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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!!!