Haemorrhagic disease of the newborn

P53

DESCRIPTION

This is due to a deficiency of vitamin K-dependent clotting factors II, VII, IX and X. All newborns who did not receive vitamin K1 at birth, especially preterm babies and breastfed babies, are at risk.

Spontaneous bleeding may be from any site but is usually gastro-intestinal, producing haematemesis or melaena. Bleeding from the umbilical stump, epistaxis and a cephalohaematoma or subgaleal haemorrhage are also relatively common.

Complications may include anaemia, hypovolaemic shock and intracranial haemorrhage with neurological damage.

There are three forms of the disorder.

Early form: presents within 24 hours of birth in newborns of mothers on treatment with anticonvulsants, e.g. phenytoin and phenobarbitone, or oral anticoagulants.

Classical form: presents during the first week of life, usually on the second to seventh day.

Late form: presents during the first to fourth month of life usually with intracranial haemorrhage in exclusively breastfed babies who did not receive vitamin K prophylaxis at birth.

DIAGNOSTIC CRITERIA

Special investigations

  • Prolonged prothrombin time (PT).
  • Normal partial prothrombin time (PTT).
  • Increased international normalised ratio (INR) with a normal platelet count.
  • Normal fibrinogen levels.
  • Normal thrombin time.

Note:

  • Exclude other causes of bleeding in the neonate.
  • Exclude swallowed blood of mother during delivery in babies with melaena. (Apt test or haemoglobin electrophoresis).

GENERAL AND SUPPORTIVE MEASURES

  • Nurse in neutral thermal environment.
  • Provide adequate nutrition.
  • Monitor:
    • blood pressure,
    • hydration,
    • heart rate,
    • SaO₂,
    • respiratory rate,
    • haematocrit,
    • body temperature,
    • blood glucose, and
    • coagulation parameters.

MEDICINE TREATMENT

  • Oxygen, if needed.
  • Fresh frozen plasma or lyophilised plasma, IV, 20 mL/kg over one hour.

If anaemic (haematocrit < 40% or Hb < 13 g/dL):

  • Packed red cells, IV, 10 mL/kg over 1 hour.
    • May be repeated if necessary.
  • Vitamin K₁, IM, 1 mg as a single dose.

Prophylaxis

  • Vitamin K₁, IM, single dose at birth.
    Full term newborns: 1 mg
    Preterm newborns: 0.5 mg

Prophylaxis with oral vitamin K formulation is not recommended.

REFERRAL

  • Deterioration of clinical condition despite adequate treatment.
  • Suspected intracranial haemorrhage.