Hemorrhagic anemia of the newborn

Introduction to neonatal hemorrhagic anemia Within 2 weeks after birth, venous blood hemoglobin 130g/L, capillary blood 145g/L, can be diagnosed as anemia, the clinical manifestations of neonatal hemorrhagic anemia vary depending on the severity of blood loss and the amount of blood loss. Newborn blood loss can occur in three different periods before, during and after birth. Prenatal blood loss is mainly caused by fetal-fetal transfusion, fetal-female transfusion, fetal-placental hemorrhage and some prenatal treatment operations. Severe acute blood loss can occur in shock, severe cases can cause death, and must be rescued in time; chronic small amount Loss of blood can cause anemia and intrauterine dysplasia in newborns, or symptoms of mild iron deficiency anemia. basic knowledge The proportion of sickness: 0.01% Susceptible people: children Mode of infection: non-infectious Complications: shock heart failure anemia neonatal hepatosplenomegaly

Causes of neonatal hemorrhagic anemia

Prenatal bleeding

Mainly through the placenta blood loss, including fetal-placental hemorrhage, fetal-fetal transfusion and twin-to-between transfusion, due to bleeding concealment, the amount of bleeding varies, the bleeding rate can be urgent, so the clinical manifestations are different.

(1) Fetal-placental hemorrhage: refers to fetal bleeding to the placenta and causes neonatal anemia, which can cause hemorrhage after placental parenchyma or hemorrhage, resulting in the following two conditions:

1 Umbilical cord around the neck: When the umbilical cord around the neck, because the umbilical vein wall is thin, the pressure of the contracted umbilical cord first blocks the umbilical vein, and then the umbilical artery, so the fetus can not get the placental blood from the umbilical vein, and the umbilical artery continues to Fetal blood returns to the placenta, and if the fetus loses blood, it can lose 20% of blood volume.

2 After cesarean section: If the position of the baby is higher than the placenta before the umbilical cord is ligated, the blood flowing through the umbilical artery continues to flow to the placenta, and due to the hydrostatic pressure, the blood continues to flow back from the umbilical vein to the fetus. The blood volume of uterine birth is lower than that of vaginal delivery.

(2) Fetal-mother transfusion:

1 There is a pressure difference between the umbilical artery and the villus gap: there is a pressure difference between the umbilical artery and the villus, and the fetal water and metabolites can reach the mother. Therefore, the fetal blood can follow this route, especially when the villi are damaged, the blood can directly enter the maternal blood circulation. Some people examined the placenta in each stage of pregnancy and found that there are many small gaps in the placental barrier, which is secondary to the vascular death and villus infarction.

2 transabdominal amniocentesis: transabdominal amniocentesis has been widely used to treat neonatal hemolytic disease and perinatal genetic metabolic disease diagnosis, puncture needle can damage the placenta caused by bleeding, it has been reported that 10.8% fetal-mother transfusion occurs in After diagnosis of amniocentesis.

3 other injuries: external reversal, intravenous oxytocin, maternal pregnancy-induced hypertension syndrome.

4 placental chorioangioma, villus cancer, etc.: fetal red blood cells can enter the blood circulation through the placenta at 4-8 weeks of gestation, or at the time of labor.

(3) Fetofetal transfutsion: twin blood transfusion is a complication of monochorionic twin pregnancy, with high perinatal morbidity and mortality. Herlitz first reported in 1941, its clinical manifestations More understanding has been made, but the pathogenesis is still unclear. In recent years, there has been some progress in the study of etiology. Therefore, there have been breakthroughs in treatment and increased survival rates.

An important condition for twin-transfusion is that there is a common fetal vascular bed between the two placenta. According to the study of placental vascular injection of milk, almost all of the vascular anastomoses exist in the single chorionic twin, with inter-arterial, inter-venous, and intercapillary The anastomosis, but mostly occurs in the movement, venous traffic type, which was proposed by Schatz in 1882, called the "third cycle", the blood supply from the arterial blood to the placental villi, from the venous return to the recipient, the incidence of the disease The mechanism has been challenged by the following new concepts:

1 Difference in serum protein concentration between twins: In 1963, Kloosterman proposed that blood donors circulate through the vascular anastomosis chronically to the recipient's circulation, because the protein can not pass through the placenta, the hypoproteinemia of the donor's circulation, the colloid osmotic pressure is low, and the water is returned to the mother. In the body, the child is dehydrated and grows backward; while the hyperproteinemia recipient has a high colloid osmotic pressure, and absorbs a large amount of water from the mother. The child grows faster, the amniotic fluid is too much, and the body edema can be caused.

2 Differences in atrial natriuretic peptide levels between twins: In 1989, Nageotte found that the atrial natriuretic peptide level of the recipients was higher than that of the donors. The release of atrial natriuretic peptide was caused by the increase of blood volume, and it also promoted the increase of fetal urine production, resulting in amniotic fluid. Too much, Wieacker agreed with this conclusion in 1992, pointing out that the increase in amniotic fluid is due to the inhibition of vasopressin release.

3 sail placenta: In 1993, Fries et al pointed out that single chorionic vaginal pregnancy combined with snail-shaped placenta had more transfusion than non-combination. They believed that the membranous umbilical cord was easily compressed, and the amount of blood flow through the umbilical vein to a twin was reduced. More blood will flow through the placenta vascular anastomosis to another fetus, causing excessive amniotic fluid, which in turn can force the umbilical vein to cause a vicious circle. The authors pointed out that puncture and extraction of a large amount of amniotic fluid can not only relieve symptoms, but also directly Etiology treatment.

The difference in the function of the placenta between the twins: In 1992, Saunders et al proposed that the cause of twin-transfusion was the uterine placental insufficiency of the donor, the resistance around the placental circulation increased, and the blood was shunted to the recipient by vascular anastomosis. In 1993, Vetter proposed a small The response to fetal placental dysfunction and growth disorders is to release growth stimuli, but it is unable to respond to this stimuli due to incomplete placental dysfunction; while the other fetus has normal placental function, which stimulates the flow through vascular anastomosis. Stimulated to promote growth, this process is called "growth factor sequence" (growth factor sequence), mostly due to obstetric accidents during childbirth, placenta and umbilical cord malformation, postpartum blood loss to the umbilicus, gastrointestinal tract and internal bleeding See, in recent years, blood loss caused by hospital-based diagnostic blood collection has also increased.

Blood loss at birth

Mostly caused by obstetric accidents during childbirth, placenta and umbilical cord deformity.

(1) Abnormal placenta: severe blood loss often occurs in the placenta previa, early placenta stripping or cesarean section missed the placenta and cause blood loss, placental malformation is more common with multi-leaf placenta, each leaf sends a fragile vein branch to the placenta, The blood vessel is prone to bleeding.

(2) Umbilical cord abnormality: the normal umbilical cord may suddenly bleed due to excessive involvement, umbilical cord malformation such as umbilical cord hemangioma, vagus blood vessels, etc., the latter is one or more blood vessels before the umbilical cord reaches its implantation site, and its blood vessel wall is thin. The lack of protection of umbilical cord-like tissue is extremely easy to rupture; the umbilical cord is placed in the placenta and the blood vessels are also passed between the amnion and the chorion without protection. The incidence of bleeding is 1% to 2%.

Blood loss after birth

Blood loss after birth is common in the umbilicus, gastrointestinal tract and internal hemorrhage. In recent years, blood loss has also increased due to hospital-based diagnostic blood sampling.

(1) Loss of blood in the umbilicus: the cause can be due to:

1 When the umbilical cord is ligated, the umbilical cord is not tightly tied or the umbilical cord stump vessel is opened again and bleeding.

2 exchange blood through the umbilical vein cannula, exchange for low hemoglobin blood with excessive maintenance fluid.

3 Diagnostic umbilical vein blood was taken several times.

(2) Intestinal blood loss: caused by neonatal hemorrhagic disease, congenital intestinal malformation or necrotizing enterocolitis.

(3) Internal bleeding: caused by birth injury, anemia often occurs 24 to 72 hours after birth, and more often accompanied by jaundice, there are several cases:

1 huge head hematoma or decidual subarachnoid hemorrhage.

2 intracranial hemorrhage: such as subdural and subarachnoid hemorrhage, large amount of bleeding can cause anemia, suffocation of hypoxia caused by ventricular hemorrhage in premature infants, bleeding volume can reach 10% to 15% of children with blood volume.

3 liver, spleen rupture.

4 adrenal hemorrhage.

Pathogenesis

Neonatal blood loss can be caused by abnormal separation of placenta (placental abruption), placenta previa, umbilical cord tear caused by birth injury, umbilical cord in the placenta with sail-like attachment tearing blood vessels, and cesarean section caused by cutting into placenta previa During childbirth, the umbilical cord is tightly wrapped around the neck or body of the fetus. Arterial blood can be pumped from the fetus to the placenta. At the same time, because the umbilical cord is blocked, the blood is prevented from flowing back to the baby through the umbilical vein. Immediately clamping the umbilical cord during childbirth may cause severe acute recession. Loss of blood (enter the placenta).

Fetal-mother bleeding in the uterus can cause recessive blood loss of varying severity. This bleeding may be acute or prolonged, or it may be chronic and repetitive. If the fetus has compensation for bleeding, its blood-to-cell ratio There will be a period of decline in volume (because blood volume is re-expanded), acute perinatal bleeding can cause fetal or neonatal shock, and the decline in hematocrit needs several hours. Positive Kleihauer test on maternal blood can confirm fetal bleeding. When there is fetal red blood cells entering the mother's blood circulation, its acid-fastening characteristics can be determined for blood smears.

Chronic fetal-fetal transfusion can occur in single-oval twins, with common blood vessels communicating between the placenta and recessive blood loss to the uterus (in the blood supply twins).

Neonatal hemorrhagic anemia prevention

Prenatal gestational-maternal blood loss (the most common type of fetal blood loss) Fetal-fetal transfusion, etiology and mechanism are not clear, can be found when amniocentesis, external reversal, intravenous oxytocin and pregnancy-induced hypertension syndrome, In addition to active prevention and treatment of pregnancy-induced hypertension syndrome, other operations should be cautious, and pay attention to identify the occurrence of this disease, and take effective diagnosis and treatment measures, fetal-fetal transfusion if the diagnosis can be diagnosed before delivery, the recipient of blood by the fetal puncture to extract too much amniotic fluid It can relieve symptoms and treat the cause.

Neonatal hemorrhagic anemia complications Complications, shock heart failure, anemia, neonatal hepatosplenomegaly

Cardiac failure can occur in severe cases. The amount of bleeding is often accompanied by shock. Chronic blood loss is complicated by anemia, liver and splenomegaly.

Symptoms of neonatal hemorrhagic anemia common symptoms hypotension hypovolemic shock shortness of breath erythrocytosis tachycardia sail placenta jaundice irritability restless ascites mobile dullness

Depending on the amount of bleeding and bleeding time, speed, a small amount of bleeding can be asymptomatic.

1. General performance

A newborn with mild blood loss is asymptomatic at birth. Acute placental blood loss occurs during childbirth. Neonatal anemia is not obvious at birth, but can cause hypovolemic shock. It needs to be differentiated from pale asphyxia. The former can not alleviate oxygen symptoms. After the inhalation of oxygen, the symptoms are relieved. After the newborn, the extracellular fluid continuously enters the blood circulation to compensate for the hypovolemia. After 24 hours, the sick child may have anemia, but no hepatosplenomegaly, intrauterine chronic blood loss, There is significant anemia at birth. Except for pallor, other symptoms are often not obvious. Even the symptoms of Hb as low as 40-60g/L are still mild, but there may be hepatosplenomegaly. In severe cases, congestive heart failure may occur. Children with small cell hypochromic anemia, increased reticulocytes, decreased serum iron, and different bleeding rates:

(1) acute blood loss: mostly blood loss at birth, pale after birth, irritability, shallow breathing, irregular or even respiratory distress, tachycardia, pulse is weak, there are shock symptoms when there is a lot of bleeding, generally no hepatosplenomegaly .

(2) Chronic blood loss: mostly for prenatal blood loss, significantly pale but not obvious respiratory distress, occasionally congestive heart failure, and more hepatosplenomegaly.

2. Different causes of blood loss

(1) Prenatal blood loss: When fetal-maternal transfusion occurs, occasionally the fetus, the maternal blood type is incompatible, the pregnant mother may have a transfusion reaction, such as chills, fever, and even acute hemolysis caused acute renal failure.

(2) Blood transfusion between twins: The incidence of transfusion between twins in a single chorionic twin pregnancy is 4% to 35%. There is no consensus on the time of transfusion between twins. It is considered to be a chronic blood loss process. But it can also occur during childbirth or turn into acute blood transfusion, the latter for acute hemorrhagic shock; the disease caused by chronic blood loss, the blood supply is pale, Hb can be 50g/L lower than the recipient, development Slow, weight can be 20% lighter than the blood, severe cases can appear edema, hepatosplenomegaly, oliguria and less amniotic fluid, severe anemia can show symptoms of heart failure such as shortness of breath, and even die in the uterus, on the contrary, blood Children are characterized by large individuals, multiple blood, heart, liver, kidney, pancreas and adrenal gland enlargement, more urine, more amniotic fluid, increased blood red blood cells, increased viscosity, hyperbilirubinemia and congestive heart failure, etc. Occasionally, the blood of the recipient's blood passes through the arterial anastomosis to the dead donor, resulting in hypotension, anemia, and secondary hypoxic ischemic injury in the brain. Twin-blood transfusion may be accompanied by a heartless deformity, ie, the donor has no heart. 2 fetuses rely on a heart of the recipient Blood, the incidence of monozygotic twin pregnancies account for about 1%, which is often also associated with single umbilical artery and hypovolemic shock, if not treated can cause death.

The earlier the twin blood transfusion occurs, the worse the prognosis is. If the perinatal mortality rate is almost 100%, the diagnosis and treatment before 28 weeks of pregnancy, the perinatal mortality rate is 20% to 45%, which is significantly higher than the double amniotic sac. Double chorion without a fetus between the fetuses.

(3) Head hematoma: also known as subperiosteal hematoma, often located on one or both sides of the top bone, local skin is not swollen, does not change color, due to slow subperiosteal hemorrhage, hematoma is more obvious after hours or 2 to 3 days after birth, It reaches the maximum range within 1 week, and gradually absorbs and shrinks. The hematoma is clearly defined. It does not cross the suture, has a sense of fluctuation, and the local skin color is unchanged. This can be differentiated from the tumor-producing (the pioneer head) and the subcapsular subdural hematoma. The latter two range can be beyond the bone seam, the birth of the tumor is found at the birth, the boundaries are not clear, the pressure is soft and concave, no fluctuation, local skin can be red or purple; skull hematoma and capsular subdural hematoma The identification is as follows. The head hematoma is located in the occipital region. It needs to be differentiated from the meningeal bulge. The latter has a sensation of swell with the breathing. The skull can be seen in the X-ray film, and the skull is complete in the skull. Occasionally, the skull is wired. Fracture, huge head hematoma can cause hemorrhagic anemia and hyperbilirubinemia. The hematoma of the skull can be absorbed slowly. It can be dissipated in 2 weeks to 3 months due to the size. When it is absorbed, the ossification of the ossification is formed at the edge of the hematoma. side, The central recess, as a crater-like changes.

(4) Capular subdural hematoma: shortly after birth, the scalp is limited to swelling. The bleeding can be spread through soft tissue. When the amount of bleeding is small, the hematoma range is limited. Some can be covered by the tumor. When the amount of bleeding is large, the swelling is swollen. The range is gradually enlarged, which can affect the entire scalp, even the amount of the eye, the eyes, the pillow or the neck and back. The hematoma has a sense of fluctuation, which often makes the front sputum difficult to clear, and the covered skin can be blue-purple. When the bleeding is severe, it can cause anemia.

(5) Liver rupture: may be caused by breech presentation, giant child, acute labor, chest and abdomen during resuscitation, intrauterine hypoxia and coagulopathy, etc. It is also reported that neonates with hepatic hemangioma, embryogenic If the tumor ruptures and causes bleeding, the hepatoma will form under the liver capsule at the beginning of the liver injury. When the amount of bleeding increases, the rupture of the liver capsule causes intra-abdominal hemorrhage. Therefore, the early symptoms are often not obvious, and the symptoms appear within 48 hours after birth. It is characterized by refusal to milk, restlessness, paleness, shortness of breath, rapid heart rate, jaundice, enlargement of the liver, swelling of the right upper abdomen and swelling of the tumor. When the hematoma is enlarged or ruptured, acute hemorrhagic shock, abdominal distension, and mobile dullness occur. Occasionally, the umbilical part is blue, that is, the Cullen sign. If the condition is acute, it may die due to hemorrhagic shock. Even if it is diagnosed before birth, there is still some difficulty. The diagnosis of this disease depends on abdominal ultrasound, or bloody liquid in abdominal cavity puncture, but no puncture. Bloody fluids can not rule out visceral hemorrhage. Treatment requires transfusion and anti-shock, surgical laparotomy for treatment.

(6) rupture of the spleen: it can occur alone or at the same time as the rupture of the liver, especially if the fetus has splenomegaly, and the treatment is ruptured with the liver.

(7) adrenal hemorrhage: the reported incidence of 1.7 , more common in babies born in the breech or diabetic mother, cesarean section has not been seen, the cause of adrenal hemorrhage is still unknown, can be seen in childbirth injury, Under the stress of hypoxia or severe infection, the destruction of adrenal neuroblastoma can also cause massive hemorrhage. Beijing Children's Hospital has seen a case of hemorrhagic shock caused by rupture of bilateral adrenal hematoma 15h after birth into a peritoneal cavity. Cell tumor, 90% of adrenal hemorrhage is unilateral, more common in the right side, the neonatal adrenal gland is relatively large, capillaries are abundant, there is lack of interstitial support around it, easy to be injured and bleeding, the right adrenal gland is located between the liver and the spine, easy to be Squeeze, its vein directly open to the inferior vena cava, affected by high venous pressure, easy to cause bleeding after injury, a small amount of bleeding can be asymptomatic, only in larger infant X-ray or autopsy to see calcification, massive bleeding Can cause shock, bruising, abdominal distension, kidney can touch the mass, bilateral, adrenal hemorrhage can appear transient adrenal insufficiency symptoms, abdominal ultrasound can be Correct diagnosis, but in severe, often only diagnosed at autopsy, in addition to anti-shock treatment, the acute adrenal insufficiency should be treated, plus hydrocortisone 5mg / (kg · d) intravenously.

(8) Kidney injury: the breech position can cause kidney rupture or adenosis of the kidney pedicle, hematuria occurs shortly after birth, the abdomen gradually swells, there is ascites and can move and move the kidney mass. When there is a lot of bleeding, there is anemia. Hemorrhagic shock, etc., abdominal ultrasound can confirm the diagnosis, differential diagnosis including renal tumor with blood and renal vein thrombosis or infarction, treatment is the same as liver rupture, laparotomy if the kidney has extensive hemorrhagic necrosis should be performed nephrectomy.

Examination of neonatal blood loss anemia

1. Blood routine examination: Acute blood loss is positive cell dysplasia, chronic blood loss is small cell hypochromic anemia, blood transfusion between twins has red blood cells, hemoglobin is increased, and red blood cells and hemoglobin are significantly reduced.

2. Hemoglobin examination in single-oval twins: The difference in hemoglobin between twins is >50g/L, and the lower value is blood loss.

3. Maternal blood erythrocyte acid elution test: fetal-mother blood transfusion diagnosis must be found in maternal blood, fetal red blood cells or maternal blood HbF> 2%, for fetal-mother transfusion, maternal red blood cell smear acid elution test is based on Fetal hemoglobin has an acid-resistant effect in acid buffer and remains in red blood cells. Mother hemoglobin is acid washed to become a blank cell. This method can not only detect fetal red blood cells, but also estimate the amount of blood loss in newborns. Inspection Method.

(1) Quantitative examination of maternal blood hemoglobin: The fetal hemoglobin in normal adult blood should be <3%. During pregnancy, the maternal blood fetal hemoglobin has a physiological increase, which can be as high as 5.7%, but its erythrocyte acid elutes and stains lightly. Red, which can be distinguished from true fetal red blood cells by bright red.

(2) Alpha-fetoprotein quantitative examination: fetal-maternal transfusion, maternal blood alpha-fetoprotein value increased.

4. Others: Transfusion between twins is associated with increased blood viscosity and hyperbilirubinemia.

B-ultrasound can be found in the liver, splenomegaly, prenatal B-ultrasound twins with the same sex, a single placenta, between the two fetuses with hair silk-like mediastinum, blood loss, fetal growth retardation, may have less amniotic fluid;

Diagnosis and diagnosis of neonatal hemorrhagic anemia

diagnosis

Confirmed according to clinical manifestations and laboratory tests.

Fetal-mother transfusion

For occultity, in addition to clinical manifestations of anemia, no jaundice, the diagnosis has certain difficulties, often rely on the following tests:

(1) Find fetal red blood cells in the maternal circulation: attention should be paid to the diagnosis:

1 Exclude the mother from any disease that increases fetal hemoglobin.

2 mother, if the ABO blood type is not matched, fetal red blood cells are easy to remove after entering the maternal blood circulation, so the acid elution method should be carried out within a few hours after delivery, otherwise it is prone to false negative, other methods include direct differential agglutination test , fluorescent antibody technology, etc., but the method is more complicated and not commonly used.

(2) Quantitative examination of maternal blood hemoglobin.

(3) Quantitative examination of alphafetoprotein.

2. Twin fetal blood transfusion

(1) Past diagnostic methods:

1 The placenta of the blood donor is pale and atrophic; the placenta is congested by the blood, the red hypertrophy, the injection of milk or the colored solution can confirm the existence of the vascular anastomosis, but in fact, the vascular anastomosis is not easy to find.

2 twins have a body weight difference of >20%, hemoglobin difference >50g/L and clinical manifestations of twins. Some scholars have found that double chorionic twins can have similar conditions, and that blood donors may not have increased hemoglobin. Compensatory erythropoietin increased, and the difference between hemoglobin between the two fetuses was not obvious.

(2) New diagnostic methods: A new diagnostic method has recently been proposed:

1 prenatal B-ultrasound test: according to the difference between the abdominal circumference of the twins > 20%, the amount of amniotic fluid, fetal edema, to determine the twin blood transfusion.

2 Fetal umbilical artery Doppler rate measurement: Observed blood flow pattern, there is a difference in systolic/diastolic ratio between twins.

3 umbilical cord puncture: can exclude chromosomal abnormalities, intrauterine growth retardation caused by congenital intrauterine infection.

3. Postnatal bleeding

See hemolytic anemia, neonatal hemorrhagic, diffuse intravascular coagulation, etc., pay attention to identification.

Differential diagnosis

1. Pale suffocation: There are many childbirth complications or intrauterine distress before birth, newborns have bruising, difficulty breathing or suspension, heart rate slowing and no Hb reduction can be identified with this disease.

2. Severe neonatal hemolytic disease: may also have pale, anemia, but often accompanied by edema, hepatosplenomegaly, jaundice within 24 hours after birth, can be identified with the disease, the diagnosis of hemolytic disease depends on specific blood group antibodies.

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