Neonatal case study scenario

DR MOHAMED ABDELAZIZ ALI

january 2014

you are called to the postnatal ward to review a baby is 8 hours old.

The midwife reported that the baby not feeding well.his mother says he is tried to feed after birth but now is not interested.on examination,the infant pale,and feels slightly floopy.he is mottled with cool peripheries and has heart rate of 160 bpm and mild recession.he has normal heart sounds.and both femoral pulses can be felt.

What is your first management step?

The baby should be resuscitated using ABC approach and taken to the neonatal unit for ongoing care and management.

What questions if any do you ask the mother?

Ask about possible events that may make infection more likely.

1-ask about prolonged ruptur of membranes ?

2-ask did the mother have any episodes of increased temperature ?

3-ask if there have been any previous pregnancies were any infants treatedfor infection ?

4-ask about UTIs ?

5-ask about premature birth,pre-eclampsia and LBW infants ?

List investigations you should carry out?

1-Blood culture: Is the definitive test. The majority of blood culture taken will grow in

48 Hs if they are going to be positive. The majority of neonatal infections are associated

with a bacteraemia and thus a +ve blood culture.

2-urine culture: Is important investigation if sepsis is suspected. If the baby is unwell and septic,the easiest way to

obtain a sample is by suprapubic aspiration of the urine

If a bag urine specimen is thought to be positive,it must have at least 150 white cells mm3 / and a pure growth more than 100 000 organisms/ml urine.

3-Full bood count: Differential white count of help. Low neutrofil count,<2.0-2.5 * 109 /L in the frist

2 days of life suggest that there is bacterial inf. Other helpful markers of infection may be the

ratio of mature to total number of neutrophils,the maximum acceptable value for excluding sepsis in the first 24 Hs is 0.16 and the ratio falls to 0.12 within 60 Hs and if this ratio > 0.2 is a good marker for infection.

4- c-reactive protein:

Is a good indicator of infection if serial measurements are made.

It is better than WBCs indices as an inf marker. It takes few Hs to rise therefor should not be used

to decide when start antibiotics. Culture-proven sepsis is unlikly if CRP does not

rise within 48 Hs of the onset of illness ,and thus generally safe to stop antibiotic if the cultures are -ve and CRP normal at 48Hs.

5- chest X-ray:

all infants suspected sepsis should have chest x-ray.

6-procalcitonin and CRP concentration in umblical cord….(new,have high specifity and sensitivity).

What is your next step in managing this baby?

After resuscitation ,stabilisation and investigations, antibiotic should be given immediately.

For early onset sepsis (most likely in this infant case) the antibiotics need to cover group B Streptoccus,listeria,and gram –ve organisms such as E. coli.

A combination of penicillin and gentamicin would be a good choice as there is action between the two against GBS.

Cephalosporin alone will have no coverage for E.coli or listeria.

The results of initial ivestigations are obtained:

Hb 14.7 g/ dL

WBCs 21.4 * 109 /L

Neut 1.7 * 109 /L

Plt 104 * 109 /L

CRP 94 mg /L urine SPA sample – no cells, no organism.

CXR shows diffuse, fine, reticluglanular pattern, much like seen in RDS.

The infant breathing without ventilatory support with some low flow oxygen to maintain his saturation.he has

had his frist dose of antibiotics and currently on maintained fluid.

What do you do now ?

In this situation which a high CRP would carry out a lumber puncture.

if the platlet count < 50,000, then a platlet transfusion should be given before the lumber puncture.

A lumber puncture is carried out, results:

RBCs 18000 / mm3

WBCs 12/ mm3

protein 2.5 g/L

Glucose 1.4 mmol/L

CSF is moderately blood stained. 6 Hs later the infant is more symptomatic having frequent apneas

and desaturations. He is intubated and ventilated .repeated bloods show the following results:

CRP 120 mg/L

Platelets 45 * 109 /L

Neutroohils 0.8 * 109 /L

Which of the following treatment consider ?

1- Fresh frozen plasma (FFP).

2-Immunoglobulins.

3-Exchange transfusion.

4-Platlets transfusion.

5-Changing antibiotics.

6-Granulocyte-macrophage colony stimulating factor (GM-CSF)

The are phone call from the microbiology department the following daysaying the blood cultures are growing Group B streptococcus. The infant CRP is now 40 mg/L and platelets stable above 100 after the platelet transfusion.

How you modify your treatmen,if at all?

Therapy can be simplified to intravenous benyl penicillin alone as GBS is very sensitive to this.

How long will you treat the baby? without meningitis ,GBS bacteraemia can be

treated with antibiotics for 10 days. If meningitis was also present, antibiotic should

be continued for at least 21 days.

What will you tell the parents? Up to 30% of pregnant women are colonised GBS The majority of neonatal inf present within 4-6 Hs

of life and about 90% of cases present within 24 Hs of life.

His infection was picked up early and treatment commenced promptly.

His infective markers are improving showing he is responding to treatment.

The baby has no signs of menigitis and is on the correct antibiotics with maximum supportive ttt.

Previously,mortality from GBS was about 50% with a mortality rate up to 100% for babies<1.5kg. Currently in UK the mortality rate is 10%.

At this stage we would be cautiously optimistic the parent.

thank you