Thrombosis of the Abdominal Aorta in a Extremely Low Birth Weight Infant: Treatment with Tissue-Type Plasminogen Activator
DOI:
https://doi.org/10.12974/2311-8687.2020.08.6Keywords:
Arterial thrombosis, Premature newborn, Aorta, Plasminogen activator, Enoxaparin.Abstract
Aortic thrombosis during neonatal period is a rare event especially when it is not related to umbilical arterial catheters. A case of a premature infant with a gestational age of 25 weeks who suddenly developed, at the age of 44 days, poor arterial saturation (SaO2 60%) and legs pale and painful, is reported. In this patient, arterial and venous eco-color Doppler showed a complete aortic thrombosis distal to the renal arteries of unknown etiology. Thrombolytic therapy with tissue-type plasminogen activator (t-PA) was immediately started with a bolus dose of 0.5 mg/kg/h followed by a continuous infusion of 0.2 mg/kg/h. Fresh frozen plasma was also infused in order to increase the concentration of plasminogen. We tried with success to avoid bleeding complications maintaining fibrinogen concentration over 500 mg/L and platelets over 100,000x109/L. Heparinisation with enoxaparin was started after 5 days of t-PA treatment and continued for 85 days. The premature infant recovered but physiotherapy and splints were needed for talipes equinovarus resulted as a consequence of distal thrombosis.
Conclusion: The strategy for treating an acute arterial thrombosis in a neonate may include thrombolytic therapy with t-PA, taking into account that the rate of plasmin generation in newborns and overall activity is decreased compared to adults. The impaired response of newborns may be enhanced not by increasing the dose of t-PA but increasing plasminogen through fresh frozen plasma infusion.
References
Albisetti M. Thrombolytic therapy in children Thromb Res; 2006; 118: 95-105. https://doi.org/10.1016/j.thromres.2004.12.018 DOI: https://doi.org/10.1016/j.thromres.2004.12.018
Emami A, Saldanha R, Knupp C, Kodroff M. Failure of systemic thrombolytic and heparin therapy in the treatment of neonatal aortic thrombosis. Pediatrics 1987; 79: 773-7
Nag UP, Greenberg RG, Leraas HJ, et al. Risk factors for thrombosis in the neonatal intensive care unit: analysis of a large national database. Blood 2018; 130(Suppl 1): 351- 3351.
Nagel K, Tuckuviene R, Paes B, Chan AK. Neonatal aortic thrombosis: a comprehensive review. Klin.Pediatr 2010; 222: 134-9. https://doi.org/10.1055/s-0030-1249662 DOI: https://doi.org/10.1055/s-0030-1249662
Nowak-Gottl U, von Kries, Gobel U, et al. Neonatal symptomatic thromboembolism in Germany: two years survey. Arch Dis Child Fetal Neonatal Ed. 1997; 76(3): F163- 7. https://doi.org/10.1136/fn.76.3.F163 DOI: https://doi.org/10.1136/fn.76.3.F163
Nosan G, Groselj-Grenc M, Paro-Panjan D. Thrombosis in newborns: experience from 31 cases. Signa Vitae 2012; 7(2): 29-32. https://doi.org/10.22514/SV72.102012.5 DOI: https://doi.org/10.22514/SV72.102012.5
Raffini L. Thrombolysis for intravascular thrombosis in neonates and children. Curr Opin Pedatr 2009; 21: 9-14. https://doi.org/10.1097/MOP.0b013e32831ef537 DOI: https://doi.org/10.1097/MOP.0b013e32831ef537
Schmidt B, Andrew M. Neonatal thrombosis: report of a prospective Canadian and international registry. Pediatrics 1995; 96(5 Pt1): 939-43. DOI: https://doi.org/10.1542/peds.96.5.939
Smith SA, Morrissey JH. Heparin procoagulant in the absence of antithrombin. Thromb Haemost 2008; 100: 160-2. https://doi.org/10.1160/TH08-05-0275 DOI: https://doi.org/10.1160/TH08-05-0275
Turebylu R, Salis R, Erbe R, Martin D, Lakshminrusimha S, Ryan RM. Genetic prothrombotic mutations are common in neonates but are not associated with umbilical catheterassociated thrombosis. J Perinatol 2007; 27: 490-495. https://doi.org/10.1038/sj.jp.7211786 DOI: https://doi.org/10.1038/sj.jp.7211786
