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Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital
Correspondence to Daisuke Shigemi, Division of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital,
51112 Tateishi, Katsushika-ku, Tokyo 1240012, Japan
E-mail: dshigemi@nms.ac.jp
Journal Website (http:!!www.nms.ac.jp! jnms! )
Stop of Maternal
Delibery
dietary supple- Neonatal
Maternal age Apgar score Neonatal hemorrhagic Neonatal
Year Author intake mentation body Fetal abnormal signs
complications (weeks of (1/5 minutes) diseases outcome
(weeks of with weight (g)
gestation)
gestation) vitamin K
1994 Yamamoto6 CD Unknown 36 2,756 1/3 Intracranial HEA Multiple intracranial unknown
hemorrhage
2001 Shimabukuro7 Gastric carcinoma 31 35 1,950 6/7 NRFS, FGR Subdural hemorrhageDischarge at
2.5 months of age
2001 Hirose8 CD + 36 2,588 9/10 HEA at temporal lobe Subdural hemorrhage Intact at
3 months of age
2001 Nishino9 CD 24 28 Unknown Unknown Increased ventricle and Subdural hemorrhage Death at
BPD 2 days of age
2001 Tamura10 HG 6 35 2,426 1/1 Intracranial HEA Subdural hemorrhage Death at
75 minutes of age
2002 Kunikata11 Hepatic dysfunction 25 27 Unknown 1/2 NRFS, HEA in ventricle Cerebral hemorrhage Death at
12 hours of age
2002 Kunikata11 CD 36 Unknown 1/3 NRFS, intracranial HEA Cerebral hemorrhage, IVH tetraplegia
2003 Sakai12 HG with Esophageal 28 31 1,702 1/2 NRFS, HEA at parietal Subdural hemorrhage tetraplegia
hiatal hernia lobe
2004 Kato13 Eating disorder Unknown 34 1,978 1/2 NRFS, HEA at brainstem Intracranial hemorrhage, tetraplegia
D. Shigemi, et al
PVL
2008 Minami14 Eating disorder 28 40 2,288 Unknown/10 HEA in ventricle IVH, cerebral atrophy, auditory disorder
deficit of left cerebellum
2008 Van Mieghem15 Post-bariatric 28 31 2,094 4/7 NRFS, reverse of MCA Subdural hemorrhage, Death at
surgery SAH 7 days of age
2008 Kawamura16 HG 10 + 20 Unknown Unknown Increased BPD and SAH Artificial abor-
ventricle tion
2009 Eventov-Friedman17 HG 32 2,198 1/1 NRFS Subdural hemorrhage, unknown
IVH, cerebral hemorrage
2009 Morikawa18 Loss of oral feeding 36 37 2,734 1/6 NRFS Bleeding tendency Discharge at
17 days of age
2012 Fujimaki19 Somatoform 10 29 766 Unknown LEA at temporal lobe, Subdural hemorrhage unknown
disorder increased BPD
2013 Morikawa20 Loss of oral feeding 30 34 2,714 2/3 NRFS Cerebral hemorrhage, IVH, unknown
hemorrhagic shock
CD: Crohn disease HG: hyperemesis gravidarum HEA: hyperechoic area NRFS: non reassuring fetal status
MCA: middle cerebral artery IVH: intraventricular hemorrhage SAH: subarachnoid hemorrhage FGR: fetal growth restriction
PVL: periventricular leukomalacia
Stop of Maternal
Delibery Neonatal Apgar
Maternal dietary supple- Fetal Neonatal
age body score Neonatal
Year Author complica- intake mentation abnormal hemorrhagic
(weeks of weight (1/5 outcome
tions (weeks of with signs diseases
gestation) (g) minutes)
gestation) vitamin K
2003 Kitamura21 HG 22 27 1,054 3/4 None Hemorrhagic Unknown
diathesis
2010 Odaka22 Choledochal 32 34 2,097 8/9 None Hemorrhagic Discharge
cyst diathesis with no
complication
2011 Bersani23 Post-bariatric + 34 2,480 Unknown None Coagulopa- Intact at
surgery thy 6 months of
age
2013 Morikawa20 Loss of oral 30 34 2,352 8/9 None Hemorrhagic Discharge at
feeding diathesis 23 days of
age
HG: hyperemesis gravidarum
toma (8 cases) was the most common neonatal disease. have shown that PT has a low sensitivity for detecting
The neonatal outcomes were: death, 4 cases (25%); tetra- vitamin K deficiency and that a decrease in the
plegia, 3 cases (18.8%); auditory disorder, 1 case (6.3%); prothrombin level of greater than 50% is needed to pro-
and induced abortion, 1 case (6.3%). long PT25. Revised Japanese guidelines for possible vita-
There have been, to our knowledge, only 2 previous min K deficiency-induced bleeding in neonates and in-
reports detailing the diagnosis of maternal vitamin K de- fants recommend either one or both of the following: ad-
ficiency and its treatment with maternal vitamin K sup- ministration of vitamin K to the neonate immediately af-
plementation6,10. In our hospital (1,800 deliveries per ter delivery or administration of supplemental vitamin K
year), 3 pregnant women with prolonged PT and hy- for at least 1 week after 36 or 38 weeks gestation to
peremesis gravidarum were identified from May 2013 pregnant women with a high risk for giving birth to neo-
through April 2014 (unpublished data). nates with such bleeding. Pregnant women with such a
Detecting low maternal vitamin K levels can be diffi- high risk include those being treated with an anticoagu-
cult before the appearance of fetal abnormalities. Also lant, antiepileptic, or antituberculotic drug and those
unclear are the level of maternal vitamin K that leads to with a complicating gastrointestinal disease, such as ce-
fetal hemorrhage and whether this level produces hemor- liac sprue. The guidelines also suggest that vitamin K
rhagic symptoms in both the mother and fetus. Because supplementation should be considered for pregnant
the vitamin K concentration is much lower in umbilical women requiring long-term intravenous nutrition26.
cord blood than in maternal blood, the fetus can be ex- In conclusion, hyperemesis gravidarum can induce ma-
posed to severe hypovitaminosis even though the vita- ternal and fetal vitamin K deficiency. Although fetal in-
min K deficit in the mother is slight. In the present case, trauterine cerebral bleeding associated with maternal vi-
inadequate fetal levels of vitamin K may be prevented by tamin K deficiency is rare, it can have a catastrophic out-
early diagnosis and treatment of the maternal vitamin K come. Effective methods for predicting, preventing, and
deficiency. Pregnant women undergoing treatment with treating fetal hemorrhagic diseases due to low maternal
total parenteral nutrition and prophylactic supplementa- vitamin K are unclear. However, prophylactic treatment
tion for vitamins A, B, C, or E should also receive sup- with vitamin K during pregnancy should be considered
plemental vitamin K to avoid possible hemorrhagic com- to avoid potential fetal bleeding.
plications in the fetus.
We performed a coagulation test during pregnancy be- Conflict of Interest: None of the authors have any conflicts of
cause maternal coagulopathy and fetal intracranial hema- interest associated this paper.
10,12,16,17
toma due to hyperemesis gravidarum were evident .
Although a maternal coagulation test yielded abnormal References
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