Late vitamin K deficiency bleeding in infants: five-year prospective study

Abstract Objective: To study the presenting clinical and demographic features, risk factors, and outcome of infants with late vitamin K deficiency bleeding. Methods: Over a 5-year study period, the presenting clinical features and outcome of all 47 infants observed aged less than 6 months, who were diagnosed with late-onset primary and secondary VKDB by detailed history, physical examination, and laboratory findings were evaluated. Confirmed primary late VKDB was diagnosed when no cause other than breastfeeding could be found, while in the secondary subtype additional risk factors compromising the vitamin K effect were diagnosed. Results: Secondary late VKDB (83%, 39 patients) was more common than the primary subtype. The mean age of patients was 10.50 ± 5.75 and 9.74 ± 6.04 weeks in primary and secondary VKDB subtypes, respectively, and the age of infants did not have a significant difference (> 0.05). The male to female ratio was 2.13:1. The residency, place and mode of delivery, gestational age, and types of feeding of patients did not have a significant difference between VKDB subtypes. The skin and gastrointestinal tract (GIT) (40.4%) followed by intracranial hemorrhage (ICH) (32%), were common sites of bleeding. Neurological complications were seen in 21% of patients; however, lethality was 23%, and the outcome of patients did not have a significant difference (p > 0.05) between VKDB subtypes. Conclusion: Secondary late VKDB is more common than the primary subtypes, and late VKDB is still a serious disease in developing countries, including Iraq, when vitamin K prophylaxis isn't routinely used at birth.

Late vitamin K deficiency bleeding in infants: five-year prospective study.

OBJECTIVE: To study the presenting clinical and demographic features, risk factors, and outcome of infants with late vitamin K deficiency bleeding. METHODS: Over a 5-year study period, the presenting clinical features and outcome of all 47 infants observed aged less than 6 months, who were diagnosed with late-onset primary and secondary VKDB by detailed history, physical examination, and laboratory findings were evaluated. Confirmed primary late VKDB was diagnosed when no cause other than breastfeeding could be found, while in the secondary subtype additional risk factors compromising the vitamin K effect were diagnosed. RESULTS: Secondary late VKDB (83%, 39 patients) was more common than the primary subtype. The mean age of patients was 10.50 ±â€¯5.75 and 9.74 ±â€¯6.04 weeks in primary and secondary VKDB subtypes, respectively, and the age of infants did not have a significant difference (p > 0.05). The male to female ratio was 2.13:1. The residency, place and mode of delivery, gestational age, and types of feeding of patients did not have a significant difference between VKDB subtypes. The skin and gastrointestinal tract (GIT) (40.4%) followed by intracranial hemorrhage (ICH) (32%), were common sites of bleeding. Neurological complications were seen in 21% of patients; however, lethality was 23%, and the outcome of patients did not have a significant difference (p > 0.05) between VKDB subtypes. CONCLUSION: Secondary late VKDB is more common than the primary subtypes, and late VKDB is still a serious disease in developing countries, including Iraq, when vitamin K prophylaxis isn't routinely used at birth.

Intoxicación con rodenticidas anticoagulantes: serie de casos y revisión de literatura / Intoxication with anticoagulant rodenticides: Case series and review of the literature

Introducción. Los superwarfarinicos (SWF) son una de las herramientas utilizadas por el ser humano para el control de roedores y a la vez son tóxicos para el hombre y pueden conducir a la muerte sin los debidos cuidados en su uso.Casos clinicos. Tres pacientes masculinos, que consultaron por sangrados (gingivorragia, epistaxis, hematuria, hemartrosis y hematomas cutaneos) asociados a alteraciones del coagulograma (Tiempo de protrombina (TP) y tiempo de tromboplastina parcial (KPTT) prolongados). Todos tuvieron exposición a superwarfarinicos. Nuestro servicio no dispone del análisis de SWF en suero. Se administró vitamina K1 en los tres pacientes y plasma fresco congelado (PFC) en uno solo (sangrado mayor: hematuria). El seguimiento se realizó mediante controles seriados de coagulograma y su evolución fue favorable. Discusión. En todos los casos, el diagnóstico de intoxicación por SWF fue clínico, basado en caracteristicas clínicas de pacientes y alteraciones en sus parámetros de coagulación, y debido a imposibilidad de derivación de análisis a otro laboratorio. Se realizo tratamiento especifico (vitamina K1 y PFC) segun recomendación de expertos, ya que no hay hasta la fecha, estudios clinicos que evaluen las diferentes opciones terapéuticas. Conclusión. La intoxicación por SWF aunque no es frecuente, debe sospecharse en casos de paciente con coagulopatia sin otras causas que puedan justificarlo. El manejo del cuadro tóxico es la reposición de vitamina k y de plasma fresco congelado, en casos donde se necesite una rápida corrección de la alteración hemostática, como los sangrados mayores. Es imprescindible la oportuna consulta con médicos hematólogos y/o la consulta con un centro regional de control de intoxicaciones para todas las exposiciones sospechosas por SWF.

Introduction. Superwarfarinics (SWF) are one of the tools used by humans for rodent control. They are toxic to humans and can lead to death without due care in its use. Clinical cases. Three male patients, who consulted due to bleeding (gingivorragia, epistaxis, hematuria, hamartrosis and skin hematomas) associated with coagulogram alterations (prolonged protombine time (PT) and partial thromboplastin time (KPTT)). All them exposure to superwarfarinics. SWF serum analysis was not available in our hospital. Vitamin K1 was administered in all three patients and fresh frozen plasma (PFC) in only one (major bleeding: hematuria). The followup was performed by serial coagulogram controls and the evolution was. Discussion. In all cases, the diagnosis of SWF intoxication was clinical, based on clinical characteristics of patients and alterations in their coagulation parameters, due to the impossibility of deriving the analysis of SWF in serum to another laboratory. Specific treatment was carried out (vitamin k and PFC) according to experts' recommendation, since there are no clinical studies to evaluate the different therapeutic options to date. Conclusion. SWF poisoning, although not frequent, should be suspected in patients with coagulopathy without other causes that may justify it. The management of toxic symptoms is the administration of vitamin K1 and fresh frozen plasma, in cases where a rapid correction of the haemostatic alteration is required, such as major bleedings. It is essential to consult with hematologists and / or consult a regional poison control center for all suspicious exposures by superwarfarins.

Late-Onset Vitamin K Deficiency Presenting as Scrotal Bruising and Mediastinal Mass.

Although there are several reports of intracranial hemorrhage associated with vitamin K deficient bleeding, there are few reported cases of extracranial manifestations, specifically involving the thymus. Here, we discuss the unique case of a 4-week-old infant presenting with scrotal discoloration, respiratory distress, and widened mediastinum, found to have thymic hemorrhage related to confirmed coagulopathy secondary to late-onset vitamin K deficiency bleeding of the newborn.

Prevención de hemorragias en el posoperatorio temprano de cirugía bariátrica: Papel de la vitamina K / Prevention of hemorrhage in the early postoperative period of bariatric surgery: Role of vitamin K

Introducción: la cirugía bariátrica es el tratamiento más eficaz para la obesidad mórbida. La hemorragia se presenta en el 0,5-5% de las pacientes. La preparación prequirúrgica con dieta líquida y el uso de antibióticos para Helicobacter pylori podría alterar el metabolismo de la vitamina K y asociarse a hemorragia. Objetivo: describir el comportamiento de la concentración de protrombina (basal = B-PT y prequirúrgica = preQ-PT) en estos pacientes. Material y métodos: se realizó un estudio de cohorte prospectivo donde se comparó la concentración de B-PT (15-180 días previos a la cirugía) y la preQ-PT (24 horas previas a la cirugía). Resultados: se incluyeron 194 pacientes, de los cuales el 72% (n = 139) fueron mujeres, de entre 19 y 69 años, con BMI (IMC) 45 (33 a 58) y pérdida de peso prequirúrgica del 7% (-2 a 17). El promedio de B-PT fue 91,9% (DE 9,529), el promedio de la preQ-PT fue 81,1% (DE 10,760); descendió un 10,8% (p < 0,001). No hubo diferencias significativas cuando se comparó el comportamiento en la preQ-PT entre los diferentes subgrupos (uso de antibióticos para Helicobacter pylori, de acuerdo con la pérdida de peso y en relación con la suplementación de vitamina K); sin embargo, siempre se detectó descenso de la preQ-PT. No hubo ninguna complicación hemorrágica (necesidad de transfusiones o reoperación); tampoco hubo muerte por hemorragias ni eventos tromboembólicos. Conclusión: realizar dosaje de protrombina 24 horas antes de la cirugía bariátrica permite detectar alteraciones iatrogénicas de la coagulación inducidas por la dieta y el uso de antibióticos.

Background: bariatric surgery is the most efficient treatment for morbid obesity. Bleeding occurs in 0.5-5% of patients. Pre-surgical preparation with liquid diet and the use of antibiotics for Helicobacter pylori could alter the metabolism of vitamin K and be associated with hemorrhage. Objective: to describe the behavior of the concentration of Prothrombin (basal = B-PT and pre-surgical = preQ-PT) in these patients. Material and methods: a prospective cohort study comparing B-PT concentration (15-180 days prior to surgery) and preQ-PT (24 h prior to surgery) was performed. Results: a total of 194 patients were included in the study, with 72% (n = 139) women aged 19-69 years, BMI 45 (33 to 58) and preoperative weight loss of 7% (-2 to 17). The media B-PT was 91.9% (SD 9.529), the media pre-PT was 81.1% (SD 10.760); declined 10.8% (p <0.001). There was no significant difference when comparing the behavior in the preQ-PT among different subgroups (use of antibiotics for Helicobacter pylori, according to weight loss and in relation to vitamin K supplementation), however, there was always a decrease of the preQ-PT. There were no bleeding complications (need for transfusions or re-intervetion), nor was there death for bleeding or thromboembolic events. Conclusion: prothrombin measurement 24 hours before bariatric surgery allows the detection of iatrogenic coagulation alterations induced by diet and the use of antibiotics.

Prothrombin Complex Concentrate for Intracerebral Hemorrhage Secondary to Vitamin K Deficiency Bleeding in a 6-Week-Old Child.

Four-factor prothrombin complex concentrate is approved for use of life-threatening bleeding secondary to vitamin K antagonism in adults. We describe the use of four-factor prothrombin complex concentrate for hemostasis in a 6-week-old child with life-threatening vitamin K dependent-bleeding who never received vitamin K prophylaxis at birth.

Functional polymorphism in gamma-glutamylcarboxylase is a risk factor for severe neonatal hemorrhage.

A neonate who received vitamin K (VK) supplementation then developed severe late-onset bleeding with abnormal prothrombin time and activated partial thromboplastine time. The bleeding was corrected after intravenous VK. Molecular analysis of the gamma-glutamylcarboxylase gene revealed a heterozygous single nucleotide polymorphism, which decreases carboxylase activity and induces VK-dependent coagulation deficiency.

Factores de riesgo asociados en la enfermedad hemorrágica del recien nacido en el Instituto de Salud del Niño / Risk factors associated with hemorrhagic disease in the newborn at the Institute of Child Health

Objetivos: Determinar los factores de riesgo asociados a enfermedad hemorrágica del recién nacido. Material y métodos: estudio retrospectivo tipo caso-control realizado en el INS, desde el período 1995-2009 con una muestra de 18 casos afectados de enfermedad hemorrágica del recién nacido y 36 controles escogidos al azar del mismo periodo, del consultorio de Control del niño sano menor de 2 meses del INSN. Resultados: los niños menores de un mes fueron el grupo más predominante en nuestros casos y controles, representando un total de 8 niños (47.1 por ciento) y 18 niños (52.9 por ciento) respectivamente, en comparación con los niños de 4 meses con un total de 1 niño (5.9 por ciento) en los casos. El género masculino represento un alto porcentaje en nuestros casos, 11 niños (64.7 por ciento), en comparación con el género femenino, 6 niñas (35.3 por ciento), asimismo, en nuestros controles, 11 niños (47.1 por ciento) y 18 niñas (52.9 por ciento), La mayoría de nuestros casos proceden de lima este, 12 niños (11.8 por ciento), en comparación con los que proceden de lima centro, 2 niños (11. 8 por ciento), en nuestros controles la mayoría procede de Lima norte con un total de 16 niños (31.4 por ciento), en comparación con los que proceden de Lima centro, 5 niños (9.9 por ciento). La mayoría de nuestros casos controles nacieron en lima centro, 12 niños (70.6 por ciento); y en nuestros controles 14 niños (40.9 por ciento). En nuestros casos, la mayoría recibió ATB previo debido a sepsis con un total de 3 niños (17.6 por ciento) y en nuestros controles debido a infección y sepsis, 3 niños (8.8 por ciento) y 2 niños (5.9 por ciento), respectivamente. La antibioterapia previa prevalece sobre la LME y profilaxis de vit K como factor desencadenante de la enfermedad hemorrágica del recién nacido...

Hemorragia intraventricular en el recién nacido prematuro / Intraventricular hemorrage in preterm neonates

El presente trabajo es producto de una revisión de la patogénesis, incidencia, tratamiento y pronóstico de la hemorragia intraventricular en el recién nacido prematuro. En las publicaciones revisadas, que incluyen series importantes de seguimiento, esta patología se presenta en 25% de los infantes menores de 1500 gramos de peso, en los que tanto la morbilidad como la mortalidad es mayor que los recién nacidos normales, ya que el desarrollo de la hemorragia intraventricular, puede producir alteraciones de flujo sanguíneo cerebral en la inmadura matriz germinal y en la red microvascular. En consecuencia la prevención de la hemorragia intraventricular está directamente relacionada con su patogénesis. Se pregona que el uso de esteroides tipo dexametazona en dosis bajas en el período prenatal y bajas dosis de endometacina en el período postnatal, pueden dar mejor neuroprotección. El tratamiento quirúrgico es excepcional y tiene indicaciones bien precisas, cuando se demuestra certeramente una hidrocefalia progresiva tardía. Por lo tanto en los neonatos prematuros con hemorragia intraventricular el mejor tratamiento actual, es el usar un sistema de seguimiento médico y farmacológico...(AU)

Hemorragia intraventricular en el recién nacido prematuro / Intraventricular hemorrage in preterm neonates

El presente trabajo es producto de una revisión de la patogénesis, incidencia, tratamiento y pronóstico de la hemorragia intraventricular en el recién nacido prematuro. En las publicaciones revisadas, que incluyen series importantes de seguimiento, esta patología se presenta en 25% de los infantes menores de 1500 gramos de peso, en los que tanto la morbilidad como la mortalidad es mayor que los recién nacidos normales, ya que el desarrollo de la hemorragia intraventricular, puede producir alteraciones de flujo sanguíneo cerebral en la inmadura matriz germinal y en la red microvascular. En consecuencia la prevención de la hemorragia intraventricular está directamente relacionada con su patogénesis. Se pregona que el uso de esteroides tipo dexametazona en dosis bajas en el período prenatal y bajas dosis de endometacina en el período postnatal, pueden dar mejor neuroprotección. El tratamiento quirúrgico es excepcional y tiene indicaciones bien precisas, cuando se demuestra certeramente una hidrocefalia progresiva tardía. Por lo tanto en los neonatos prematuros con hemorragia intraventricular el mejor tratamiento actual, es el usar un sistema de seguimiento médico y farmacológico...

[Re-emergence of hemorrhagic disease in newborns. Implications for its prevention]. / Resurgimiento de enfermedad hemorrágica del recién nacido. Implicaciones para su prevención.

OBJECTIVE: To describe the occurrence of hemorrhagic disease of the newborn (HDN) at a tertiary care pediatric hospital of Morelos state. MATERIAL AND METHODS: A retrospective case series study was conducted between 1997-2000 at Hospital del Niño Morelense (Morelos State Children's Hospital), in 46 newborns aged under 12 weeks. Study subjects were referred from peripheral units with a diagnosis of HDN. RESULTS: The severe late-onset form of HDN was present in 91% of the cases. Fifty-two percent of childbirths were assisted by a physician and 48% by an empiric midwife. Application of vitamin K was unknown in 61% of cases, in 39% it was not applied and in 4% it was applied. The majority of infants presented severe symptoms due to intra-cranial bleeding, 11% died, and 41% had severe disease sequelae. CONCLUSIONS: Given the high prevalence of HDN in the State of Morelos, reproductive health programs should be reviewed and training programs intensified to promote the utilization of vitamin K by physicians and nurses for preventing this disease.

Resurgimiento de enfermedad hemorrógica del recién nacido. Implicaciones para su prevención / Re-emergence of hemorrhagic disease in newborns. Implications for its prevention

OBJECTIVE: To describe the occurrence of hemorrhagic disease of the newborn (HDN) at a tertiary care pediatric hospital of Morelos state. MATERIAL AND METHODS: A retrospective case series study was conducted between 1997-2000 at Hospital del Niño Morelense (Morelos State Children's Hospital), in 46 newborns aged under 12 weeks. Study subjects were referred from peripheral units with a diagnosis of HDN. RESULTS: The severe late-onset form of HDN was present in 91 of the cases. Fifty-two percent of childbirths were assisted by a physician and 48 by an empiric midwife. Application of vitamin K was unknown in 61 of cases, in 39 it was not applied and in 4 it was applied. The majority of infants presented severe symptoms due to intra-cranial bleeding, 11 died, and 41 had severe disease sequelae. CONCLUSIONS: Given the high prevalence of HDN in the State of Morelos, reproductive health programs should be reviewed and training programs intensified to promote the utilization of vitamin K by physicians and nurses for preventing this disease.

[Effect of oral and intramuscular vitamin K on the factors II, VII, IX, X, and PIVKA II in the infant newborn under 60 days of age]. / Efecto de la vitamina K oral e intramuscular sobre los factores II, VII, IX, X y PIVKA II en el recién nacido hasta los 60 días de edad. Relación con la alimentación.

BACKGROUND: Neonates on exclusive breast feeding that do not receive vitamin K at birth are at higher risk hemorrhagic disease of the newborn. AIM: To compare the effect of oral or intramuscular administration of vitamin K1 (VK1), on clotting factors II, VII, IX, X and PIVKA II, in children until the 60 days of age with exclusive breast feeding or mixed feeding. PATIENTS AND METHODS: Forty healthy full term infants, distributed in two groups, A: 20 with mixed feeding (formula-feeding and breast-feeding) and B: 20 with exclusive breast feeding, were studied. Nine infants of each group received 1 mg of VK1 intramuscularly and eleven 2 mg VK orally 5 ml of cord blood was collected initially from each infant. Venous blood samples were taken on 15, 30 and 60 days of age. RESULTS: All factors increased in a progressive form reaching levels over 50% at 60 days of age, in both groups. PIVKA II decreased significantly during the study period (p < 0.01). Factor II increased more in children with mixed feeding that received intramuscular vitamin K, than in the rest of study groups. No other differences between groups were observed. No infant had an abnormal bleeding during the study period. CONCLUSIONS: Oral administration of vitamin K is as effective as the intramuscular route in the prevention of the hemorrhagic disease of the newborn.