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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
