and
gave him an intramuscular injection .
• Next day the mother noticed that baby
is bleeding from the injection site, and
skin around it is red in color.
• What has happened ?

17. Next day
• Baby started vomiting and developed
fits with arching of body and uprolling
of eyes.
• Mother rushed to the hospital
• What has happened to the baby ?

18. Examination findings
• GCS of 5 / 15
• Constricted pupils
• Bulging fontenal
• Neck rigidity
• Pulse rate = 165 per minute
• respiratory rate = 80 per minute,
• temperature = 100 F.
• What is your diagnosis ?

19. Investigations
• Hb 6.4 gm / dl
• TLC 12000, p = 55%, L = 45%
• Platelets 275000 / cumm
• Prothrombin time 120 seconds
• APTT 90 seconds
• What is your diagnosis ?

21. Vitamin K Deficiency Bleeding
(HEMORRHAGIC DISEASE OF NEWBORN)
Intra ventricular Hemorrhage

22. How baby AS was managed ?
• Vitamin K IV dose
• Packed cells tranfusion
• Fresh frozen plasma
• Transient Intraventricular drain to
remove the hemorrhage and reduce the
intracranial pressure (with help of
neurosurgery department)

23. What happened next
• After the intraventricular drainage,
baby started improving and taking his
feeds gradually. He was sent home in a
stable condition.
• Will this baby have any long-term
neurological consequences ?

24. Types of VKDB / H.D.N.
• Early onset - Day 1
• Classical - Day 2 - 8
• Late Onset 1 - Day 9 -28
• Late onset 2 - Day 29 -180
(2-6 Months)

25. Vitamin K Deficiency
Bleeding
HEMORRHAGIC DISEASE OF
NEWBORN
CLINICAL STUDY
43 patients

26. CLINICAL STUDY
Vitamin K Deficiency Bleeding
• Early onset Day 1 2 5%
• Classical onset Day 2-7 11 26%
• Late Onset Day 8-28 10 23%
• Late onset Month 2-12 20 46%

27. 0
2
4
6
8
10
12
14
16
18
20
D 1 D 2-7 D8-28 mo1-
12
Early onset
Classical
Late 1
Late 2
CLINICAL STUDY – Cases of
Vitamin K Deficiency Bleeding

28. Vitamin K Deficiency Bleeding
Late onset

29. VKDB cases - S E X
E C L1 L2 Total
Male = 1 6 5 19 31 (72%)
Female= 1 5 5 1 12 (28%)
Total = 2 11 10 20 43

30. VKDB cases - MODE OF BIRTH
E(2) C(11) L1(10) L2(20) All
S.V.D. 2 7 7 20 36 (85%)
C/S 0 4 1 0 5 (10%)
Not Known 0 0 2 0 2 (5%)

31. VKDB cases - PLACE OF BIRTH
E C L1 L2 All
Home 1 5 4 16 26 (60%)
Clinic 1 1 3 4 9 (20%)
Hospital 0 5 1 0 6 (15%)
Not Known 0 0 2 0 2 (5%)

32. VKDB cases - FEEDING PATTERN
E(2) C (11) L1(10) L2(20) All
Breast Feeding 2 11 10 18 41 (95%)
Mixed Feeding 0 0 0 2 2 (5%)
Bottle Feeding NIL

33. VKDB cases – Neurological Findings
E(2) C(11) L1(10) L2(20) All(43)
Coma 0 0 2 13 26
↑ ICP 0 0 4 10 14
Fits 0 0 2 4 6
Hemiplegia 0 0 1 3 4
Liver with 0 0 0 3 3
spleen

34. VKDB cases - SITE OF BLEEDING
E(2) C(11) L1(10) L1(20) All
Skin 0 1 5 11 17 (40%)
Umbilicus 0 1 1 1 3 (7%)
G1 2 7 2 2 13 (30%)
I/Cranial 0 2 4 13 19 (44%)
Injection Site 0 2 2 6 10 (23%)
Urine 0 1 0 1 2 (5%)
Oral 0 1 0 0 1 (2%)

35. VKDB cases - MANAGEMENT
E C L1 L2 All
Vit K 2 11 10 19 42
Blood 2 10 9 18 39
Transfusion

36. Publication
Risk factors, presentations and
outcome of the haemorrhagic
disease of newborn.
Muhammad Tariq Rana, Nuzhat
Noureen, Imran Iqbal.
J Coll Physicians Surg Pak Jan
2009;19(6):371-4.

37. Publication Results
• Mean age = 51.65 ± 39.49 days.
• Late onset disease = (72%)
• Exclusive breastfeeding = (90%)

38. Publication Results
• Intracranial haemorrhage = 52%
• Death = 40%

39. Vitamin K deficiency Bleeding
 Vitamin K deficiency /Hemorrhagic disease of
newborn is a serious disease presenting not
only in newborns but also in infants.
 Late onset Vitamin K deficiency commonly
presents as intracranial bleeding.

40. Vitamin K deficiency Bleeding
 Late onset Vitamin K deficiency Bleeding
 is associated with exclusive breast feeding in
our infants.
 Every newborn should be given Vitamin K as
prophylaxis against Vitamin K deficiency
(Haemorrhagic disease of newborn)

41. Vitamin K deficiency Bleeding
VITAMIN K PROPHYLAXIS AT BIRTH
 1 mg (0.1 ml) IM at day 1
OR
 1 mg oral at day 1, 7, 28

42. VITAMIN K PROPHYLAXIS
Should be given to infants with
risk factors of Vitamin K deficiency
exclusive breast feeding
liver disease
malabsorption

43. Medical Ethics