Elective Diaries: A bleeding Newborn
This was the case of an 8-day old sero-exposed (born to a HIV positive mother) male infant who presented with severe jaundice and significant bleeding including hematemesis (vomiting blood) and hematochezia (passage of fresh blood through the anus), suspected to be Hemorrhagic Disease of the Newborn on a background history of severe birth asphyxia.
The baby was admitted to the Newborn Intensive Care Unit at our host hospital in Malindi (during my elective with Medics Abroad) due to the birth asphyxia which occurred due to the fact that the baby had limb presentation and the mother was rushed in for an emergency cesarean section. There was a history of meconium aspiration and the baby had to be resuscitated.
4 days before my assessment, the baby presented with severe jaundice and a day later, internal bleeding (seen in urine and feces), vomiting blood, as well as prolonged bleeding time. following various lab examinations of the blood, the white blood cells, red blood cells, and the platelet counts were all below reference ranges.
- Head and Neck: There was normal hair distribution, no deformities, the fontanelles were normotensive, the neck was soft. The skin and sclera were yellow.
- Chest wall: On inspection of the chest wall, there were no visible deformities and the chest moved symmetrically with respiration. On auscultation of the lungs, there was bilateral air entry and no abnormal sounds were noted. On auscultation of the heart, heart sounds S1 and S2 were present, though tachycardic. No murmurs were heard and the apex beat was not displaced.
- Abdomen: On inspection, the abdomen was mildly distended and on palpation, mild hepatomegaly was noted. There were no other palpable masses, no bowel sounds were heard.
- Limbs: On examination of the limbs, they were stiff and there were no deformities.
What happened next:
As a result of the bleeding, the baby was transfused with Fresh Frozen Plasma (FFP) and Platelets but this didn’t help and two days later, the baby was still bleeding. He was transferred to a better equipped Intensive Care Unit in Mombasa, Kenya.
Here are a few things I’ve learned about Hemorrhagic Disease of the Newborn from this case:
- HDN occurs due to vitamin K deficiency and hence lack of vitamin k dependent clotting factors.
- Newborn babies are predisposed to vitamin K deficiency due to the minimal transplacental passage of vitamin K, limited hepatic storage of vitamin K, low vitamin K concentration in breast milk, etc.
- HDN is classified according to the timing of first symptoms:
- Early Onset (within 24 hours)
- Classic Onset (within 2-7 days)
- Late Onset (within 2 weeks to 6 months)
- It is mostly due to liver immaturity.
- Some common presentations are pallor, jaundice, tense fontanelles, hepatomegaly, anemia.
- The most common bleeding sites are umbilicus, gastrointestinal tract, site of circumcision, venous puncture site, and later possible intracranial bleeding.
- It occurs mostly in babies not given vitamin K at birth and so stresses the importance of vitamin K prophylaxis at birth.
- The management would include FFP and Platelet transfusion. Also, slow intravenous vitamin K infusion.
- The prognosis: In absence of intracranial hemorrhage, the prognosis in an otherwise healthy infant is excellent. With Intracranial hemorrhage, the prognosis depends on the extent and location of the hemorrhage because of the motor and intellectual deficits.
Featured image: Uwakmfon Udeh
Uwakmfon is a medical student at the University of Debrecen, Hungary.