Open Access

Case series
Newborn haemorrhagic disorders: about 30 cases

Brahim El Hasbaoui1,&, Lamia Karboubi1, Badr Sououd Benjelloun1

1
Paediatric Medical Emergency Department, Children’s Hospital, Faculty of Medicine and Pharmacy, University Mohammed V, Rabat, Morocco

&
Corresponding author: Brahim El Hasbaoui, Paediatric Medical Emergency Department, Children’s Hospital, Faculty of Medicine and Pharmacy,
University Mohammed V, Rabat, Morocco

Key words: New-bornhaemorrhagic disease, vitamin K, breastfeeding

Received: 22/06/2017 - Accepted: 05/09/2017 - Published: 18/10/2017

Abstract
The haemorrhagic disorders are particularly frequent in neonatal period. Their causes are varied and their knowledge is capital for their good
management. Our purpose was to describe the epidemiological, diagnostic, and common causes of new-bornhaemorrhagic syndrome in paediatric
emergency medical department of the Rabat Children's Hospital. We conducted a descriptive study from December 2015 to April 2016, about new-
borns admitted to medical emergencies for haemorrhagic syndrome defined by bleeding, exteriorized or not, whatever its importance, severity,
causes and the associated clinical and biological disorders. Between December 2015 and April 2016, we identified 30 cases of newborn
haemorrhagic syndromes on 594 hospitalizations (5.05%). The sex-ratio (M/F) was 1.5. None of them received vitamin K after birth and all were
breastfed. Preterm infants accounted for 10%. The presentation of haemorrhage encountered was dominated by visceral bleeding especially
digestive (80%), followed by epistaxis (10%), Haematuria (7%), and skin haemorrhage (3%). Physical examination was normal in most of cases
with exception (nine babies had pallor with hypotonia, three babies suffered from hypovolemic shock, respiratory distress(10%), drowsiness, poor
sucking and fever. The most common cause of bleeding disorder was haemorrhagic disease of the new-born (80%), disseminated intravascular
coagulation (DIC) (10%), esophagitis (6.67%) and isolated thrombocytopenia (3.33%). At the end of our study, given the high frequency of
vitamin k deficiency bleeding disease despite the prophylaxis received, a strengthening of the prevention system is necessary.

Pan African Medical Journal. 2017;28:150. doi:10.11604/pamj.2017.28.150.13159

This article is available online at: http://www.panafrican-med-journal.com/content/article/28/150/full/

© Brahim El Hasbaoui et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)

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Introduction neurologic examination, cranial CT and/or magnetic resonance
imaging (MRI), electroencephalographic study.

The haemorrhagic disorders are particularly frequent in neonatal

period. Causes of bleeding in the neonate are multifactorial, and
include disseminated intravascular coagulation, Vitamin K deficiency, Results
hereditary bleeding disorders, thrombocytopenia, platelet function
defects, hepatic disease, and trauma [1]. In 1894 Townsend [2] Our study encompassed eighteen males and twelve females. The
first used spontaneous the term "haemorrhagic disease of the mean gestational age of the population was 38 weeks. Five babies
newborn" to describe the spontaneous bleeding' occasionally were post-term while three new-borns were preterm. Twenty-seven
encountered in newborn infants, and he reported fifty cases from new-borns had normal spontaneous delivery. Two of the deliveries
the Bosten Lying-in Hospital. He was unable to determine the cause were at home. Twenty-five childs had been born at a local birthing
for the condition but recognized that he was dealing with a definite center, attended solely by midwives. According to the mothers,
clinical syndrome resulting from a deficiency in Vitamin K and there were "no problems" with the pregnancy or delivery, although
Vitamin K-dependent cofactors. Haemorrhagic disease of the new- the mother did not know the number of antenatal visits, extent of
born (HDN) is a rare disease with high mortality and morbidity [3]. antenatal laboratory evaluation, or details of the infant's perinatal
It is one of the most frequent causes of intracranial haemorrhage in care. No further information could be obtained from the birthing
the first year of life. New-borns have only 20-50% of adult center. The mean birth weight was 2700g. The delivery histories
coagulation activity. Lack of vitamin K administration at birth, were uneventful and the family histories were negative for any form
exclusive breast feeding, chronic diarrhea and prolonged use of of hereditary or acquired bleeding disorder. None of them had
antibiotics make them more prone to vitamin K deficiency bleeding received vitamin K at birth. Twenty-seven babies were fully
[4]. Through this work, we tried to describe presenting clinical and breastfed; three babies were on mixed feeding. The presenting
laboratory features of new-born haemorrhagic disorders and complaints and examination findings are described in Table 1. There
determine their different causes. were no histories of antibiotic usage, protracted diarrhoea in all
babies. The laboratory evaluation revealed the following: the
meanhaemoglobin 16 g/dl, nine babies presented anaemia, while

Methods four babies had thrombocytopenia. Three babies had leukopenia.

The PT and PTT values of twenty-seven babies were longer than
control values. In three patients, PT was longer than 60 seconds
Between December 2015 and April 2016 thirty patients were
and MT longer than 120 seconds. Fibrinogen levels was low in three
admitted to paediatric emergency medical department of Rabat
cases. Liver function tests were normal in twenty-seven cases.
Children's Hospital, with the diagnosis of onset haemorrhagic
Vitamin K dependent factor activities (factors II, VII, IX and X)
disorder. The detailed history included the mother's general health
measured in three infants were decreased. Cranial and abdominal
and medical condition prior to delivery, the place of birth, and
ultrasounds were normal in all our cases. The most common cause
whether vitamin K was given at birth. Laboratory studies included
of bleeding was Haemorrhagic disease of the newborn, a disease
complete blood count, partial thromboplastin time (PTT),
resulting from a deficiency in Vitamin K and Vitamin K-dependent
prothrombin time (PT), and liver function tests. Vitamin K-
cofactors, it was seen in twenty-four babies (80%), followed by
dependent factor activities were performed when possible. After
Disseminated intravascular coagulation (DIC) in three cases (10%),
blood had been drawn for the baseline evaluation, vitamin K (l-2mg)
esophagitis in two cases and isolated thrombocytopenia in one
was given intravenously. In babies with severe anaemia packed red
cases (Figure 1). Bleeding tendency was treated in all patients with
blood cells and fresh frozen plasma were given. Cranial
1-2 mg vitamin K2 intravenously. Blood, platelet and fresh-frozen
ultrasonography and computed tomography (CT) were performed in
plasma (FFP) transfusions with curative antibiotic in DIC. Proton
all babies for the diagnosis and the evaluation of intracranial
pump inhibitor (PPI) was administered in patients with esophagitis
bleeding. Follow-up of all infants was carried-out monthly in the
and platelet transfusion in case of isolated neonatal
child neurology unit for the first 3 months, and every 3 months
thrombocytopenia.
thereafter. The outcome was assessed by head circumference,

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Discussion was l/19 570 among new-borns who had received vitamin K orally
at birth [14]. Three patterns of haemorrhages due to vitamin K
deficiency in infancy are identified. Early haemorrhagic disease of
New-born Haemorrhagic syndromes are frequent, and represent
the new-born (HDN) occurs at birth or within the first 24 hours of
2.17% of neonatal hospitalization in Salem et al. [5] and 5.9% in
delivery, frequently seen in babies whose mothers are on
Jabnoun et al. [6]. There are many causes of bleeding disorder in
antitubercular (isoniazid and/or rifampicin), or antiepileptic (such as
the neonate and include disseminated intravascular coagulation,
phenytoin and phenobarbital) drugs. It is often life threatening [4].
Vitamin K deficiency, hereditary bleeding disorders,
Classical HDN accounts for gastrointestinal, nasal, skin and
thrombocytopenia, platelet function defects, hepatic disease, and
circumcision bleeding that occurs between 2-5 days of neonatal
trauma [1] (Table 2). Haemorrhagic disease of the newborn (HDN)
period and life-threatening bleeding is rare. Late-onset disease is
is one of the most frequent bleeding disorders in infancy [4]. First
almost exclusively confined to breastfed infantsand can be seen
described by Townsend, [2] results from a deficiency in Vitamin K
during infancy but predominantly at 4-8 weeks of life.Late HDN can
and, consequently, in the coagulation factors dependent on Vitamin
present with convulsions, poor sucking, irritability and pallor.
K. In umbilical blood the level of factors II, VII, IX, and X are nearly
Haemorrhages of gastrointestinal system, mucosal membranes and
normal, but then decline to a nadir usually between 48 and 72 hours
skin can accompany the disease.Mortality is reported in 14-50%
after birth. Levels slowly rise as dietary supplies of Vitamin K and
cases by various authors [15]. Risk of intracranial haemorrhage in
establishment of intestinal flora allow hepatic synthesis of
late HDN is reported in 50-80% cases [16]. While subdural is the
dependent cofactors s but remain below adult values for the first
most common location for haemorrhage, subarachnoid
several weeks of life [7]. Cow's milk contains 60µg/L of Vitamin K;
haemorrhage is the second most common type. Administering
breast milk contains 15 µg/L [8,9]. Consequently, symptomatic
vitamin K to every new-born at birth can impede the disease, which
haemorrhage (occurring in 0.25% to 0.5% of un-prophylactically
has a high morbidity and mortality [11,15]. Oral prophylaxis of
treated infants [10] has been noted more frequently in breast-fed
vitamin K is preventive against early and classical haemorrhagic
than in formula-fed infants unless Vitamin K prophylaxis is given
disease, but parenteral administration of vitamin K is required for
[7,9]. Vitamin K deficiency can also occur due to secondary causes.
the late disease [13,16]. Current recommendations for vitamin K
Chronic diarrhea, cystic fibrosis, biliary atresia, celiac disease, alpha
prophylaxis are to give vitamin K to all new-borns as a single
1-antityripsin deficiency, abetalipoproteinemia and a history of war
intramuscular dose of 0.5 to 1 mg. Findings of Cochrane review
far in usage for a long period may induce vitamin K deficiency [11].
(2009) are as follows - "A single dose (1.0 mg) of intramuscular
In our study, none of our patients had received vitamin K at birth
vitamin K after birth is effective in the prevention of classic HDN.
and there was no history of antibiotic usage, protracted diarrhoea.
Either intramuscular or oral (1.0 mg) vitamin K prophylaxis improves
The usual presentation is a manifestation of haemorrhage; melena,
biochemical indices of coagulation status at one to seven days.
umbilical bleeding, haematuria, epistaxis, generalized ecchymosis,
Neither intramuscular nor oral vitamin K has been tested in
and circumcision site bleeding are possible manifestations, and the
randomized trials with respect to effect on late HDN. If intracranial
neonate also may bleed from iatrogenic puncture sites [12]. Physical
or other serious haemorrhage occurs administration, either IM or IV,
examination usually is within normal limits except for the
is both safe and effective, an infusion of 10 to 15 mL/kg of fresh
manifestation of bleeding unless the disease is complicated by
frozen plasma will immediately correct the haemostatic defect and
intracranial haemorrhage or hypovolemic shock. Laboratory
clinical haemorrhage usually stops within two hours of
evaluation reveals prolongation of both the PT and PTT, reflecting
administration. This infusion also is used if the coagulation defect is
Factors II, VII, IX, and X deficiencies, but the platelet count,
unknown because haemostatic levels (> 20%) of all potential factor
peripheral smear, fibrinogen level, thrombin time, and fibrin split
deficiencies (except congenital hypoprothrombinaemia and
products are normal [12].
afibrinogenemia) and cessation of bleeding will result [1].
Profoundanaemia and shock may be corrected by 20 mL/kg whole
The incidence of vitamin K deficiency bleeding in early infancy was
blood transfusion.
calculated to be decreased in Germany from l/14 000 to l/70 000
with single oral prophylaxis and to l/420 000 with single parenteral
In our study: Newborn haemorrhagic disease was the most
vitamin K prophylaxis [13]. The occurrence of late HDN in Sweden
frequent bleeding disorder, it was seen in twenty-four babies

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(80%), and the early form concerned seven babies while the classic  Therefore, strengthening of the prevention system is
form was found in seventeen cases. No late forms were observed in necessary.
our series. The PT and PTT were longer than control values. Vitamin
K was given IM, and 10 mL/kg of fresh frozen plasma was
administered over two hours. Following this therapy, the bleeding
Competing interests
stopped within the next two hours, and no further bleeding sites
developed. Disseminated intravascular coagulation (DIC) was noted
The authors declare no competing of interests.
in 3 cases, they had hypovolemic shock: they were lethargic, very
pale with profound hypotonia, tachycardia, tachypnoea and oliguria
at the presentation, the capillary refill time (CRT) was > 3 s.
Laboratory evaluation reveals: pancytopenia, Prothrombin time (PT) Authors’ contributions
was very low whereas partial thromboplastin time (PTT) was
markedly elevated aggravated by renal and liver failure. Doctor Brahim El Hasbaoui: Editing, bibliographic search, design,
Unfortunately, they died despite of Blood, platelet and fresh-frozen reviews; Pr Lamia Karboubi; Corrections, critical reviews, appraisals,
plasma (FFP) transfusions with curative antibiotic. Esophagitis has bibliographic search, approval final version; Pr B.S. Benjelloun;
been noticed in 2 new-borns presented an isolated digestive Corrections, critical reviews, appraisals, bibliographic search,
haemorrhage with normal haemostasis. Isolated thrombocytopenia approval final version. All the authors contributed to the conduct of
was observed in one case. this work. All authors also state that they have read and approved
the final version of the manuscript.

Conclusion
Tables and figure
The low concentration of vitamin K in human breast milk and the
predisposition to vitamin K deficiency bleeding following exclusive Table 1: Characteristics and clinical data at the admission
breast feeding is emerging as a matter of concern especially in Table 2: Most common causes of bleeding in the neonate
developing countries where exclusive breast feeding is vigorously Figure 1: Causes of bleeding disorder
advocated to promote optimal health in the infant. Most reports of
late HDN have been in babies born at home and not given vitamin K
prophylaxis.
References

What is known about this topic

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 Haemorrhagic disease of the new-born, a disease
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Table 1: Characteristics and clinical data
at the admission
Number
of Percentage
cases
Presentation
of
Haemorrhage
Digestive
24 80%
bleeding
epistaxis 3 10%
Haematuria 2 7%
cutaneous
1 3%
haemorrhages
*Physical
examination
Normal 21 70%
Hypovolemic
3 10%
shock
Pallor 9 30%
Hypotonia 9 30%
Respiratory
3 10%
distress
* More than one finding could be present
in one patient.

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Table 2: Most common causes of bleeding in the neonate
Complications of pregnancy (abruption, previa, dead twin, maternal
shock)
Hypoxia
Disseminated intravascular coagulation Septicemia (bacterial - - group B strep)
(viral - - TORCH)
Respiratory distress syndrome.
Necrotizing enterocolitis
hemorrhagic disease of the newborn Vitamin K deficiency
Hemophilia A and B
Other factor deficiencies.
AfibrinogenemiaJdysfibrinogenemia
Platelets
von Willebrand's
Hereditary and familial
Hereditary bleeding disorders Clotting factors thrombocytopenia
Bernard Soulier Syndrome
Wiscott Aldrich
Infections (sepsis, viremia)Intravascular coagulation
syndromes s/p exchange
transfusion Immune
Thrombocytopenia
disorders (SLE, ITP,
antiplatelet antibodies)
Uremia
Platelet function defects Acidosis
Sepsis
Hepatitis (TORCH)
Hepatic disease Alpha-l-antitrypsin deficiency
Metabolic defects
Trauma Child abuse if unexplained

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Figure 1: Causes of bleeding disorder

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