Haemorrhagic

 

INTRODUCTION

 

          Haemorrhagic diseases of the new born is one of the life threatening problem lashing most of the countries.  Blood volume in the term baby is approximately 80-100 ml / kg and in the preterm baby 90-105ml/kg therefore even a small haemorrhage can be potentially fatal.  In this section new born haemorrhages are discussed according to their principle causes i.e., trauma, hypoxia, coagulopathies and other causes.

 

DEFINITION

 

          It is a syndrome characterized by spontaneous internal or external bleeding in association with hypoprothrombinaemia and very low levels of other vitamin K dependent coagulation factors (II, VII, IX and X).

 

ETIOLOGY

A.   Abnormalities of clotting factors

1.   Deficiencies of Vitamin K dependent factors (II, VII, IX, X)

2.   Drugs received by mother during pregnancy like phenytoin, coumarin compounds, salicilates etc.

B.    Disseminated intravascular coagulation (DIC)

C.    Platelet dysfunction

D.   Inherited abnormalities of blood coagulation

E.    Trauma

F.    Others – Liver dysfunction

CLASSIFICATION

A.    Hemorrhage due to trauma

                                         i.    Cephalhematoma

                                       ii.    Subaponeurotic hemorrhage

                                      iii.    Subdural hemorrhage

B.   Hemorrhage due to hypoxia

                                         i.    Subarachnoid hemorrhage

                                       ii.    Periventricular or intraventircular hemorrhage

                                      iii.    Periventricular leucomalacia

C.   Hemorrhage related to coagulopathies

                                         i.    Vitmain K deficiency bleeding

                                       ii.    Thrombocytopenia

                                      iii.    Disseminated Intravascular coagulation (DIC)

                                      iv.    Inherited coagulation factor deficiencies

D.   Hemorrhage related to other causes

                                         i.    Umbilical hemorrhage

                                       ii.    Vaginal bleeding

                                      iii.    Hematemesis and melena

                                      iv.    Hematuria

                                        v.    Bleeding associated with intravascular access.

HEMORRHAGE DUE TO TRAUMA

1. Cephalhematoma

Definition

          A cephalhaematoma is an effusion of blood under the periosteum that covers the skull bones.

 

Causes

1.   Friction between the fetal skull and the pelvic bones in normal delivery

2.   Vaccum – assisted births

 

Clinical Manifestation

Ø  Swelling appears after 12-24 hours of delivery.

Ø  Swelling grows larger over subsequent days and can persist for weeks.

Ø  The swelling is circumscribed , firm, does not pit on pressure, does not cross a suture and is fixed.

 

Nursing Management

Ø  No treatment is necessary

Ø  Swelling subsides when the blood is reabsorbed by 6-8 weeks.

Ø  Precautions to prevent infection and avoidance of trauma are important.

 

2. SUBAPONEUROTIC HAEMORRHAGE

Definition:

          The epicranial aponeurosis under the scalp is pulled away from the periosteum of the skull bones and bleeding occurs between with resultant swelling.

 

Incidence

Insidence is estimated to be 1 in 2500 births

Ø  Vaccum – assisted births

Ø  Primiparous women

Ø  Severe dystocia

Ø  Occipitolateral or posterior head positions

Ø  Preterm babies

Ø  Precipitate births

Ø  Macrosomia

Ø  Coagulopathies

 

Clinical manifestations

Ø  Swelling

o   Present at birth

o   Increases in size

o   Firm

o   Fluctuant mass

Ø  Scalp is movable rather than fixed.

Ø  Swelling can cross sutures and extend into the subcutaneous tissue to neck and eyelids.

Ø  Experiences pain while moving the head

Ø  Bruising may be present

 

Nursing Management

Ø  No treatment is necessary

Ø  The blood is reabsorbed and the swelling resolves over 2-3 weeks.

 

3. Subdural haemorrhage

Definition

          When there is trauma to the fetal head involving excessive compression, abnormal stretching and eventully tearing of the dura can occur, leading to rupture of the venous sinuses and the development of a subdural hemorrhage.

 

 

Predisposing circumstances

Ø  Precipitate or rapid birth

Ø  Malpositions

Ø  Malpresentations

Ø  Cephalopelvic disproportion

Ø  Undue compression during forceps maneuvers

 

Clinical Features

Ø  Slight hemorrhage produce hematoma which may remain stationary or increase in size.

Ø  Vomiting

Ø  Irritability

Ø  Failure to gain weight

Ø  Convulsion

Ø  Inco-ordinate ocular movements

Ø  Neck retraction

 

Diagnosis

Ø  Cranial ultrasound scan

Nursing Management

Ø  Control the consequences of asphyxia and raised intracranial pressure

Ø  Subdural taps

B.Hemorrage due to Hypoxia

1.  Subarachnoid Hemorrhage

Definition:

          This hemorrhage occurs when small amounts of capillary or venous bleeding takes place in the subarachnoid space due to tear of some small veins running from the brain to one of the sinuses.

 

Clinical features

Ø  No sign in the first week of life.

Ø  After a week, the baby may show signs of twitching of the extremities, incordinated eye movements and generalized convulsions.

Ø  Restlessness.

Ø  Apeneic spells in preterm babies.

Diagnosis

Ø  Computerized tomography (CT) scanning

Ø  Lumbar puncture, cerebrospinal fluid will be uniformly blood stained.

Nursing Management

Ø  Control of the consequences of asphyxia and of convulsions.

Ø  The condition is usually self limiting.

2. Periventricular or INtraventricular Hemorrhage

          The mechanism of hemorrhage is due to intense congestion of the fragile coroidal plexus due to anoxia leading to rupture causing haemorrhage.  This is the most common and serious of all intracranial hemorrhages.

 

Incidence:

Ø  It affects infants of less than 32 weeks gestation and those weighing less than 1500 gm.

 

Managmeent

          Prenatal administration of steroids to the mother to stimulate the maturation of surfactant followed by the administration of artificial surfactant postnatally to the preterm baby has reduced the incidence of intraventricular hemorrhage in the recent years.

 

3. Periventricular leucomalacia

          Reduced perfusion results in areas of ischaemia and degeneration of the nerve fibre tracts, disrupting nerve pathways between areas of the brain and between the brain and spinal cord.  This softening and necrosis of tissue is periventricular leucomalacia and is visible on ultrasound scan.

 

          Care instituted to reduce the incidences of periventricular haemorrhage can also reduce the incidence of periventricular leucomalacia or the severity of the related ischaemic damage.

 

C. HAEMORRHAGE RELATED TO COAGULOPATHIES

1. Vitamin K deficiency bleeding

          It was previously known as haemorrhagic disease of the newborn.

 

Definition:

          This is due to a temporary deficiency of the specific clotting factors, factor II (prothrombin) factor VII (proconvertin), Factor IX (plasma thromboplastin component) and factor X (thrombokinase). These factors are proteins which require vitamin K to convert them into active clotting factors.

Incidence:

          The babies who are more susceptible to develop haemorrhagic diseases are those suffering from birth trauma, asphyxia, postnatal hypoxia and those who are pre-term of low birth weight or who are receiving antibiotic therapy.

Ø  Infants who have liver disease or cystic fibrosis.

 

Clinical manifestations

Ø  Bleeding from the umbilicus

Ø  Bleeding from puncture sites

Ø  Bleeding from nose and the skin as bruising

Ø  Malena

Ø  Hemetemesis

Ø  Extracranial and intra cranial bleeding

 

Diagnosis

Ø  Blood test

Prolonged prothrombin and partial thromboplastin times.

Platelet count is normal

 

Nursing Management

Ø  Administration of Vit K, 1-2 mg intramuscularly

Ø  Transfusion of fresh frozen plasma and / or transfusion of the specific clotting factors.

 

2. Thrombocytop4enia

Definition

          It is a low count of circulating platelets less than 100,000 cubic mm and results from a decreased rate of formation of platelets for an increased rate of consumption.

 

Risk Factors

1.   Babies who have a severe congenital or acquired infection.  Eg: Syphilis, rubella, boxoplasmosis

2.   Mothers who have idiopathic thrombocytopenia purpura, systemic lupus erythematosus or thyrotoxicosis.

3.   Mothers who take thizaine diuretics

4.   Babies with iso-immune thrombocytopenia and inherited thrombocytopenia.

 

Clinical Features:

In mild cases

1.   A petechial rash appears soon after birth with few localized petichiae.

 

In severe cases

Ø  Wide spread and serious haemorrhage from the multiple sites.

 

Diagnosis

Ø  History collection

Ø  Clinical examinations

Ø  Low Platelet count whereas, coagulation time, fibrin degradation products and red blood cell morphology are normal.

 

Nursing Management

Ø  No treatment is required in mild cases.

Ø  It can be controlled by diet (Vitamin K and can give anti-allergic drug (Avil, cetrizine).

Ø  A transfusion of platelet concentrate may be required in severe cases.

Ø  In immune – mediated thrombocytopenia, intravenous immunoglobulin administration is helpful.

 

3. Disseminated intravascular coagulation (DIC)

Definition:

          It is an acquired coagulation disorder associated with the release of thromboplastin from damaged tissue, stimulating abnormal coagulation and fibrinolysis.

Causes

A.   Material Causes

a.   Pre-eclampsia

b.   Eclampsia

c.    Placental abruption

B.  Fetal causes

a.   Severe fetal distress

b.   Presence of dead twin in the uterus

c.    Traumatic birth

C.  Neonatal causes

a.   Hypoxia and acidosis

b.   Severe bacterial or viral infections

c.    Hypothermic

d.   Hypotension

e.    Thrombocytopenia

 

Clinical manifestations

·        Generalized purpuric rashes

·        Bleeding from multiple sites

·        Pulmonary and intra-cranial haemorrhage

·        Multiple micro-thrombi appear in circulation

·        Tissue ischemia and damage

·        Haematuria

·        Reduced urine out-put

·        Anaemia

 

Diagnostic evaluation

·        History collection for the evidence of pre-eclampsia, eclampsia, placental abruption etc.

·        Clinical examinations

o   Low platelet count

o   Low fibrihogen level

o   Distorted and fragmented red blood cells.

o   Low hemoglobin and raised fibrin degradation products with a prolonged prothrombin time and partial thromboplastin time.

 

Nursing Management

·        Correction of underlying causes.

·        Transfusion of fresh, frozen plasma, cryoprecipitates, concentrated clotting factors and platelets.

·        Transfusion of whole blood or red cells concentrate are required for anaemic babies.

·        An exchange transfusion of fresh heparinised blood for removing fibrin degradiation products at the some time replacing the clotting factors.

·        Heparin administration to reduce fibrin deposition.

 

4. Inherited coagulation factor deficiencies

Definition:

          These are x-linked recessive conditions such as haemophilic (factor VIII deficiency) and Christmas disease (factor IX deficiency) rarely cause problems in the neonatal period but may present with excessive bleeding after birth trauma or surgical intervention such as circumcision.

 

Incidence:

          It is most frequently inherited by the union of an unaffected male and a female carrier.  The incidence of female haemophilia is very rare.

Clinical features

·        Bruises easily and have a tendency towards nose bleeds and gum bleeding

·        Haematuria

·        Intrcranial bleeding which is life threatening.

·        Bleeding in the joints (haemorthrosis)

 

Diagnosis

·        Genetic history

·        Clinical symptoms

·        Laboratory tests includes a complete blood count, platelet function test and clotting studies.

·        Prolonged partial thromboplastin time (PTT)

 

Nursing Management

·        Replacement transfusion (factor VIII and IX) in the form of  cryoprecipitate made from fresh plasma.

 

D.HAEMORRHAGE RELATED TO OTHER CAUSES

1. Umbilical haemorrhage

1.   This usually occurs as a result of poorly applied cord ligature.

2.   The use of plastic cord clamps usually cause umbilical haemorrhage.

3.   Tampering with partially separated cords before they are ready to separate is discouraged.

4.   A purse – string suture should always be inserted if umbilical bleeding does not stop after 15 to 20 minuts.

 

2. Vaginal bleeding

·        This blood stained mucous occurring in the first days of life is also referred to as pseudomenstruation.

·        This pseudomenstruation is due to the withdraw of maternal oestrogen.

 

3. Haematemesis and melaena

·        This appears when the baby swallow maternal blood during delivery or from cracked nipples during breast feeding.

·        The other causes of haematemosis includes oesophagial gastric or duodenal ulceration the other cause of melaena includes intestinal duplication, haemangiomas with in the gut necrotizing enterocolitis and anal fissures.

 

4. Haematuria

·        It can be associated with coagulapathies, urinary tract infections, and structural abnormalities of the urinary tract.

·        Birth trauma may also causes renal contusion and haematuria.

·        Suprapublic aspiration of urine  may also cause haematuria.

 

5. Bleeding associated with intravascular access

          Dislodgement of catheters from the vessels or from accidental disconnection of the catheter from the infusion administration set.

Eg:- Umbilical arterial and venous catheters

          Central venous lines

          Radial and femoral lines

 

Nursing Management:

·        Umbilical cord should be tied tightly in order to prevent umbilical haemorrhage.

·        Catheter haemorrhages can be prevented by closed observation and careful handling of infants and their lines.

·        Continuous pressure should be applied  to the site specially for the umbilicus until haemostasis occurs.

·        A replacement transfusion of whole blood or packed red cells may be required.

 

CONCLUSION

 

          Hemorrhage in the newborn can be due to trauma or hypoxia, or it can be related to coagulopathies and other causes.  Prognosis is fevourable if the blood loss is less and the treatment is promptly initiated.  Even a small amount of blood loss may be lethal and should be replaced by blood transfusion if necessary.

 

 

BIBLIOGRAPHY

 

1.   D.C. Dutta, Text Book of Gynaecology, 6^th Edition, New Central Book Agency (P) Ltd., Culcutta., Pg.No.481-482.

2.   annamma Jacob’s, A comprehensive Text Book Edition, 2^nd Pg.No.565-572

3.   Parul Dutta, Pediatric Nursing Pg.No.342-348.

4.   Myles, Text Book of Midwifes Page No.829-837.