AND
MANAGEMENT
OF BLEEDING
NEONATE
OVERVIEW
INTRODUCTION
HEMOSTASIS
ETIOLOGY
CLINICAL APPROACH
MANAGEMENT
PREVENTION
SUMMARY
INTRODUCTION
Neonates are at higher risk of bleeding due
to decreased activity of certain coagulation
factors, impaired platelet function and
suboptimal defence against clot formation.
Preterm baby has added hazards of
increased vascular permeability and inability
to effectively utilise vitamin K for synthesis
of coagulation factors.
Bleeding is a common problem in sick
neonates and can be life threatening.
HEMOSTASIS
Hemostasis depends upon interaction
between vessel wall, platelets and
coagulation factors.
As a result of injury to vascular endothelium,
three events takes place simultaneously:
1)Vasoconstriction
2)Platelet plug formation
3)Fibrin thrombus formation
PRIMARY HEMOSTATIC MECHANISM
collagen exposure
vonwillebrand factor
Platelet adhesion
release reaction
ADP,TXA2,seratonin
Platelet aggregation
Platelet clump
thrombin
Platelet plug
ROLE OF VITAMIN K
Vitamin K helps in post translational
gamma carboxylation of glutamic acid
residues of coagulation factors
II,VII,IX,X and Protein C&S.
COAGULATION FACTORS AND THEIR
BIOLOGIC HALF LIFE
COAGULATION FACTOR BIOLOGIC HALF
LFE(HR)
I Fibrinogen 90
II Prothrombin 60
III Thromboplastin
IV Calcium
V Proaccelerin/Labile factor 12-36
VII Proconvertin/Stable factor 6-8
VIII Antihemophilic factor 8-12
IX Sturt prower factor 12-24
X Christamas factor 32-58
XI Plasma thromboplastin antecedent 48-72
XII Hageman factor 48-52
XIII Fibrin stabilising factor 72-120
Coagulation pathway:
ETIOLOGY
1. DEFICIENT CLOTTING FACTORS
A)Transitory deficiencies of procoagulant vitamin K
dependent factors II,VII,IX,X and anticoagulant factors
Protein C and Protein S are characteristic of newborn
period and may be accentuated by following
1) lack of administration of vitamin K at birth
2) administration of total parenteral nutrition
3) administration of antibiotics
4) maternal intake of certain drugs during pregnancy
which interfere with vitamin K effect on synthesis of
coagulation factors
ex: phenytoin , phenobarbitone , salicylates, warfarin.
Contd....
B)Associated with systemic diseases:
infection
shock
anoxia
NEC
RVT
use of vascular catheter
ECMO
Contd...
C)Inherited abnormalities of clotting factors:
1)X-linked recessive
- haemophilia A & B
2)Autosomal dominant
- VWD
-Dysfibrinogenemia
3)Autosomal recessive
-Factor VII or XIII deficiency
-Factor XI deficiency
-VWD type 3
Contd...
2)PLATELET PROBLEMS
A)QUALITATIVE
Glanzmans thrombasthenia
Bernard soulier syndrome
Platelet type VWD
Maternal use of antiplatelet drugs
Contd...
B)QUANTITATIVE
Immune thrombocytopenia.
Maternal preeclampsia or HELLP syndrome.
DIC.
Inherited marrow failure syndromes.
Congenital leukaemia.
Inherited thrombocytopenia syndromes.
Consumption of platelets in clots or vascular
EXAMINATION
LABORATORY TESTS
HISTORY
1)Family h/o excessive bleeding or clotting
2)Maternal medications
eg.phenytoin,asprin
3)Pregnancy and birth history
4)Maternal h/o birth to an infant with
bleeding disorder
5)Any illness,anomalies or procedures
done to
the infant
EXAMINATION
Platelet count-thrombocytopenia is
defined as platelet count
<1,50,000/cu.mm and severe
thrombocytopenia as <50,000/cu.mm
Contd...
Coagulogram:
1)Prothrombin time is a test of extrinsic
clotting system.
-PT >17sec is abnormal in both term and
preterm.
2)APTT is a test of so called intrinsic clotting
system.
-APTT >45sec in term and >55sec in preterm
is generally considered to be abnormal.
-Normal values may vary between laboratories
Normal values for laboratory
screening tests in neonate
Laboratory Premature Term infant Child 1-2 mon
infant having having of age
test received vit k received vit k
Platelet count 1,50,000- 1,50,000- 1,50,000-
4,00,000 4,00,000 4,00,000
low Normal