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.

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.

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.

Can we more efficiently save patients with vitamin K-dependent coagulopathy caused by superwarfarin intoxication?

No abstract available.

Evaluation of risk factors in patients with vitamin K-dependent coagulopathy presumed to be caused by exposure to brodifacoum

BACKGROUND/AIMS: Recently, many cases of vitamin K-dependent coagulopathy of unknown origin have been reported. Such patients lack any relevant family history and have no systemic disease, raising suspicion of superwarfarin intoxication. We evaluated individual risk factors causing coagulopathy and hemorrhagic symptoms in patients with suspected superwarfarin intoxication. In addition, we determined how to effectively treat vitamin K-dependent coagulopathy caused by suspected superwarfarin intoxication. METHODS: Seven patients with suspected superwarfarin intoxication who lacked any definitive history of rodenticide ingestion were included. Thirty-one patients initially diagnosed with rodenticide poisoning were also included. We performed a retrospective chart review of all subjects and examined clinical data including patient demographics and medical histories. RESULTS: Patients initially diagnosed with rodenticide poisoning were divided into two groups, one of which had a laboratory abnormality (prothrombin time [PT] > 13 seconds) and another group with PTs in the normal range. There was no significant difference between the two groups in any of age, gender, the extent of chronic alcohol consumption, the causative rodenticide, psychiatric problems, ingestion of drugs interacting with warfarin, the extent of intoxication, or the type of ingestion attempt. The albumin level of the former group was significantly lower than that of the latter group (p = 0.014). Furthermore, a significant difference between the two groups was evident in terms of simultaneous ingestion of rodenticide and alcohol (p = 0.023). CONCLUSIONS: Most patients with superwarfarin poisoning did not exhibit any complication. When such complications were evident, they were associated with serum albumin level and coingestion of rodenticide and alcohol.

[Hemorrhagic disease of newborn in children's hospital at damascus university and medical staff compliance to prophylactic vitamin k administration]

To determine the morbidity and mortality due to hemorrhagic disease of the newborn HDNB [vitamin K induced hemorrhagic disease] at Damascus University Children's Hospital [DUCH], and degree of medical staff compliance for applying related guidelines. A retrospective descriptive study of 307 patients with the diagnosis of HDNB at DUCH during 2000-2009. Ages ranged between 1 day and three months. Clinical, hematological and imaging studies were considered in all cases before final diagnosis of HDNB were established. A specimen of 307 patients were diagnosed having HDNB after the national guidelines for prophylactic vitamin K administration to newborns were established in 2000 by ministry of health. Early HDNB was found in 5.8%, classic HDNB in 14.3% and late HDNB in 78.8%. Home delivery contributed 32.9% of cases where hospital delivery 52.44% and private clinic delivery in 14.6%. Vitamin K injection after delivery was given in 14.2% [28 of 197] of well documented cases. Intra cranial hemorrhage was the most common complication especially in the late form of the disease 54.1%. Other hemorrhagic complications were as follows: skin 14.9%, gastrointestinal 18.6% and circumcision 8.7%. Death occurred in 23% of cases [n=71]; seizures occurred in 10% of survivors HDNB is still present as a cause of morbidity and mortality in newborn period and early infancy in area of the study; vitamin K administration at delivery is not a routine practice despite of clear national guidelines

Effect of prophylactic dose of vitamin K on occurrence of hemorrhagic disease in newborn

To determine the effect of prophylactic dose of Vitamin K on occurrence of hemorrhagic disease in newborn. Non randomized controlled study was conducted in Children Hospital Quetta during June to December 2009. Total 300 healthy full term neonates between 2[nd] to 7[th] days of life were included in the study. They are divided into 2 groups; group 1 consisted of 100 neonates who were given prophylactic dose of vit K in a dose of 1.0mg intramuscularly and group 2 consisted of 200 neonates who did not receive prophylactic dose of Vit K as their parents did not agree. They were followed up till 12 weeks of life, for development of bleeding from any site. There are 3 types of Hemorrhagic disease of newborn according to age of manifestation. In early onset bleeding occurred within 24 hours of life, in classical onset bleeding occurred from 2[nd] to 7[th] days of life and in late onset bleeding occurred during 2[nd] to 12[th] week of life. In group 1 only 2 neonates [2%], out of 100 presented with late onset of hemorrhagic disease of newborn, one [50%] with gastrointestinal tract bleeding and other [50%] with subcutaneous bleeding. In group 2, out of 200neonates 14[7%] developed bleeding, 9 [64.3%] presented with classical onset and 5 [35.7%] with late onset. Commonest clinical manifestation in group 2 was gastrointestinal tract bleeding [28.8%], 2nd common manifestation was haematuria [21.4%] and umbilical cord bleeding [21.4%], followed by prolonged bleeding after circumcision [14.2%] and subcutaneous [14.2%]. Male to female ratio was 1.3:1

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...

Hemorrhagic disease of the newborn: clinical presentation and response to treatment with vitamin k

1] To determine the clinical presentation of hemorrhagic disease of the newborn. 2] To assess the response to injection vitamin K in this condition. This was a descriptive, analytical study conducted from January, 2002 to December, 2002 in the National Institute of Child Health, Karachi. All patients who presented with bleeding were admitted in the neonatal unit of the National Institute of Child Health, Karachi. After sending blood for investigations, 2mg. Vitamin K was injected intravenously. In babies with continuous or profuse bleeding, fresh frozen plasma was also given. PT and APTT were repeated after 6 to 12 hours and after one week. Data collection was done by means of a proforma. Analysis was on SPSS version 8.0. 50 cases were included in the study 78% were born at home and did not receive vitamin K at birth. 72% were low birth weight. 80% were breastfed. Gastrointestinal tract, nasal mucosa and skin were the commonest sites of bleeding. PT and APTT were prolonged in all the cases. Their values improved after six hours and normalized in one week. Vitamin K deficiency causing hemorrhagic disease of the newborn is a common problem in neonates. It shows a dramatic response to vitamin K injection. It is more common in male, preterm and low birth weight babies

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...

Late hemorrhagic disease of newborn.

The clinical features of 14 infants diagnosed with late hemorrhagic disease of newborn (LHDN), of which 10 did not receive vitamin K prophylaxis, are presented. All infants were exclusively breast-fed and 12 did not have any underlying illness to explain the abnormal coagulation profile. The common presenting symptoms were seizures (71%), vomiting (57%), poor feeding (50%) and altered sensorium (36%). Physical examination shared pallor in all infants and a bulging anterior fontanel in 64%. Intracranial bleed was the predominant manifestation (93%), with CT scan showing intracranial bleed in 78%. Eight infants (57%) succumbed to their illness, while 36%had neurological sequelae. Since LHDN leads to significant morbidity and mortality, it should be prevented by providing vitamin K prophylaxis to all newborns.

Intracranial hemorrhage in late hemorrhagic disease of the newborn.

This study was conducted to evaluate the clinical profile and outcome in late hemorrhagic disease of the newborn (HDN) with particular reference to intracranial hemorrhage. Infants (n = 42) presenting with late HDN from January 1998 to December 2001 were studied. Majority (76%) were in the age group of 1-3 months. All were term babies on exclusive breast-feeding and none received vitamin K at birth. 71% patients presented with intracranial hemorrhage, commonest site being intracerebral and multiple ICH. Visible external bleeding was noted in 1/3rd of patients only. Three patients expired. Late HDN is still an important cause of mortality and morbidity in developing countries where vitamin K prophylaxis is not routinely practiced. Isolated intracranial hemorrhage is a common mode of presentation.

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.

An epidemiological study on vitamin K deficiency bleeding in infants under six months / 中华预防医学杂志

<p><b>OBJECTIVE</b>To understand the incidence and relevant affecting factors of infant vitamin K deficiency bleeding (VKDB) in Shandong Province.</p><p><b>METHODS</b>With stratified cluster sampling, 28 156 live newborns from five districts and six counties were surveyed for the condition of bleeding from their birth to 6 months based on standard diagnostic criteria. A 1:2 matched case-control study of VKDB was performed.</p><p><b>RESULTS</b>An overall incidence of VKDB was 3.27 per thousand in Shandong; higher in the rural areas (4.96 per thousand ) than in the urban areas (1.19 per thousand ). Most of the bleeding cases were breast-fed babies (about 95.57%) and incidence of VKDB in pre-term babies (22.52 per thousand ) was higher than that in term ones (2.96 per thousand ). Mothers' drug taking during pregnancy, asphyxia at birth, breast-feeding and illness within two weeks after birth were risk factors for it. Use of vitamin K after birth and bottle-feeding were protective factors for it.</p><p><b>CONCLUSIONS</b>Incidence of VKDB is higher in Shandong Province, as compared to other areas all over the country at the same time period. It is very important to prevent VKDB, focusing on high-risk babies in the rural areas, including those of preterm, breast-fed and suffering illness after birth.</p>