Vitamin K Deficient

Bleeding
Aswini A/P Nalla Mutthu Krishna
Gandi
012013050215
 INTRODUCTION
Vitamin K deficiency can cause severe
haemorrhage in the newborn.
The term haemorrhagic disease of the
newborn (HDN) was coined by Charles
Townsend in 1894 to describe an acquired
bleeding disorder in the newborn due to
vitamin K deficiency.
Nowadays, the term HDN is replaced by
vitamin K deficiency bleeding (VKDB), as
neonatal bleeding is often not due to
vitamin K deficiency and VKDB often
occurs after the 4-week neonatal period.
 Vitamin K
The following 3 forms of vitamin K are
known:
K 1: Phylloquinone is predominantly
found in green leafy vegetables,
vegetable oils, and dairy products.
Vitamin K given to neonates as a
prophylactic agent is an aqueous,
colloidal solution of vitamin K 1.
K 2: Menaquinone is synthesized by
gut flora.
 CLASSIFICATION OF VKDB

Classification Age

Early VKDB 0 to 24 hours

Classic VKDB 1 to 7 days

1 to 12
Late VKDB
months
 EPIDEMIOLOGY
The frequency of vitamin K deficiency
bleeding in varies with the use of vitamin K
prophylaxis, the efficacy of prophylaxis
programs, frequency of breastfeeding, and the
vitamin K content of locally available
formulas.
Late vitamin K deficiency bleeding has fallen
from 4.4-7.2 cases per 100,000 births to 1.4-
6.4 cases per 100,000 births in reports from
Asia and Europe after regimens for
prophylaxis were instituted.
THANK YOU
 ETIOLOGY AND
PATHOPHYSILOG
Y
AZAHARI B.MOHD SHARI
EARLY-ONSET VKDB
Cephalhematoma
Ventouse delivery.

Intracranial bleeding
Usually associated with maternal medication that block
action of vitamin K
Examples: Anti-tubercular, Anti-convulsant, Anti-Coagulant

Intrathoracic bleeding

Gastrointestinal bleeding (commonest)

CLASSIC VKDB
Bleeding from the skin and mucous membranes
- eg, the nose and gums.

Prolonged bleeding following circumcision.

Bleeding from the umbilical stump.

Gastrointestinal bleeding.

Intracranial bleeding are uncommon.

LATE-ONSET VKDB
The most common is intracranial
bleeding
Refusal of Vitamin K prophylaxis at birth

Exclusive breastfeeding

Fat malabsorbtion
Biliary atresia
PATHOPHYSIOLOGY
Newborn infants at risk of Vit. K deficiency
1. Immature liver does not efficiently utilize Vit. K

2. Low Vit.K stores

A sterile gut
Poor placental transfusion of Vit.K
Low Vit.K content of breast milk

.In infants, plasma concentration of all Vit. K

dependent factor are about 20% of the adult values,
after a month the level rise within normal limits.
 The risk also increase with maternal
ingestion during pregnancy of warfarin or
other coumarin-like anticoagulants,
certain antibiotics (ie, cephalosporins),
and some anticonvulsant.
 VITAMIN K DEFICIENT
BLEEDING (VKDB)
CLINICAL FEATURES
DIFFERENTIAL DIAGNOSIS
INVESTIGATION

AZRY CHAU CHUNG SAN 01 2012 10 0120

 CLINICAL FEATURES
Babies with VKDB might develop any of the
following signs:

1. Bruises, especially around the babys head and face

2. Bleeding from the nose or umbilical cord
3. Skin colour that is paler than before. For darker
skinned babies, the gums may appear pale
4. After the first 3 weeks of life, the white parts of your
babys eyes may turn yellow (jaundice).
5. Black sticky tarry stool, or hematemesis.
6. Irritability, seizures, excessive sleepiness, or a lot of
vomiting may all be signs of bleeding in the brain
 CLINICAL FEATURES

Unfortunately, in the majority of cases of

VKDB, there are NO WARNING SIGNS before
a life-threatening event starts.
 CLINICAL FEATURES
COMMON BLEEDING SITE

Early VKDB (severe)

1. Head (cephalhaematoma, scalp,
subperiosteal)
2. Intra-thoracic
3. Intra-abdominal
4. Gastrointestinal tract
 CLINICAL FEATURES
COMMON BLEEDING SITE

Classical VKDB
1. Gastrointestinal tract
2. Umbilicus
3. Skin
4. Nose
5. Circumcision site
 CLINICAL FEATURES
COMMON BLEEDING SITE

Late-onset VKDB
1. Intra-cranial
2. Gastrointestinal tract
3. Skin
 DIFFERENTIAL DIAGNOSIS
Differential diagnosis Description
Disseminated intravascular Usually occur secondary to sepsis
coagulation (DIC) Prolonged PT, PTT,
thrombocytopenia
Elevated D-dimers level
Decreasing plasma fibrinogen
Liver failure Prolonged PT & PTT
Normal platelets count
Increased level of liver enzyme &
bilirubin level
Haemophilia Prolonged PTT
Normal PT and platelets count
Family history of haemophilia
Factor VIII & IX inhibitor screen
 DIFFERENTIAL DIAGNOSIS
Differential diagnosis
Immune Thrombocytopenia Purpura
Thrombotic Thrombocytopenia
Purpura
Von Willebrands disease
Other rare congenital clotting factor
deficiencies
Factors V, VII, X, XI, XII, XIII
Description
Thrombocytopenia
Normal PT and PTT
Normal PT, PTT and platelets count
Family history of bleeding diathesis
VWF maybe be low or increased
Plasma factor VIII is reduced
Factors V and X deficiency will
have prolonged PT and PTT
Factors XI, XII, XIII will have
prolonged PTT and normal PT
Factors VII deficiency will have
prolonged PT and normal PTT
 INVESTIGATION
i. Coagulation profile
Prothrombin time (PT)
International normalised ratio (INR)

ii. Platelets count

iii. Level of PIVKA-II

iv. Vitamin K level, rarely used

*PIVKA (protein induced in vitamin K absence)

 DIAGNOSIS CRITERIA
PT that is 4 the control value

and

At least one of these following:

i. Normal or raised platelet count, normal fibrinogen
and absent fibrin degradation products.
ii. PT returning to normal after VK administration.
iii. PIVKA (usually that of factor II) level exceeding
normal controls.
 Management, counselling, and
complication of VKDB

Che Ku Ashraf Helmi Bin Che Ku Mazuan

012012100095
Management

Infants : IM 1 mg vitamin K followed with

coagulation profile should be decrease within
6 hours and normalise within 24 hours.
Adolescents : IM 2.5-10 mg vitamin K
Life threatening bleeding : Fresh Frozen
Plasma infusion.
Children with malabsorption :
High dose oral vitamin K ( 2.5 mg twice/week) / (
5 mg/day)
if orally failed, administer parenterally.
Counselling

All symptomatic infant requires Vitamin

K injection.
Assurance that Vitamin K is less toxicity
because it has no upper limit for
overdose.
Exclusively breastfed baby should take
supplement oral vitamin K.
Watch out for any symptom and sign of
Intracranial hemorrhage and occult
bleeding.
Complication

Severe occult bleeding

Intracranial Hemorrhage
Death
References

https://www.aap.org/en-us/Pages/Defau
lt.aspx
https://www.cdc.gov/ncbddd/vitamink/fa
cts.html
http://emedicine.medscape.com/article
/974489-treatment#showall
 Fo
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w-
up
pl
an
Pro
gn
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Up
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HASHIMAH MOHD
s HANAFI
012012100319
FOLLOW-UP VISIT: (Needed if the
patient present with the same signs and
FOLLOW-UP PLAN
symptoms after treatment)

Assess the general health of the

In Malaysia,
neonate. VKDB is rare
Assess infant behavior. case, so it is
Review results of outstanding mostly
laboratory tests including the newborn treated if
screen. there is signs
and
Perform any necessary tests
symptoms of
Excellent prognosis to most
of the affected babies. PROGNOSIS

(If absence of intracranial haemorrhage)

Intracranial hemorrhage and late

VKDB associated with VKDB
account for the mortality.
(Depends on the extent and location of the
haemorrhage where complications may
include motor and intellectual deficits)
Although 83% of parents reported an awareness of the risks
of not receiving vitamin K, only 67% reported an awareness
of bleeding. Additionally, only 17% reported an awareness of
UPDATES
intracranial bleeding specifically, and 9% the risk of death.

Despite awareness of risks, only 6 of fifty-three parents (11%)

who completed the survey and initially refused IM
prophylaxis decided to accept it after discussions with
study workers.
Reasons for
Refusal of
The top 3 reasons for refusal were:
Newborn
(1) Concerns that the ingredients in the injection were synthetic or
Vitamin K
toxic,
Prophylaxis:
(2) The impression that the dose of vitamin K was excessive and
therefore may be harmful, and
Implications for
(3) Fear of adverse side effects.
Management
and Education
1. Hamrick et al, 2016. Reasons for refusal
of newborn vitamin K prophylaxis:
implications for management and
education. Hospital pediatrics, 6(1),
pp.15-21. [Online] Available at:
http://hosppeds.aappublications.org/conte
nt/6/1/15
[Accessed 1 April 2017]
2. https://
www.uptodate.com/contents/overview-of-t
he-routine-management-of-the-healthy-ne
wborn-infant?source=see_link