Transcript January 2014

THE MEDICAL CITY
Department of Obstetrics and Gynecology: Section of Perinatology
and the
Department of Pediatrics
PERINATAL/NICU CONFERENCE
Monthly Statistics Report
January 2014
Marco Manzano and Clarissa Pangilinan, MD
3rd Year Resident – Pediatrics
Maria Edwardina G. De Leon, MD
3rd Year Resident – Obstetrics and Gynecology
TOTAL BIRTHS
Number (%)
Total Births
200
Live births
200 (100.0%)
Stillbirths
0 (0.0%)
Delivered from normal
mothers (%)
117 (58.5 %)
Delivered from high risk
mothers (%)
83 (41.5 %)
Total Births, January 2014
ACCORDING TO TYPE OF MOTHERS
Delivered from Normal Mothers
Delivered from High Risk Mothers
TOTAL BIRTHS
41%
NUMBER
117
83
200
Normal mothers
High risk mothers
59%
Total Births, January 2014
ACCORDING TO NUMBER OF FETUS
Singleton
Multifetal (n = 2)
TOTAL LIVE BIRTHS
NUMBER
196
4
200
Total Births, January 2014
ACCORDING TO AGE OF GESTATION
Term
Preterm
Postterm
TOTAL LIVE BIRTHS
1%
9%
NUMBER
181
18
1
200
Term
Preterm
Postterm
90%
Total Births, January 2014
ACCORDING TO PLACE OF PRENATAL CARE
Registered
Non-registered
TOTAL LIVE BIRTHS
NUMBER
198
0
200
Registered
Non-Registered
100%
NURSERY ADMISSIONS
December vs January
January 2013 vs January 2014
Deliveries By Levels
NICU Referral (n=9)
• Inborn Transfer = 8
• Inborn Readmission = 1
Isolation (n=8)
• Inborn Transfer = 2
• Inborn Readmission = 2
• Outborn Admission = 4
NEONATAL
MORBIDITIES
Neonatal Morbidities, January 2014
NUMBER OF NEONATAL MORBIDITIES
Incidence among total live births
Delivered from Normal Mothers
Delivered from High Risk Mothers
36
115 per 1000 LB
19
17
47%
53%
Normal mothers
High Risk mothers
Top 5 Conditions Occurring Among
High Risk Mothers, January 2014
DM
28
Anemia
27
HPN
23
UTI
21
BANIAE
8
0
5
10
15
20
25
30
Top 5 Maternal Conditions Associated with
Neonatal Morbidities, January 2014
Prematurity = 4
DM
28
Anemia
27
HPN
23
UTI
21
BANIAE
8
0
5
10
15
20
25
30
Top 5 Maternal Conditions Associated with
Neonatal Morbidities, January 2014
DM
28
Prematurity = 3
LGA = 2
SGA = 1
Low birth weight = 1
Anemia
HPN
27
23
UTI
21
BANIAE
8
0
5
10
15
20
25
30
Top 5 Maternal Conditions Associated with
Neonatal Morbidities, January 2014
DM
28
Anemia
27
Prematurity = 4
LGA = 1
Low birth weight = 1
HPN
UTI
23
21
BANIAE
8
0
5
10
15
20
25
30
Top 5 Maternal Conditions Associated with
Neonatal Morbidities, January 2014
DM
28
Anemia
27
HPN
23
Prematurity = 1
LGA = 3
UTI
BANIAE
21
8
0
5
10
15
20
25
30
Top 5 Maternal Conditions Associated with
Neonatal Morbidities, January 2014
DM
28
Anemia
27
HPN
23
UTI
21
BANIAE
8
0
5
LGA = 1
Poor APGAR = 1
10
15
20
25
30
CONGENITAL
ANOMALIES
Congenital Anomalies,
January 2014
NUMBER OF NEONATES WITH
CONGENITAL ANOMALIES
Incidence among total live births
2
15 per 1000 LB
Delivered from normal mothers
1
Delivered from high risk mothers
1
Congenital Anomalies,
January 2014
Cleft Palate
1
Imperforate Anus
1
Congenital anomalies: January 2013
Antenatal detection and Neonatal outcome
Congenital
Anomalies
Cleft Palate
N
1
Ultrasound
Neonatal
outcome
WHCC
Done
Detected
Not
Outside
Detected
Survived Died
R
1
Imperforate Anus
R
CASE 1: Cleft Palate
•
•
•
•
M. M. P.
28, G1P0, 39
CC: vaginal bleeding
PNCU: regular,
unremarkbale
• Past
Medical/Personal/Social/
Family History: U/R
•
•
•
•
Stable Vital Signs
IE: 3cm, 50%, -3, (-)BOW
CTG: Category 1 trace
Intrapartum stay x 10hrs
• s/p PCS
• Female
APGAR 9,9
3140 g
MT 38 AGA
CASE: Cleft Palate
• S.M.P.
• Full term via stat
cesarean section due to
NRFHRP
• 28 year old G1P1 (0101)
• 39 1/7 weeks AOG, MT
38 AGA
• Apgar 9, 9
•
•
•
•
•
BW 3140 g
BL 51 cm
HC 34 cm
CC 34 cm
AC 30 cm
• Maternal History:
– UTI- 1st trimester, treated with cefuroxime
• Past Medical History:
– (+) asymptomatic MVP
• Family History:
– Diabetes, Hypertension, Heart disease, Stroke
• Personal/Social History
– Unremarkable
• OB History:
– G1 – present pregnancy
• Feeding history
– Mixed feeding, expressed breastmilk+milk formula
Physical Findings
•
•
•
•
•
•
•
•
•
•
Thinly meconium-stained amniotic fluid
Flat fontanels
No molding
Cleft palate
(-) alar flaring
Good air entry, no retractions
HR 150bpm, Good cardiac activity,
Soft abdomen
Grossly female genitalia
Full pulses
Diagnosis
• Live Term Baby Girl
• Cleft palate
PLAN
• NPO
• ENT Referral
• Therapeutics:
–
–
–
–
Obturator fitting c/o pedia dentist
OGT feedings
Feeding plate
Breast feed as tolerated
Course in the NICU
Subjective
Objective
• Day 1 of life
• Tolerates milk
formula (10-15
ml every 2
hours)
• Active
• No vomiting or
regurgitation
• 5 urine output
• 3 meconium
passages
• T – 36.8 C HR
146 bpm RR 49
cpm
• Weight 3020 g
• (+) cleft palate
• OGT at level 17
• Good air entry
• Good cardiac
tone, no
murmurs
• Soft abdomen
• Full pulses
Assessment
• Term baby girl
• Cleft Palate,
Incomplete
Plan
• Continue
feedings
• Referral to
pedia dentist
Course in the NICU
Subjective
Objective
• Day 2 of life
• Tolerates milk
formula (15-20
ml every 2
hours)
• Active
• No vomiting or
regurgitation
• 5 urine output
• 6 meconium
passages
• T – 36.9 C HR
145 bpm RR 49
cpm
• (+) cleft palate
• Good air entry
• Good cardiac
tone, no
murmurs
• Soft abdomen
• Full pulses
Assessment
• Term baby girl
• Cleft Palate,
Incomplete
Plan
• Pedia dentist:
No need for
obturator plate
at this time
• Referral to
maxillofacial
surgeon
• For obturator
fitting as
outpatient
pending
surgical
intervention
Cleft Palate







Failure of the palatal shelves to fuse
Cleft palate: 1 in 2500 (Caucasians)
Cleft lip+/- cleft palate: 1 in 750
Cleft palate: Females > Males
Cleft lip: Males > Females
Syndromes associated w/ Cleft Lip +/- cleft palate : >200
Ethnic factors (Cleft lip +/- cleft palate)
 Native Americans (1 in 230 to 1,000)
 Asians (1 in 400 to 850)
 African Americans (1 in 1,300 to 5,000)
 Incidence of associated congenital malformations and of
impairment in development is increased: Cleft palate alone >
cleft lip
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Clefting Defects
• between the 6th and 9th weeks AOG
– primary palate begins to form at about 35 days
– complete lip development by the 6th week
– palatal fusion follows
• Cleft lip: interruption or hypoplasia of the mesenchymal layer
 failure of fusion of the medial nasal process, maxillary
process, and lateral nasal process (unilateral or bilateral)
• Cleft palate: palatal shelves fail to fuse
• Multifactorial traits:
– Genetic: mutations in single genes (TBX22, IRF6, MSX1); Part of
chromosomal aneuploidy or deletion syndromes (trisomy 13,
velocardiofacial syndrome)
– environmental factors: teratogens (anticonvulsants)
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Cleft Palate
 Occurs in the midline and might involve only the uvula or can
extend into or through the soft and hard palates to the
incisive foramen
 When associated with cleft lip: involve midline of the soft
palate and extend into the hard palate on one or both sides,
exposing one or both of the nasal cavities as a unilateral or
bilateral cleft palate
 Can also have a submucosal cleft indicated by a bifid uvula,
partial separation of muscle with intact mucosa, or palpable
notch at the posterior of the palate
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th Edition
Pierre Robin sequence (PRS)
•
•
•
•
•
 micrognathia (small mandible)
 retropositioned tongue
 U-shaped cleft palate
failure of the mandible to grow properly  positioning of the
tongue in the back of the pharynx  blocks the ability of the
palatal shelves to fuse properly
severe respiratory distress: mortality rate as high as 30%
careful monitoring: first 1 to 4 weeks
over time, the lower jaw generally “catches up” in growth vs.
surgical intervention (jaw expansion)
isolated birth defect, but may be part of syndromes such as
trisomy 18 or Stickler syndrome
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Trisomy 18
• Edward’s Syndrome
• second most common autosomal trisomy
after trisomy 21
• severe psychomotor and growth retardation,
microcephaly, microphthalmia, malformed
ears, micrognathia or retrognathia,
microstomia, distinctively clenched fingers,
and other congenital malformations
Stickler Syndrome
• distinctive facial appearance, eye abnormalities,
hearing loss, and joint problems
• somewhat flattened facial appearance
– underdeveloped bones in the middle of the face,
including the cheekbones and the bridge of the nose
• High myopia, glaucoma, cataracts, retinal
detachment
• Hearing loss
• Loose or hypermobile joints, arthritis, scoliosis,
khyphosis, platyspondyly
Velocardiofacial Syndrome
• structural or functional palatal abnormalities,
cardiac defects, unique facial characteristics,
hypernasal speech, hypotonia, and defective
thymic development
• DiGeorge Syndrome (10%)
– at least 2 of the following features:
• Conotruncal cardiac anomaly
• Hypoparathyroidism, hypocalcemia
• Thymic aplasia, immune deficiency
Cleft Palate: Treatment
 Immediate problem: Feeding
 Difficulty creating sufficient
suction in the mouth to
complete a feeding without
tiring
 Soft artificial (cross-cut) nipples
with large openings, a
squeezable bottle
 Plastic obturator
 Small, frequent feedings, not
longer than 30mins
 Burped 2-3x during a feeding:
bottle positioned as upright as
possible to avoid air in the
nipple, or fed with an angled
bottle
 Timing of surgical correction
is individualized
 Width of the cleft
 Adequacy of the existing
palatal segment
 Morphology of the
surrounding areas
 Neuromuscular function of
the soft palate and
pharyngeal walls
Cleft Palate: Treatment
• Cleft lip: “rule of 10s”– 10lbs, 10 weeks old, and hgb of 10.0 g/dL
• Goals of surgery:
–
–
–
–
Union of the cleft segments
Intelligible and pleasant speech
Reduction of nasal regurgitation
Avoidance of injury to the growing maxilla
• Cleft palate: Usually by 1 year of age (speech development)
• Furlow double-opposing Z-plasty (most common)
– may need revisions as they grow older
• When delayed beyond 3rd year: a contoured speech bulb can be
attached to the posterior of the maxillary denture
• Cleft palate: usually crosses the alveolar ridge and interferes with
teeth formation in the anterior maxillary region
– May be displaced, malformed, or missing (replaced by prosthetics)
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th Edition
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Cleft Palate: Treatment
• Postoperative management: gentle aspiration of nasopharynx
(minimizes atelectasis or pneumothorax which are common
complications)
• Maintenance of clean suture line and avoidance of tension on
the sutures
• Bottle-fed with arms restrained and with elbow cuffs
• Fluid or semi-fluid diet for 3 wks
• Hands, toys, and other foreign bodies are kept away from the
surgical site
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th Edition
Cleft Palate: Sequelae
• Recurrent otitis media and subsequent hearing loss
• Displacement of maxillary arches and teeth malposition
• Misarticulations and velopharyngeal dysfunction (10-20%
after repair)
– Emission of air from the nose
– Hypernasal quality
– Compensatory misarticulations (glottal stops)
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th Edition
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
CASE 2: Imperforate Anus
•
•
•
•
•
•
•
•
M. B. R.
33, G2P1 (1001), 38
s/p PCS for arrest of descent
CC: irregular uterine
contractions
PNCU: U/R
Past Medical: s/p Harrington
rod insertion
Personal/Social History: U/R
Family History: (+) DM,
Hypertension
• Stable Vital Signs
• IE: 1cm, 50%
• CTG: category 1 trace
• s/p Repeat CS
• Male
APGAR 9, 9
3350 g
MT 38 AGA
Pertinent Data: Imperforate Anus
•
•
•
•
•
•
•
PBR
Delivered via Scheduled Repeat Cesarean Section
33 year old G2P2 (2002)
AOG: 38 1/7 weeks
MT: 38 AGA
Apgar Score: 9,9
Anthropometrics:
• BW= 3350 grams
• BL= 52 cm
• HC= 34 1/2 cm
• CC= 34 cm
• AC= 29 cm
Pertinent History: Imperforate Anus
•
Maternal History: 3rd Trimester, Cough and Colds, no
medications given
•
Past Medical History: Scoliosis s/p Spine surgery (1993)
•
Family History: Diabetes, Hypertension
•
OB History:
• G1- 2009- PCS for Arrest of descent- LFT- MaleTMC- No FMC
• G2: Present Pregnancy
•
Personal Social: Post-graduate, Works as a market
researcher, no vices
Physical Examination: Imperforate Anus
•
•
•
•
•
•
•
•
•
Had good cry and activity
Clear amniotic fluid
Flat and open fontanelles
Good air entry, no retractions
Regular cardiac rhythm, HR at 150 bpm
Soft Abdomen
Grossly male genitalia
Imperforate Anus
Full pulses
Diagnosis: Imperforate Anus
•
•
Term Baby Boy
t/c Imperforate Anus
PLANS:
•
•
•
Transfer to Level III care
Maintain on NPO
Referral to Surgery
Course in the NICU: Imperforate Anus
Subjective
-
5th HOL
On NPO
No vomiting
Active
Objective
-
-
T: 36.7, HR
143, RR: 44
Good air
entry, no
retractions
Good cardiac
tone
Soft abdomen
(+)
Imperforate
anus
Assessment
-
Term Baby
Boy
t/c
Imperforate
Anus
Plan
-
-
Insert OGT
For
Babygram
Observe for
any fecalith
material with
UO
IVF
HGT
monitoring
Course in the NICU: Imperforate Anus
Subjective
-
7th HOL
On NPO
No vomiting
Active
(+) UO: no
Fecalith
matter noted
Objective
-
-
-
T: 36.9, HR
147, RR: 42
Good air
entry, no
retractions
Good cardiac
tone
Soft abdomen
(+)
Imperforate
anus
Babygram:
Normal
Assessment
-
Term Baby
Boy
t/c
Imperforate
Anus
Plan
-
IVF
Course in the NICU: Imperforate Anus
Subjective
-
20th HOL
On NPO
No vomiting
Active
(+) UO
Objective
-
-
-
T: 36.7, HR
151, RR: 43
Good air
entry, no
retractions
Good cardiac
tone
Soft
abdomen,
slightly dilated
(+)
Imperforate
anus
Assessment
-
Term Baby
Boy
t/c
Imperforate
Anus
Plan
-
-
For cross
table lateral
abdominal Xray in prone
position
For anoplastly
Start
Ampicillin and
Gentamycin
Course in the NICU: Imperforate Anus
Subjective
-
26th HOL
No vomiting
(+) UO
Evacuation of
meconium
intra-op
Objective
-
-
Stable vital
signs
Good air
entry, no
retractions
Good cardiac
tone
Soft abdomen
(+) Anal pack
Assessment
-
Term Baby
Boy
Imperforate
Anus
s/p Anoplasty
Plan
-
Feedings
resumed
Course in the NICU: Imperforate Anus
Subjective
-
-
3rd DOL
Tolerates 20
ml every 2
hours with
breastfeeding
No vomiting
(+) UO
(+) meconium
Objective
-
-
-
Good air
entry, no
retractions
Good cardiac
tone
Soft abdomen
Full pulses
Assessment
-
Term Baby
Boy
Imperforate
Anus
s/p Anoplasty
Plan
-
For rooming
in
(Discharged
at the 5th
DOL)
Imperforate Anus
- Absence
- Occurs
of an anal opening
in 1 in 5000 births
- May have other associated problems: VACTERL
Orphanet J Rare Dis. 2011; 6: 56.
Published online 2011 August 16. doi: 10.1186/1750-1172-6-56
If the air column is more
than 1 cm from the
perineum, a colostomy is
indicated.
Cross table lateral prone Xray
The presence of meconium at
the perineum, a bucket-handle
malformation (ie, a prominent
skin tag located at the anal
dimple, below which an
instrument can be passed), and
an anal membrane (through
which meconium is visible).
A flat bottom or flat perineum,
as evidenced by the lack of a
midline gluteal fold and the
absence of an anal dimple,
indicates that the patient has
poor muscles in the perineum.
Anoplasty
Colostomy
NEONATES WITH
APGAR < 7
Neonates with APGAR < 7,
January 2014
NUMBER OF NEONATES WITH
APGAR < 7
Incidence among total live births
Delivered from low risk mothers
Delivered from high risk mothers
2
5 in 1000 LB
0
2
CASE 3: APGAR 5, 4
• J. C. A.
• 32, G1P0, 40
• CC: watery vaginal
discharge
• Past Medical: GDM – 9
wks AOG, on Insulin 26u
BID; Asthma – Symbicort
inhaler PRN; Thyroid
disease
• Personal/Social History:
U/R
• Family History: (+) DM
• 148/92, HR 66, RR 18, 36C
• SE: moderate pooling of
greenish amniotic fluid
• IE: 4cm, 70%, -3, (-) BOW
• s/p STAT PCS
• Male
APGAR 5, 4, 4
4210 g
MT 39 LGA
Identifying Data
• Live, term, baby boy delivered via STAT
caesarian section for nonreassuring fetal heart
rate pattern to a 33 year old G1P1 (1001) at 40
weeks age of gestation
• BW= 4210g BL= 452 cm HC= 35 ½ cm
CC= 37 cm AC= 32 cm
• MT 39 weeks LGA
• AS 5, 4, 4
Maternal History
• 1st trimester
– Started prenatal check-up (13x for the whole pregnancy)
– Ultrasound 5x = normal
– Threatened abortion given Isoxilan and bed rest for 2 months
• 2nd trimester
– Gestational Diabetes = FBS = 250, referred to endocrinologist 
started on insulin 12 ‘u’ BID
– FBS repeat after a month = 180, insulin increased to 14 ‘u’ BID
until 26 ‘u’ 2x/day
– (+) UTI (pus cells = 50-60) treated with Cefalexin for 7 days,
repeat urinalysis = normal
• Upon admission, noted to have variable decelerations with
latest at 70 bpm 3x, with thickly stained amniotic fluid
Past Medical History
• Bronchial asthma since childhood on
Symbicort 350mcg 1 puff PRN
• Thyroid nodule 2007 s/p total thyroidectomy,
no maintenance medications, last thyroid
function test  June 2013 (normal results)
Family History
• Maternal grandparents : diabetes
• Maternal grandfather: hypertension
• Maternal grandmother: thyroid disease
Personal Social History
• College undergraduate
• Entrepreneur
• No vices
Upon delivery
• Had thickly stained amniotic fluid, with weak
cry, heart rate of 150s, cyanotic, with some
flexion and grimace Suctioning and
stimulation done
• At 5 minutes: still cyanotic, no cry but with
spontaneous respiration, heart rate of 80s 
positive pressure ventilation done  heart
rate now 120s, with acrocyanosis, no cry
At 6 minutes, heart rate became 70  positive pressure
ventilation done  heart rate of 110, still with no cry, and
acrocyanosis

intubated with ET size of 3.5 level 12

Pink, with some flexion, heart rate 160, Good air entry, rales on
both lung fields, good cardiac tone, soft abdomen, 2 umbilical
arteries and 1 vein, stained cord, full pulses
•
•
•
•
•
•
•
Transferred to Level 3
Hooked to a mechanical ventilation support
Placed on NPO
Work-up: CBCPC, Blood Culture and Sensitivity, CRP
Chest Xray obtained
VBG done
Antibiotics and Dobutamine drip started at
5mcg/kg/min
• IV fluids started
• BP and O2 saturations obtained
Complete Blood Count
Hgb
Hct
WBC
N
L
M
E
160
49
23.7
29
63
06
02
CRP: 0.49 mg/dl
band
Plt
172
Chest Xray
Impression: Meconium Aspiration Pneumonia with
10th Hour of Life
• Noted to have desaturations to 70’s, with alar
flaring and subcostal retractions
• Dopamine started for heart support however
held due to tachycardia
• Surfactant 4ml/kg given
• Referred to Cardiology for evaluation and
management
• 2D Echo done
2D Echo
•
•
•
•
•
•
•
•
•
Situs Solitus
AV & VA concordance
Normal venous connections
Patent foramen ovale 6mm
Intact IV septum
Moderate TR
Mildly dilated RA & RV
Patent ductus areteriosus 3-4mm
Conclusion: Consistent with Persistent
Pulmonary Hypertension
16th hour of life
• O2 saturations at 83-88%
• Minimal urine output
• Milrinone started at 0.5mcg/kg/min for
pulmonary vasodilation
• Dobutamine increased to 10/mcg/kg/min
Day 1-2 of life
S
O
A
P
• Intubated
• With
spontaneous
respirations,
occasional
desaturations
, no cyanosis
• With
episodes of
agitation
• Adequate
urine output
1.7cc/kg/hr
BP 67/25 CR 154 RR 68
Pre O2sats 94% Post O2
sats 92%
Flat fontanelles
Light jaundice to
abdomen
+subcostal retractions,
good air entry, rales on
both lung fields
Regular cardiac rhythm,
no murmur
Soft abdomen
Full pulse
Persitent
Pulmonary
Hypertension
• Mech.Vent.Settings
adjusted
• Phototherapy started
• IVF adjusted
• Dobutamine,
Milrinone Drip
continued
• Morphine Drip
Started
• Antibiotic continued
• Fentanyl given as
relaxant as needed
• VBG obtained
Meconium
Aspiration
Syndrome
Day 3 of Life
S
O
A
P
• (+) Fever
• Intubated
• With
spontaneous
respirations
• With ocassional
desaturations,
no cyanosis
BP 68/27 CR 154 RR
72 O2sats 98%
T37.8
Flat fontanelles
Light jaundice to
abdomen
+subcostal
retractions, good
air entry, harsh
breath sounds
Regular cardiac
rhythm, no murmur
Soft abdomen
Full pulse
Persitent
Pulmonary
Hypertension
• Feeding with EBM
started
• Mech.Vent.Settings
adjusted
• Phototherapy
continued
• IVF adjusted
• Dobutamine,
Milrinone, Morphine
Drip continued
• Antibiotic shifted to
Ceftazidime and
Oxacillin
• CBC, CRP, BCS
repeated
• Electrolytes, Bilirubin
levels obtained
• Repeat Chest Xray
done
Meconium
Aspiration
Syndrome
Complete Blood Count
Hgb
Hct
WBC
N
L
M
E
band
Plt
142
43
8.5
63
28
04
01
04
148
CRP
Mg
Na
K
0.49
2.51
142
4.2
Total Bilirubin Direct
Bilirubin
Indirect
Bilirubin
14.85
12.95
2.12
High Risk
Zone
Chest Xray
Impression:
Interval regression
of bilateral
infiltrates/edema
Day 4 of Life
S
O
A
P
• No recurrence of
Fever
• Intubated
• With
spontaneous
respirations
• With ocassional
desaturations,
no cyanosis
BP 74/39 CR 165 RR
61 O2sats 98%
Flat fontanelles
Very Light jaundice
to face
+shallow subcostal
retractions, good
air entry, harsh
breath sounds
Regular cardiac
rhythm, no murmur
Soft abdomen
Full pulse
Persitent
Pulmonary
Hypertension
• Midazolam Drip
started at
0.5mcg/kg/min
• BCS (Staph.
Haemolyticus)
• Transferred to
isolation
Meconium
Aspiration
Syndrome
Day 5 of life
S
O
A
P
• Intubated
• With
spontaneous
respirations
• No
desaturations,
no cyanosis
BP 68/31 CR 167 RR
50 O2sats 94%
Flat fontanels
Very Light jaundice
to face
+subcostal
retractions, good
air entry, harsh
breath sounds
Regular cardiac
rhythm, no murmur
Soft abdomen
Full pulse
Persitent
Pulmonary
Hypertension
• Mech.Vent.Setti
ngs adjusted
• Phototherapy
discontinued
• Feeding
increased and
IVF adjusted
• Dobutamine drip
discontinued
• Milrinone and
Morphine drip
decreased
• Midazolam Drip
continued
• Lumbar
puncture done
Meconium
Aspiration
Syndrome
Day 6 of life
Day 7 of life
• Blood CS: Staph. Haemolyticus
• Sensitive to Vancomycin, resistant
to Ceftazidime
• Antibiotic shifted to Vancomycin
• Milrinone drip discontinued
• Mech.Vent. adjusted
• + coughing episodes
• Midazolam drip discontinued
• Given Ipratropium Bromide +
Salbutamol nebulization for cough
Day 8 of life
•
•
•
•
•
Extubation done
no desaturation, tachypnea, not in distress
Hooked to CPAP then discontinued
Nebulization with Salbutamol for 24hrs
Repeat cbc, crp, blood cs done
Complete Blood Count
Hgb
Hct
WBC
N
L
M
E
band
Plt
176
54
17.2
69
20
08
0
03
114
CRP: 1.4 mg/dl
Day 9 – Day 14 of life
• Good cry and activity
• No cyanosis, tachypnea, sign of respiratory
distress
• Feeding increased then fed as tolerated
• Vancomycin completed for 10days
• Referred to Pediatric Ophtalmologist for Retina
screening and Development Pedia for evaluation
• Discharged
Final Diagnosis
•
•
•
•
•
Live Term Baby
Meconium Aspiration Syndrome
Persistent Pulmonary Hypertension
Sepsis (Staphylococcus Haemolyticus)
Hyperbilirubinemia Unspecified
MECONIUM ASPIRATION SYNDROME
AND PERSISTENT PULMONARY
HYPERTENSION
• Meconium passage in utero  gasping by the fetus or
newly born infant can cause aspiration of meconiumcontaminated amniotic fluid  can obstruct airways,
interfere with gas exchange, and cause severe
respiratory distress
• Meconium-stained amniotic fluid: 10-15% births; term
and post term
• Meconium aspiration syndrome: 5%, 30% require
mechanical ventilation, 3-5% usually die
• May be depressed and require resuscitation at birth
• At increased risk of PPHN
• Aspirated meconium  vasospasm, hypertrophy
of the pulmonary arterial musculature, and
pulmonary hypertension that lead to
extrapulmonary right-to-left shunting through the
ductus arteriosus or the foramen ovale
• results in worsened ventilation-perfusion
mismatch, leading to severe arterial hypoxemia
 persistent pulmonary hypertension of the
newborn (PPHN)
• Aspirated meconium also inhibits surfactant
function.
Diagnosis

PPHN should be suspected in all term infants who
have cyanosis with or without fetal distress, IUGR,
moconium stained amniotic fluid, hypoglycemia,
and others.

A PaO2 gradient between a preductal (right radial
artery) and a postductal (umbilical artery) site of
blood sampling >20mmHg sugests right-to-left
shnting throughthe ductus arteriosus
94
Diagnosis

Real-time 2D echo combined with doppler flow
studies
-demonstrates right to left shunting across a patent
foramen ovale and a ductus arteriosus.

Tricuspid or Mitral insufficiency
Holosystolic murmur
 Can be visualized in the 2D echo with poor contractility
when PPHN is associated with myocardial ischemia

95
Treatment

Directed correctingany predisposingdisease
 Hypoglycemia, polycythemia

To improve poor tissue oxygenation

Response unpredictable, transient, and complicated
by the adverse effects of drugs or mechanical
ventilation
96
Treatment

Initial management
 Oxygen
 Correction of acidosis, hypotension, and
hypercapnia
 Intubation and mechanical ventilation
- hyperventilation is used to reduce pulmonary
vasoconstriction by lowering pCO2 (~25mmHg)
and increase the pH (7.5-7.55)
97
Treatment

Inhaled NO
 Potent and selective pulmonary vasodilator
 Initial dose 1-20ppm
 Improves oxygenation
 Reduces the need for ECMO
 Initial improvement but not sustained, ECMO is
required
 If there’s sustained improvement, usually
weaned by the 5th day of therapy.
98
Treatment
Extracorporeal


Membrane Oxygenation (ECMO)
When response to 100% oxygen, mechanical
ventilation, and drugs is poor
A form of cardiopulmonary bypass that
augments systemic perfusion and provides gas
exchange
99
Treatment

Extracorporeal Membrane Oxygenation (ECMO)


Venous bypass: Blood is initially pumped
through the ECMO circuit at arate ~80% of the
estimated cardiac output of 150-200ml/kg/min
Venous return passes through a membrane
oxygenator, warmed, and returns to the aortic
arch.
100
Treatment

Extracorporeal Membrane Oxygenation (ECMO)


This requires complete heparinization to prevent
clotting in the circuit, patients at high risk for IVH
are not candidates
Complications: thromboembolism, bleeding,
stroke, air embolization, others
101
Prognosis




Survival varies
Long term outcome for patients is reated to the
associated HIE and the ability to reduce pulmonary
vascualr resistance
Long term prognosis who survive after treatment
with hyperventilation is comparable to that infants
who have underlying illnesses of equivalent
severity
 Birth asphyxia
 Hypoglycemia
ECMO: favorable, 85-90% survive, 60-75% of
survivors appear normal at 1-3.5 yrs of age
102
CASE 4: APGAR 7, 5
•
•
•
•
M. I. P.
34, G2P0 (0010), 29
CC: vaginal bleeding
G1-2012-8 weeks AOG,
spontaneous abortion
• Past
Medical/Personal/Social
History/Family History:
U/R
• 103/72, HR 98, RR 19,
36.5C
• SE: minimal pooling of
blood with some clots
• IE: 1cm, <50%, -3,(+)BOW
• CTG: Category I trace
• s/p NSD
• Male
APGAR 7, 5
1510 g
Baby I.P.
•
•
•
•
•
•
Live, Baby Boy
NSD
34 year old, G2P1 (0111)
Preterm at 29 weeks AOG by LMP
31 weeks, AGA by Maturity Testing
APGAR Score: 7 and 5
Anthropometrics:
•
•
•
•
•
•
Birth weight: 1510 grams
Birth lenght: 41 cm
Head Circumference: 29 cm
Chest Circumference: 25 cm
Abdominal Circumference: 23 cm
Appropriate for Gestational Age
Maternal History:
• Day of admission  vaginal spotting,
preterm labor  admitted at IMU for tocolysis
• Past Medical History:
• unremarkable
• Family History:
• Diabetes mellitus
• Personal/Social History:
• Non smoker, Non alcoholic drinker
OB History:
• G1 – 2012: spontaneous abortion at 8 weeks
AOG , D&C done
• G2-2014: Present Pregnancy
UPON DELIVERY:
• Clear amniotic fluid
• One loose cord coil
At the Delivery Room
Grimace
Some flexion
HR 160
HR decreased
HR improved
Spont. Respirationthen
Acrocyanosis
Color improved
1st min
2nd min
Drying, wrapping
Stimulation
out
Suctioning secretions
continued
Free flow O2
thenreintubation done
HR= 60
3rd- 5th min 6th min
PPV initiated
Chest compression
Intubation
Epinephrine given
ET pulled
PPV
Upon Transfer to NICU
•
•
•
•
•
•
ET tube in place
Equal breath sounds
Patient had pink color
HR 120-130
Better activity
Good respirations
Admitting Diagnosis:
• Live, Baby Boy
• Preterm at 29 weeks AOG by LMP, 31 weeks
by Maturity testing
• Appropriate for Gestational Age
• Respiratory Distress Syndrome
• Sepsis Unspecified
PROBLEMS:
1. Respiratory Distress Syndrome
•
•
•
•
Intubation  CPAP
Surfactant therapy
VBGs
Chest Xray
• Chest Xray
1/24
pH
pCO2
pO2
HCO3
O2Sat
BE
7.391
50.7
26.9
30.7
49.4
5.4
Compensated Respiratory Acidosis
1/25
pH
pCO2
pO2
HCO3
O2Sat
BE
7.382
47.2
40.2
28
73.5
2.7
Compensated Respiratory Acidosis
1/26
pH
pCO2
pO2
HCO3
O2Sat
BE
7.293
52.7
35.9
25.4
60.4
-1.7
Respiratory Acidosis
• Surfactant deficiency
disease considered,
Neonatal pneumonia less
likely
2. Sepsis unspecified
•
•
•
•
Antibiotics (Ampicillin, Amikacin)
CBC
Blood CS
CRP
1/24
1/26
Hgb
Hct
WBC
Neu
Lym
Mon
Eos
Plt
152
46
10.9
52
40
06
02
263
Hgb
Hct
WBC
Neu
Lym
Mon
Eos
Plt
133
40
8.8
36
55
05
04
208
CRP: 0.01
Blood CS: No growth for 7 days
HGT: 63 – 89 - 112
3. Hyperbilirubinemia unspecified
•
Phototherapy
The End
CASE 5: Skipped beats
•
•
•
•
C. G. B.
25, G1P0, 38 5/7
CC: uterine contractions
Past
Medical/Personal/Social
History: U/R
• Family History:
Hypertension
• 103/72, HR 98, RR 19,
36.5C
• SE: minimal pooling of
blood with some clots
• IE: 1cm, <50%, -3,(+)BOW
• CTG: Category 1 trace
• s/p PCS
• Female
APGAR 9, 9
2890 g
Birth History
ARB
• Delivered via STAT Primary Cesarean Section for
arrest in cervical dilatation
• 25 year old G1P1 (1001)
• AOG: 38 5/7 weeks
• MT: 39 AGA
• Apgar Score: 9,9
• Anthropometrics:
•
•
•
•
•
•
BW= 2890 grams
BL= 47 cm
HC= 35 cm
CC= 32 cm
AC= 27 cm
•
Maternal History: 1st Trimester, Cough and Colds, no
medications given
•
Past Medical History: Breast cyst, Left, s/p
Excision(2012)
•
Family History: Hypertension
•
OB History: present pregnancy
Personal Social: College graduate, housewife, no vices
•
Upon Delivery
•
•
•
•
•
•
•
•
Good cry and activity, no cyanosis
Clear amniotic fluid
Flat and open fontanelles
Good air entry, no retractions
Irregular cardiac rhythm, HR 140 bpm, no
murmur (skipped beats, 10 -13x per minute)
Soft Abdomen
Grossly normal female genitalia
Full pulses
Initial Impression
Term Baby Girl
• r/o Cardiac Pathology
•
PLAN:
• Transfer to Level 3 of care hook to cardiac
monitor
• Refer to a pediatric cardiologist
– Hook to cardiac monitor
– BP and oxygen saturations on all extremities
Course in the NICU
Subjective
Objective
- 3rd HOL
- Good suck, cry,
and activity
- Able to latch
-
-
T: 36.8, HR
146, RR: 44
No cyanosis,
no alar flaring
Good air entry,
no retractions
Irregular
cardiac
rhythm, with 12 skipped
beats/minute
Full pulses
Assessment
Plan
Live term baby girl
r/o cardiac
pathology
- Monitor vital
signs every hour
- Hook to cardiac
monitor
- BP and O2 sats
on all
extremities
- Watch out for
25-30 skipped
beats/minute
• Stable vital signs
• BP on all extremities:
61/31
63/38
65/30
61/35
• Oxygen saturations on all extremities: 100%
Course in the NICU
Subjective
Objective
- 10th HOL
- Good suck, cry,
and activity
- Tolerates 1015ml of milk
feedings
-
-
T: 37, HR 122,
RR: 44
No cyanosis,
no alar flaring
Good air entry,
no retractions
Irregular
cardiac
rhythm, with 25 skipped
beats/minute
Full pulses
Assessment
Plan
Live term baby girl
r/o cardiac
patholog
- Bed side 2Decho
- EG-7
• 2D echo
–
–
–
–
–
PFO 4.2mm
Left to right shunt
Trivial mitral regurgitation
PDA 1.8 continuous blow
Normal transitional circulation; no arrhythmia
• Cardiology remarks:
–
–
–
–
Common incidental finding in newborns
Structural abnormality ruled out
No signs of heart failure noted
Refer for >5 skipped beats per minute
• EG7 results:
–
–
–
–
–
–
–
–
–
–
–
–
Na: 138 mmo/L
K: 4.3 mmo/L
iCal: 1.21 mmo/L
Hct: 47%
pH: 7.37
pCO2: 47 mmHg
pO2: 38mmHg (80-105)
HCO3: 27 mmo/L
TCO2: 28 mM
Beecf: 2 mM
sO2: 69% (95-98)
tHB: 16 g/dL
Course in the NICU
Subjective
Objective
- 24th HOL
- Good suck, cry,
and activity
- Tolerates 1015ml of milk
feedings every 2
hours
-
-
T: 36,5, HR
148, RR: 56
No cyanosis,
no alar flaring
Good air entry,
no retractions
Regular
cardiac
rhythm, no
skipped beats
Full pulses
Assessment
Plan
Live term baby girl
- Rooming in
Course in the NICU
Subjective
Objective
- Day 2 of life
- Good suck, cry,
and activity
- Breastfeeding
-
-
T: 36,5, HR
148, RR: 56
No cyanosis,
no alar flaring
Good air entry,
no retractions
Regular
cardiac
rhythm, no
skipped beats
Full pulses
Assessment
Plan
Live term baby girl
- May go home
- For ECG Normal
Neonatal Arrhythmias
• Arrhythmias in fetuses and newborns are
relatively common -- up to 90% of newborns
and 1% to 3% of pregnancies
• Life-threatening arrhythmias are uncommon
• Almost all arrhythmias fall into one of three
categories
– irregular
– tachycardic
– bradycardic
• Arrhythmias are found in 1–5% of newborns
during the first 10 days of life
• Most are premature supraventricular beats
that will disappear during the first month of
life
• The development of symptoms depends on
the rate and duration of the arrhythmia
• tachyarrhythmia - 240–300bpm
• Bradyarrhythmia - <100bpm
Normal Newborn ECG
Sinus Pause
Sinus Arrhythmia
• Sinus pauses from 800 to 1,000 msec may
occur in healthy newborns
• Such pauses usually are followed by escape
beats from the atria or the atrioventricular
(AV) junction
• Pauses of more than 2 seconds are considered
abnormal
• Possible causes:
– oversedation, (drugs passed through the placenta)
– hypothermia
– central nervous system abnormalities
– increased intracranial pressure
– increased vagal tone
– obstructive jaundice
– hypothyroidism
DISTRIBUTION OF BIRTHS
January 2014
Distribution of Deliveries According to
Birthweight
2%
11%
AGA
LGA
SGA
87%
Classification Based on Best
Score
SGA
AGA
LGA
TOTAL
Preterm
2
16
0
18
Term
1
157
23
181
Post Term
0
1
0
1
TOTAL
3
174
23
200
Small for Gestational Age Infants,
January 2014
NUMBER OF SGA NEONATES
Incidence among total live births
Delivered from normal mothers
Delivered from high risk mothers
3
10/1000 LB
1
2
A. Maternal factors
2
B. Fetal Factors
0
C. Unknown factor
1
Large for Gestational Age Infants,
January 2014
NUMBER OF LGA NEONATES
Incidence among total livebirths
Delivered from normal mothers
Delivered from high risk mothers
23
41 /1000 LB
15
8
A. Maternal factors
Gestational diabetes mellitus
B. Fetal Factors
Fetal Macrosomia
5
3
DISTRIBUTION OF
BIRTHS ACCORDING
TO GESTATIONAL
AGE ON DELIVERY
Distribution of Births According to
AOG on Delivery
Livebirths = 200
1%
9%
Term
Preterm
90%
Postterm
Weight vs MT
Wt
(grams)
600999
10001499
15001999
20002499
25002999
30003499
35003800
>3800
Grand
Total
<28
28-29
30-31
32-33
1
1
2
34-35
36-36
6/7
37-39
40-42
> 42
1
2
2
1
Grand
Total
2
1
1
5
3
10
13
3
67
3
73
56
7
63
29
6
35
6
3
9
169
19
7
0
200
Weight vs LMP
Wt
(grams)
600999
10001499
15001999
20002499
25002999
30003499
35003800
>3800
Grand
Total
<28
28-29
30-31
32-33
34-35
36-36
6/7
37-39
40-42
> 42
Grand
Total
2
1
1
2
2
2
1
1
3
4
4
1
12
1
8
56
7
72
60
11
71
22
8
30
4
4
8
146
31
200
5
13
5
Weight vs Best Score
Wt
(grams)
600999
10001499
15001999
20002499
25002999
30003499
35003800
>3800
Grand
Total
<28
28-29
30-31
2
1
1
2
1
2
5
2
4
4
10
37-39
40-42
> 42
Grand
Total
34-35
1
2
36-36
6/7
32-33
6
1
12
57
9
72
61
10
71
22
8
30
4
4
8
150
32
0
200
Livebirths and Preterm Delivery,
January 2014
NUMBER OF PRETERM NEONATES
Incidence among total livebirths
Delivered from low risk mothers
Delivered from high risk mothers
18
94 in 1000 LB
6
12
ROOMING IN AND
BREASTFEEDING
RATES
Rooming-In Rate
• Total No. of Babies Eligible for Rooming
In = 182/ 200 (91%)
• Rooming-In Rate = 180/182 (98.9%)
Breastfeeding Rates
BREASTFEEDING RATE
N (Total deliveries) = 200
JCI: 92.80% (exclusively BF/Term NB -exclusions)
BFHI: 92.86% (exclusively BF + w/medical indications of not BF/total no of live births)
Pure
Mixed
Formul
a Only
None
Donor
Total
Level I (n=58)
Roomed in (n=57)
50
8
0
0
1
58
Level II (n=134)
79
52
0
0
3
134
Level III (n=7)
1
3
0
0
3
7
Isolation (n = 1)
0
1
4
0
0
1
130
64
4
0
6
200
Level
Grand Total
GENERAL INDICES
OF PERINATAL DEATH
Neonatal Mortality,
January 2014
NUMBER OF MORTALITIES
Incidence among total live births
PERINATAL MORTALITY RATE
Crude Perinatal Mortality Rate
1 mortality / 200 total births
Corrected Perinatal Mortality Rate
0 non-lethal mortalities+0 stillbirth /200
total births
1
5 per 1000 LB
5 per 1000 TB
5 per 1000 TB
MORTALITY
CASE
CASE 6: Mortality Case AAA
•
•
•
•
•
•
• 137/93, HR 108, RR 17,
36.8C
A. A. A.
• IE: soft, closed, uneffaced
27, G1P0, 33 2/7
CC: minimal variability on • CTG: Category 2 trace
CTG
(+) GDM, (+) GHPN
• s/p STAT PCS
s/p repair of cleft lip
• Female
Family History: (+) DM
APGAR 5, 4
1420g
MT 32 AGA
G. A.
• Live Preterm Baby Girl
• Stat Cesarean Section for Non-reassuring Fetal
Status
• 27 y/o G1P1 (0101)
• 33 2/7 weeks AOG
• Anthropometrics:
– BW: 1420 gms; BL 41 cm; HC 28 cm; CC 24 cm; AC
23 cm
• Maturity Test: 32 weeks AGA
APGAR SCORE
1st minute
3rd minute
5th minute
10th minute 15th minute
Appearanc
e
1
1
1
1
2
Pulse
2
2
1
2
2
Grimace
1
1
1
1
1
Activity
0
0
0
1
1
Respiration
1
1
1
1
1
TOTAL
5
5
4
6
7
Problems
• Prematurity
• Respiratory and Cardiac
– Persistent Desaturations despite mechanical
ventilation
• Metabolic
– Persistent Acidosis despite correction
2D Echocardiography
•
•
•
•
Bilobed Liver
Dilated hepatic veins
Aorta anterior and left to the spine
IVC to the right of the spine, same level as
aorta
• Heart is mesocardiac in position pointing to
the left
• Poor RV function
• Severe Tricuspid Regurgitation
•
•
•
•
•
Mild Mitral Regurgitation
Mild Aortic Insufficiency
Multichamber enlargement
Dilated coronary arteries
Ejection fraction 61%
Final Diagnosis
• Intractable Metabolic Acidosis
• Heart Failure secondary to Neonatal
Myocarditis
• Respiratory Distress Syndrome s/p Surfactant
Therapy
• Poor APGAR
• Prematurity
THANK YOU!!!