11. HAEMORRHAGE IN THE NEWBORN INFANT

Question 1

Intraventricular hemorrhage decription:

Answer 1

• O riginate from the vessels of the germinal matrix located above nucleus caudatus.
• Germinal matrix is important for intrauterine development of CNS but disappears after 35 week of gestation.
• Observed mainly in preterm neonates with incidence up to 40% in newborns with body weight <1000 g.
• Usually occur in the first 24 hours of life but can be found in the first 3 days.

Question 2

IVH risk factors:

Answer 2

Prematurity
Hypothermia
Hypoxemia
Fragile vessels in the germinal matrix
Fluctuations in blood pressure and cerebral blood flow
Perinatal asphyxia
Cerebral ischemia followed by increased perfusion

Question 3

IVH grading:

Answer 3

• IVHs are confirmed with ultrasound.

4 degrees of severity of IVH have been defined. I and Il grade IVH have better prognosis.

• In grade I, IVH blood collection is observed in the subependymal space.
• In grade Il blood collection occupies less than 50% of ventricular volume.
• In grade III LVH lateral ventricles are filled with blood.
• In grade IV IVH periventricular hemorrhage is also observed.

Question 4

IVH Clinical manifestations:

Answer 4

• Asymptomatic or may preset with discrete neurological symptoms like abnormal popliteal angle.
• Seizures are observed in 15% of eases.
• In grade Ill and IV sudden deterioration of the status is observed:
  Pallor
  Bradycardia
  Hypoxemia
  Impaired consciousness
  Decreased reactivity and locomotor activity
  Bulging fontanelle
  Apnea
  And later - widening of sutures and fontanels, rapid increase of head circumference.

Question 5

Prognosis:

Answer 5

Most common complications are post hemorrhagic hydrocephalus and porencephalic periventricular cyst.

In grade I and II prognosis is good with mild stabile dilation of lateral ventricles and slightly higher incidence of neurological involvement

Question 6

IVH treatment:

Answer 6

Providing stable haemodynamic and ventilation, anticoagulation, anemia correction.
In posthemorrhagic hydrocephalus in Ill and IV grade IVH insertion of a ventriculoperitoneal shunt is needed.

Question 7

ICH in term infants - common types:

Answer 7

Infratentorial subdural haemorrhage is the most common in asymptomatic infants and primary subarachnoid hemorrhage is most common in symptomatic patients.

Epidural hemorrhages are rare and extradural hemorrhages are observed in cases of difficult foetal forceps extraction.

Question 8

ICH in term infants - maternal risk factors

Answer 8

Hypertension
Autoimmune diseases
Drug use
Administration of medications such as aspirin, and alloimmune thrombocytopenia.

Question 9

ICH in term infants - perinatal risk factors:

Answer 9

Birth trauma
Perinatal asphyxia
Need for resuscitation
Congenital coagulopathy
Prolonged delivery
Use of forceps and vacuum extraction

Question 10

ICH in term infants - slinical symtpoms

Answer 10

Impaired consciousness
Convulsions during first 48 hours
Changes in muscle tone and reflexes
Signs of increased intracranial pressure - tense fontanelle, ocular symptoms, apnea, and bradycardia

Question 11

ICH in term infants - diagnosis

Answer 11

1. Somatic and neurological status.
2. Blood tests: complete blood count, coagulation status.
3. Imaging.
   - CT is highly sensitive to detect the acute haemorrhage; MRI is preferred in subacute phase.
   Ultrasound has a lower sensitivity in these cerebral hemorrhages and other imaging tests are more appropriate in suspected intracranial hemorrhage.
4. Electrophysiological tests.

Question 12

ICH in term infants - treatment

Answer 12

Appropriate ventilation and infusion therapy, anticonvulsive treatment, correction of coagulation disorders and thrombocytopenia.
Neurosurgical treatment is required only in about 3% of term infants with intracranial haemor-
rage.
Prevention of cerebral haemorrhage in late forms of haemorrhagic disease requires vitamin K administration (2 mg vit. K per os after birth, before discharge and at the end of the first month).

Question 13

Subdural hemorrhages:

Answer 13

Seen in association with birth trauma, cephalopelvic disproportion, forceps delivery, large for gestational age infants, skull fractures, and postnatal head trauma.
The subdural hematoma does not always cause symptoms immediately after birth; with time, however, the RBCs undergo hemolysis and water is drawn into the hemorrhage because of the high oncotic pressure of protein, resulting in an expanding symptomatic lesion.
Anemia, vomiting, seizures, and macrocephaly may occur in an infant who is 1 to 2 months of age and has a subdural hematoma.
Child abuse in this situation should be suspected and appropriate diagnostic evaluation undertaken to identify other possible signs of skeletal, ocular, or soft tissue injury.
Occasionally, a massive subdural hemorrhage in the neonatal period is caused by rupture of the vein of Galen or by an inherited coagulation disorder, such as hemophilia.
Infants with these conditions exhibit shock, seizures, and coma.
The treatment of all symptomatic subdural hematomas is surgical evacuation.

Question 14

Subarachnoid hemorrhages:

Answer 14

May be spontaneous, associated with hypoxia, or caused by bleeding from a cerebral arteriovenous malformation.
Seizures are a common presenting manifestation, and the prognosis depends on the underlying injury. Treatment is directed at the seizure and the rare occurrence of posthemorrhagic hydrocephalus.

Question 15

Hemorrhagic disease of the newborn:

Answer 15

Disease more common among breastfed infants
Occurs in the first few weeks of life.
It is rare in infants who receive prophylactic intramuscular vitamin K on the first day of life.
Factor 2, 7, 9 and 10.
e/ transient vitamin K deficiency. Liver immaturity and also impaired bacterial flora (produce vitamin K) if the mother had a vitamin K deficiency.
Hemorrhagic disease of the newborn usually is marked by generalized ecchymoses, gastrointestinal hemorrhage, or bleeding from a circumcision or umbilical stump; intracranial hemorrhage can occur, but is uncommon.
Early 2-7 days and late 4-12 weeks.
Causes maternal drugs phenytoin and phenobarbital lead to vitamin K deficiency.
Hemorrhage in first 4 hours and late hemorrhage due to malabsorption.
Investigations/ anemia , check factor levels 2,7,9,10 ; check prothrombin time , bleeding time (they are prolonged)
20mg to mother before delivery.
The American Academy of Pediatrics recommends that parenteral vitamin K (0.5 to 1 mg) be given to all newborns shortly after birth
Blood transfusion and plasma transfusion if serious.
Birth trauma can cause spleen and liver damage and lead to bleeding.