Case of the Month
Pamela Heaberlin, MS, RN, NNP-BC ❍ Section Editor
Vitamin K Deficiency Bleeding A Case Study Christopher W. Woods, MSN, RN, NNP-BC; Amanda G. Woods, MSN, RN, NNP-BC; Carmen K. Cederholm, BSN, RN
ABSTRACT Vitamin K deficiency bleeding (VKDB), formerly known as hemorrhagic disease of the newborn (HDN), is a bleeding disorder in neonates that is caused by inadequate serum levels of vitamin K. Vitamin K is a nutrient essential for adequate function of the coagulation cascade. Certain internal and external factors place newborn infants at higher risk for VKDB. Therefore, vitamin K prophylaxis has become the standard of care for newborns. Although the American Academy of Pediatrics recommends the administration of vitamin K to newborns, some parents are choosing to withhold vitamin K administration at birth. This case study describes an infant who developed VKDB in the absence of vitamin K prophylaxis. Although parents ultimately have the right to choose whether or not to administer vitamin K, as healthcare professionals, it is important to provide education regarding the potential complications of withholding vitamin K and the signs of VKDB if vitamin K prophylaxis at birth is withheld. Key Words: hemorrhagic disease of the newborn, vitamin K deficiency bleeding, vitamin K, vitamin K prophylaxis
CASE STUDY Baby A was a term female infant born via uncomplicated vaginal delivery. Maternal serologies were unremarkable. Per parental preferences, she did not receive vitamin K or hepatitis B vaccine after delivery. She was discharged to home and was reported to have an uneventful course until, at 27 days of age, she developed severe bleeding from her umbilical stump. The parents used direct pressure but were unable to stop the bleeding. At this time, her parents called her primary care physician and were directed to take her to the emergency department. Author Affiliations: Wake Forest Baptist Health (Mr Woods) and Novant Health Forsyth Medical Center (Ms Woods), Winston Salem, and Alamance Regional Medical Center, Burlington, North Carolina (Mrs Cederholm). The authors declare no conflict of interest. Correspondence: Christopher W. Woods, MSN, RN, NNP-BC, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, NC 27157 ([email protected]). Copyright © 2013 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000026 402
She presented at the emergency department with profuse bleeding from the umbilical stump. Parents denied history of bruising, fever, respiratory distress, feeding intolerance, or changes in voiding, stooling, or activity. However, parents reported a small scratch on her leg, which had been oozing for the previous 24 hours. Parents denied family history of hemophilia or coagulopathy. On admission, her complete blood cell count with differential was unremarkable with hemoglobin of 14.1 g/dL. Coagulation studies showed prolonged prothrombin time (PT) and partial thromboplastin time (PTT) without evidence of disseminated intravascular coagulation (Table 1). Blood cultures were obtained and she was started on ampicillin and cefotaxime. With concerns for coagulopathy and her persistent bleeding, and after 2 unsuccessful attempts to stop the bleeding from her umbilical stump by cauterization, she was transferred to a medical center with a hematology service. During a review of systems with hematology, the parents stated a history of small nose bleeds occurring over the past 24 hours and noted that she also appeared paler in color at that time. On examination, her pressure dressing to her umbilicus was saturated with blood and her umbilicus was still oozing. She was hemodynamically stable and Advances in Neonatal Care • Vol. 13, No. 6 • pp. 402-407
Copyright © 2013 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Summary of Coagulation Studies Normal Values Term Infant (12)a
Transferring Hospital
On Admission
4 h After FFP
Prothrombin time
13-20 s
>100
>100
14.5
Partial thromboplastin time
30-45 s
>200
>200
25.9
1-2
16
International normalized ratio Derived fibrinogen
150-300 mg/dL
1.43 250
312
Abbreviation: FFP, fresh-frozen plasma. a
Normal values may differ from laboratory to laboratory.
breathing comfortably on room air with normal oxygen saturations. Laboratory values at her admission showed a hemoglobin of 10.7 g/dL, prolonged PT and PTT (Table 1), and low coagulation factors II, VII, IX, and X (Table 2). She was transfused with 10 mL/kg fresh-frozen plasma (FFP) and given 5-mg vitamin K by mouth. About 2 hours after arrival at the emergency department, she developed compensated hemorrhagic shock with an elevated heart rate of 160 to 170 beats per minute, normal blood pressures, wellperfused extremities, and capillary refill at 3 seconds. She was noted to have oxygen saturations of 93% on room air and was placed on a nasal cannula to maintain adequate oxygen saturations. A normal saline bolus of 10 mL/kg was given and 10 mL/kg packed red blood cells was ordered. A computed tomographic (CT) scan of the head was obtained, which showed a left occipital parenchymal hemorrhage, adjacent small volume of extra-axial
hemorrhage without mass effect, and a right frontal scalp hematoma (Figure). She was transferred to the neonatal intensive care unit (NICU) for further management at which time she received the packed red blood cell transfusion. Shortly after being admitted to the NICU, her hemorrhaging subsided. Coagulation studies were obtained at approximately 4 hours after FFP administration and were normalized (Table 2). One additional packed red blood cell transfusion was required to achieve a hemoglobin of 8.6 g/dL. She weaned to room air shortly after the blood transfusion was completed. A magnetic resonance imaging was obtained, which showed the hemorrhage unchanged when compared to CT scan obtained earlier the same day at which time intramuscular (IM) vitamin K was given. Complete blood cell counts with differentials were obtained throughout the admission (Table 3). She was discharged home after 72 hours of monitoring.
VITAMIN K AND NORMAL PHYSIOLOGY
TABLE 2. Summary of Coagulation Factor Studies On Normal Admission Values (13)a Intrinsic pathway screen Factor VIII assay
192
38%-150%
Factor IX assay
Pamela Heaberlin, MS, RN, NNP-BC ❍ Section Editor
Vitamin K Deficiency Bleeding A Case Study Christopher W. Woods, MSN, RN, NNP-BC; Amanda G. Woods, MSN, RN, NNP-BC; Carmen K. Cederholm, BSN, RN
ABSTRACT Vitamin K deficiency bleeding (VKDB), formerly known as hemorrhagic disease of the newborn (HDN), is a bleeding disorder in neonates that is caused by inadequate serum levels of vitamin K. Vitamin K is a nutrient essential for adequate function of the coagulation cascade. Certain internal and external factors place newborn infants at higher risk for VKDB. Therefore, vitamin K prophylaxis has become the standard of care for newborns. Although the American Academy of Pediatrics recommends the administration of vitamin K to newborns, some parents are choosing to withhold vitamin K administration at birth. This case study describes an infant who developed VKDB in the absence of vitamin K prophylaxis. Although parents ultimately have the right to choose whether or not to administer vitamin K, as healthcare professionals, it is important to provide education regarding the potential complications of withholding vitamin K and the signs of VKDB if vitamin K prophylaxis at birth is withheld. Key Words: hemorrhagic disease of the newborn, vitamin K deficiency bleeding, vitamin K, vitamin K prophylaxis
CASE STUDY Baby A was a term female infant born via uncomplicated vaginal delivery. Maternal serologies were unremarkable. Per parental preferences, she did not receive vitamin K or hepatitis B vaccine after delivery. She was discharged to home and was reported to have an uneventful course until, at 27 days of age, she developed severe bleeding from her umbilical stump. The parents used direct pressure but were unable to stop the bleeding. At this time, her parents called her primary care physician and were directed to take her to the emergency department. Author Affiliations: Wake Forest Baptist Health (Mr Woods) and Novant Health Forsyth Medical Center (Ms Woods), Winston Salem, and Alamance Regional Medical Center, Burlington, North Carolina (Mrs Cederholm). The authors declare no conflict of interest. Correspondence: Christopher W. Woods, MSN, RN, NNP-BC, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, NC 27157 ([email protected]). Copyright © 2013 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000026 402
She presented at the emergency department with profuse bleeding from the umbilical stump. Parents denied history of bruising, fever, respiratory distress, feeding intolerance, or changes in voiding, stooling, or activity. However, parents reported a small scratch on her leg, which had been oozing for the previous 24 hours. Parents denied family history of hemophilia or coagulopathy. On admission, her complete blood cell count with differential was unremarkable with hemoglobin of 14.1 g/dL. Coagulation studies showed prolonged prothrombin time (PT) and partial thromboplastin time (PTT) without evidence of disseminated intravascular coagulation (Table 1). Blood cultures were obtained and she was started on ampicillin and cefotaxime. With concerns for coagulopathy and her persistent bleeding, and after 2 unsuccessful attempts to stop the bleeding from her umbilical stump by cauterization, she was transferred to a medical center with a hematology service. During a review of systems with hematology, the parents stated a history of small nose bleeds occurring over the past 24 hours and noted that she also appeared paler in color at that time. On examination, her pressure dressing to her umbilicus was saturated with blood and her umbilicus was still oozing. She was hemodynamically stable and Advances in Neonatal Care • Vol. 13, No. 6 • pp. 402-407
Copyright © 2013 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
ANC-D-13-00080R1.indd 402
23/11/13 1:48 AM
Vitamin K Deficiency Bleeding
403
TABLE 1. Summary of Coagulation Studies Normal Values Term Infant (12)a
Transferring Hospital
On Admission
4 h After FFP
Prothrombin time
13-20 s
>100
>100
14.5
Partial thromboplastin time
30-45 s
>200
>200
25.9
1-2
16
International normalized ratio Derived fibrinogen
150-300 mg/dL
1.43 250
312
Abbreviation: FFP, fresh-frozen plasma. a
Normal values may differ from laboratory to laboratory.
breathing comfortably on room air with normal oxygen saturations. Laboratory values at her admission showed a hemoglobin of 10.7 g/dL, prolonged PT and PTT (Table 1), and low coagulation factors II, VII, IX, and X (Table 2). She was transfused with 10 mL/kg fresh-frozen plasma (FFP) and given 5-mg vitamin K by mouth. About 2 hours after arrival at the emergency department, she developed compensated hemorrhagic shock with an elevated heart rate of 160 to 170 beats per minute, normal blood pressures, wellperfused extremities, and capillary refill at 3 seconds. She was noted to have oxygen saturations of 93% on room air and was placed on a nasal cannula to maintain adequate oxygen saturations. A normal saline bolus of 10 mL/kg was given and 10 mL/kg packed red blood cells was ordered. A computed tomographic (CT) scan of the head was obtained, which showed a left occipital parenchymal hemorrhage, adjacent small volume of extra-axial
hemorrhage without mass effect, and a right frontal scalp hematoma (Figure). She was transferred to the neonatal intensive care unit (NICU) for further management at which time she received the packed red blood cell transfusion. Shortly after being admitted to the NICU, her hemorrhaging subsided. Coagulation studies were obtained at approximately 4 hours after FFP administration and were normalized (Table 2). One additional packed red blood cell transfusion was required to achieve a hemoglobin of 8.6 g/dL. She weaned to room air shortly after the blood transfusion was completed. A magnetic resonance imaging was obtained, which showed the hemorrhage unchanged when compared to CT scan obtained earlier the same day at which time intramuscular (IM) vitamin K was given. Complete blood cell counts with differentials were obtained throughout the admission (Table 3). She was discharged home after 72 hours of monitoring.
VITAMIN K AND NORMAL PHYSIOLOGY
TABLE 2. Summary of Coagulation Factor Studies On Normal Admission Values (13)a Intrinsic pathway screen Factor VIII assay
192
38%-150%
Factor IX assay
