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APPROACH

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

vessel injury Vasoconstriction

endothelial lining disruption

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

lesions with out DIC.


Heparin induced thrombocytopenia.
Contd...
3)VASCULAR PROBLEMS
CNS hemorrhage
Pulmonary hemorrhage
AV malformations
Hemangiomas
Contd...
4)MISCELLANEOUS
a)Trauma
Rupture of spleen/liver associated with
breech delivery
Retroperitoneal/intraperitoneal bleeding may
present as scrotal ecchymosis
Subduralhematoma,cephalhematoma,subgale
al
hemorrhage
b)Liver dysfunction
CLINICAL APPROACH
HISTORY

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

Is the newborn baby well or sick at the onset


of bleeding?
WELL BABY SICK BABY
-swallowed maternal blood -DIC
-Vitamin k deficiency -Infection viral
-clotting factor deficiency
bacterial
-immune thrombocytopenia -Liver disease
-maternal drug intake -birth asphyxia
Contd...
Petechiae,small superficial
ecchymosis or mucosal bleeding s/o
PLATELET PROBLEM

Large bruises are s/o CLOTTING FACTOR


DEFICIENCY,DIC,LIVER DISEASE or VITAMIN-K
DEFICIENCY
Contd...
Enlarged spleen s/o CONGENITAL
INFECTION or ERYTHROBLASTOSIS

Jaundice s/o INFECTION,LIVER DISEASE or


RESORPTION OF LARGE HEMATOMA

Abnormal retinal findings s/o INFECTION


INVESTIGATIONS
Complete blood count
Peripheral blood smear
Apt test
PT
APTT
Fibrinogen
D dimer assays
Clotting factor assays
Neurosonogram
PIVKA
contd...
Platelet count, coagulogram and
peripheral smear must be done in all
cases and the rest of investigations
should be individualised

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

Prothrombin 14-22 13-20 12-14


Time(S)

Partial 35-55 30-45 25-45


Thromboplastin
Time(s)
Fibrinogen(mg/d 150-300 150-300 150-300
l)
Peripheral smear - useful for
1)rough estimation of platelet count-
count number of platelets in 10 oil
immersion fields and multiply by
15,000.
2)size of platelets can be estimated
and fragmented RBCs can be seen in
case of DIC.
APT test
- to r/o swallowed maternal blood.
-this should be done if the baby has only GI bleed,
clinically well and onset will be with in 3 days of life.
Procedure-mix 1 part of gastric aspirate or stool or
vomitus with 5 parts of distilled water centrifuge it
and seperate the clear pink supernatant.Add 1ml of
1%NaOH to 4ml of the supernatant.
Result- HbA changes from pink to yellow
brown(maternal blood) HbF stays pink(fetal blood)
because HbF is alkali resistant.
Interpretation of coagulation tests in
newborn
Sick platelet PT PTT Likely diagnosis
baby s
low normal normal Platelet consumption(NEC,
infection, thrombosis)
low increase increased DIC , protein C deficiency
d
normal increase increased Liver disease ,
d heparinisation
normal normal normal Local cause- vascular ,ulcer
Well low normal normal Maternal drug intake ,
baby Immune thrombocytopenia ,
occult infection, thrombosis
normal increase increased HDN
d
normal normal increased Inherited clotting factor
deficiency
Management
Principles of therapy:
Goal should be the well being of infant rather than
correcting the laboratory abnormalities
Therapy should be focused on treating the
underlying disease such as septicemia, infection,
shock, hypoxia , acidosis in addition to the
supportive therapy and replacing the appropriate
blood components
Use blood components rather than whole blood
when ever possible
Use blood products only when they are absolutely
nesessary
Treatment
Emergency treatment
Supportive care
Blood component therapy
Treatment of specific disorders
Emergency management
Give vit k 1-2mg IV/IM slowly
Give FFP and PRC as needed and as
soon as possible
Supportive care
Nurse the infant in thermo neutral environment
Ensure -oxygenation
-perfusion,
-euglycemia
Correct -hypoxia,
-acidosis,
-Dyselectrolytemia
-hypotension and shock
Monitor vitals
BLOOD COMPONENT
THERAPY
GUIDELINES FOR PLATELET
TRANSFUSION
Platelet count <30,000/cubic mm,
Transfuse all neonates even if asymtomatic.
Platelet count 30,000-49,000/cubic mm,
Transfuse if,
a)clinically unstable
b)birth wt <1500g and <7days old
c)concurrent coagulopathy
d)previous significant hemorrhage(grade3or4 IVH)
e)prior to surgical procedure
f)post operative period(72hours)
Contd...
Platelet count 50,000-1,00,000/cubic
mm,
Transfuse if,
a)active bleeding
b)NAIT with intracranial bleed
c)before or after neurosurgical
procedures
Dose-10ml/kg
GUIDELINES FOR FRESH FROZEN
PLASMA TRANSFUSION
DIC
Vit-k deficiency bleeding
Bleeding in congenital coagulation factor deficiencies
when more specific treatment is unavailable or
inappropriate
Reconstitution of packed RBCs for exchange
transfusion
Sick neonates with unspecified coagulation disorder
due to sepsis,DIC,NEC,hepatitis etc
Before undertaking invasive procedure in an infant
having PT/APTT 1.5-2 times of normal value
Dose-10-15ml/kg
GUIDELINES FOR CRYOPRECIPITATE
TRANSFUSION
Congenital factor VIII deficiency
Congenital factor XIII deficiency
Afibrinogenemia and
Dysfibrinogenemia
Vonwillebrands disease
Dose-10ml/kg
TREATMENT OF SPECIFIC
DISORDERS
DIC
Baby appears sick and may have petechiae,GI
hemorrage,oozing from venipunctures,
infection,asphyxia or hypoxia.
PLC decreased,PT and APTT increased,fibrinogen
decreased,D-dimers increased,fragmented RBC
seen on peripheral smear.
Rx
a)underlying cause should be treated
eg:sepsis,NEC,asphyxia
b)confirm that vitamin K has been given
contd...
c) Platelets and FFP are given as needed
d) If bleeding persists
i) exchange transfusion with fresh citrated whole blood
or reconstituted whole blood(packed rbc,platelets,FFP)
ii) continuous transfusion with platelets,packed rbc and
FFPas needed
iii)administration of cryoprecipitate for
hypofibrinogenemia
iv)if consumption coagulopathy is associated with
thrombosis of large vessels and not with concurrent
bleeding,heparinization with out a bolus may be
considered.
HEMORRHAGIC DISEASE OF
NEWBORN
Type Age Typical site of Cause
bleed

Intracranial, Maternal drugs,


Early <24hrs gastrointestinal, inherited
intra abdominal. coagulopathy.

GIT, mucosal, Missing the dose


Classic 2-7 days umbilical stump, of vit K at birth.
injection sites

Intracranial, GIT, Cholestasis,


Late 2-16 weeks skin. diarrhoea,
idiopathic.
Contd...
Rx
1)Vitamin K 1-5mg IV slowly.
2)FFP or Fresh whole blood in case
of serious bleeding particularly in
premature infants or those with liver
disease.
IMMUNE
THROMBOCYTOPENIA
Autoimmune thrombocytopenia is due to
antibodies directed against an antigen on
mothers own platelets.
Alloimmune thrombocytopenia is due to
antibodies directed against paternal platelet
antigens.
Suspected in well baby with isolated severe
thrombocytopenia usually in first 24hours of life.
There can be a history of affection of previous
sibling
Contd...
Rx
a)platetelet transfusion when
PLC <30,000/cmm,irrespective of
bleeding
PLC 30,000-49,000/cmm,if minor bleeding
PLC 50,000-99,000/cmm,if major bleeding
b)IVIG: 0.4g/kg/day for 5 days or 1g/kg/day
for 2 days
c)Prednisolone 2mg/kg/day
MANAGEMENT OF ISOLATED
ALTERED GASTRIC ASPIRATE
Give stomach wash with NS.
If altered aspirate continues, send
platelet count and coagulogram.
If platelet count and coagulogram is
normal or stress bleeding is
suspected,give IV Rantidine 0.5
mg/kg/dose BD for Preterm and
1.5mg/kg/dose TID for term babies.
PREVENTION OF BLEEDING
Give 1mg vit-k IM to all babies
>1.5kg and 0.5mg to all babies
<1.5kg.
Give vit-k weekly to babies on
TPN,broad spectrum antibiotics and
sick neonates.
Give 10mg vit-k IM/IV to mothers
24hrs before delivery, who are on
drugs like
phenobarbitone,phenytoin,antiTB
SUMMARY
Well baby
platelets

low Normal

PT normal Increase Normal Normal


d

PTT Normal increase increased Normal


d

Likely Immune HDN Clotting Local cause,


diagnosi thrombocytopenia, factor qualitative
s occult infection, deficiency platelet
maternal drug intake defects,
XIII deficiency
Treatme Platelet transfusion Vit K FFP Supportive
nt 1- CPP
2mg,FFP
Sick baby
Platelets
Low Normal
PT Normal Increased Increased Normal
PTT Normal Increased Increased Normal
Likely Platelet DIC, Liver disease Local cause-
diagno consumption(NEC, protein C Heparinisatio Vascular,
sis infection, deficiency n ulcer
thrombosis)
Treatm Treat the cause , Treat the Supportive Supportive
ent platelet transfusion cause Vit K
Restore FFP
homeostasis
Blood
component
therapy
Thank u