Hemorrhagic disease of newborns - rare, but accurate! Hemorrhagic disease of newborns.

The birth of a child is a happy event, which is accompanied by worries from the parents. The baby was born and received 10 points on the Apgar scale, but this does not mean that the child is completely healthy. One of the common pathologies of newborns is hemorrhagic disease.

Having heard the diagnosis of the long-awaited baby, parents begin to look for ways to eliminate the problem. To find a solution, you need to know how to live with this problem, and whether it is possible to protect your child from the disease.

What is hemorrhagic disease?

Hemorrhagic disease of newborns is a pathology associated with the function of blood clotting. It develops due to a deficiency of vitamin K in the body of a newborn. The incidence rate is low - 0.3-0.5% of all babies are born with the disease. Vitamin K is an important component of the blood clotting process. It is produced in a newborn 4-5 days after birth.

The lack of substance quickly makes itself felt. The quality of coagulation deteriorates significantly, and increased bleeding develops. Against this background, the child exhibits a special diathesis. Bruising and signs of bleeding are the main symptoms of hemorrhagic disease.

For what reasons does it occur in newborns?

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There are several causes of the disease: primary and secondary. Attribution of the causes of pathology to one of these types depends on at what stage of pregnancy and childbirth the problem arose.

To determine the cause of hemorrhagic disease of newborns, it is necessary to conduct a diagnosis.

Primary pathologies are easily diagnosed in the first days of life and occur during pregnancy. Secondary ones are more serious because there is a deficiency of plasma clotting factors.

Types and symptoms of pathology

The symptoms of the disease depend on the form of the disease. It is based on 2 signs: bleeding and the formation of bruises on the child’s body. Violations can be noticed by an ultrasound specialist during an intrauterine examination of the fetus, when it is possible to diagnose internal bleeding of an unborn baby.

Symptoms appear on the 7th day of the baby’s life. Symptoms are divided into early and late forms. The early form is quite rare. The clinical picture of the disease appears within 24 hours after birth.

Early, classical and late forms

Depending on the time of onset of symptoms, several subtypes of the disease are distinguished: early, classic and late forms of hemorrhagic disease. If the baby is breastfed, symptoms may appear a little later, since mother's milk contains thromboplastin, which is responsible for blood clotting. Each type of pathology is characterized by its own manifestations:

Form of the disease	Characteristic	Symptoms
Early	The first symptoms appear 12-36 hours after birth. One of the rarest forms of the disease. Consequences of the mother taking drugs prohibited during pregnancy.	vomiting with blood (“coffee grounds”); nose bleed; internal bleeding into the parenchyma of the liver, spleen and adrenal glands; in the prenatal period - hemorrhages in the brain.
Classical	The clinical picture becomes clear 2-6 days after birth. The most common type of disease.	bloody vomiting; bloody black stool; scattered all over the body dark spots, similar to blood clots under the skin; bleeding from the umbilical wound; cephalohematomas (we recommend reading:); increased bilirubin in the blood as a result of gastrointestinal bleeding; jaundice of newborns.
Late	Late hemorrhagic disease of newborns appears on the 7th day after birth. Evolving in the background systemic diseases and lack of preventive vitamin K injections.	The classic symptoms of late hemorrhagic disease of the newborn include weakness, pale skin, sharp drop blood pressure, resulting in hemorrhagic shock.

Primary and secondary hemorrhagic disease

When classifying the disease, primary and secondary are distinguished hemorrhagic disease. They differ in the characteristics of their course and the factors of their occurrence. Primary occurs when general content There was initially little vitamin K in the baby's blood, and after birth it was not supplied to the mother's milk. Active production of intestinal microflora begins on the 5th day.

The secondary type implies a pathology associated with impaired synthesis of blood clotting due to impaired liver function. Another cause of secondary disease is the baby’s prolonged stay on parenteral nutrition. As a rule, the most severe forms of the disease are diagnosed in very premature infants and babies with serious pathologies of the liver and intestines.

At the slightest suspicion of hemorrhagic disease after discharge from the hospital, you must urgently call an ambulance. Parents should be alert to unexpectedly appearing bruises on the baby’s body. Another reason to see a doctor is that when blood is taken from a finger, it does not stop for a very long time. All this is a reason for a serious examination.

Diagnostic methods

Effective treatment hemorrhagic disease of the newborn begins with diagnosis. The sooner it is carried out, the greater the chances for a high-quality life for the child in the future. A blood test is considered the most informative; in addition to it, an ultrasound is always prescribed abdominal cavity and neurosonography:

Diagnostics	The essence of the study
Complete blood count (CBC)	The level of hemoglobin and red blood cells, platelets is detected. In hemorrhagic disease, the concentration of the first two factors is significantly reduced, and the number of platelets does not exceed normal limits.
Urinalysis, stool examination	It is carried out to identify hidden bleeding and blood impurities in the biomaterial.
Coagulogram, or assessment of blood clotting	In the presence of pathology, the clotting time exceeds 4 minutes.
Ultrasound, neurosonography	Hemorrhages are detected in the periosteum of the cranial bones, in the tissue of the central nervous system and other organs and systems.

To differentiate the disease from pathologies with similar symptoms, including “maternal blood swallowing syndrome”, hemophilia, thrombocytopenia, von Willebrand disease, an Apta test is additionally performed. Vomit and feces containing blood are diluted with water and a pink solution containing hemoglobin is obtained.

Features of treatment

Treatment methods directly depend on the severity of the pathology.

In case of moderate form, the baby will be prescribed vitamin therapy: for 3 days the baby will artificially receive synthetic vitamin K, and its deficiency will be completely replenished. For better absorption, intramuscular or intravenous injections are used.

Main therapeutic methods:

1. in case of vomiting with blood, it is necessary to lavage the stomach with saline solution and administer aminocaproic acid by mouth;
2. for internal gastrointestinal bleeding, an enteral mixture with thrombin, androxon and aminocaproic acid is prescribed (we recommend reading:);
3. at severe forms, accompanied hemorrhagic shock, immediate infusion of fresh frozen blood plasma is indicated;
4. glucocorticosteroids that help strengthen the walls of blood vessels, vitamin A and calcium gluconate are prescribed as maintenance therapy.

Forecast

If the disease occurs in mild form and is treatable, the prognosis is good. With timely and adequate treatment, there will be no threat to the child’s future life; relapses and complications of the pathology with the general clinical picture are excluded.

The baby’s life is in serious danger if a severe pathology with heavy bleeding and hemorrhages. Manifestations that provoke disturbances in the functioning of the heart and disruptions in the functioning of the adrenal glands are considered mortally dangerous. Cerebral hemorrhages are especially dangerous due to their consequences.

Preventive actions

Prevention of the disease begins at the planning stage of the baby. Being pregnant, a woman needs to take care of her health. There are often cases when it becomes necessary to use antibacterial therapy. It should only be carried out under the supervision of a gynecologist, provided that the benefits of such treatment are higher than the risks to the fetus. It is necessary to visit a doctor in a timely manner and undergo all necessary tests.

The expectant mother should include in her diet foods containing a large number of vitamin K. These are all green vegetables: green beans, cabbage, peas, spinach. Introduction artificial vitamin possible only by medical indications with its pronounced deficiency. At risk are premature babies, babies with birth injuries or those who are bottle-fed.

Difficult pregnancy, taking antibiotics, vitamin deficiency and others negative factors affect not only the woman’s health, but also lead to the child developing 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 microelement retains calcium, which is actively involved in the formation of bones.

In the majority European countries and the USA carries out the prevention of hemorrhagic disease of newborns. Since the main causes of the anomaly are known, children are immediately prescribed Vikasol, which compensates for the lack of natural vitamin K in the body.

Why does the 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. Disturbance of intestinal microflora and dysbacteriosis in a baby.

Lack of vitamins breast milk contributes to the appearance of primary pathology. Secondary disease develops with early birth if the liver and pancreas do not perform their functions. Probable Cause disturbances in the synthesis of vitamin K - fetal hypoxia. This component enters through the placenta, and in infants - with milk during feeding. With a deficiency of this substance, abnormal bleeding occurs.

Pathogenesis and forms of disorder

At insufficient production Vitamin K in the liver produces passive plasma factors that are unable to retain calcium and do not participate in the synthesis of substances that promote blood clotting, as a result of which the time of thrombosis and thromboplasty increases.

Hemorrhagic syndrome in newborns it has several varieties. The early form is thought to occur while the baby is in the womb. It develops if a pregnant woman takes pharmaceuticals. A child is born with hematomas, hemorrhages on the skin, adrenal glands, spleen, liver, and intestines. The feces take on a black tint.

The baby may die if help is not provided if the bleeding continues continuously.

Most often, the classical form of the 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, the late form of the disease makes itself felt, in which:

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

These symptoms often occur severe complications. Developing hypovolemic shock, the baby’s blood pressure drops, the filling of the heart muscle decreases, which is fraught with the appearance of multiple organ failure.

Features of symptoms

The clinical picture of 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 forms in the periosteum area. The pathology is accompanied by hemorrhages; signs appear depending on the organ in which they appear:

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

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

In the classic type of the disease, red spots cover the entire body, and 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 disrupted.

With absence urgent help with internal hemorrhages, the consequences can be very sad.

Diagnostic methods

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

External examination reveals diffuse changes on the skin. A blood test determines 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 clotting time. In a sick newborn it exceeds 4 minutes. The duration of bleeding is calculated.

Examination of urine and feces can detect uncharacteristic impurities. To identify internal cephalohematomas and ulcers, the baby undergoes 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 conducted to exclude them. Red vomit and black stools may occur if the newborn ingests the woman's blood. To check this, an Apta test is prescribed.

The baby's feces are placed in water, mixed and sent to a centrifuge. Sodium hydroxide is dripped into the liquid obtained after removing the sediment. Brown color the solution indicates the presence of mother’s blood, pink confirms the abnormality in the baby.

How to treat a newborn?

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

During the treatment of hemorrhagic disease, basic blood parameters and clotting time are constantly checked. It is impossible to exceed the vitamin norm, otherwise anemia develops and the amount of bilirubin increases, which is dangerous due to the appearance of jaundice.

Drugs are quickly transfused when there is a significant decrease in hemoglobin, heavy bleeding provokes the occurrence of hypovolemic shock, the consequences can result in the death of the newborn. To prevent this from happening, use prothrombin complex or fresh plasma. After the bleeding has stopped, a red blood cell transfusion is started, the baby is injected with glucocorticosteroids, and calcium gluconate is prescribed.

When treating a newborn for hemorrhagic disease, doctors give clinical guidelines. Even if the baby cannot suckle, you need to feed him expressed milk. The components that this product is rich in help normalize blood clotting.

Prognosis and prevention

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

If the pathology is complicated and there is no urgent help, the baby dies:

• from heart failure;
• due to hemorrhage in the brain;
• in case of dysfunction 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 to premature babies, those who were injured during childbirth, and those on parenteral nutrition. The risk group includes children who were born during surgery caesarean section, suffered from asphyxia, oxygen starvation, and are treated with pharmaceuticals.

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

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

Hemorrhagic disease, which is accompanied by heavy bleeding, leads to a significant deterioration in the baby’s health, dysfunction of the liver, kidneys, digestive organs, cardiac muscle. When the first signs of pathology appear, the newborn is prescribed replacement therapy, which allows you to stop the progression of the disease.

RCHR (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 newborns (P54.0), Hemorrhagic disease of the fetus and newborn (P53), Gastrointestinal intestinal bleeding in the newborn (P54.3), Bleeding from the rectum in the newborn (P54.2), Melena in the newborn (P54.1)

Neonatology, Pediatrics

general information

Short description

Approved by the 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: year 2013.

Protocol users: neonatologists of obstetric organizations and pediatricians of hospitals and primary care.

Classification

Clinical 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:

Taking indirect anticoagulants (from the neodicoumarin group) by the mother during pregnancy

Prematurity

Absence or insufficient breastfeeding

Long-term use of antibiotics wide range actions

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 neonatal HRD manifests itself with bleeding on days 2-5 of life. The appearance of melena, hematomesis, skin hemorrhages (ecchymoses, petechiae), nosebleeds, etc. is 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.

Diagnostic criteria

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:

Full inspection of a 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 must 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 into required quantity(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

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

Preventive actions:

To prevent hemorrhagic disease in a newborn after birth, it is necessary to administer vitamin K 1 mg intramuscularly once (oral administration of the drug is possible 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 treatment

Hospitalization

Indications for hospitalization:

Obstetrics organization of any level, pediatric medical institution.

Information

Sources and literature

1. Minutes of 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 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.

Hemorrhagic disease of the newborn (HDN) is a hemorrhagic diathesis resulting from the inferiority of blood clotting factors, the activity of which is determined by the concentration of vitamin K in the body.

Causes

Hemorrhagic disease of newborns is diagnosed with a frequency of 0.25-1.5% in post-Soviet countries. In those countries where children are given vitamin K immediately after birth for preventive purposes, the incidence rate does not exceed 0.01%.

Based on the mechanism of development, primary and secondary GRBN are distinguished. Primary hemorrhagic disease of the newborn is caused by a violation of the synthesis of blood coagulation factors due to a lack of vitamin K. The tendency to develop pathology in the first days of life is associated with a natural deficiency of vitamin K, which occurs for the following reasons:

• its synthesis occurs in the intestines, the microflora of which in the child is in the process of formation;
• vitamin K practically does not penetrate the placenta;
• Breast milk contains very little of it - 2 mcg/l.

But to start pathological process these factors are not enough. Hemorrhagic disease of newborns, as a rule, develops in the presence of certain prerequisites. Among them:

• taking indirect anticoagulants, anticonvulsants and broad-spectrum antibiotics during pregnancy;
• gestosis, toxicosis;
• liver diseases and chronic non-inflammatory intestinal pathologies in the expectant mother.

The causes of secondary hemorrhagic disease of newborns are a decrease in the production of PPPF (polypeptide precursors of plasma factors) of blood coagulation, which occurs in the liver. In addition, the pathology can be caused by the administration of coumarin and neodicoumarin (vitamin K antagonists).

The main factors on the part of the child that can provoke a decrease in the synthesis of PPPF and a lack of vitamin K:

• prematurity;
• hypoxia;
• long-term intravenous nutrition;
• late breastfeeding;
• deterioration in the absorption of microelements in the intestine due to dysbiosis or malabsorption syndrome;
• diseases of the pancreas, liver, biliary tract, intestines;
• antibiotic treatment.

Pathogenesis

Hematological functions of vitamin K:

• activation of the processes of gamma-carboxylation of excess glutamic acid in prothrombin (blood coagulation factor II), proconvertin (VII), antihemophilic globulin B (IX) and Stuart Prower factor (X);
• stimulation of plasma proteins C and S, which are involved in coagulation mechanisms.

With vitamin K deficiency, passive factors II, VII, IX and X are formed in the liver: they are not able to bind calcium and participate in blood clotting. As a result, the prothrombin and activated partial thromboplastic time is prolonged, which manifests itself in the form of an increased tendency to bleeding. This is how hemorrhagic disease of newborns develops.

Symptoms

Depending on the specifics of the clinical picture, early, classic (typical) and late forms of hemorrhagic disease of newborns are distinguished.

The early version of the pathology is rare and is characterized by the manifestation of symptoms during the first day of the child’s life. Main manifestations:

• hemorrhagic spots (hemorrhages) on the skin, especially in the buttocks;
• cephalohematoma - an accumulation of blood between the periosteum and the skull, on the surface of which visible pinpoint hemorrhages(petechiae);
• bleeding in the lungs;
• hemorrhages in the spleen, liver, adrenal glands;
• hematemesis - vomiting blood;
• intracranial hemorrhages;
• anemia.

Signs of hemorrhages in internal organs:

• brain – the appearance of neurological disorders;
• lungs – shortness of breath, blood in sputum discharged when coughing;
• liver – increase in its size, abdominal pain;
• adrenal glands – weakness, decreased activity, refusal to eat.

Classic hemorrhagic disease of newborns develops 2-4 days after birth. Its symptoms are similar to those early form. Added to them:

• hemorrhagic spots on the skin throughout the body;
• bleeding from the nose and navel;
• melena – intestinal bleeding that occurs due to the formation of ulcers on the intestinal mucosa and is diagnosed when blood is detected in the stool;
• hemorrhage in the kidneys, accompanied by the appearance of blood in the urine.
• uterine bleeding.

As a rule, bleeding is not profuse. But in severe cases, blood is released continuously. Without help, the child may die from shock as a result of blood loss.

Late hemorrhagic disease of newborns begins at 2-8 weeks of a child’s life. Its signs:

• bruises on the epithelial membranes and skin;
• internal hemorrhages;
• intestinal bleeding;
• blood in vomit;
• cerebral hemorrhages;
• severe anemia.

A possible consequence of hemorrhagic disease of newborns is, which occurs as a result of significant blood loss and anemia (hemoglobin level decreases by 2-3 times). It is accompanied by pallor, weakness, decreased blood pressure and impaired thermoregulation.

Diagnostics

Hemorrhagic disease of the newborn is diagnosed based on clinical symptoms and laboratory tests.

Main research:

• blood test - allows you to detect a decrease in the concentration of hemoglobin and red blood cells, as well as a normal platelet count;
• urine and stool tests show blood impurities;
• check of the coagulation system (coagulogram) - demonstrates prolongation of prothrombin and activated partial thromboplastic time with normal level thrombin time;
• assessment of blood clotting time – increased (more than 4 minutes);
• bleeding time calculation is normal (2-4 minutes).

Instrumental methods that make it possible to identify internal hematomas and bleeding:

• neurosonography;
• Ultrasound of the abdominal cavity and retroperitoneal zone.

Hemorrhagic disease of newborns is differentiated from hemophilia, von Willebrand disease, thrombocytopenic purpura and thrombasthenia.

In addition, bloody vomiting and melena can be the consequences of a child swallowing maternal blood. This is checked using the Apta test. Water is added to the biomaterial sample and it is centrifuged. Then a sodium alkali solution is dripped into the liquid and the color reaction is monitored: yellow-brown coloring indicates the presence of age-related hemoglobin from the mother’s blood, and pink coloring indicates the presence of fetal hemoglobin from the child’s blood.

Treatment

The basis for the treatment of hemorrhagic disease of newborns is the replenishment of vitamin K deficiency. The drug “Vikasol” in the form of a solution is most often used. It is an artificial analogue of vitamin K.

A 1% vitamin solution is administered intramuscularly or intravenously for 2-3 days. The approximate dose is 0.1-0.15 ml per 1 kg of child’s weight. Injections or infusions are carried out once a day. During therapy, hematological parameters are monitored, in particular, changes in blood clotting factors dependent on vitamin K are assessed.

During treatment, it is important to control the dosage of vitamin K. If it is in excess, complications may occur:

• anemia with intracellular inclusions;
• increased bilirubin levels, which can cause kernicterus;
• hemolytic anemia.

In case of severe bleeding, to compensate for blood loss, a bolus (rapid) intravenous transfusion of one of two drugs is performed:

• fresh frozen plasma – 15 ml/kg;
• concentrated prothrombin complex – 30 units/kg.

To eliminate the consequences of a decrease in hemoglobin, a transfusion of red blood cells (5-10 ml/kg) is performed. In addition, glucocorticoids may be prescribed to strengthen the capillary walls, vitamin A and calcium gluconate.

In case of hemorrhagic disease of newborns, breastfeeding should not be stopped. If the child is very weak or is separated from the mother, he is fed expressed milk based on age needs. Breast milk contains thrombokinase, a substance that has a hemostatic effect.

Forecast

Uncomplicated HRBN has favorable prognosis given that adequate treatment. As a rule, in the future the pathology does not transform into other hemorrhagic diseases.

The risk of death occurs when:

• massive bleeding;
• disruption of the heart;
• development of adrenal insufficiency;
• hemorrhages in the brain.

Prevention

Prevention of hemorrhagic disease of newborns consists of preventive administration of vitamin K. The dosage for the “Vikasol” solution is 0.1 ml/kg. The treatment regimen is 1 time per day for 1-3 days.

Vitamin K is administered to children at risk, including:

• born significantly prematurely;
• receiving antibiotics;
• those on parenteral nutrition;
• those who have suffered birth trauma, hypoxia or asphyxia;
• born by caesarean section.

In addition, newborns are at risk if during pregnancy a woman:

• took anticoagulants, antibiotics, antituberculosis or anticonvulsants;
• suffered from gestosis due to estrogen deficiency, enteropathy, hepatopathy or intestinal dysbiosis.

In these cases, vitamin K can be prescribed to expectant mothers shortly before and after childbirth.

In addition, early breastfeeding and natural feeding are considered preventive measures for GRBN.

Hemorrhagic diathesis appears when there are changes in the links of hemostasis (such as damage to vascular wall) and occur in a state of increased bleeding in both an adult and a child’s body. Hemorrhagic disease is bleeding of the mucous membranes. It can be detected by passing a detailed blood test.

What are hemorrhages

In medicine, spontaneous bleeding from blood vessels in any part of the body is called hemorrhage. This pathological syndrome manifests itself in patients in response to external influence or in the presence of internal diseases. Hemorrhagic disease occurs due to damage to the integrity of the walls of blood vessels, a decrease in the number of platelets, and a violation of coagulation hemostasis. In this case, blood flows beyond the boundaries of the blood vessel through the damaged area. The types of abnormalities depend on which part of the body they appear in.

Hemorrhagic syndrome is typical for what diseases?

Among the forms of hemorrhagic diseases, hereditary and acquired disorders of hemostasis are distinguished. The latter are associated with multifactorial disorders of the blood coagulation system (for example, acute syndrome ICE), defeat blood vessels dismetabolic, immune, toxic-infectious, immunocomplex origin, abnormalities of adhesive proteins in blood plasma, damage to platelets and megakaryocytes. Hereditary hemorrhagic diseases are caused by:

• pathologies of plasma factors of the blood coagulation system;
• hereditary disorder of hemostasis;
• genetic structural changes in the vascular wall.

Hemorrhagic diathesis in children

Due to a lack of vitamin K, hemorrhagic syndrome of newborns may develop, among the signs of which are: hemorrhagic skin rashes, umbilical bleeding. Intestinal bleeding or intracerebral hemorrhage may occur. Doctors name the following reasons for the occurrence of hemorrhages in newborns: during pregnancy, the mother took phenobarbitals, salicylates or antibiotics. Hemorrhagic disease in children occurs when:

• neoplastic lesion connective tissue;
• thrombocytopenia;
• coagulopathies;
• vasopathy;
• hemophilia.

Pathogenesis of hemorrhagic syndrome

As a mechanism for the development of hemorrhagic syndrome and its manifestations, doctors describe the following picture of pathogenesis:

1. impaired coagulation (DIC) and platelet production;
2. changes in collagen structure, fibrinogen properties, vascular walls:
   • for circulatory disorders;
   • decreased neurotrophic function of the central nervous system;
   • violation of the angiotrophic function of platelets.

Hemorrhagic diseases - classification

The following types of hemorrhagic syndromes have been described in medicine: hematoma, petechial-spotted, mixed bruise-hematoma, vasculitic-purpuric, angiomatous. The listed types differ in the nature of their manifestation and causes. In each individual case, it is necessary to follow the individual treatment tactics chosen by the attending physician. Description of hemorrhagic diathesis according to the type of disease:

1. The hematoma type is caused by chronic genetic bleeding. This serious disease due to decreased coagulability manifests itself in the patient in the form of painful sensations with hemorrhages in the joints (hemarthrosis), dysfunction musculoskeletal system. In case of injury, internal hematomas form in soft tissues extensive swelling, which causes pain.
2. The petechial-spotted type is also called the bruise type because external manifestations on the body in the form of bruises, as can be seen in the photo. Appears in cases of blood clotting disorders (lack of coagulation factors, hypo- and dysfibrinogenemia), thrombocytopathy and thrombocytopenia (thrombocytopenic purpura).
3. Microcirculatory-hematoma, or mixed bruise-hematoma bleeding develops in the presence of immune inhibitors of factors IX and VIII in the blood, an overdose of thrombolytics and anticoagulants, disseminated intravascular coagulation, von Willebrand's disease, severe deficiency of prothrombin complex factors and factor XIII. Externally this type The disease manifests itself through petechial-spotted skin hemorrhages, large hematomas in the retroperitoneal region and intestinal wall, and petechial skin rash.
4. Symptoms of the vasculitic purpuric type are a red skin rash (erythema). With the disease, there is a tendency to bleeding in the intestines and inflammation of the kidneys (nephritis), immune and infectious vasculitis, and disseminated intravascular coagulation syndrome.
5. The angiomatous type develops in the area of ​​arteriovenous shunts, angiomas, and telangiectasia. This type of disease is characterized by hemorrhages in the area of ​​vascular anomalies and persistent bleeding of permanent localization.

Causes of hemorrhagic syndrome

Hemorrhagic symptoms may develop with vascular anomalies, disorders of coagulation hemostasis, enzyme activity, blood coagulation system, or when taking medications that interfere with platelet aggregation. Experts were able to identify a type of disease in which there is a high risk of hemorrhage:

• hepatitis;
• oncology;
• severe viral infections;
• cirrhosis of the liver;
• lack of prothrombin in the blood;
• hemophilia;
• leukemia;
• vasculitis.

The causes of hemorrhages depend on the primary or secondary form of the disease. The first is characterized by the presence of genetic determination: there is a defective gene in the body that can cause a hemorrhagic disease at any time. The secondary form occurs from damage to the walls of blood vessels (in an autoimmune process, mechanical damage, inflammation and chemical intoxication), with secondary thrombocytopenia, DIC syndrome, hemorrhagic vasculitis and deficiency of prothrombin complex factors.

Symptoms of hemorrhagic syndrome

There is a connection between localization areas hemorrhagic diathesis and clinical picture, intensity of manifestation, specificity of symptoms of the disease. Signs of hemorrhage in the nasal cavity are manifested by recurrent bleeding from telangiectasia (dilation of small vessels). This manifestation of symptoms is also typical for hemorrhages in the lips, mouth, pharynx and stomach. At the age of up to 30 years and during puberty, the frequency of bleeding from telangiectasia increases. Other signs include:

• dissecting hematomas;
• skin manifestations;
• delayed bleeding;
• decreased platelet count;
• superficial ecchymoses;
• petechiae;
• hemarthrosis.

Treatment of hemorrhagic syndrome

The treatment of hemorrhage depends on the symptoms and cause of the disease in patients. IN complex therapy involved: immunoglobulin, plasmapheresis, glucocorticosteroids. For inflammation of blood vessels (vasculitis), non-hormonal immunosuppressants, non-steroidal anti-inflammatory drugs (NSAIDs) are taken, corticosteroid therapy (glucocorticoid) is used and attempts are made to reduce the symptoms of inflammation. For hemophilia A, the missing factor VIII, and for hemophilia B – XI. After a detailed blood test, the doctor helps the patient choose treatment tactics.

Among the fundamental principles of therapy are:

• symptomatic treatment;
• intravenous injection a synthetic analogue of vitamin K - vikasol, calcium chloride and ascorbic acid;
• if necessary, transfusions of blood, its components (platelet, erythrocyte mass) and plasma are carried out;
• taking medications that help strengthen the walls of blood vessels (ethamzilate);
• for local treatment of hemorrhages the following are indicated: dry thrombin, homeostatic sponge, aminocaproic acid.

Consequences of hemorrhagic disease

If hemorrhages are detected, you should not panic, but you should immediately consult a doctor. At mild degree disease and timely treatment, the prognosis of the disease is favorable. However, there are cases when, with late detection of the disease, severe complications of hemorrhagic syndrome occur, which can lead to death.

Among these consequences are: massive internal bleeding, cerebral hemorrhages, cardiac dysfunction, adrenal insufficiency. The child may experience hypovolemic shock, which manifests itself through a decrease in blood pressure and body temperature, weakness, and pallor. To prevent the described consequences, it is necessary to immediately take the child for a consultation with a pediatrician as soon as symptoms are noticed.

Prevention of hemorrhagic syndrome

Compliance with simple preventive measures can protect against the development of pathologies. Reveal hemorrhagic bleeding A blood test will help, and you can reduce the risk of its occurrence if:

• within half an hour after birth, attach the baby to the breast;
• administer vitamin K by injection to children at risk;
• administer vitamin K injections during parenteral (intravenous) nutrition;
• administer intramuscular vitamin K during or before labor if the mother is taking anticonvulsants.

Video: Neonatal hemorrhagic syndrome