Bleeding in newborns

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  • 1.Bleeding in Newborns Dr. Kalpana MallaMD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]

2. Introduction Neonates are susceptible to bleeding forvarious reasonsImmaturity of the haemostatic systembecause of quantitative and qualitativedeficiency of coagulation factorsMaternal disease and drugsBirth traumaOther conditions - sepsis and asphyxia 3. Clinical presentation Bleeding in neonates may present withOozing from the umbilical stumpCephalhaematomaBruising , PetechiaeBleeding from peripheral venipuncture orprocedure sitesBleeding into scalp 4. Clinical presentationBleeding following circumcisionIntracranial haemorrhageBleeding from mucous membranesUnexplained anemia and hypotension 5. A detailed history and examination essentialin the assessment of bleeding neonateHistory includes Maternal diseases as ITP, preeclampsia anddiabetes Maternal exposure to drugs asaspirin, anticonvulsants, rifampicin andisoniazid Family history of bleeding disorders Previous affected siblings 6. Laboratory Evaluation PTTIntrinsic cascade PTExtrinsic cascade (II, VII, IX, X) Platelet count - Bleeding Time Clotting factor Factor Analysis Platelet functions 7. Etiology Coagulation disorders - acquiredcongenital Platelet disorders -thrombocytopenia function defects Combination of above factors DIC Defects in fibrinolytic pathway Trauma 8. Coagulation disorders Transient- Vitamin K deficiency Maternal drug use Congenital - Autosomal dominant- vWFX linked recessive VIII,IXAutosomal recessive II,V,VII 9. Vitamin K deficiency VKD factors Required for gammacarboxylation of II, VII, IX, and X Causes breast milk has low vit Klack of gut florano placental transfer 10. VKDB Early , Classic, and Late forms Early VKDB in first day Severe bleeding GI and ICH Cause Maternal drug intakePhenytoin, phenobarb,ATT, warfarin 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 ofplacental transferLate form : 2-8 weeks of age Boys > girls, 5-10/1 lac Well , breastfed, term baby Liver disease Malabsorption 12. Management of VKDB Prolonged PT , APTT (if severe) Normal platelets and fibrinogen PIVKA half life of 70 hrs Factor assays of vit K dependentfactors Treatment 1mg iv or sc FFP in severe cases and PCC 13. Prophylaxis of VKDB Early VKDB- single IM inj of vit K atbirth and oral Vit K to mother forlast 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. Hemophilia in the Newborn Factor VIII or XI deficiency A good family history goes a long way 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 characteristicFamily history absent in 30% Inv prolonged APTT, normal PT, normalplatelets. Factor VIIIc assay level 10% mild 16. Hemophilia A Treatment Factor VIII concentrates50 -100 U/kg Raise level to 100% In ICH factor infusion for 14 days In doubtful cases cryoprecipitate or FFP Management of antenatally detectedcases: - Avoid difficult delivery , oral Vit K - Cord blood bleeding tests, factor VIII - No role for prophylactic Factor VIII 17. CNS Bleed 18. Hemophilia BXLR 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. 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 smallerInadequate production of thrombopoietin 20. Baby Platelet 21. Causes of thrombocytopenia Immune-mediated Associated with infection - Bacterial or Non-bacterial Drug-Related Increased peripheral consumption of platelets Disseminated IntravascularCoagulation, Necrotizingenterocolitis, hypersplenism Genetic and Congenital Anomalies Miscellaneous asphyxia, IUGR, PIH, GDM 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. Late Thrombocytopenia Late onset sepsis and NEC Congenital infection Maternal ITP, SLE Congenital / Inherited conditions 24. Infection Most common cause of thrombocytopeniain infants LOS > EOS 50% of babies have platelets < 1 lac/cmm 65%, and 47% - sensitivity and specificityfor sepsis Viral infections ( intrauterine) causesevere thrombocytopenia. 25. Immune Thrombocytopenia Neonatal allo-immune thrombocytopenia(NAIT) Incidental thrombocytopenia ofpregnancy or Gestationalthrombocytopenia Autoimmune thrombocytopenic purpura 26. Neonatal allo-immunethrombocytopenia (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, purpuraICH in 10% with sequelae 27. NAIT Management fetal blood sampling andplatelet transfusion or maternal IVIG If previous sibling had a significant bleed Caesarian section In newborn maternal platelets or HPAcompatible platelets IVIG 1gm/k for 2 days or 0.5g/k for 4 days 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. Congenital causes TAR , Fanconis anemia, Congenital amegakaryocytic anemia Trisomy 21, 18,13 Wiskott Aldrich syndrome Noonans and Aperts Syndromes 30. TAR (Thrombocytopenia & Absent Radii) Congenital Findings Thrombocytopenia Absent radii bilaterally Small shoulders Abnormal knees Malabsorption History Platelets stabilize ? Leukemia 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. Thrombin time Measures final step of clotting cascade Normal values in newborn Prolonged inhypofibrinogenemia, dysfibrinogenemia,heparin and FDP Reptilase time: uses a snake venom Not sensitive to heparin 33. Approach in healthy baby Plt PT PTT Diagnosis NNITP , marrow aplasia N VKDB N N Clotting defects N N NTrauma, XIIIplatelet function 34. Approach in sick neonates Plt PT PTTDiagnosis DIC N N Sepsis, NEC,RVT N Liver disease N N NAcidosis, hypoxia 35. Bleeding infant Screening testsPT, APTT,TT,PLTBT , Fg, PFAAll tests normalAll abnormalXIII, alpha2- APAPTT prolongedPT prolongedDIC, Liver failure,PAI, vWFlVIII,IX,XI,XII,vWFVKDB, WarfarinSevere VKDB hypofg 36. Thank youDownload more documents and slide shows on TheMedical Post [ www.themedicalpost.net ]