Differential Diagnosis of Anemia - Part 2 - Tala Talks NICU

Good afternoon, welcome to Tala Talks Nikki, where we break down complicated medical concepts and make them really easy for you to understand. Maybe too easy for you to understand, maybe we're simplifying it too much. So this is the second part of the lectures on anemia and please go back and see the earlier one because I set up this very elaborate analogy involving chimpanzees and bananas which won't make any sense to you unless you watch that. So now we're going to be talking about the two other main categories of why neonates are anemic. The first one was when the bone marrow does not produce enough blood. Again go back and watch the first episode so that you understand what's going on here. The second main reason for why neonates can be anemic is that they could lose their blood. So their bone marrow is producing the blood adequately but going back to the analogy, the zookeeper has been delivering the bananas, has been putting them in the sack, but the sack has a huge hole in it and every time he puts them in the bananas are just all falling into the creek and the chimpanzee isn't able to get them. So any bleeding from the baby obviously is also going to cause anemia or low red blood cell count. The loss of blood can be from before the baby is born, as the baby is being born, or after the baby is born. So before the baby is born it could be because of a fetal maternal hemorrhage. All babies let a little bit of blood go into the mother's circulation. That's a very normal part of pregnancy and actually that is why that we're able to do the genetic testing at like 11, 12, 13 weeks because a little bit of the baby's DNA has gotten into the mother's circulation. So we can take the mother's blood and look at the DNA on that and make predictions about the baby. So a little bit of fetal maternal hemorrhage is fine but if a lot of blood goes into the mother's circulation then obviously that's a problem. Or there could be a twin-twin transfusion. This can only happen in identical twins because the identical twins have to share a placenta because it's the sharing of the placenta that could result in uneven blood flow between one twin and the other. So again, identical twins for twin-twin transfusion. Also there could be a placental abruption where the placenta just rips off the wall of the uterus. That's obviously going to result in massive blood loss everywhere. Or a placenta previa when the placenta is like lying really low down next to the cervix. So as labor is progressing more and more blood could be lost. So all of those things can happen before the baby is born. During delivery there could be a fetoplacental transfusion. So for example if the baby is held up as soon as the baby's born, if the baby's held up really high up above the placenta then some of that blood will drain into the placenta. Just like you know how Simba is being held up at the beginning of Lion King. Is it Simba or Simba? I said Simba. Oh okay. I was going to say Simba but I thought you were going to say he's not attached to the placenta. No. That would have been more appropriate. That For example a fetoplacental transfusion like that. Or there could be some sort of cord prolapse or something where the cord gets stuck in the vaginal canal and blood is still draining from the baby but it's no longer going to the baby. That's also going to end up with a fetal anemia in the perinatal period. Or obviously the third category is that the baby has bleeding issues after the baby's born. So it could bleed into the brain. This happens especially in preemie babies. So an intracranial hemorrhage or intramentricular hemorrhage is most common in a premature baby. You can have a cephalohematoma which is where you kind of get bleeding right underneath the periosteum of the bone. And this happens very commonly especially in kind of more traumatic deliveries. Or you can even have really bleeding anywhere in your body. I mean you can bleed from a badly cut umbilical cord. You can bleed into pretty much every organ especially for example the liver. So a kind of subcapsular hematoma of the liver. Or the bleeding could be completely iatrogenic. Iatrogenic means that it's our fault. That it's the fault of the doctors and nurses and everybody else that's taking care of the baby. So um iatrogenic in this case would be that we're drawing so much blood from the baby to make sure that the baby's okay that they end up being anemic. Unfortunately that is going to be a significant cause of anemia in especially premature babies because we have to follow their blood. So that was the huge category of that there was a hole in the sack. And that the baby just lost blood. And again going back to the fact that the zookeeper was bringing the bananas. There's nothing wrong with the bananas but they were all falling into the river. So now the last and the third big category is that the zookeeper is bringing the bananas. There's no hole in the sack but there's something wrong with the bananas themselves. So either they like get overly ripe really really quickly or some other entity is coming in whether it's raccoons or bugs or whatever else and just consuming up the bananas and destroying them before the chimpanzees can eat them. So the third big category is increased destruction of the red blood cells. We call this hemolysis which is basically when you're having lysis or busting of the red blood cells. So this could be either because there's something wrong with that batch of red blood cells or that batch of bananas. So for example the red blood cells could have an enzyme defect where they just don't last as long. This happens in G6PD. So G6PD deficiency or there could be a membrane defect. So the little membrane that's kind of surrounding the cell isn't as strong as it should be and so the red blood cells don't live as long. That would be the case in spherocytosis or there's something wrong with a hemoglobin. The way that the hemoglobin is made inside the red blood cell just means that that red blood cell does not survive as long. That would be the case in like an alpha thalassemia. So those are all reasons why there's something wrong with the red blood cell itself and eventually that's why the red blood cell doesn't live as long. Interestingly and I'm not going to talk about this more now but in sickle cell disease normally that would be a reason why the red blood cell doesn't live as long. Neonates do not really suffer from sickle cell disease because they are born with a different type of hemoglobin. So until that hemoglobin pretty much leaves their body they don't have issues with their red blood cells sickling. So even though they do they obviously are born or not born with sickle cell disease it's not necessarily an issue in the neonatal period. So then the last category of why a baby might have anemia is again going back to the bananas is if the bugs or the raccoons or whatever are coming and destroying it. So there's some outside force that are destroying those red blood cells. In the unit we see that most commonly with immune hemolysis. So for whatever reason and I can definitely discuss this more the mother produces antibodies against the baby's red because it's very important. We worry about this most in O type mothers and in RH negative type mothers. So again that's concerning in mothers with an O blood type and an RH negative. So the most concerning for mothers to form antibodies against their baby's red blood cells is an O negative mother. Mothers who are B, mothers who are A, mothers who are AB don't produce the antibodies that can cross the placenta. So we worry about that in O and RH negative mommies. So just to mention this again as I mention it in every single talk another big reason why red blood can get destroyed is sepsis. So sepsis can end up with this thing called DIC where basically everything gets consumed up. All the platelets, all the coagulation factors and the red blood cells as well can just get destroyed as well. So that is another cause of hemolysis. So now you know the main categories of why a baby would have neonatal anemia. I hope you learned something today. If you do have any questions or you want me to clarify anything more or better then please comment below. Otherwise please like and subscribe so that you can stay up to date with these great NICU lectures. Thank you.