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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