Bleeding in newborns


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Bleeding in newborns

  1. 1. Bleeding in Newborns Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ ]
  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 into scalp
  4. 4. Clinical presentationBleeding following circumcisionIntracranial haemorrhageBleeding from mucous membranesUnexplained anemia and hypotension
  5. 5. • A detailed history and examination essential in the assessment of bleeding neonateHistory includes• Maternal diseases as ITP, preeclampsia and diabetes• Maternal exposure to drugs as aspirin, anticonvulsants, rifampicin and isoniazid• Family history of bleeding disorders• Previous affected siblings
  6. 6. Laboratory Evaluation• PTT Intrinsic cascade• PT Extrinsic cascade (II, VII, IX, X)• Platelet count -• Bleeding Time• Clotting factor• Factor Analysis• Platelet functions
  7. 7. Etiology• Coagulation disorders - acquired congenital• Platelet disorders -thrombocytopenia function defects• Combination of above factors – DIC• Defects in fibrinolytic pathway• Trauma
  8. 8. Coagulation disorders• Transient - Vitamin K deficiency Maternal drug use• Congenital - Autosomal dominant- vWF X linked recessive – VIII,IX Autosomal recessive – II,V,VII
  9. 9. Vitamin K deficiency• VKD factors – Required for gamma carboxylation of II, VII, IX, and X• Causes – breast milk has low vit K lack of gut flora no placental transfer
  10. 10. VKDB• Early , Classic, and Late forms• Early VKDB – in first day• Severe bleeding – GI and ICH• Cause – Maternal drug intake Phenytoin, phenobarb, ATT, warfarin
  11. 11. VKDBClassical 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 transferLate form : 2-8 weeks of age• Boys > girls, 5-10/1 lac• Well , breastfed, term baby• Liver disease• Malabsorption
  12. 12. Management of VKDB• Prolonged PT , APTT (if severe)• Normal platelets and fibrinogen• PIVKA – half life of 70 hrs• Factor assays of vit K dependent factors• Treatment – 1mg iv or sc• FFP in severe cases and PCC
  13. 13. 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
  14. 14. Hemophilia in the Newborn • Factor VIII or XI deficiency – A good family history goes a long way
  15. 15. 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
  16. 16. Hemophilia A• Treatment – Factor VIII concentrates 50 -100 U/kg• Raise level to 100%• In ICH – factor infusion for 14 days• In doubtful cases – cryoprecipitate or FFP• Management of antenatally detected cases: - Avoid difficult delivery , oral Vit K - Cord blood bleeding tests, factor VIII - No role for prophylactic Factor VIII
  17. 17. CNS Bleed
  18. 18. 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
  19. 19. 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
  20. 20. Baby Platelet
  21. 21. Causes of thrombocytopenia• Immune-mediated• Associated with infection - Bacterial or Non- bacterial• Drug-Related• Increased peripheral consumption of platelets – Disseminated Intravascular Coagulation, Necrotizing enterocolitis, hypersplenism• Genetic and Congenital Anomalies• Miscellaneous – asphyxia, IUGR, PIH, GDM
  22. 22. Early thrombocytopenia• Placental insufficiency (PIH, IUGR,DM)• NAITP• Birth asphyxia• Perinatal infection• Maternal autoimmune causes( ITP, SLE)• Congenital infection• Inherited – TAR, Wiskott- Aldrich
  23. 23. Late Thrombocytopenia• Late onset sepsis and NEC• Congenital infection• Maternal ITP, SLE• Congenital / Inherited conditions
  24. 24. Infection• Most common cause of thrombocytopenia in infants• LOS > EOS• 50% of babies have platelets < 1 lac/cmm• 65%, and 47% - sensitivity and specificity for sepsis• Viral infections ( intrauterine) cause severe thrombocytopenia.
  25. 25. Immune Thrombocytopenia• Neonatal allo-immune thrombocytopenia (NAIT)• Incidental thrombocytopenia of pregnancy or Gestational thrombocytopenia• Autoimmune thrombocytopenic purpura
  26. 26. 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
  27. 27. 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
  28. 28. Autoimmune Thrombocytopenia• Maternal ITP or SLE• Transplacental transfer of autoantibodies• Bleeding manifestations are less severe• ICH occurs in less than 1%• Platelets at birth, and day 2• If less than 30,000/cmm – to give IVIG• Platelet transfusion is not useful
  29. 29. Congenital causes• TAR , Fanconis anemia,• Congenital amegakaryocytic anemia• Trisomy 21, 18,13• Wiskott Aldrich syndrome• Noonan’s and Apert’s Syndromes
  30. 30. TAR (Thrombocytopenia & Absent Radii)• Congenital• Findings – Thrombocytopenia – Absent radii bilaterally – Small shoulders – Abnormal knees – Malabsorption• History – Platelets stabilize – ? Leukemia
  31. 31. PT and APTT• PT: measures extrinsic pathway• VII, X, II, V• Normal range : preterm:13s(10.6s-16.2s) term : 13s(10.1-15.9s)• APTT: Measures intrinsic pathway• VIII, IX,XI,XII, X,II, V• Uses a contact activator like kaolin , silica• Normal values: Term-42.9s(31s-54s) Preterm – 53.6s( 27.5 – 79s)
  32. 32. Thrombin time• Measures final step of clotting cascade• Normal values in newborn• Prolonged in hypofibrinogenemia, dysfibrinogenemia, heparin and FDP• Reptilase time: uses a snake venom• Not sensitive to heparin
  33. 33. Approach in healthy baby• Plt PT PTT Diagnosis• ↓ N N ITP , marrow aplasia• N ↑ ↑ VKDB• N N ↑ Clotting defects• N N N Trauma, XIII platelet function
  34. 34. Approach in sick neonates• Plt PT PTT Diagnosis• ↓ ↑ ↑ DIC• ↓ N N Sepsis, NEC,RVT• N ↑ ↑ Liver disease• N N N Acidosis, hypoxia
  35. 35. Bleeding infant Screening tests PT, APTT,TT,PLT BT , Fg, PFAAll tests normal All abnormalXIII, alpha2- AP APTT prolonged PT prolonged DIC, Liver failure, PAI, vWFl VIII,IX,XI,XII,vWF VKDB, Warfarin Severe VKDB hypofg
  36. 36. Thank youDownload more documents and slide shows on The Medical Post [ ]