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CASE DISCUSSION

CASE DISCUSSION. Presenter:R2.5 蔡瑋峻 Date: 2016/09/09. Patient profile. Name: 陳 x 潔之女 Chart number: 1776XXXX Age: 0-day-old Gender: female Admission date: 2016/ 08/30, Born at 2016/08/30 10:30 Chief Complaints: Poor activity after birth and progressive swelling over scalp.

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CASE DISCUSSION

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  1. CASE DISCUSSION Presenter:R2.5 蔡瑋峻 Date: 2016/09/09

  2. Patient profile • Name:陳x潔之女 • Chart number: 1776XXXX • Age: 0-day-old • Gender: female • Admission date: 2016/08/30, Born at 2016/08/30 10:30 • Chief Complaints: • Poor activity after birth and progressive swelling over scalp

  3. Presentillness • G1P1, GA37+1, • Born via NSD • Prolonged delivery (Arrest of descent>2hrs) -->Vacuum extraction

  4. Mother’s history • Prenatal examination in 婦兒安: • No amniocentesis. NIFTY: normal. • Her level II sonar : no obvious fetal anomaly • The latest prenatal examination: • 1.umbilical cord around neck • 2.meconium in amniotic fluid • 3.calcification at placenta • ->fetal distress->delivery

  5. Mother’s history • No gestational diabetes mellitus • No pregnancy induced hypertension • Vaginal swab showed no GBS colonization • No recent fever or discomfort

  6. After birth • BBW: 3060gm, AGA, Apgar score: 3->6->7 • 1.Poor muscle tone, pale appearance • ->weak moro reflex, weak grasp reflex • 2.Progressive swelling over scalp • ->

  7. Growth and development: • BW:3060gm(15th-50th percentile) • BL:47.5cm(3th-15th percentile) • HC:34cm(50th-85th percentile)

  8. Family history

  9. Physical examination • HEENT: • Swelling of the baby's scalp • Progressive to occipital. • Cross suture line(+) • Huge soft and fluctuated mass over head, ill defined border • Anterior fontanel: unidentifiable Posterior fontanel: <1 f.b. Fracture: no; Molding: yes; Cephalohematoma: yes; • Caput succedaneum: yes; • Highly suspected subgaleal hemorrhageRaccoon eyes(-) • T: 37.7°C, P: 184/min, R: 60/min • BP: 51/27mmHg (MAP 35 < 37) • Respiration: nasal CPAP • Color: pale and anemic

  10. Chest: symmetric expansion, no retraction • bilateral clear breath sounds • Heart: tachycardia, regular heart beat, murmur(-) • Abdomen: flat and soft, hypo to normo-active bowel sound, no muscle guarding, no wound • Extremities: mild cold, had peripheral pulsation • Brachial plexus palsy(-), clavicle fracture(-) • Skin: no rashes, no petechiae

  11. NE • Level of consciousness: lethargic, Crying: weak • Spontaneous movement: poor • Pupil size/light reflex: 2.5mm + /2.5 + • Moro`s reflex: weak • Grasp reflex: weak; • Rooting reflex: weak • Barbinski sign: dorsi/dorsi flexion

  12. Impression • Perinatal asphyxia, complicated with hypoxic ischemic encephalopathy(HIE) • Birth trauma with subgaleal hemorrhage • Hypovolemic shock • Respiratory distress

  13. Plan • Diagnostic plan: • CBC(PLT)/DC,PT/APTT... • AST/ALT, BUN/CREA, CK, CK-MB, hsTnT… • Electrolyte: Na, K, Ca, P, • Dextrose, microgas, Hct • Head circumference • CXR, Brain image

  14. Laboratory data

  15. Therapeutic plan: • IVF D10W supply and fluid challenge • Blood transfusion; Correct coagulopathy • Empiric antibiotics: ampicillin and gentamicin • O2 support: nasal CPAP • Hypothermia therapy for hypoxic ischemic encephalopathy

  16. / • Fluid challenge: 10 mL/kg of N/S, 10 mL/kg of 5% Albumin • Transfusion: pack RBC 10 mL/kg*3, FFP 10 mL/kg*5 • Inotropic agent: dopamine and dubutamine 4mcg/kg/min • I/O: +364.6cc/24hrs, U/O: 1.1cc/kg/hr

  17. Clinical course • 8/30-9/02 Hypothermia therapy: whole body cooling • 9/01 urine output improving, • 9/02 apnea episode, bradycardia>CPCR 2 minutes, IMV mode • 9/03 extubation, nasal CPAP • 9/04 Room air • 9/05 MRI, transfer to level 2 • 9/08 MBD

  18. T1 T2

  19. Discussion:Subgaleal hemorrhage

  20. The mother was primiparous in 95% cases, • 48% had a prolonged second stage (>120 minutes) • 43% had prolonged rupture of membranes (>12 hours). • Thirteen infants (62%) were born by instrumental vaginal delivery. 

  21. Based on the presence of a fluctuating hemorrhagic mass that crossed suture lines and extended toward the neck • 0.6/1000 deliveries and 4.6/1000 vacuum-assisted deliveries. • Thirteen patients (31%) had a poor outcome (five died, four had epilepsy, three with severe auditory dysfunction, two with cerebral palsy, and one with renal vein thrombosis • Poor prognostic factors: transferred from other hospitals (P < 0.001), significantly more hypotension (P < 0.001), and seizures (P < 0.05), anemia, coagulopathy, metabolic acidosis, and renal impairment

  22. Severe hypovolemia and coagulopathy, but not intracranial hemorrhage, were the most commonly associated clinical problems with mortality.

  23. Subgaleal hemorrhage is a rare complication of delivery. • In the first newborn hemophilia was finally diagnosed. The second neonate was diagnosed with neonatal alloimmune thrombocytopenia

  24. THANKS FOR YOUR ATTENTION

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