Causes and consequences of hemorrhagic disease of the newborn, forms and symptoms of pathology, treatment. Causes, symptoms and treatment of hemorrhagic disease of the newborn

Hemorrhagic disease of the newborn is a pathology associated with insufficiency of blood clotting factors. It is known that some of its elements are responsible for blood clotting. In particular, these blood elements are of the following nature:

• prothrombin;
• proconvertin;
• vitamin K.

However, vitamin K is not a blood element. But it must be contained in the body of the child. Otherwise, blood clotting is impaired. What is the main mechanism of hemorrhages?

Hemorrhages are formed due to increased fragility and the presence of vascular permeability. In the latter case, the permeability is disturbed due to certain factors. In turn, the wall of the vessels is depleted, due to which hemorrhages are observed.

Hemorrhagic disease is a pathology of the blood system. That is, any damage can cause persistent bleeding. Or prolonged bleeding, this is the danger of the disease.

What it is?

Hemorrhagic disease is a pathological process involving the hematopoietic system, mainly designed for impaired blood clotting. Hemorrhagic disease in newborns also manifests itself as hemorrhagic diathesis.

The disease is most dangerous in premature babies. This is due to the prolonged outflow of blood. Hemorrhagic disease in newborns can be delayed until the third week.

Bleeding is localized in various places. Most often, bleeding occurs in newborns in the following systems:

• bleeding on the skin;
• bleeding from the navel;
• bleeding from the mucous membranes of the nose and mouth;
• bleeding from the intestines.

The reasons

What are the main etiological causes of hemorrhagic disease of the newborn? The most common cause of hemorrhagic disease is the pathological condition of the vessels. Namely, their increased fragility and permeability.

The causes of this disease is the birth of a child not on time, but before the due date. In addition, the causes of congenital hemorrhagic disease in newborns are:

• pathology of the gastrointestinal tract;
• pathological conditions of the mother.

In the latter cases, the pathological conditions of the mother can be caused by artificial exposure to chemicals. Also, the disease can be caused by the presence of toxicosis.

Pregnant toxicosis in the absence of proper treatment can cause hemorrhagic disease. The lack of potassium also plays an important role in the development of hemorrhagic disease. Or .

Symptoms

What are the main clinical signs of hemorrhagic disease? The main symptoms of hemorrhagic disease include the presence of a gag reflex. Moreover, the gag reflex is accompanied by the presence of blood.

The disease is characterized by hematemesis. The most dangerous symptom of the disease is the presence of bleeding in the internal organs. Most often, bleeding occurs in the following organs:

• liver;
• adrenals.

Among the clinical symptoms of hemorrhagic disease, skin manifestations are observed. Pinpoint hemorrhage can be found on the skin of a child. Among the symptoms of hemorrhagic disease in a child, lesions of a different nature are observed.

Moreover, these lesions are detected in a much later stage of hemorrhagic disease. One of the symptoms at a late stage of the disease is the presence of blood in the urine. Blood in the urine can be long lasting.

Symptoms of intoxication are also characteristic of the disease. Moreover, the development of infectious shock is possible. Infectious shock, or rather its symptoms are manifested as follows:

• asthenia;
• low blood pressure;
• decrease in body temperature;
• pale skin.

That is, this condition indicates the presence of shock. A sick child at the same time has the above symptoms. If certain measures are not taken, the child may die. Since low blood pressure and body temperature indicates a pathological process.

More details on the site: site

This site is aimed at general acquaintance with information!

Diagnostics

The diagnosis is established on the basis of a hemorrhagic study. Mostly these studies relate to the picture of the blood. The number of cells of the coagulated system is determined. Platelets are responsible for clotting.

It is also appropriate to use the method for determining hemoglobin. Usually, children have a small amount of hemoglobin, which indicates the process of bleeding. However, several days must pass, only after that a reduced amount of hemoglobin is determined.

Diagnosis is also directed to the study of the patient's feces. Often streaks of blood are found in the stools. This applies to both feces and vomit. The clotting factor is also determined.

To determine the clotting factor, it is necessary to conduct an instrumental study. The most informative coagulogram. This disease should be distinguished from other pathologies of blood coagulation. For example, with a congenital pathology of clotting disorders.

Diagnosis of hemorrhagic disease in children is carried out immediately. That is, it is better to carry it out urgently. Otherwise, complications arise. Relevant in the diagnosis of the consultation of doctors. To make a diagnosis, consultation of the following specialists is used:

• pediatrician;
• hematologist.

Only the specialists listed above will help determine the diagnosis. Diagnosis is directed to the ultrasound technique. In this case, the following organs are examined through the use of ultrasound:

• liver;
• gastrointestinal tract;
• spleen.

To determine bleeding, this technique is the most accessible. However, confirmation of the blood picture is required. What indicates the presence of hemorrhagic pathology.

Prevention

Measures to prevent hemorrhagic disease in children are aimed at the treatment of lactating women. Namely, the use of vitamin therapy. Including vitamin therapy is used to provide the body with potassium.

It is also necessary to treat congenital pathologies of the child. This mainly concerns the liver and spleen. Prevention of hemorrhagic disease in children also includes the following activities:

• control of conditions during pregnancy;
• blood control of a pregnant woman;
• early treatment and detection of toxicosis in a pregnant woman;
• It is advisable not to use chemicals during pregnancy.

It is also necessary to prevent the birth of premature babies. Since premature babies most often suffer from this disease. Than children born at term. Pregnancy planning is an important preventive measure. In particular, pregnancy is planned as follows:

• taking vitamins by a woman;
• taking prophylactic drugs of natural origin;
• treatment of diseases of the gastrointestinal pathology;
• no bad habits during pregnancy;
• strengthening immunity;
• body correction;
• no trauma during childbirth.

It is also appropriate to take certain medications after the baby is born. But these drugs are calculated directly at the reception by the child. The best way to administer them is intramuscular. Potassium is used in the same way.

With a preventive purpose, consultations of specialists are shown. Only experts will help determine the next steps. Especially in the prevention of complications.

Treatment

What are the main methods of treatment for hemorrhagic disease in children? The main therapeutic measures include the use of vitamin therapy. Vitamin therapy is based on the use of vitamins. Vikasol is taken not only for preventive purposes, but also for therapeutic purposes.

For children, a certain dosage of the drug is indicated. Usually the course of treatment is not long. But the age of the child and the severity of the disease in the treatment of vikasol are taken into account.

Plasma is widely used in the treatment of hemorrhagic disease in children. This allows you to restore the loss of blood. Especially with heavy prolonged bleeding.

However, blood plasma is also administered to the child at a certain rate. Usually the dosage is determined by the weight characteristics of the child. With a significant loss of red blood cells, infusions are used. Intravenous infusions are necessary for the prevention and treatment of shock conditions.

RBC transfusion is also designed for a certain dosage. Dosage is selected according to body weight. Therefore, the treatment of hemorrhagic disease is aimed at the strict control of doctors. Without a doctor's prescription, it is better not to use therapeutic therapy!

In adults

Hemorrhagic disease in adults is diagnosed at any age. Moreover, it is adults who contribute to the development of the disease in children. Women are usually at risk for morbidity. And reproductive age.

Hemorrhagic disease in adults can begin in childhood. Subsequently, the symptoms of this disease are exacerbated. That is, in addition to skin manifestations in an adult, the following symptoms can be traced:

• decrease in blood pressure;
• the lowest body temperature;
• weakness;
• point hemorrhages;
• massive blood loss.

The clinic of the disease in adults resembles hemophilia. That is why the diagnosis of hemorrhagic disease in an adult is aimed at a differentiated study. The disease can be observed in pregnant women.

Even liver pathology can cause disease. Therefore, the prevention of the disease in an adult includes:

• definition of diseases;
• definition of bleeding;
• bleeding prevention;
• exclusion of injuries;
• treatment of conditions of toxicosis in pregnant women.

It is possible to cure the disease in adults, relying on a comprehensive treatment process. It includes the application of general strengthening measures. The use of blood transfusion and vitamins. Accordingly, in adults, the dosage of drugs in the treatment is higher than in children.

In the elderly

Hemorrhagic disease in the elderly is quite difficult. It is also associated with impaired vascular permeability, as well as depletion of the vascular wall. This disease can be diagnosed in older people since childhood.

Hemorrhagic disease is more often observed before the age of fifty. Moreover, it rarely registers. This is associated with the presence of deaths. The main manifestations of hemorrhagic disease in the elderly are:

• increased fragility of blood vessels;
• bleeding into internal organs;
• vascular necrosis;

Moreover, in older people with this disease, vascular necrosis may develop. This leads to death. Severe lesions of internal organs are not only manifested in bleeding, but also in violation of their functions.

Diagnosis of the disease in the elderly is aimed at examining the anamnesis. In this case, the presence of the disease in childhood is traced. Which indicates the prescription of the disease and the presence of a chronic course.

Elderly people with a severe chronic course of the disease are placed in a hospital. That is, hospitalization of a sick elderly person is carried out. Because the elderly are at high risk of death.

Forecast

In hemorrhagic disease, the overall prognosis can be favorable or unfavorable. It all depends on the course of the disease. A favorable prognosis is observed in the absence of shock situations.

An unfavorable prognosis is observed with a severe picture of the disease. Especially if the chronic nature of hemorrhagic disease is traced. After all, the chronic process is the most dangerous.

With massive bleeding, the prognosis worsens. Massive bleeding leads to long-term disorders. Most often, these violations of a functional nature.

Exodus

Death is diagnosed when the patient's condition is weakened. Also, if the patient could not be brought out of infectious shock. Lack of treatment contributes to the formation of adverse outcomes.

Recovery comes with proper therapy. Adequate treatment contributes to the improvement of the patient's condition. Dangerous liver damage in this disease.

Severe liver damage can cause a poor outcome. Therefore, timely treatment contributes to the improvement of not only the patient's condition, but also the condition of internal organs. After all, the functional features of the organs and systems of the body are responsible for overall health.

Lifespan

In hemorrhagic disease, the patient's condition influences life expectancy. If there is massive bleeding. That life expectancy is reduced.

The chronic process in this disease reduces the quality of life. Therefore, the disease should be treated at the initial stage of its development. The blood picture must be restored.

The age of the patient influences the duration of life. The older the patient, the worse the manifestations of the disease. Any injury can cause irreversible effects. Pulmonary bleeding is also dangerous.

Heavy pregnancy, taking antibiotics, vitamin deficiency and other negative factors affect not only the woman's health, but also lead to the fact that the child develops late hemorrhagic disease of the newborn.

Abnormal changes in the blood begin when the fetus is still in the womb. The process of its coagulation and thickening is not complete without proteins, for the production of which vitamin K is responsible. This trace element retains calcium, which is actively involved in bone formation.

In most European countries and the United States, hemorrhagic disease of the newborn is being prevented. Since the main causes of the anomaly are known, children are immediately prescribed Vikasol, which makes up for the lack of natural vitamin K in the body.

Why does a violation occur?

Primary pathology develops in a child when he is still in the womb or immediately after birth. Provoke the appearance of the disease:

1. Problems with the digestive organs in a pregnant woman.
2. The presence of prolonged toxicosis.
3. Uncontrolled use of sulfonamides, tetracycline antibiotics, cephalosporins, anticoagulants, carbamazepine.
4. Violation of the intestinal microflora and dysbacteriosis in a baby.

The lack of vitamins in breast milk contributes to the appearance of primary pathology. A secondary disease develops during early childbirth, if the liver and pancreas do not perform their functions. The probable cause of impaired vitamin K synthesis is fetal hypoxia. This component enters through the placenta, in infants - with milk during feeding. With a deficiency of such a substance, abnormal bleeding occurs.

Pathogenesis and forms of violation

With insufficient production of vitamin K in the liver, passive plasma factors are formed that are not able to retain calcium, do not participate in the synthesis of substances that promote blood clotting, as a result of which the time increases - prothrombized and thromboplastic.

Hemorrhagic syndrome in newborns has several varieties. It is believed that the early form occurs when the baby is in the womb. It develops if a pregnant woman takes pharmaceutical drugs. A child is born already with hematomas, hemorrhages on the skin, adrenal glands, in the spleen, liver, and intestines. The stool becomes black.

The baby may die if no help is provided if the bleeding continues continuously.

Most often, the classic form of pathology is diagnosed, which occurs in infants in the first days of birth and is often accompanied by skin necrosis. The child suffers from bloody vomiting, red discharge from the navel and nose.

2-3 months after the birth of the baby, a late form of the disease makes itself felt, in which:

1. Hematomas cover most of the body.
2. Purulent formations appear.
3. The volume of blood decreases.

With such symptoms, severe complications often occur. Hypovolemic shock develops, the pressure drops in the baby, the filling of the heart muscle decreases, which is fraught with the appearance of multiple organ failure.

Features of symptoms

The clinical picture in the early form of the disease appears immediately after the birth of the baby. In addition to the presence of hemorrhagic spots on the buttocks and other parts of the body, a cephalohematoma is formed in the periosteum. Pathology is accompanied by hemorrhages, the signs appear depending on the organ in which they appear:

1. The liver increases in size, the baby has a stomach ache.
2. If it enters the lungs, shortness of breath occurs, when coughing, red sputum is released.
3. The child weakens, refuses to eat if the hemorrhage has occurred in the adrenal glands.

With this form of anomaly, anemia develops, neurological disorders are observed. The baby is suffering from hematemesis.

With the classic variety of the disease, red spots cover the entire body, ulcers form on the intestinal mucosa. Blood appears in the urine.

The late form is manifested by multiple hematomas on the skin, severe anemia. Hemoglobin drops sharply, thermoregulation is disturbed.

In the absence of urgent care for internal hemorrhages, the consequences can be very sad.

Diagnostic methods

If hemorrhagic disease is suspected, laboratory tests and examination using instrumental methods are performed.

External examination reveals diffuse changes on the skin. A blood test will determine the level of hemoglobin, the number of red cells, platelets and fibrinogen. In the presence of pathology in any form, these indicators deviate from the norm.

A coagulogram is prescribed to check the clotting time. In a sick newborn, it exceeds 4 minutes. The duration of bleeding is calculated.

The study of urine and feces allows you to detect uncharacteristic impurities. To identify internal cephalohematomas and ulcers, the baby is given an ultrasound of the peritoneum. Neurosonography helps to find hemorrhages in the periosteum.

Many symptoms of hemorrhagic disease are similar to thrombasthenia and some other pathologies. The study is carried out in order to exclude them. Red vomit and black stools may occur if the newborn has swallowed a woman's blood. To check this, the Apta test is assigned.

The child's feces are placed in water, mixed and sent to a centrifuge. Sodium hydroxide is dropped into the liquid obtained after removing the precipitate. The brown color of the solution indicates the presence of the mother's blood, pink confirms the deviation in the baby.

How to treat a newborn?

Upon learning that a child has a hemorrhagic disease, parents often panic, do not believe in a successful outcome, although with timely therapy and a mild form of the disorder, treatment ends in recovery. It is aimed at eliminating the lack of vitamin K. The baby is given an injection subcutaneously or injected into a vein with a one percent solution of Vikasol. Both procedures are performed once a day for three days.

In the process of treating hemorrhagic disease, the main blood parameters and clotting time are constantly checked. It is impossible to allow excess of the norm of the vitamin, otherwise anemia develops, the amount of bilirubin increases, which is dangerous with the appearance of jaundice.

The drugs are quickly transfused with a significant decrease in hemoglobin, severe bleeding provokes the occurrence of hypovolemic shock, the consequences can result in the death of the newborn. To prevent this from happening, use a prothrombin complex or fresh plasma. After stopping the bleeding, they begin to transfuse the erythrocyte mass, the baby is injected with glucocorticosteroids, calcium gluconate is prescribed.

When treating a newborn for hemorrhagic disease, doctors give clinical recommendations. Even if the baby cannot breastfeed, you need to give him expressed milk to drink. The components that this product is rich in contribute to the normalization of blood clotting.

Forecast and prevention

A mild form of hemorrhagic disease with proper and timely therapy is cured. The baby recovers completely, the skin is cleared of spots and purulent formations, hematomas disappear.

With a complicated pathology and the absence of urgent care, the baby dies:

• from heart failure;
• due to cerebral hemorrhage;
• in violation of the work of the adrenal glands.

To prevent the development of the disease, children are given an analogue of vitamin K, which is produced artificially. The drug is prescribed for premature babies, those that were injured during childbirth, are on parenteral nutrition. The risk group includes children who were born during a caesarean section, suffered from asphyxia, oxygen starvation, are treated with pharmaceuticals.

In modern perinatal centers, an in-depth examination of newborns is carried out. Prevention of hemorrhagic disease is necessary for babies whose mothers suffered from toxicosis, had problems with the intestines, complications in the last stages of pregnancy in the form of preeclampsia and bleeding.

Vikasol is prescribed to children if, while carrying them, a woman was treated with antibiotics, took sulfonamides, anticoagulants, and anti-tuberculosis drugs.

Hemorrhagic disease, which is accompanied by heavy bleeding, leads to a significant deterioration in the health of the baby, impaired functions of the liver, kidneys, digestive organs, and heart muscle. When the first signs of pathology appear, the newborn is prescribed replacement therapy, which makes it possible to stop the development of the disease.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2014

Hematemesis of the newborn (P54.0), Hemorrhagic disease of the fetus and newborn (P53), Gastrointestinal haemorrhage of the newborn (P54.3), Rectal haemorrhage of the newborn (P54.2), Melena of the newborn (P54.1)

Neonatology, Pediatrics

general information

Short description

Approved by the Expert Commission

For Health Development

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 coagulation factors.

I. INTRODUCTION

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 of the newborn

P54.3 Gastrointestinal haemorrhage of newborn

Abbreviations used in the protocol:

HRP 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

Protocol development date: year 2013.

Protocol Users: neonatologists of obstetric organizations and pediatricians of hospitals and PHC.

Classification

Clinical classification

Early hemorrhagic disease fetus and newborn: manifests itself on the first day after birth, due to the low level of 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 a slight intake of vitamin K with 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 violation of the synthesis of polypeptide precursors of blood coagulation factors due to liver disease (hepatitis, atresia of the bile ducts, 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:

Reception by the mother during pregnancy of anticoagulants of indirect action (from the neodicumarin group)

prematurity

No or insufficient breastfeeding

Long-term use of broad-spectrum antibiotics

long-term parenteral nutrition

Liver disease

B. Clinical manifestations:

In the early form of HrB, bleeding occurs in the first hours or days after birth in the form of skin hemorrhages, intracranial hemorrhages, and cephalohematomas.

The classic form of HRP in newborns is manifested by bleeding on the 2nd-5th day of life. The appearance of melena, hematomesis, skin hemorrhages (ecchymosis, petechiae), nosebleeds, etc. are characteristic. Children with severe birth trauma, hypoxia have a high risk of hemorrhages under the aponeurosis, internal hematomas, etc.

The late form of HrB in newborns is realized against the background of tolerated diseases.

Diagnostic criteria

Complaints and anamnesis:

History data to identify newborns who may have signs of bleeding before birth are presented in item 11 A (A. Risk factor analysis).

Physical examination:

A complete examination of the newborn is carried out 2 hours after birth, in which skin hemorrhages, intracranial hemorrhages, cephalohematomas can be detected already in the first hours or days with adequately performed childbirth.

Laboratory research

Blood sampling technique for the study of hemostasis:

Make sure that the blood is drawn freely, without obstruction.

You must use a centrifuge tube from the refrigerator.

Completely fill the test tube with blood up to the indicated mark (usually no more than 1.5 ml).

If the blood clotted during sampling, then another tube must be taken.

In the absence of access or the impossibility of taking 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

With signs of DIC syndrome, the following parameters are additionally examined: fibrinogen degradation products (FDP), D-dimer.

Conducting additional studies depends on the results of previous studies and the recommendation of a consultant hematologist.

Limits of the norm

Differential Diagnosis

Differential Diagnosis

Differential diagnosis is carried out between the following diseases: hereditary hemorrhagic diseases due to a deficiency of coagulation factors, liver diseases, DIC.

Medical tourism

Get treatment in Korea, Israel, Germany, USA

Medical tourism

Get advice on medical tourism

Treatment

Purpose of treatment:

Stop bleeding;

Stabilization of the state (hemodynamics, gas exchange)

Treatment tactics

Medical treatment:

Urgent care

All newborns with impaired hemostasis who have not received vitamin K at birth should receive vitamin K at the rate of 100 mcg/kg intramuscularly.

If prothrombin 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 violations persist, repeat the previous dose of FFP.

If there is no effect after the introduction of FFP, cryoprecipitate is used at the rate of 5 ml / kg for 30 minutes.

Repeat the study of prothrombin and activated partial thromboplastin time and, if their violations persist, administer cryoprecipitate at the same dose.

Monitoring

If the indications are maintained, it is necessary to repeat the blood coagulation 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, a specialist hematologist should be consulted.

Other treatments: no.

Surgical intervention: no.

Preventive actions:

For the prevention of hemorrhagic disease of the newborn after birth, it is necessary to inject vitamin K IM 1 mg once (peroral administration of the drug is possible according to the instructions).

Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:

Normalization of blood coagulability indicators.

Drugs (active substances) used in the treatment

Hospitalization

Indications for hospitalization:

Obstetric organization of any level, MO pediatric profile.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
   1. 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 DisChild. Sep 2007;92(9):741-3. . 3) Pichler E, Pichler L. The neonatal coagulation system and the vitamin K deficiency bleeding - a mini review. Vienna Med Wochenschr. 2008;158(13-14):385-95. . 4) Oldenburg J, Marinova M, Müller-Reible C, Watzka M. The vitamin K cycle. Vitam Horm. 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 ClinNutr. 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. Child's Nerv 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 Pediatric 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 paediatrician. Eur J Pediatr. Feb 2009;168(2):127-34. . 18) Young T.E., Mangum B. Vitamins and Minerals. In: NEOFAX 2008. edition. Montavale, NJ: Thomson Reuters; 2008:288-9.

phillipt, 10-15% propolis solution, 1% solution of eucalyptus ball leaf extract, etc.). Use ultraviolet irradiation of the umbilical wound. With fungus of the navel, the doctor performs the treatment of the umbilical wound by cauterizing the granulations with a 5% solution of silver nitrate. In the phlegmonous form of omphalitis, dressings are used with a solution of dimethyl sulfoxide, with hydrophilic ointments (levosin, levomekol), with hypertonic solutions of 5-10% sodium chloride solution, 25% magnesium sulfate. With necrotic omphalitis and gangrene of the umbilical cord after surgery, the wound is treated in an open way using hydrophilic ointments (see above). With phlebitis and arteritis of the umbilical vessels, the toilet of the umbilical wound is performed, similar to the weeping navel and purulent omphalitis, as well as dressing with 2% troxerutin gel.

When used in an obstetric hospital, film-forming preparations (Lifuzol and others) approved for the treatment of the umbilical wound, in cases of signs of omphalitis, the film is removed with 70% ethyl alcohol; further processing of the umbilical wound is carried out as indicated above.

General treatment is described in the Pemphigus of the Newborn section. Surgery. A surgical benefit is shown in the case of abscess formation with phlegmonous omphalitis. With necrotic omphalitis and gangrene of the umbilical cord, it is necessary to carry out a non-cracking

Forecast. Favorable for non-severe forms of omphalitis, inflammation of the umbilical vessels, provided timely and adequate therapy. Phlegmonous and necrotic omphalitis, gangrene of the umbilical cord with complications (up to sepsis) can be fatal.

Questions for the exam. Infectious and inflammatory diseases

skin and subcutaneous tissue. Vesiculopustulosis. pemphigus, abscesses, exfoliative dermatitis, candidiasis of the skin and mucous membranes, panaritium, paronychia, phlegmon. Etiology. clinical picture. Diagnostics. differential diagnosis. Treatment. Rational choice of antibiotics.

Diseases of the umbilical cord, umbilical wound and blood vessels. Omphalitis, thrombophlebitis, arteritis of the umbilical vessels, gangrene of the umbilical cord. Etiology. clinical picture. Diagnostics. Differential diagnosis (fistulas, cysts, etc.). Treatment.

Chapter XI. Hemorrhagic disease of the newborn

HEMORRHAGIC DISEASE OF THE NEWBORN

(HrDN) is an acquired or congenital disease of the neonatal period, manifested by increased bleeding due to a deficiency of coagulation factors, the activity of which depends on vitamin K.

Epidemiology: The incidence of HrDN is 0.25–1.5%. Prophylactic administration of vitamin K preparations immediately after birth led to a decrease in the incidence of HrDN to 0.01% or less.

Etiology: Vitamin K deficiency in a newborn may be associated with the following factors:

From the mother's side: the appointment during pregnancy of anticoagulants of indirect action (from the neodicoumarin group), anticonvulsants (phenobarbital, difenin, phenytoin, etc.), large doses of broad-spectrum antibiotics, anti-tuberculosis drugs (rifampicin, etc.); preeclampsia against the background of low estrogen synthesis (daily excretion of estrogen in the urine is less than 10 mg); hepato- and enteropathy in the mother; dysbiosis and intestinal dysbacteriosis.

From the side of the child: prematurity, late breastfeeding, no or insufficient breastfeeding, long-term parenteral nutrition, prescription of broad-spectrum antibiotics, malabsorption syndrome, biliary atresia, hepatitis and other types of cholestatic jaundice, pancreatic cystic fibrosis, celiac disease.

Classification. There are three forms of HRD:

1. Early - rare, characterized by the appearance of hemorrhagic symptoms in the first 24 hours after birth, more often caused by the mother taking drugs that enter the placental / fetal circulation before birth and affect the neonatal production of vitamin K;

2. Classic - develops most often on the 2nd-5th day of life in

newborns who are breastfed and have inadequate absorption;

3. Late - develops at the age of 2 weeks - 6 months after birth, in association with inadequate intake of vitamin K (low content of vitamin K in breast milk) or due to inadequate absorption of vitamin K caused by diseases of the liver and biliary tract. The late form of vitamin K-dependent bleeding is more common in boys than girls and is more common in summer than in winter.

Pathogenesis: vitamin K is a coenzyme of microsomal liver enzymes that catalyze the gamma-carboxylation of glutamic acid residues in prothrombin (factor II), proconvertin (factor VII), antihemophilic globulin B (factor IX) and StuartPrower factor (factor X), as well as anticoagulant proteins ( protein C and S), bone and kidney proteins. With a lack of vitamin K in the liver, inactive factors II, VII, IX and X are synthesized, unable to bind calcium ions and fully participate in blood clotting.

Vitamin K crosses the placenta very poorly, so its content in cord blood is always lower than in the mother's body. In children, almost zero content of vitamin K is often detected. After birth, the intake of vitamin K with breast milk is insignificant, and the active production of vitamin K by the intestinal microflora begins from 3-5 days of a child's life. Therefore, in newborns and infants, prolonged diarrhea, the use of broad-spectrum antibiotics that suppress the intestinal microflora, can cause vitamin K deficiency and hemorrhages.

Colostrum and human milk contain vitamin K, on ​​average, 2 μg/l, while cow's milk contains, on average, 5 μg/l, so human milk cannot meet the needs of a newborn in vitamin K, and therefore its additional synthesis is necessary. intestinal microflora. It is known that the formation of the intestinal microflora occurs gradually, and therefore the synthesis of vitamin K is not sufficiently active. This is confirmed by the fact that hemorrhagic disease of the newborn is more likely to develop in children who are breast-fed, compared with children who are bottle-fed.

Research. Complete blood count (with platelet count) and urinalysis, hematocrit, coagulogram, fibrinogen degradation products (PDF), total bilirubin level and its fraction, level of vitamin K-dependent coagulation factors (II, VII, IX, X), ultrasound depending from the location of the hemorrhage. If necessary, research to exclude hepatitis, cystic fibrosis.

Anamnesis, clinic. With an early form, a child already at birth (hemorrhagic disease can begin even in utero) or in the first hours of life, skin hemorrhages, cephalohematoma, or intracranial hemorrhages are detected, determined by ultrasound of the brain. Skin hemorrhagic syndrome is especially pronounced in the presenting part (buttocks, etc.), provoking factors are: severe asphyxia, birth trauma. Possible

pulmonary hemorrhages, hemorrhages in the abdominal organs (especially often in the liver, spleen, adrenal glands), hematemesis (hematemesis), melena.

The classic form of HRD is characterized by the appearance of melena and hematemesis, skin hemorrhages (petechiae and ecchymosis), bleeding when the umbilical cord falls off or after circumcision of the foreskin in boys, nosebleeds, and cephalohematomas are possible. In children with severe hypoxia, birth injuries, there is a high risk of intracranial hemorrhages, hemorrhages under the aponeurosis, internal hematomas, pulmonary and other bleeding.

The late form of HRD may be manifested by intracranial hemorrhages (in more than 50% of cases), extensive skin ecchymosis, chalky, hematemesis, bleeding from injection sites.

Melena is intestinal bleeding, diagnosed by the detection of a pink rim around the feces on the diaper, may be accompanied by hematemesis. The cause of melena is the formation of small ulcers on the mucous membrane of the stomach and duodenum, in the genesis of which the excess of glucocorticoids in the newborn as a result of birth stress, ischemia of the stomach and intestines plays a leading role. A certain role in the occurrence of melena and hematemesis is played by increased acidity of gastric juice, gastroesophageal reflux and peptic esophagitis.

The diagnosis of HRD is established in the presence of characteristic manifestations of the disease and is confirmed by the results of laboratory tests.

General blood analysis- with significant blood loss, posthemorrhagic anemia is detected, the platelet count is normal or slightly increased.

Blood chemistry- in children with melena, hyperbilirubinemia is possible due to increased breakdown of red blood cells in the intestine.

Coagulogram / hemostasiogram - hypocoagulation shift

(prolongation of blood clotting time, prothrombin time and activated partial thromboplastin time), deficiency of vitamin K-dependent coagulation factors (II, VII, IX, X).

NSG, ultrasound of the abdominal cavity - the nature of the changes depends on the location of the hemorrhages.

Differential Diagnosis HRD should be carried out with:

1. with other variants of hemorrhagic diathesis - thrombocytopenic purpura, hereditary coagulopathy - hemophilia;

2. melena in children of the first day of life must be differentiated from the “swallowed blood syndrome” of the mother, which develops in

one in three children who have blood in the stool on the first day of life. To do this, use the Apt test: bloody vomit or feces are diluted with water and a pink solution containing hemoglobin is obtained. After centrifugation, 4 ml of the supernatant is mixed with 1 ml of 1% sodium hydroxide solution. A change in the color of the liquid (assessed after 2 minutes) to brown indicates the presence of hemoglobin A in it, i.e. maternal blood, and the preservation of the pink color -

about hemoglobin of the child (hemoglobin F), i.e. - about chalk.

3. with abundant or recurrent melena, bleeding from the anus, it is necessary to exclude anorectal trauma, papillomas, intestinal angiomatosis and other surgical pathology.

Tab. 2.49. Differential diagnosis of hemorrhagic

neonatal disease and DIC

Treatment, treatment objectives: stopping vitamin K deficiency, stopping bleeding, treating manifestations of HrDN.

Treatment regimen: O Mandatory treatment: Vikasol.

Auxiliary treatment: fresh frozen plasma, thrombin, epsilon-aminocaproic acid, concentrated prothrombin complex preparation (PPSB), sodium bicarbonate solution, adroxon, erythrocyte mass.

Indications for hospitalization: all children with or suspected HRD should be hospitalized.

Diet. Children with HRD are fed with expressed breast milk 7 times a day in accordance with age requirements, this is due to the presence of thromboplastin in human milk.

The introduction of vitamin K intramuscularly or intravenously (preferably) at a dose of 1-2 mg (vitamin K1), but you can enter a 1% solution of vikasol (vitamin K3) at a dose of 0.1-0.15 ml / kg (5 mg full-term and 2- 3 mg preterm). In our country, so far, vikasol (vitamin K3) is predominantly prescribed - a water-soluble derivative of menadione, but less effective than phylloquinone (vitamin K1). Vikasol causes the effect not by itself, but by the phylloquinone and menadione formed from it in the liver. Considering that only a small percentage of vikasol is converted into phylloquinone and menadione, vikasol is administered 2 times a day, sometimes even 3 times. High doses of vikasol (more than 10 mg) or its long-term administration are dangerous because of the possibility of the formation of Heinz bodies in erythrocytes, the development of hyperbilirubinemia due to increased hemolysis.

With continued heavy bleeding, the simultaneous administration of fresh frozen plasma at the rate of 10-15 ml / kg intravenously or a concentrated preparation of the prothrombin complex (PPSB) at a dose of 15-30 U / kg intravenously is indicated. Rapid blood loss of 10-15% of the circulating blood volume leads to the development of shock, while the introduction of PPSB is contraindicated, as it can cause DIC.

With the development of hypovolemic shock due to posthemorrhagic anemia, red blood cell transfusion is carried out at the rate of 5-10 ml/kg (after transfusion of fresh frozen plasma in a dose of

Local therapy for melena: 50 ml of a 5% solution of ε-aminocaproic acid + 20 mg of dry thrombin + 1 ml of a 0.025% solution of adroxon - 1 tsp each. 3 times a day and 0.5% sodium bicarbonate solution, 1 tsp. 3 times a day.

In case of bleeding from the umbilical stump - ligation of the umbilical residue, hemostatic sponge, thrombin solution locally.

Prevention of HrDN consists in the appointment of vitamin K. For this purpose, a 1% solution of vikasol is administered intramuscularly once to children from

risk groups for the development of HRD at the rate of 0.1 ml/kg during 2-3 days of life.

Questions for the exam. Hemorrhagic disease of the newborn. Etio-

logic. Pathogenesis. clinical picture. Diagnostics. differential diagnosis. Treatment. Prevention.

Fortunately, hemorrhagic disease of the newborn is an infrequent phenomenon, it occurs 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 might think, and it’s good if you are right. Otherwise, only a lightning-fast reaction of parents to alarming symptoms will help save the baby ... So, as they say: "forewarned is forearmed."

Causes of hemorrhagic disease of the newborn

The cause of hemorrhagic disease is vitamin K deficiency which is essential for normal blood clotting. Its lack leads to various bleeding, which is dangerous for the life of the child.

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, and birth trauma.

Newborns who, according to doctors, are at risk, are given a prophylactic dose of vitamin K immediately after birth ( Vikasol).

In late hemorrhagic disease, the causes of occurrence are somewhat different, we will dwell on them in more detail a little later.

Symptoms and treatment of hemorrhagic disease of the newborn

Since classical hemorrhagic disease develops on 2-4 days after birth(rarely on the first day), that is, while the child is still in the hospital, then parents just need to trust the professionalism of doctors and not interfere with the treatment of the baby.

The most common symptoms of classic hemorrhagic disease are nasal and gastrointestinal bleeding, incessant bleeding from or after. Therefore, if the baby spit up with blood, his nose bleeds, the injection site bleeds for a long time, the umbilical wound or there is blood on the diaper, do not wait for the next bypass, ask the neonatologist to examine the newborn unscheduled, because the sooner treatment begins, the greater the chance of success .

If the blood test confirms the diagnosis, then the baby immediately start to heal. Treatment consists of intramuscular administration of vitamin K, plasma and blood transfusions (in especially severe cases). In addition, about 6 times a day, a newborn is fed with 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 full 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 also possible here, 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, respectively, in the maternity hospital a prophylactic dose of vitamin K, suffering from transient liver failure(an indirect sign of such insufficiency is jaundice, which has not passed by 1 month) and, oddly enough, are exclusively breastfeeding. What is it about breastfeeding? It turns out that the intestines of children who feed on mother's milk are colonized by flora, which does not cope well with the synthesis of vitamin K2, while with artificial feeding, everything is quite the opposite.

The danger of late hemorrhagic disease of the newborn is that if you do not start treatment as soon as possible, then massive intracranial hemorrhage can't be avoided. The high percentage of mortality from the late form of this disease is associated precisely with the complexity 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 the bill goes literally for minutes.

So parents should be alert the appearance of bruises on the body of the baby- in any quantity and any size. There is no need to think under what circumstances the baby could get such an injury - he rubbed the button from the bodysuit, hit the crib, lay down on the rattle ... Do not look for excuses, but call an ambulance, as this is the first wake-up call!

If blood was taken from the baby for analysis, and finger won't stop bleeding, then this is already a sure sign of problems with blood clotting, which means that a reason to urgently call doctors. Why such a hurry? 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 it’s better to “overdo it” in this matter.

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 be able to put it into practice!