380 likes | 517 Views
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.
E N D
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’ 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
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 grimaceSuctioning 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 70positive 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 CRP: 0.49 mg/dl
Chest Xray Impression: Meconium Aspiration Pneumonia with superimposed pulmonary edema
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 • 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
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
Chest Xray Impression: Interval regression of bilateral infiltrates/edema
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 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 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
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 shntingthroughtheductusarteriosus 29
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
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
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
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
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
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
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
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
Thank You! 38