bleeding in newborns
TRANSCRIPT
Bleeding in Newborns
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Dr. Kalpana MallaMD Pediatrics
Manipal Teaching Hospital
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
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
Clinical presentation
· Bleeding following circumcision · Intracranial haemorrhage · Bleeding from mucous membranes · Unexplained anemia and
hypotension
• A detailed history and examination essential in the assessment of bleeding neonate
History 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
Laboratory Evaluation
• PTT Intrinsic cascade• PT Extrinsic cascade (II, VII, IX,
X)• Platelet count - • Bleeding Time• Clotting factor• Factor Analysis• Platelet functions
Etiology
• Coagulation disorders - acquired
congenital• Platelet disorders -
thrombocytopenia function
defects• Combination of above factors –
DIC• Defects in fibrinolytic pathway• Trauma
Coagulation disorders
• Transient - Vitamin K deficiency Maternal drug use• Congenital - Autosomal dominant-
vWF X linked recessive –
VIII,IX Autosomal recessive –
II,V,VII
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
VKDB
• Early , Classic, and Late forms• Early VKDB – in first day• Severe bleeding – GI and ICH• Cause – Maternal drug intake Phenytoin, phenobarb,
ATT, warfarin
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
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
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
Hemophilia in the Newborn
• Factor VIII or XI deficiency– A good family history goes a long
way
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
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
CNS Bleed
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
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
Baby Platelet
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
Early thrombocytopenia
• Placental insufficiency (PIH, IUGR,DM)
• NAITP• Birth asphyxia• Perinatal infection• Maternal autoimmune causes( ITP,
SLE)• Congenital infection• Inherited – TAR, Wiskott- Aldrich
Late Thrombocytopenia
• Late onset sepsis and NEC• Congenital infection • Maternal ITP, SLE• Congenital / Inherited conditions
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.
Immune Thrombocytopenia
• Neonatal allo-immune thrombocytopenia (NAIT)
• Incidental thrombocytopenia of pregnancy or Gestational thrombocytopenia
• Autoimmune thrombocytopenic purpura
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
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
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
Congenital causes
• TAR , Fanconis anemia, • Congenital amegakaryocytic anemia• Trisomy 21, 18,13• Wiskott Aldrich syndrome• Noonan’s and Apert’s Syndromes
TAR (Thrombocytopenia & Absent Radii)
• Congenital• Findings
– Thrombocytopenia– Absent radii bilaterally– Small shoulders– Abnormal knees– Malabsorption
• History– Platelets stabilize– ? Leukemia
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)
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
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
Approach in sick neonates
• Plt PT PTT Diagnosis• ↓ ↑ ↑ DIC• ↓ N N Sepsis,
NEC,RVT• N ↑ ↑ Liver
disease• N N N Acidosis,
hypoxia
Bleeding infant
Screening testsPT, APTT,TT,PLT
BT , Fg, PFA
All tests normalXIII, alpha2- AP
PAI, vWFl
APTT prolongedVIII,IX,XI,XII,vW
F
PT prolongedVKDB, Warfarin
All abnormalDIC, Liver failure,
Severe VKDBhypofg
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