Transcript OBSTRETICS BLEEDING - Mahidol University

Extern Conference
Thursday 27th September 2007
History
A
preterm AGA 8 days old male
infant with complaint of jaundice
History

PI : the patient was born at 35+6 weeks of
gestational age (on 14th sep 07) by
spontaneous vertex delivery, with birth
weight 2610 gm AGA, HC 32 (P3-10 ) cm and
body length 48 cm(P3-10). Apgar scores
were 10,10 at 1&5 minutes, respectively.
Prenatal history was normal.
Maternal history
His mother is 15-years old. G1P0A0. First
ANC at GA 26 weeks x 4 times. Her blood
group is B with Rh positive. Blood serology
was all negative. Hct 35%, MCV 90
 No family history of hematologic disease
 She came to the hospital with premature
contraction, no PROM.

History

On the 2nd date of birth ,he developed
visible jaundice. Physical examination
was unremarkable. GA 36 weeks by
Ballard’s score. ABO and Rh blood types
of the patient and his mother revealed no
incompatibility. G-6-PD enzyme was
normal. Coombs’ test was negative. Blood
smear showed no hemolysis. Reticulocyte
count was 7.22
History
At that time, phototherapy was started and
continued for 4 days. The microbilirubin
was declined. He was discharged home on
18thsep 07, the 5th day of birth.
 BW was 2560 gm on the discharged day.

History

After discharge home (DOL 3D21HR), he
was given only breast feeding, about 10
times per day, 20 minutes each feed.
Frequency of urination was 10 times per
day, yellowish color. Frequency of
defecation was 3-4 times per day,
yellowish color
History

On the admission day (DOL=7), his mother
brought him to Siriraj hospital to follow up
his jaundice clinical. He had no fever,
active but still icteric.
History
Diet : breast feeding only
 Immunization : HBV , BCG at birth
 No history of neonatal jaundice in family

Physical examination






V/S : T 37c, BP 55/35mmHg ,RR 54/min,
PR 141/min
BW 2470 gm HC 32 cm BL 48 cm
GA : active, mildly pale, marked jaundice, no
petechiae or rash, no dyspnea.
HEENT : no cephalhematoma, no macroglossia,
no tongue tie, AF 2x3 cm ,PF 1x1 cm
Eyes : no cataract ,cornea clear
CVS : normal s1 and s2, no murmur
RS : normal breath sound, no adventitious
sound.
Physical examination
Abdomen : soft, no distention, bowel
sound positive, liver and spleen can’t be
palpated.
 CNS : normal reflexes, normal muscle
tone

Problem list
Maternal teenage pregnancy
 Preterm AGA male infant, NL, BW 2610 g ,
Apgar 10,10
 History of visible jaundice on 2nd day of
life with phototherapy treatment for 4 days
 Recurrent visible jaundice on DOL 7

Neonatal jaundice
A
yellow discoloration of the skin,
mucous membrane, and sclera in the
first 4 weeks of life after birth.
 Neonatal
jaundice is visible when
total serum bilirubin exceeds 5 mg/dl
Physiologic jaundice
Pathologic jaundice
After 48 hr of life
In 24 hr or after 2 wk
Total serum bilirubin
< 12 mg/dl (term)
< 15 mg/dl (preterm)
 < 5 mg/dl/d
Total serum bilirubin
> 12 mg/dl (term)
> 15 mg/dl (preterm)
 > 5 mg/dl/d
Persist
 7 d of age (term)
 14 d of age (preterm)
Persist
> 14 d of age (term)
> 21 d of age (preterm)
Common disease in neonatal jaundice
Unconjugated
hyperbilirubinemia
Hemolytic disease of the
new born
• G-6-PD deficiency
• Sepsis
• Breast feeding / Breast
milk jaundice
• Extravasation
•
Conjugated
hyperbilirubinemia
•Biliary
atresia
•Neonatal hepatitis
Pathology

Bilirubin production
Hemolysis
 Extravasation


Bilirubin conjugation


Impaired hepatic function
Bilirubin excretion
Biliary tract obstruction
 Intestinal obstruction
 Increase enterohepatic circulation

In this patient

DDX
Hemolytic jaundice
 Breast feeding jaundice

Investigation
CBC with slide
 TB/DB/MB

reticulocyte count
 TSH
 Coombs’ test
normal
 G6PD
 Blood group

Investigation (21/9/07)

The blood examination was performed.
Microbilirubin : 21.4 mg/dL.
 TB : 26.2
 DB : 2.5
 CBC : Hb 9.8 Hct 27.4% WBC 9440 (N 46% L
49% M 3% E 2%) Plt 484000
 MCV 83 RDW 18.1 anisocytosis 1+
poikilocytosis 1+
 reticulocyte count 3.11 (0.1-1.3)


TSH 3.08 mcu/ml (0-18)
Review blood smear
Normochromic normocytic RBC
 Anisocytosis 2+ , poikilocytosis 1+,
polychromasia few
spherocyte 2+
 WBC no band form
 Platelets adequate

Problem list
Maternal teenage pregnancy
 Preterm AGA male infant, NL, BW 2610 g ,
Apgar 10,10
 History of visible jaundice on 2nd day of
life with phototherapy treatment for 4 days
 Recurrent visible jaundice on DOL 7
 anemia

Neonatal jaundice
Direct hyperbilirubinemia
Indirect hyperbilirubinemia
•Neonatal hepatitis
Coombs’ Test ,Blood types
- Intrauterine infection
Negative
•Biliary atresia
•Sepsis
Positive
Dx:Isoimmunization
etc
•Rh
Hemoglobin or Hct
•ABO
•Other
Low or normal
High
Coombs’ test negative
Hemoglobin or Hct
Low or normal
High
Dx: Polycythemia
Reticulocyte count
•Maternal-fetal transfusion
High
Normal
•Twin-twin transfusion
•Delay cord clamping
RBC morphology
•Intrauterine hypoxia
Dx:-Physiologic jaundice
Abnormal
-Extravascular blood in body tissue
-Increase enterohepatic circulation
-Breast milk jaundice
-Hypothyroidism
-Metabolic errors -Hormone+drugs
Non-specific
Diagnostic
Dx : -RBC abnormality
Dx: -Spherocytosis
-Hemoglobinopathy
-Elliptocytosis
-Enzyme deficiency
-Stomatocytosis
-Hemolysis -DIC /sepsis
-Pyknocytosis
DDx
Hemolytic
jaundice
Breast feeding jaundice
DDx
Hemolytic
jaundice
Most likely diagnosis

Indirect hyperbilirubinemia from
hemolysis
-HS
-Thalassemia
Treatment

Goals
Prevention of kernicterus
 Treatment of underlying conditions
 Maintenance of hydration and
nutrition


Interventions
Intensive Phototherapy
 Exchange transfusion

Phototherapy

Indication for early phototherapy





Bilirubin rising faster than 0.5mg/dL/hr or
5mg/dL/d
Persistent, severe metabolic or respiratory
acidosis
Sepsis
Sick VLBW infants
Indication for phototherapy in infants >35
weeks gestation
AAP: Clinical Practice Guideline: Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks Gestation, July 2004
In this case
Exchange transfusion

Indication in infants 35 weeks gestation or more
In this patient
Double phototherapy
Hct/MB : 32/22.2
4 hours
Hct/MB : 32/22.7
Pre-transfusion : Hct/MB 21/15.4
Exchange transfusion
Post-transfusion : Hct/MB 31/8.9
Exchange transfusion




Action
 Replacement of the neonate’s blood with
donor blood that has normal level of serum
bilirubin
Mechanism: removes bilirubin and
antibodies from circulation and correct
anemia
Most beneficial to infants with hemolysis
Generally never used until after intensive
phototherapy attempted
Exchange transfusion

Indication


Intensive phototherapy
fails
TB exceed the level
indicated in guideline


Despite intensive phototherapy
for 6 hrs
Signs of acute bilirubin
encephalopathy
Principle of exchange transfusion
Two-volume exchange (160 ml/kg)
 Push-pull method (5 ml/kg/2-3min)
 Time 60-90 min
 In case of blood group incompatibility ,
choose bl gr. which compatible with both
mom and baby.

Complication
Phototherapy
Tanning, Bronze baby syndrome,
lactose intolerance
hemolysis, skin burns, dehydration,
skin rashes
Diarrhea
Retinal Change
*prevent by shielding eyes from light
Riboflavin deficiency (occur in prolongd
phototherapy)
* prevent by daily riboflavin intake of 0.3
mg.
Exchange transfusion
From
the procedure.
Embolization with air or thrombi,
thrombosis, arrythmia,
overheparinization, apnea, bradycardia,
cyanosis, vasospasm, hypothermia,
volume overload, arrest,
From blood products.
Hyperkalemia, hypernatremia,
hypocalcemia, acidosis, coagulation
disturbance, blood-borne infections.
*Monitoring of electrolytes, platelet count,
coagulation parameters, and arterial blood
gases is recommended.
Progression
Date and time
Hct /MB
22/9/07 :
7D18Hr
45/12.5 (15)
NPO
10%D/N/5
22/9/07 :
8D
22/9/07 :
8D10Hr
46/11.1 (15)
BM/SI
44/11.6 (15)
BM/SI
23/9/07 :
8D23Hr
Nutritional
status
39/7.5 (15) Off BM/SI
photo
Progression
Date and time
23/9/07:
9D11Hr
24/9/07:
10D3Hr
Hct /MB
Nutritional
status
39/9.1
BM/SI
43/8.9
BM/SI
Plan of management
Continue breast feeding
 Consult hematologist to find out the cause
of hemolytic anemia
-Inclusion body test : negative

-Hb typing : pending
 Observe clinical of kernicterus
Complication of neonatal jaundice

Acute bilirubin encephalopathy

The acute manifestations of bilirubin toxicity in
the 1st week after birth.
 Early
phase: lethargic and hypotonic
 Intermediate phase: stupor, irritability, high pitched cry
fever, hypertonia
 Advance phase: Retrocollis-opisthotonos, shrill cry,
apnea, coma, sometimes seizure and death

Kernicterus

The chronic and permanent clinical sequelae of
bilirubin toxicity
Discharge

Assessment before discharge

Predischarge bilirubin
 Use

nomogram to determine risk zone
Assessment of risk factors
TSB Zone before discharge
High-risk zone
Newborns
n (%)
Newborns Who Subsequently
Developed a TSB Level
> 95th Percentile, n (%)
6
39.5
High intermediate-risk zone
12.5
12.9
Low intermediate-risk zone
19.6
2.26
Low-risk zone
61.8
0
Discharge

Assessment before discharge

Predischarge bilirubin
 Use

nomogram to determine risk zone
Assessment of risk factors
TSB Zone before discharge
High-risk zone
Newborns
n (%)
Newborns Who Subsequently
Developed a TSB Level
> 95th Percentile, n (%)
6
39.5
High intermediate-risk zone
12.5
12.9
Low intermediate-risk zone
19.6
2.26
Low-risk zone
61.8
0
Follow-up Care
 Plan
based on
 Age in hours at discharge
 Risk of excessive hyperbilirubinemia
 Availability and reliability of follow-up
Follow-up Care
• Timing of follow-up
Infant Discharged
Should be Seen by age
Before age 24 hours
72 hours
Between 24-48 hours
96 hours
Between 48-72 hours
120 hours
Follow-up Care

Follow up assessment should include

Body weight, % change from BW,
adequacy of intake, the pattern of voiding
and stooling, presence or absence of
jaundice
Clinical judgment should be used to
determine the need for a bilirubin
measurement.
 If there is any doubt about the degree
of jaundice. Blood testing should be
done.

Follow-up Care

Some harmful advice and beliefs have to
be changed. All health personnel should
not advise parents to supplement water or
dextrose water to newborns or expose
newborns to sunlight.
Follow-up Care

Parents should be educated and provided
with adequate educational materials at
discharge regarding jaundice, feeding
adequacy and symptoms to watch for, the
risks of untreated hyperbilirubinemia, and
the need for close follow-up of their
infants after discharge
THANK YOU