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Bleeding in neonates
Presented byModeratorDr Bibek agarwal Dr Reeta bora

DM(neonatology)

Bleeding new born

Incidence 10-15% sick newborn in NICU in newborn is an emergency may bleed

Bleeding They

physiological qual/quant defect of clotting factors maternal drugs

NORMAL HAEMOSTATIC MECHANISM

Normal haemostasis a complex process. Functions of haemostatic mechanism To maintain blood in fluid state within vascular system. To arrest bleeding at the site of bleeding or blood loss by formation of a haemotatic plug. To ensure the eventual removal of the plug when healing is complete. Normal physiology maintains a delicate balance between these conflicting tendencies. Deficiency or exaggeration of any one may lead to Thrombosis or haemorrhage. Normal haemostasis involves - Vascular responses. - Platelet Plug formation. - fibrin deposition.

COMPONENTS OF NORMAL HAEMOSTASIS

Blood

vessels.

Platelets. Coagulation Coagulation Fibrinolytic

factors. factor inhibitors.

system

Physiological handicaps in newborn

Qualitative

& quantitative defect of activity & concentration of

hemostasis
Decreased

factors
Poor

function of platlets though no.is normal blood vessels ATIII & plasminogen,thereby suboptimal defence against clot

Fragile Low

causes
Deficient

clotting factor

-transitory :TPN,AB,maternal drugs -clotting disturbance:DIC,NEC,RVT -inherited xLinkedR:hemophA&B AD:vWD,dysfibrinogenemia AR:factor II,V,VII,X,XI

causes contd
Platelet

problem soulier

quality:glanzmann thrombasthenia,Bernard syndrome,platlet type vWD quantity:immune thrombocytopenia-mat ITP,NAIT maternal pre eclampsia/HELLP

severe uteroplacental

contnd
Vascular

etiology: CNS/,pulm hemmorrag,AV malformation

MISC.trauma

Diagnostic evaluation of bleeding Newborn

History: baby well or sick at onset of bleed what is the GA family history inj vit K given/not site of bleeding mat History time of onset of bleeding

Physical exam
Check

vitals:

gen app,pallor,icterus,,HR,RR,CRT,BP,color whether sick or well

Site

of bleeding:localised/generalised superficial/deep

Type

of bleed:petechae,purpura,echymosis

Systemic exam
All

system esp of intrauterine

Abdomen:evidence

infection
CNS:cephalhematoma,subgaleal

bleed
CVS:bruit/murmur

Lab tests
Initial

screen

CBC with platelet count PBS study next PT PTT TT others

CBC

2 imp information-severity & duration of bleed -platelet count isolated anaemia,thrombocytopenia,leukemia pancytopenia presence of platelet clump

PBS

no,size,morph of RBC & platelet fragmentaion of rbc large platelet patelet clumps

Coagulation screening t
PT

measures extrinsic & common pathway measures intrinsic & common pathway >17 s of any age abnormal >45-50 s term abnormal

PTT PT

PTT

Prolonged

PTT in absence of heparin contamination indicates factor deficiency.

thrombin

time(TT)

-tests deficiency/dysfunction of fibrinogen -measures the time requirement to form clot when thrombin is added to plasma

subsequent tests
Based

on clinical picture & initial screen assay

report
DIC:FDP,D-Dimer Specific PIVKA Apt

factor assay

test to differentiate GI bleed/mat blood

Interpretation of coaglation tests

Sick
platele PT t low

nb
PTT

Increase increased d N N N N

DIC. ,platelet consumption-NEC thrombosis,infection Local cause vascular,ucer

low N

Well

nb
PTT

platelet PT

increased increased HDN

decreas N ed N N

ITP,thrombosis,occult infection

Increased Clotting factor deficiency

In diff clinical scenario

.

PT DIC

PTT

platele FDP t N N N

fibrioge clinically n N shock icterus Liver ds malabsorp tion

Liver failure Vit K deficiency

causes in
sick : DIC , consumptive thrombocytopenia well : vitamin k deficiency, immune thrombocytopenia & local trauma

Vit K Deficiency bleeding

Hemorrhagic disease of newborn Age <24 Sites of bleed Intracranial Intrathoracic intraabdomina causes Maternal therapy

Type Early

coumarins, AEDs, ATTs rifamp, & salicylates.

Classic 2-7d late 1-3 mth

Umblicus, GIT, nose , Missing the dose of following surgery vit k at birth

Intracranial , GIT, Chronic diarrhea, liver skin dis, idiopathic

Disorders of platelets

1.

Qualitative disorders maternal drugs: aspirin, indomethacin or inherited conditions Glanzmanns thrombasthenia

2. Quantitative disorders immune : isoimmune & autoimmune Systemic bacterial / viral infections DIC

Apt test
mix 1 part gastric aspirate / vomitus/ stool with 5 parts distilled water. Centrifuge the mixture ansd separate the clear pink supernatant. Add 1 ml of 1% NaOH to 4 ml of the supernatant and look for the colour change.samples of maternal blood (HbA)become brown while fetal blood ( Hb F) remains pink. Alwas run simultaneous controls with maternal and fetal blood

management
Principles

of therapy

-goal should be the well being of infant -replacement of appropriate blood comp if needed -use blood products when absolutly necessary

Emergency

If active bleed is seen

-FFP,pRBC,vitK as needed after blood has been collected

Supportive

thermoneutral env

oxygenation,perfusion,euglycemia

correct hypoxia,acidosis,electrl,shock

Treatment

-correct hypoxia,acidosis,shock,electrls -FFP 10-15 cc/kg -platelet conc 1 unit (=30cc)to raise 1lac

Blood component therapy

component content dose Expected outcome

packedRBC 250-300cc/u 10-15cc/kg 4cc/kg Hb by 1gm

Platelet conc

510cc/kg 7x1010plat/u nit 1U/ml

10cc/kg raises plat by 0.75-1lac

FFP

10-15cc/kg Improovment inPT PTT

Clinical bleeding
Treat

shock by blood transfusion or other volume expanders. Replace the lost blood if volume of blood loss exceeds 10% Keep cross matched blood ready for emergency transfusion in case of further bleed Give vitamin K 1 mg IV Treat underlying cause HDN : FFP 10 ml /kg along with vitamin K1 mg IV.Repeat PT/PTTK after 12 hours to see response Known deficiency of clotting factors- FFP 10ml/ kg or factor concentrates. .

INDICATIONS OF PLATLET TRANSFUSION

Platelet Count (x109) <30 action Transfuse if bleeding Consider transfusion in all other cases Tranfuse if bleeding Consider transfusion if: <1000g and <7 days Clinically unstable (e.g. fluctuating BP) Previous major bleeding (e.g. Grade 3-4 IVH, pulmonary haemorrhage) Current minor bleeding Concurrent coagulopathy Requiring surgery or exchange transfusion

30 49

50 - 99 >99

Transfuse only if bleeding Do not transfuse

DIC
Vitamin K 1 mg IV FFP 10 ml/kg 8 -12 Platelet transfusions to keep counts > 50, 000/cu.mm Exchange transfusion with fresh blood * Treat underlying cause eg. Antibiotics for sepsis If thrombosis of large vessels occurs , heparin 30u /kg IV stat, followed by 10u/kg/hr to keep PTTK 1.5 2.0 times normal LOW MOL WT HEPARIN

Prevention :
10

mg vitamin K IM/IV 24 hrs before delivery to mothers who are on anticonvulsants , ATTs or coumarins mg vitamin K IM /IV at birth to all babies above 1500gms and 0.5 mg to all babaies <1500 gm mg vitamin K IM / IV weekly to babies

Thank you