Vitamin K Deficiency Bleeding Workup

Updated: Dec 13, 2017
  • Author: Dharmendra J Nimavat, MD, FAAP; Chief Editor: Santina A Zanelli, MD  more...
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Workup

Approach Considerations

A full coagulopathy work-up and hematology consultation are required if clinical and laboratory findings are suggestive of non–vitamin K deficiency bleeding.

If liver disease is suspected, a work-up that includes functional tests and imaging are mandatory.

Hereditary defects in the coagulation system must always be considered among the differential diagnosis.

If the cause of bleeding is not straightforward, clinicians may need to perform other procedures like endoscopic retrograde cholangiopancreatography (ERCP) to rule out hepatobiliary diseases.

If liver biopsy is indicated, histopathology with and without special stains or biochemical analyses may be helpful to rule out hepatitis, biliary atresia, [27, 28]  tumors, and inherited metabolic diseases of the liver.

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Laboratory Studies

Coagulations studies

A prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, and a platelet count should be included in the initial workup for vitamin K deficiency bleeding (VKDB) in a newborn. A thrombin clotting time (TCT) is optional.

Note the following:

  • A prolonged PT is usually the first laboratory test result to be abnormal in vitamin K deficiency bleeding; however, no laboratory test result can confirm the diagnosis of vitamin K deficiency bleeding.

  • A direct blood measurement of vitamin K is not useful, because its levels normally are low in newborns.

  • Levels of protein induced by vitamin K antagonism (PIVKA II) are increased in vitamin K deficiency bleeding, but this study is generally not available outside of research laboratories.

  • Infants with vitamin K deficiency bleeding typically have a prolonged PT with platelet counts and fibrinogen levels within the normal range for newborns. The presence of thrombocytopenia or a prolonged aPTT should prompt workup for other causes of bleeding during the neonatal period. For example, maternal transfer of antiplatelet antibodies in mothers with immune thrombocytopenia via breastfeeding may be associated with persistent neonatal thrombocytopenia. [29]

The diagnosis of vitamin K deficiency bleeding is confirmed if administration of vitamin K halts the bleeding and reduces the PT value.

There appears to be a significant association between median platelet count and platelet mass with intracranial hemorrhage in neonates at days 1, 2, and 3 after diagnosis of gram-negative sepsis. [30]

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Imaging Studies

Intracranial bleeding is rare and usually associated with other causes of bleeding, particularly thrombocytopenia; however, intracranial hemorrhage has been reported in vitamin K deficiency bleeding (VKDB) and can be fatal.

Neonatal sepsis due to gram-negative bacteria (eg, Enterobacter species) is also a cause of intracranial bleeding. [30]

Investigate any neurologic symptoms with imaging. Magnetic resonance imaging (MRI) does not expose the neonate to radiation, and this imaging modality is becoming the preferred way to study the brain because tissue damage can be better defined.

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