Case study
Background
Maternal history
39 years old, Para 9 (1 set of twin)
Antenatally :
1.DCDA (Dichorionic diamniotic) twin
2.
DCDA twin
Dating scan done at 16 weeks and was referred to
GOPD team for twin pregnancy
Through out pregnancy paramenters corresponds to
age
Counselled for LSCS + BTL at term
Proceeded to EMLSCS
Intra-Op : Liquor Clear
Baby out vigorous (at 6.47pm), good breathing effort, good
tone, good cry
Initial steps done, HR> 100bpm, pink, and wrapped
APGAR 9/10/10
Family Tree
Mother is a housewife
Mother has Bronchial
asthma
No history of prematurity
on previous pregnancy
Immunization history
Growth chart
Length 39 cm (below
5th percentile)
Head circumference :
30 cm (at 3rd to 10th
percentile)
Body weight : 1.69 kg
( 3rd to 10th
percentile)
General Examination
Upon admission
Active upon handling, CRT <2sec,
good pulse volume,
warm peripheries,
pink,
+tachypnic with RR 65 and subcostal recession, nasal flaring but no grunting
Vital signs
MAP : 51
Respiratory Rate : 65
Temperature : 36.6
DXT : 5.9
Neonatal Examination
Facies : No syndromic looking
Sutures : No overlapping sutures
Fontanelle : Anterior and posterior fontanelle normotensive
Scalp: No swelling, no caput, no cephalohematoma
Eyes : 2 eyes
Ears : 2 ears
Nose : 1 nose, 2 nostrils
Mouth : No cleft palate/ No cleft lips
Neck : No short neck
Clinical Summary
Baby boy (twin 1) born premature at 34weeks 2 days
via EMLSCS for leading twin in transverse lie in labour
(spontaneous prematurity) with respiratory distress
Diagnosis
1. Prematurity at 34 weeks 2 days
Ballard Score : 34-36 week
2. Respiratory Distress Syndrome
3. Presumed Sepsis
4. Infant of GDM mother
Diagnosis
Points support
Respiratory Distress
Syndrome
Transient Tachypnic in
Newborn
caeserean section
Congenital pneumonia
Points against
No maternal fever,no
chorioamnionitis, PROM,
sign or symptoms of
sepsis, no fever,
1. Prematurity
1. Prematurity at 34 weeks 2 days
Ballard Score : 34-36 week
Corrected age 34 weeks 3 days
Chest Xray :
Ground Glass appearance
3) Presumed Sepsis
Presumed sepsis for spontaneous prematurity
Started IV C-Penicillin 50,000 IU/kg BD
IV Gentamicin 3.5/kg OD
Blood C&S 48 H : No growth
Completed IV C-penicillin and IV Gentamycin for total 3
days
Bilirubin
level
PL
ET
Day 3
181
240
340
Day 4
204
240
340
Day 5
256
240
340
Day 6
209
240
340
Day 8
186
240
340
Day 10
230
240
340
Day 11
190
240
340
Day 14
215
240
340
Day 21
211
240
340
Day 28
148
240
340
Action
Single
Phototherapy
Not on phototherapy
On single Phototherapy
Not on phototherapy
USG results
Day 1 (29/3/16)
Day 7 (4/4/16)
Bilateral no IVH
Day 14 (11/4/16)
Day 21 (18/11/16)
Day 28 (25/4/16)
Case Discussion
Definition
Preterm is defined as babies born alive before 37 weeks of
pregnancy .
Subcategories based on gestational age:
Extremely preterm ( < 28 weeks)
Very preterm (28 to <32 weeks)
moderate to late preterm (32 to < 37 weeks).
The categories for birth weight are:
Low birth weight (< 2500 g)
Very low birth weight (< 1500 g)
Extremely low birth weight (< 1000 g)
Complication of Preterm
Complication by System
The Lung
volumes
Pathophysiology
Clinical Presentation
History
Preterm
h/o perinatal asphyxia
Physical Exam
Sign and symptoms of RDS
Diagnosis
CXR
ABG
MANAGEMENT
-Antenatal- steroid (glucocorticoid) component of
surfactant
- Post natal
1. surfactant replacement therapy
(survanta)
2. Respiratory support (mechanical
ventilation)
Surfactant
A surface-active lipoprotein complex
(phospholipoprotein) formed by type II alveolar
cells.
Functions :
To increase pulmonary compliance
To prevent atelectasis (collapse of the lung) at the end of
expiration.
To facilitate recruitment of collapsed airways.
In malaysia, there are 2 types of surfactant
Survanta, a natural surfactant, bovine derived
4ml/kg per dose
Curosurf, a natural surfactant, porcine derived
1.25ml/kg per dose
Method of administration
Insert a 5 Fr feeding tube that has been cut to a suitable
length so as not to protrude beyond the tip of the
ETT on insertion, through the ETT.
Continue PPV in between doses and wait for recovery
before the next aliquot, with adjustments to settings if
there is bradycardia or desaturation. Administration over
15 minutes has been shown to have poor surfactant
distribution in the lung fields.
Alternatively the surfactant can be delivered through the
side port on ETT adaptor without disconnecting the
infant from the ventilator. There will be more reflux of
surfactant with this method.
Apnea of Prematurity
Definition :sudden absence of breathing that lasts at
least 20 seconds or is associated with bradycardia or
cyanosis (oxygen desaturation) in an infant < 37
weeks.
Incidence : occurs in >50% infants <1500g and 90%
of infants <1000g.
Causes
The abnormal control of breathing seen in apnea of
prematurity represents neuronal immaturity of the
brain.
Types :
Central : absence of respiratory effort with no gas
flow and no evidance of obstruction
Obstructive : continued ineffective respiratory
effort with no gas flow
Mixed central and obstrucctive : most common
type
Prevention
1. To prevent recurrence
Nurse baby in thermo neutral environment
Nursing in prone can improve thoroco abdominal
wall
KMC
2. Monitoring : Vital signs
3. Drug therapy : IV aminophylline/theophylline
PO caffeine citrate
Hematological Problems
Jaundice
Definition : level of bilirubin in the serum rises
above 85mmol/L (5mg/dL)
Mostly 80% premature babies will develop
jaundice in the first week of life while only 60 % in
term.
The main reason due to immature liver
Mechanism:
Increased bilirubin load in hepatocyte as result of
decreased erythrocyte survival
Decreased hepatic uptake of bilirubin from plasma
Defective bilirubin conjugation
Hypothermia
Definition
Newborn infant has immature
thermoregulation
According to WHO
Normal range : 36.5C- 37.5C
Cold stress : 36.0C- 36.5C
Moderate hypothermia :32.0C- 36.0C
Severe hypothermia : <32C
Consequences of hypothermia
When the body fails to compensate the
excessive heat loss, following
complications arise:
Clotting disorder
Shock
IVH
Management
Preparing and Maintaining a Warm
Environment
Plastic wrap in the Delivery Room
Delivery Room Temperature/radiant warmer
Caregiving & close monitor during NICU
Stabilization
Pre warmed in incubator or humidifier
KMC
Anemia of prematurity
At birth-> Normal value of infant >34 weeks is
Hb= 14-20g/dl
retic count 3-7%
Remain unchanged until 3rd weeks OL, then decline
to 11g/dL at 8-12 weeks OL (physiological anemia of
infancy)
Management
PO Ferrous Ammonium citrate 30mg/kg OD(Start at
day 14 of life)
Asymptomatic neonates with Hb levels of 7g/dl or
lower may require transfusion
If transfusion is not provided, close monitoring is
required
Packed cell transfusion 10-20ml/kg is given at rate of
2-3ml/kg/hr
The Heart
Pathophysiology
Blood flows from aorta to pulmonary artery
Risk Factors
Prematurity
RDS and surfactant treatment
Fluid administration
Asphyxia
Congenital syndrome eg congenital rubella
syndrome
Diagnosis
Clinical Presentation
Tachypnea
Tachycardia
Apnea
Heart murmur
Hypotension
Respiratory deterioration
Hepatomegaly
Bounding pulses
Cxr
Echocardiography
Management
Ventilatory support
Fluid Restriction
Indomethacin a prostaglandin synthases
inhibitor that is effective in promoting ductal
closure OR
Ibuprofen-nonselective cyclooxygenase inhibitor
that close the duct.
Surgery
The Abdomen
1) Necrotizing Enterocolitis
An ischemic and inflammatory
necrosis of the bowel,
primarilly affecting premature
neonates after the initiation of
enteral feeding
Occurs in 6-7% of VLBW
infants, 90% occur in preterm
infant
Presents with
feeding intolerance
blood in stools
Bilious vomiting
abdomen distended
other nonspecific signs
III. Advanced:
1. Systemic Signs (respiratory and metabolic acidosis, respiratory
failure, hypotension, decreased urine output, shock,
neutropenia, DIC
2. Intestinal Signs (Tense, discolored abdomen with spreading
abdominal wall edema, induration, discoloration)
3. Radiological Signs (pneumoperitoneum)
Stage 1 NEC
Diffuse gaseous
distension of
intestine
Stage II NEC
Management:
-Nil by mouth to allow gastrointestinal rest 7-14days
-Gastric decompression
-Vital signs and abdominal circumference
-Strict input and output monitoring
-Laboratory monitoring (check Complete blood count,
electrolytes, blood and urine culture prior antibiotic
-metronidazole)
Surgical referal for confirmed stage II or III
Complications:
death (20-30%), stricture formation, short gut
syndrome (9%), frequent/loose stools, impaired growth,
worse neurodevelopmental outcome
The Brain
Treatment:
Supportive
Shunting for hydrocephalus
Screening for IVH: day 1, 3 and 7 of life
Metabolism
1) Hypoglycemia
Premature baby, esp with low birthweight
have limited glycogen stores and immature
liver function
Sx includes: jitteriness, irritability, apnoea,
cyanosis, hypotonia, poor feeding, convulsion
Mx: prevention and early detection at birth
Hypoglycemia
Blood glucose (BG)< 2.6 mmol/L
BG <1.5mmol/L
Or symptomatic
Repeat BG in 30min
If still hypoglycemia:
Reevaluate
Increase volume by 30ml/kg/day
If still hypoglycemia :
Reevaluate
Increase concentration to D 12.5%-D15%
Repeat BG in 30min
Infection
Newborn are at risk of infection because their
immune systems are not yet mature, and this
is especially true for premature babies.
This is partly because they have a lower
immune function than term babies.
Some babies acquire an infection during the
birth process.
Usually cover with c-penicillin (for GBS) and
gentamicin (for gram negative bacteria)
Premature Counselling
Content of counselling
Chances of survival
Possible complications
Long term outcomes
Give them opportunity to tour NICU so
that they can better see their own baby
underneath it all
Bedside manner
Avoid overloading information
Conveyed it in a caring, empathetic
manner
Understands that hope helps people get
through the most dire situations
Reference
Paediatric Protocol For Malaysian Hospital, 3rd
edition, 2013, KKM.
Neonatology, Lange 7th edition, 2014.
Nelson Textbook of Pediatric, 17th edition, 2014
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