Late hemorrhagic disease of the newborn (clinical analysis). Hemorrhagic disease of the newborn: clinical guidelines
In newborns, this is a pathology characterized by the appearance of spontaneous bleeding and caused by the insufficiency or absence of certain elements. This disease usually manifests itself from the second to fifth birthday of the child.
Reasons
Hemorrhagic disease of newborns has two types: primary and secondary. In the first case, the cause of bleeding is an insufficient amount of vitamin K in a person’s blood. It is he who is considered “mainly responsible” for the process of its collapse. The second form of the disease occurs in premature or very weak children. In this case, in addition to the lack of vitamin K, the baby’s liver works poorly.
According to many doctors, hemorrhagic disease of newborns may be directly related to the use of certain medicines pregnant woman, which negatively affected the functioning of the child’s liver. Such drugs include the popular aspirin, various antibiotics, anticonvulsants and some sedatives.
Signs
Hemorrhagic disease of newborns is manifested by the following symptoms:
- bleeding from the nose;
- bleeding from the gastrointestinal tract;
- vomiting with bloody discharge;
- bleeding of the navel;
- the appearance of hematomas of various types;
- hemorrhage of internal organs (in the adrenal glands, liver, etc.).
How is this disease diagnosed?
The diagnosis is based on visible clinical data, test results and hematological studies. The latter include:
- platelet count;
- identification of combined activity of factors II and VI;
- blood smear;
- performing a special thrombotest;
- identifying the amount of hemoglobin in the blood.
newborns: late form
In some cases this pathology may occur only 2-3 weeks after the birth of the baby. This often affects newborns who are breastfed and have problems with metabolic disorders.
Treatment of this pathology
Therapy of this disease is as follows:
- baby needs to do 3 days intramuscular injection Vikasol solution (1%) - approximately 0.3-0.5 ml 2 times a day;
- taking medications that contribute to - ascorbic acid, routine, calcium chloride;
- at heavy bleeding plasma or a special drug is prescribed;
- taking substitution and symptomatic drugs;
- oxygen therapy.
Prevention of this disease
To prevent the development of hemorrhagic disease, it is necessary for absolutely all women to take vitamin K during childbirth. If labor is difficult, then add a dose 12 hours after the start labor activity. The newborn also needs to be prescribed this vitamin without waiting for signs of the disease to appear.
Viral hemorrhagic disease
This is a type of pneumonia. This type of disease is typical for rabbits.
RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2014
Hematemesis of the newborn (P54.0), Hemorrhagic disease of the fetus and newborn (P53), Gastrointestinal bleeding of the newborn (P54.3), Rectal bleeding of the newborn (P54.2), Melena of the newborn (P54.1)
Neonatology, Pediatrics
General information
Brief description
Approved on Expert commission
On health development issues
Ministry of Health of the Republic of Kazakhstan
Hemorrhagic disease of the newborn- a disease manifested by increased bleeding due to inadequate activity of vitamin K-dependent blood clotting factors.
I. INTRODUCTORY PART
Protocol name: Hemorrhagic disease of the newborn
Protocol code
ICD code X:
P53 Hemorrhagic disease of the fetus and newborn.
P54.0 Hematomesis of the newborn.
P54.1 Melena of the newborn.
P54.2 Bleeding from the rectum in a newborn
P54.3 Gastrointestinal bleeding in a newborn
Abbreviations used in the protocol:
GrD is a hemorrhagic disease.
IVH - intraventricular hemorrhage
APTT - activated partial thrombin time
PTT - prothrombin time
FFP - fresh frozen plasma
PDF - degradation products of fibrinogen and fibrin
Date of development of the protocol: 2013
Protocol users: neonatologists of obstetric organizations and pediatricians of hospitals and primary care.
Classification
Early hemorrhagic disease fetus and newborn: manifests itself in the first days after birth, which is due to low level vitamin K in the fetus (no more than 50% of the adult level).
Classic hemorrhagic disease newborn: manifests itself in the first week after birth due to insignificant intake of vitamin K from breast milk and the lack of proper intestinal microflora involved in the synthesis of vitamin K.
Late hemorrhagic disease newborns - manifests itself between 2 and 12 weeks of life and is caused by a secondary disruption of the synthesis of polypeptide precursors of blood coagulation factors due to liver disease (hepatitis, biliary atresia, prolonged parenteral nutrition or malabsorption syndrome, etc.).
Diagnostics
II METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
A. Analysis of risk factors:
Mother taking anticoagulants during pregnancy indirect action(from the neodicoumarin group)
Prematurity
Absence or insufficient breastfeeding
Long-term use of broad-spectrum antibiotics
Long-term parenteral nutrition
Liver diseases
B. Clinical manifestations:
In the early form of GRB, bleeding occurs in the first hours or days after birth in the form of skin hemorrhages, intracranial hemorrhages, and cephalohematoma.
The classic form of HRD in newborns manifests itself with bleeding on days 2-5 of life. The appearance of melena, hematomesis, skin hemorrhages (ecchymoses, petechiae), nosebleeds, etc. are typical. Children with severe birth trauma and hypoxia have a high risk of hemorrhages under the aponeurosis, internal hematomas, etc.
The late form of HRD in newborns occurs against the background of transmitted diseases.
Complaints and anamnesis:
Anamnesis data that makes it possible to identify newborns who may have signs of bleeding even before birth are presented in paragraph 11 A (A. Analysis of risk factors).
Physical examination:
A complete examination of the newborn is carried out 2 hours after birth, during which skin hemorrhages, intracranial hemorrhages, and cephalohematomas can be detected already in the first hours or days if the birth is adequately performed.
Laboratory research
Blood sampling technique for hemostasis studies:
Make sure that when collecting blood, the blood comes out freely and without difficulty.
You must use a centrifuge tube from the refrigerator.
Completely fill the tube with blood to the indicated mark (usually no more than 1.5 ml).
If the blood has clotted during collection, you need to take another tube.
If there is no access or it is impossible to draw blood from a vein, it can be taken from an arterial catheter in the required amount (1 ml).
Scope of study:
Clotting time
Prothrombin time
Activated partial thromboplastin time
Fibrinogen
If there are signs of DIC syndrome, the following parameters are additionally examined: fibrinogen degradation products (FDP), D-dimer.
Carrying out additional research depends on the results of previous studies and the recommendation of the haematologist consultant.
Normal limits
Differential diagnosis
Differential diagnosis is made between the following diseases: hereditary hemorrhagic diseases due to deficiency of coagulation factors, liver diseases, DIC syndrome.
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Treatment
Goal of treatment:
Stop bleeding;
Stabilization of the condition (hemodynamics, gas exchange)
Treatment tactics
Drug treatment:
Urgent Care
All newborns with impaired hemostasis who did not receive vitamin K at the time of birth should receive vitamin K at a rate of 100 mcg/kg intramuscularly.
If prothrombin time and activated partial thromboplastin time are outside the upper limit of normal, FFP should be administered intravenously over 30 minutes at a rate of 10-15 ml/kg.
Repeat the study of prothrombin and activated partial thromboplastin time and, if their disturbances persist, repeat the previous dose of FFP.
If there is no effect after administration of FFP, cryoprecipitate is used at a rate of 5 ml/kg for 30 minutes.
Repeat the study of prothrombin and activated partial thromboplastin time and, if their disturbances persist, administer cryoprecipitate in the same dose.
Monitoring
If the indications persist, it is necessary to repeat the blood clotting test every 12 hours.
It is necessary to identify and treat the cause of coagulopathy: sepsis, shock, hypothermia, hypoxia, etc.
If coagulopathy persists for more than 24 hours, consultation with a hematologist is necessary.
Other treatments: no.
Surgical intervention: no.
To prevent hemorrhagic disease in a newborn after birth, it is necessary to administer vitamin K intramuscularly 1 mg once (possibly oral administration drug according to the instructions).
Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
Normalization of blood clotting parameters.
Drugs ( active ingredients), used in the treatment
Hospitalization
Indications for hospitalization:
Obstetrics organization of any level, pediatric medical institution.
Information
Sources and literature
- Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
- 1) Bandyopadhyay PK. Eight. In: Vitamins and Hormones. Vol 78. Elsevier Inc; 2008:157-84. . 2) Clarke P, Shearer MJ. Vitamin K deficiency bleeding: the readiness is all. Arch Dis Child. Sep 2007;92(9):741-3. . 3) Pichler E, Pichler L. The neonatal coagulation system and the vitamin K deficiency bleeding - a mini review. Wien Med Wochenschr. 2008;158(13-14):385-95. . 4) Oldenburg J, Marinova M, Müller-Reible C, Watzka M. The vitamin K cycle. VitamHorm. 2008;78:35-62. . 5) Paiva SA, Sepe TE, Booth SL, et al. Interaction between vitamin K nutrition and bacterial overgrowth in hypochlorhydria induced by omeprazole. Am J Clin Nutr. Sep 1998;68(3):699-704. . 6) Greer FR. Vitamin K status of lactating mothers and their infants. ActaPaediatr Suppl. Aug 1999;88(430):95-103. . 7) vonKries R, Shearer MJ, Widdershoven J, Motohara K, Umbach G, Gobel U. Des-gamma-carboxyprothrombin (PIVKA II) and plasma vitamin K1 in newborns and their mothers. ThrombHaemost. Oct 5 1992;68(4):383-7. . 8) Booth SL, Suttie JW. Dietary intake and adequacy of vitamin K. J Nutr. May 1998;128(5):785-8. . 9) Greer FR, Mummah-Schendel LL, Marshall S, Suttie JW. Vitamin K1 (phylloquinone) and vitamin K2 (menaquinone) status in newborns during the first week of life. Pediatrics. Jan 1988;81(1):137-40. . 10) Ozdemir MA, Karakukcu M, Per H, Unal E, Gumus H, Patiroglu T. Late-type vitamin K deficiency bleeding: experience from 120 patients. Childs Nerve Syst. Feb 2012;28(2):247-51. . 11) Takahashi D, Shirahata A, Itoh S, Takahashi Y, Nishiguchi T, Matsuda Y. Vitamin K prophylaxis and late vitamin K deficiency bleeding in infants: fifth nationwide survey in Japan. Pediatric Int. Dec 2011;53(6):897-901. . 12) Darlow BA, Phillips AA, Dickson NP. New Zealand surveillance of neonatal vitamin K deficiency bleeding (VKDB): 1998-2008. J Paediatr Child Health. Jul 2011;47(7):460-4. . 13) Alatas FS, Hayashida M, Matsuura T, Saeki I, Yanagi Y, Taguchi T. Intracranial Hemorrhage Associated With Vitamin K-deficiency Bleeding in Patients With Biliary Atresia: Focus on Long-term Outcomes. J PediatrGastroenterolNutr. Apr 2012;54(4):552-7. . 14) American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics. Jul 2003;112(1 Pt 1):191-2. . 15) American Academy of Pediatrics, Committee on Nutrition. Nutritional Needs of Preterm Infants. In: Ronald E. Kleinman, MD. Nutritional needs of preterm infants. In: Pediatrics Nutrition Handbook. 5th. Elk Grove Village, IL: American Academy of Pediatrics; 1998:23-46. 16) Greer FR, Marshall SP, Foley AL, Suttie JW. Improving the vitamin K status of breastfeeding infants with maternal vitamin K supplements. Pediatrics. Jan 1997;99(1):88-92. . 17) Van Winckel M, De Bruyne R, Van De Velde S, Van Biervliet S. Vitamin K, an update for the pediatrician. Eur J Pediatr. Feb 2009;168(2):127-34. . 18) Young TE, Mangum B. Vitamins and Minerals. In: NEOFAX 2008. edition. Montavale, NJ: Thomson Reuters; 2008:288-9.
The first seven days of a person’s life are usually called the early neonatal period. Majority congenital diseases appears precisely at this time. 3-5 out of 1000 infants have hemorrhagic disease. It is characterized by excessive bleeding in the stomach, nose and umbilical region due to a lack of vitamin K.
What is hemorrhagic disease and why does it occur in newborns?
The first days after birth, the child’s body adapts to new conditions. Rebuilding vitally important systems and organs, the pulmonary circulation is turned on, the lungs begin to work, and the intestines are gradually populated by microorganisms.
Vitamin K is one of the main components of normalizing the blood coagulation process. It is involved in protein synthesis and is used by the liver to make prothrombin, which thickens the blood. Bacterial flora in the adult body produce sufficient amounts of this vitamin; dark green leafy vegetables are rich in it. In infants intestinal microflora is not yet formed, so hemorrhagic disease of newborns occurs.
The deficiency of K-vitamin-dependent factors is most acutely felt on the 2-4th day of life. The situation normalizes within a few days, when more mature liver cells are included in the synthesis process.
There can be several reasons for the occurrence of K-hypovitaminosis:
- intestinal dysbiosis - the production of bacterial intestinal flora begins only 3 days after birth;
- lack of vitamins during the fetal period - it is difficult for vitamin K to penetrate the histohematic barrier, so in adults its amount is 2 times greater than in a newborn;
- low vitamin content of breast milk – daily consumption vitamins are not always covered mother's milk, then you need to adjust your diet;
- taking anticoagulants and Aspirin by a pregnant woman;
- congenital disorders of the intestines or liver;
- toxicosis of a pregnant woman;
- drugs for the treatment of maternal tuberculosis;
- decreased estrogen levels in the baby;
- obstruction of the bile ducts.
The occurrence of hemorrhagic disease is facilitated by the prematurity of the child. In this situation, the liver does not produce enough polypeptide precursors plasma factors involved in blood clotting.
The development of the disease is facilitated by the birth of a child before the due date. Late hemorrhagic disease of the newborn is caused by a lack of vitamin K production due to:
- late attachment to the maternal breast and intravenous nutrition;
- malabsorption - nutrients poorly absorbed by the intestines;
- antibiotics such as 3rd generation cephalosporins;
- lack of oxygen for the fetus;
- birth injuries;
- artificial delivery;
- violations respiratory functions at the moment of birth.
The first colostrum, received by the baby from the mother's breast 15-30 minutes after birth, contains many vitamins and microelements. It populates the intestines with microflora and helps further the production of bacteria in the body. The mechanism of coagulopathy in a newborn is rarely triggered. A small dose of vitamin K is enough to maintain stable blood circulation in a healthy child. As a rule, the occurrence of pathology at an early stage is provoked by a woman’s illnesses during pregnancy.
Classification and symptoms of the disease
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Usually the disease manifests itself in newborns immediately and is successfully treated in the maternity hospital. It is more difficult to stop bleeding after the baby is discharged.
Parents do not always correctly assess the symptoms and are in no hurry to seek medical help. The baby's recovery is only possible with treatment. initial stage And light form hemorrhagic disease. Serious blood loss, malfunction of the heart, lungs, and cerebral bleeding often lead to fatal consequences.
Early and late forms
Depending on the duration of the disease, doctors distinguish the following forms:
- early – develops 1-2 days after birth, characterized by severe tissue bleeding;
- classical - occurs on days 3-5 of life;
- late – most dangerous form, appears only at 2-8 weeks of life and can provoke hemorrhage in internal organs and the brain (see also:).
In the presence of hemorrhagic disease in a newborn, increased bilirubin The disease is easily diagnosed because its symptoms are difficult to confuse with other diseases. The baby has:
- bruises, ecchymoses and petechiae;
- nosebleeds;
- weakness, lethargy, decreased motor activity;
- umbilical bleeding;
- blood in stool or urine;
- bloody vomiting, cough (we recommend reading:);
- increased bilirubin;
- neurological symptoms of intracranial hemorrhage;
- "acute" stomach.
The presence does not always indicate internal bleeding. It could also be the mother's blood that entered his body during childbirth. In order to determine the nature of melena, an Apta test is performed:
- stool is diluted with water until it turns pink;
- the supernatant is isolated from the solution;
- add sodium hydroxide in a ratio of 5:1;
- After 2-3 minutes, the shade of the solution is analyzed.
The yellowish-brown color indicates the presence of adult hemoglobin, that is, maternal hemoglobin. If the color has not changed, it is the blood of a newborn.
Primary and secondary forms
Depending on the factor that provoked the lack of vitamin K in the body, hemorrhagic disease in newborns is classified into:
- primary – initially there is a deficiency of vitamin K;
- secondary – its main causes are liver pathologies and impaired synthesis of PPPP in the infant.
The intrauterine development of the disease leads to the fact that at birth, cephalohematomas are visible on the baby’s head - tumors with visible pinpoint hemorrhages (more details in the article:). Hemorrhagic disease in newborns late form sometimes it appears even in the third month of the baby’s life. It develops reactively, after the appearance of numerous bruises, intracranial hemorrhage occurs, so it is important to pay attention to early symptoms in time and seek medical help. A child is at risk if:
- there are many bruises on the body - in the first months the baby’s movement is limited, so he is not able to hit himself;
- the site of injection and blood collection for analysis bleeds for a long time;
- pale skin.
Severe disease provokes hypovolemic shock due to sudden loss of fluid due to diarrhea or vomiting. It is characterized by a decrease in blood volume in the body and a drop in blood pressure.
Features of treatment
Treatment of hemorrhagic disease of newborns should begin when the first signs appear. Prompt diagnosis and therapy is the key to a child’s successful recovery. The main task facing parents and doctors is to compensate for vitamin K deficiency, and it is important to follow the dosage and use a set of procedures:
- breastfeeding - the baby is fed breast milk every 3 hours, the portion depends on age, with thrombocytopenic purpura feeding continues for at least 4 weeks;
- administration of a 1% solution of vitamin K - drugs are administered intravenously, but in mild cases intramuscular administration is possible once a day, the dosage is calculated depending on the baby’s body weight (0.1-0.15 ml per 1 kg);
- Vikasol solution - an artificial analogue of vitamin K, which stops bleeding, but is less effective, is used every 12 hours, dose - 2-4 mg;
- bolus plasma transfusion - carried out for recurrent bleeding (dosage - 15 ml/kg);
- solutions of thrombin, sodium bicarbonate, aminocaproic acid with Adroxon (we recommend reading:);
- preparations based on ascorbic acid, rutin, calcium gluconate or calcium chloride;
- glucocorticosteroids or specific antibiotics;
- transfusion of red blood cells (5-10 ml/kg) - the doctor prescribes the procedure if the disease is complicated by hypovolemic shock.
During treatment of the disease, it is very important to adhere to breastfeeding Excess vitamins can lead to complications such as:
- hemolytic anemia;
- kernicterus, associated with increased bilirubin levels (we recommend reading:);
- anemia.
Reception too large quantity hemostatic drugs can cause the development of hyperbilirubinemia and activation of Heinz bodies. In this regard, treatment is carried out exclusively in a hospital setting, and the prescription and use of drugs is controlled by a neonatologist.
Consequences of hemorrhagic disease of newborns
Professional and timely medical care allows you to quickly eliminate mild forms of the disease. The risk of death is high in children who have experienced:
- large blood loss;
- disturbance of cardiac activity;
- disruptions in the development of the adrenal glands;
- cerebral hemorrhage.
To prevent the development of pathology, it is recommended that children at risk be given intramuscular vitamin K immediately after birth (birth ahead of schedule– 0.5 mg, and for full-term babies with normal weight body dose is increased to 1 mg). Early breastfeeding is also an excellent preventive measure. The pathology does not transform into other diseases; upon completion of treatment, the symptoms disappear, and the body little man continues to develop without any disturbances.
Fortunately, hemorrhagic disease of newborns is an infrequent phenomenon, occurring in only 2-5 children out of 1000, and doctors encounter its more dangerous late form even less often - 5-20 children per 100 thousand. “So this is definitely not about us,” you will think, and it’s good if you turn out to be right. Otherwise, only lightning-fast reaction parents on alarming symptoms will help save the baby... So, as they say: “forewarned is forearmed.”
Causes of hemorrhagic disease of newborns
The cause of hemorrhagic disease is vitamin K deficiency, which is necessary for normal blood clotting. Its lack leads to various bleedings that pose a danger to the child's life.
Factors contributing to the development of hemorrhagic disease include the mother taking a number of medications during pregnancy (indomethacin, phenytoin, acetylsalicylic acid, antibiotics), immaturity or prematurity of the newborn, perinatal hypoxia, asphyxia, untimely breastfeeding, as well as birth injuries.
Newborns who, according to doctors, are at risk are given a prophylactic dose of vitamin K immediately after birth ( Vikasol).
The causes of late hemorrhagic disease are somewhat different; we will dwell on them in more detail a little later.
Symptoms and treatment of hemorrhagic disease of newborns
Since classical hemorrhagic disease develops in 2-4 days after birth(rarely on the first day), that is, while the child is still in the maternity hospital, parents just need to trust the professionalism of the doctors and not interfere with the treatment of the baby.
The most common symptoms of classical hemorrhagic disease are nose and gastrointestinal bleeding, continuous bleeding from or after. Therefore, if the baby spits up with blood, his nose is bleeding, the injection site bleeds for a long time, the umbilical wound or there is blood on the diaper, do not wait for the next round, ask the neonatologist to examine the newborn unscheduled, because the sooner treatment begins, the greater the chances of success .
If a blood test confirms the diagnosis, the baby should be immediately they begin to treat. Treatment consists of intramuscular injection vitamin K, plasma and blood transfusions (especially severe cases). In addition, about 6 times a day the newborn is fed expressed breast milk, which helps stop bleeding due to the fact that it contains thrombokinase.
If the diagnosis is timely and the treatment of hemorrhagic disease is correct, newborns will quickly complete recovery occurs.
Late hemorrhagic disease of the newborn
Late hemorrhagic disease affects children aged 1 to 4 months, most often appearing at 2 months. However, exceptions are possible here too, that is, infants both older than the specified age and younger can get sick. The late form of the disease has a slightly different nature - it is caused by the fact that the intestinal flora is not able to synthesize vitamin K2 in sufficient quantity. This disease is more severe and much more dangerous than the classic version.
Who is at risk? As a rule, these are full-term children who did not receive a prophylactic dose of vitamin K in the maternity hospital and suffer from transient liver failure (indirect sign such insufficiency is jaundice that has not resolved by 1 month) and, oddly enough, are exclusively on breastfeeding . What does breastfeeding have to do with it? It turns out that the intestines of children fed with mother's milk are populated by flora that does not cope well with the synthesis of vitamin K2, while with artificial feeding the situation is quite the opposite.
The danger of late hemorrhagic disease of newborns is that if treatment is not started in as soon as possible, That large-scale intracranial hemorrhages can't be avoided. High percentage mortality from the late form of this disease is associated precisely with the difficulty of its recognition. Since this phenomenon is considered very rare, not every local pediatrician will be able to interpret the symptoms in a timely manner, and parents are often in no hurry to see a doctor, not realizing that in such a situation literally minutes count.
So, parents should be wary the appearance of bruises on the baby’s body- in any quantity and any size. There is no need to think about under what circumstances the baby could have received such an injury - rubbed with a button from a bodysuit, hit the crib, lay down on a rattle... Don’t look for excuses, but call an ambulance, as this is the first alarm bell!
If a baby's blood was taken for analysis, and my finger won't stop bleeding, then this is a sure sign of problems with blood clotting, which means a reason to urgently call doctors. Why such a rush? The fact is that the very first visible symptoms, such as bruises on the body, bleeding, etc., will develop into intracranial hemorrhage in just 1-2 days, so this issue It’s better to “be on the safe side.”
And finally, I would like to wish your children good health. Let the knowledge gained from this article remain only theoretical, and you will never have the opportunity to put it into practice!
– a pathology that occurs when there is a deficiency of blood coagulation factors against the background of endogenous or exogenous vitamin K deficiency. Manifested by vomiting mixed with blood, bloody tarry stools, skin hemorrhages, hematomas and internal hemorrhages. Rarely accompanied by hemorrhagic shock, the development of jaundice and the formation of erosions of the mucous membranes of the gastrointestinal tract. Diagnosis is based on determining the number of platelets, studying a coagulogram, performing ultrasound and neurosonography. Treatment consists of replacement therapy with synthetic analogues of vitamin K, stopping internal bleeding and correcting hypovolemia.
General information
hemorrhagic diathesis, characterized by a deficiency of II (prothrombin), VII (proconvertin), IX (antihemophilic globulin B) and X (Stewart-Power factor) coagulation factors with vitamin K deficiency in the child’s body. The pathology was first described in 1894 by Charles Townsend, but the introduced term was initially used for all congenital hemorrhagic conditions. Prevalence is 0.3-0.5% among all newborns. After the introduction of mandatory prophylaxis with vitamin K analogues at birth, the incidence decreased to 0.02%. About 3-6% of cases of hemorrhagic disease of newborns are a consequence of the mother taking pharmacotherapeutic drugs during pregnancy.
Causes of hemorrhagic disease of newborns
The cause of hemorrhagic disease of newborns is insufficiency of synthesis of blood coagulation factors II, VII, IX and X. The formation of these factors takes place in liver tissues by γ-carboxylation of glutamic acid under the influence of vitamin K. With endogenous or exogenous vitamin K deficiency, functionally immature factors are produced that have a stronger negative charge on their surface. Such factors cannot bind to Ca ++ and then to phosphatidylcholine. As a result, fibrin is not formed and a red blood clot does not form.
Primary, or exogenous, vitamin K deficiency is caused by insufficient intake of it into the body during pregnancy. Provoking factors for hemorrhagic disease of newborns are maternal disorders: the use of anticonvulsants (carbamazepine, convulex), anticoagulants and antibacterial drugs broad spectrum of action (cephalosporins, tetracyclines, sulfonamides), premature birth, liver diseases, enteropathy, eclampsia, dysbacteriosis, poor nutrition.
Secondary, or endogenous, deficiency is caused by insufficient synthesis of polypeptide precursors of plasma coagulation factors (PPPF) in the child’s liver tissues. This form of the disease, as a rule, is provoked by disorders on the part of the newborn: liver diseases (hepatitis), malformations (anomalies in the structure of the biliary tract), functional immaturity of the liver parenchyma, malabsorption syndrome, antibiotic therapy, lack of prophylactic administration of vikasol (an analogue of vitamin K) after childbirth, artificial or long-term parenteral feeding. The first few days of a child’s life, his gastrointestinal tract is in a sterile state - the microflora that promotes the absorption of vitamin K has not yet had time to form, which also aggravates the secondary endogenous deficiency of this compound.
Classification of hemorrhagic disease of newborns
Taking into account the period of onset of the first symptoms, hemorrhagic disease of newborns has following forms:
- Early. Symptoms occur in the first 12-36 hours after birth. Rarely seen. Usually a consequence drug therapy mother.
- Classic. The manifestation of symptoms occurs on days 2-6. The most common form.
- Late. Develops after 1 week of life, rarely occurs before the age of 4 months. As a rule, it is formed against the background of provoking diseases or the absence of preventive injections of vitamin K.
Symptoms of hemorrhagic disease of newborns
Symptoms of hemorrhagic disease of newborns depend on the time of development of the disease. Early form gives detailed symptoms in the first 24 hours of a child’s life. The primary manifestation is vomiting with blood of the type “ coffee grounds"(hematemesis). Internal bleeding may occur (more often in the parenchyma of the liver, adrenal glands, spleen and lungs). In some cases, this pathology occurs even before birth and is manifested by hemorrhages in the brain tissue, petechiae and ecchymoses on the skin from the moment of birth.
The classic form most often manifests itself on the 4th day. Her clinical picture includes hematemesis, melena, petechiae and ecchymoses throughout the body. The first symptom is usually black, tarry stools. Bleeding from umbilical wound and cephalohematomas. When using obstetric instruments during childbirth and severe asphyxia against the background of vitamin K deficiency, subcutaneous hematomas, subgaleal and intracranial hemorrhages can form. With severe gastrointestinal bleeding, an increase in bilirubin is detected (mainly due to the indirect fraction) as a consequence of massive hemolysis of red blood cells in digestive tract under the influence gastric juice. This condition is accompanied by prolonged jaundice, erosions of the mucous membranes duodenum and pylorus. The last two complications can aggravate blood loss and form a “vicious circle”.
The late form has a clinical picture similar to the classic one, but usually occurs on days 7-14 of life and more often occurs with complications. Approximately 15% of children with this form are at risk of developing hemorrhagic shock, manifested general weakness, pallor skin, a drop in blood pressure and a decrease in body temperature.
Diagnosis of hemorrhagic disease of newborns
Diagnosis of hemorrhagic disease of newborns consists of identifying risk factors, conducting an objective examination, studying the results of laboratory and instrumental methods research. When collecting an anamnesis, a neonatologist or pediatrician is able to detect predisposing factors: the mother’s medication intake, poor diet, concomitant diseases, etc. Also, during the interview, it is important to establish the first symptoms of the child’s disease and their severity at the time of occurrence.
Physical examination makes it possible to determine diffuse hemorrhages on the skin (rarely - locally, on the buttocks), jaundice with hyperbilirubinemia, disorder general condition and symptoms of hypovolemia in hemorrhagic shock. Laboratory tests are aimed at assessing the hemostatic system. The platelet level, thrombin time and fibrinogen amount are determined. The time of blood clot retraction (indicators within normal limits), activated partial thromboplastin time (aPTT), Bürker blood clotting time and plasma recalcification time (results indicating a deficiency of coagulation factors) are determined. In the UAC, signs of anemia are possible. Ultrasound and neurosonography can detect hemorrhages in the periosteum of the skull bones, central nervous system tissue and other organs.
The disease is differentiated from the syndrome of “swallowing of maternal blood”, disseminated intravascular coagulation, idiopathic thrombocytopenic purpura, hemophilia A and B, von Willebrand disease. During differential diagnosis An Apta test, platelet count assessment, coagulogram and determination of coagulation factor deficiency are performed.
Treatment of hemorrhagic disease of newborns
Etiotropic treatment of hemorrhagic disease of newborns involves replacement therapy with vitamin K analogues. In pediatrics they use synthetic drugs vitamin K (vicasol). The duration of administration is from 2 to 4 days, depending on the results of control tests. If hematemesis is present, gastric lavage is performed saline solution, aminocaproic acid is administered through a probe. If confirmed gastrointestinal bleeding an enteral mixture containing thrombin, adroxon and aminocaproic acid is indicated. Treatment of hemorrhagic shock involves restoration of bcc using infusion therapy using 10% glucose solution, 0.9% NaCl, fresh frozen plasma and prothrombin complex (PP5B).
Forecast and prevention of hemorrhagic disease of newborns
For uncomplicated hemorrhagic disease of the newborn, the prognosis is favorable. With the development of hemorrhages in the brain tissue, 30% of children experience severe damage to the central nervous system. In some cases, death is possible. There are no relapses. The formation of other hemostasis disorders after recovery is not typical.
Prevention is carried out for all children at risk. The risk group includes premature patients with a gestation period from 22 to 37 weeks, children with birth trauma of newborns, patients on artificial or parenteral feeding, newborns receiving antibacterial agents, and babies born from mothers with risk factors. Preventive measures consist of a one-time administration of Vikasol, early and full breastfeeding. On at the moment Vitamin K analogues are recommended to be administered to absolutely all children at birth. On the mother's part, it is necessary to limit the intake of provoking medications as much as possible and provide adequate treatment concomitant diseases during pregnancy, visit regularly antenatal clinic and undergo appropriate examinations (ultrasound, OAC, OAM and others).