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Identifying Data

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.

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Identifying Data

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  1. 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

  2. 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’ BIDuntil 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

  3. 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)

  4. Family History • Maternal grandparents : diabetes • Maternal grandfather: hypertension • Maternal grandmother: thyroid disease

  5. Personal Social History • College undergraduate • Entrepreneur • No vices

  6. 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

  7. 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

  8. 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

  9. Complete Blood Count CRP: 0.49 mg/dl

  10. Chest Xray Impression: Meconium Aspiration Pneumonia with superimposed pulmonary edema

  11. 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

  12. 2D Echo • SitusSolitus • AV & VA concordance • Normal venous connections • Patent foramen ovale 6mm • Intact IV septum • Moderate TR • Mildly dilated RA & RV • Patent ductusareteriosus 3-4mm • Conclusion: Consistent with Persistent Pulmonary Hypertension

  13. 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

  14. Day 1-2 of life

  15. Day 3 of Life

  16. Complete Blood Count

  17. Chest Xray Impression: Interval regression of bilateral infiltrates/edema

  18. Day 4 of Life

  19. Day 5 of life

  20. 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

  21. Complete Blood Count CRP: 1.4 mg/dl

  22. 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

  23. Final Diagnosis • Live Term Baby • Meconium Aspiration Syndrome • Persistent Pulmonary Hypertension • Sepsis (Staphylococcus Haemolyticus) • Hyperbilirubinemia Unspecified

  24. Meconium Aspiration Syndrome and Persistent Pulmonary Hypertension

  25. Meconium passage in utero gasping by the fetus or newly born infant can cause aspiration of meconium-contaminated 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

  26. 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.

  27. 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 shntingthroughtheductusarteriosus 29

  28. 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 30

  29. Treatment • Directed correctinganypredisposingdisease • Hypoglycemia, polycythemia • To improve poor tissue oxygenation • Response unpredictable, transient, and complicated by the adverse effects of drugs or mechanical ventilation 31

  30. 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) 32

  31. 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. 33

  32. 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 34

  33. 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. 35

  34. 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 36

  35. 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 37

  36. Thank You! 38

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