Euro Pathology 2018: Intra and Post Circumcision Bleeding in Nigerian Neonates: Correlation with Hemostatic Parameters

Circumcision is one of the oldest operations known. In Nigeria there is dearth of knowledge about the incidence of post-circumcision bleeding. Only one out of every seven males in the world is circumcised, however circumcision is the rule rather than the exception within all Nigerian ethnic groups and religions. This study investigated the relationship between some hemostatic parameters, family history and bleeding associated with circumcision of male infants in Ibadan, South West Nigeria. Materials and methods: The study design involved a population of 244 male infants drawn from University College Hospital and Oluyoro Catholic Hospital, in Ibadan, Nigeria. Pre-circumcision PT and aPTT, factor VIIIc level, Platelet Count, incidence of Intra and post-operative bleeding were determined. Results: None of the infants had a family history of bleeding disorder or thrombocytopenia. Six of the full term neonates (2.5%) had prolonged PT while only 2 of the subjects (0.8%) had prolonged aPTT. The factor VIIIc level was between 31-49% in 16.1%, while 1.6% of the neonates had levels between 20-26%. Intra-operatively, 28.9% (manual method, Gomco Clamp) and 4.9% (plastibell) had moderately severe bleeding while excessive postcircumcision bleeding was found in 2.8% and 6.8% for manual methods and plastibell respectively. Conclusion: There was a positive correlation between pre-circumcision aPTT and the degree of post circumcision bleeding. A relationship would have been expected to exist between post-circumcision bleeding and factor VIIIc but this was not found to be significant in this study. Activated Partial Thromboplastin Time would probably be sufficient as a screening hemostatic test for the detection of neonates that may be at risk of bleeding post-operatively.

It is customary in Africa, especially in Nigeria, to circumcise all male infants after the 7th day of life. Male circumcision is often performed in south-western Nigeria as a routine, crossing social, ethnic and religious barriers without prior coagulation screening tests. Babies are presented to the hospital the morning of surgery and are discharged home within one hour of surgery. This study was undertaken to regulate the correlation between intra-and post-circumcision bleeding and the hemostatic parameter in newborns, thereby determining the relevance of a laboratory investigation before circumcision to reduce the incidence of post-hemorrhagic complications.

Materials and Methods
It was a cross-sectional study in a hospital environment. The population studied came from University College Hospital (UCH) and Our Lady of Apostles Hospital (OLA), both in Ibadan, Nigeria. The study proposal was approved by the UI / UCH institutional review committee in Nigeria (IRC protocol No. UI / IRC / 04/0102). Informed consent was obtained from all mothers before collecting samples from their male infants.
A total of 3.8 ml of venous blood was taken from each male newborn immediately before the circumcision of the superficial veins on the back of the hand. 2 ml were dispersed in a sample vial of ethylene diamine sodium tetra acetate (EDTA) for a complete blood count and 1.8 ml was added to 0.2 ml of 3.2 M trisodium citrate to factor VIIIc, PT and aPTT. The complete hemogram was analyzed using the ADVIA 60 automated closed tube hematology system (TA9-92161E00) manufactured by Bayer®. Factor VIIIc, PT and aPTT were treated using standard manual procedures with the commercial thromboplastin reagent (lot number 0001702088) and the aPTT reagent (lot number 0015601078).
The method of circumcision recycled by the surgeon (UCH) Gomco clamp or the nurse (OLA) plastibell for Journal of Pathology and Disease Biology each of the subjects were influenced by the method routinely employed by either institution at the time of the study. The methods of Gomco clamp and plastibell use were followed strictly by the surgeon and the nurse performing the procedure. Anesthesia (dorsal penile nerve block or topical anesthetic cream) was not used on any of the infant though suture materials were provided in case of bleeding complication. Intra operative blood loss was assessed during surgery by the surgeon or the nurse performing the procedure using the weight of the blood soaked gauze (average sized plain gauze soaked with 5 ml of blood weighed approximately 5.3 kg). Post-operative bleeding was evaluated by the social worker during the home visits within the follow up period using the same method. A moderately severe bleed is blood loss superior than 10 ml of blood calculated from the weight / number of specific gauze used intra and post-operatively.

Results
A total of 244 male infants under 28 days of age were recruited for the study. None of the infants had a family history of bleeding disorders. All infants had a hematocrit value between 48 and 58 percent and a platelet count of 163 to 394 x 109 / l which fell within the normal reference range. One hundred ninety-eight (81.1%) of the infants bleed minimally (<10 ml), fortyfive (18.4%) had intraoperative bleeding> 10 ml during the procedure. However, one (0.4%) of infants (Gomco forceps method) bleed severely (> 30 ml) during surgery, which justifies their admission and observation for 24 hours after surgery. This child had normal INR and aPTT values.
The majority (97.5%) of circumcised children had a normal international normalized ratio (INR) of between 0.9 and 1.2. The remaining 2.5%, representing 6 of the infants, had prolonged disturbed INR (1.3-3.8). Of the six infants, who had disturbed the INR values, five had minimal bleeding (<10 ml, considered normal) while only one had moderate bleeding intraoperatively (~ 10 ml).
Two (0.8%) of the infants had prolonged deranged aPTT values of 55 and 57 seconds. Both of them had normal intra operative bleeding while the neonate with aPTT value of 57 sec had moderately severe post-operative bleeding. A positive correlation was found between aPTT and post-operative bleeding, p = 0.001. However, there was no significant correlation between PT / aPTT values and intra-operative bleeding p = 0.534; p = 0.276 respectively. Out of the subjects, 4 (1.6%) had factor VIIIc level between 5-30% (Low), 39 (16.0%) had level between 31% and 50% (borderline) while 201 (82.4%) had level between 51 and 200%. Intra-operatively, 28.9% (manual method, Gomco Clamp) and 4.9% (plastibell) had moderately severe bleeding while excessive post-circumcision bleeding was found in 2.8% and 6.8% for manual methods and plastibell respectively.

Conclusion
A pre-circumcision test such as aPTT is an important screening test for the risk of post-operative bleeding. The time to partial activated thromboplastin will likely be sufficient as a hemostatic screening test to predict post-circumcision bleeding in infants.