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Bleeding in neonates
Presented byModeratorDr Bibek agarwal Dr Reeta bora
DM(neonatology)
Bleeding They
vessels.
system
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
MISC.trauma
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:
of bleeding:localised/generalised superficial/deep
Type
of bleed:petechae,purpura,echymosis
Systemic exam
All
Abdomen:evidence
infection
CNS:cephalhematoma,subgaleal
bleed
CVS:bruit/murmur
Lab tests
Initial
screen
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
thrombin
time(TT)
-tests deficiency/dysfunction of fibrinogen -measures the time requirement to form clot when thrombin is added to plasma
subsequent tests
Based
report
DIC:FDP,D-Dimer Specific PIVKA Apt
factor assay
nb
PTT
Increase increased d N N N N
low N
Well
nb
PTT
platelet PT
decreas N ed N N
ITP,thrombosis,occult infection
PT DIC
PTT
platele FDP t N N N
causes in
sick : DIC , consumptive thrombocytopenia well : vitamin k deficiency, immune thrombocytopenia & local trauma
Hemorrhagic disease of newborn Age <24 Sites of bleed Intracranial Intrathoracic intraabdomina causes Maternal therapy
Type Early
Umblicus, GIT, nose , Missing the dose of following surgery vit k at birth
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
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
Platelet conc
FFP
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. .
30 49
50 - 99 >99
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