the medical city department of obstetrics and gynecology: section of perinatology and the
DESCRIPTION
PERINATAL/NICU CONFERENCE Monthly Statistics Report February 2014 Khlaire D. Pioquinto , MD 3 rd Year Resident – Pediatrics Paolo Augusto U. Campos, MD 3 rd Year Resident – Obstetrics and Gynecology. THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the - PowerPoint PPT PresentationTRANSCRIPT
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PERINATAL/NICU CONFERENCEMonthly Statistics Report
February 2014
Khlaire D. Pioquinto, MD3rd Year Resident – Pediatrics
Paolo Augusto U. Campos, MD3rd Year Resident – Obstetrics and Gynecology
THE MEDICAL CITYDepartment of Obstetrics and Gynecology: Section of Perinatology
and theDepartment of Pediatrics
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TOTAL BIRTHS
Number (%)
Total Births 151
Live births 150 (99.3%)
Stillbirths 1 (0.7%)
Delivered from normal mothers (%)
85 (56.6 %)
Delivered from high risk mothers (%)
66 (43.4 %)
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Total Births, February 2014ACCORDING TO AGE OF GESTATION NUMBER
Term 129 Preterm 21 Postterm 1
TOTAL LIVE BIRTHS 151
85%
14%
1%
TermPretermPostterm
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Total Births, February 2014ACCORDING TO PLACE OF PRENATAL CARE NUMBERRegistered 151Non-registered 0TOTAL LIVE BIRTHS 151
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Total Births, February 2014ACCORDING TO AGE OF GESTATION NUMBER
Term 130 Preterm 21 Postterm 1
TOTAL LIVE BIRTHS 151
86%
14%
TermPretermPostterm
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Total Births, February 2014ACCORDING TO PLACE OF PRENATAL CARE NUMBERRegistered 151Non-registered 0TOTAL LIVE BIRTHS 151
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NURSERY ADMISSIONS
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January 2014 vs February 2014
Deliveries0
50
100
150
200
250
200
151
JanuaryFebruary
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February 2013 vs February 2014
Total Deliveries0
50
100
150
200173
151
Feb-13Feb-14
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Deliveries by Levels
42%
47%
11% 1%
N= 151
Level ILevel 2Level 3Isolation
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Admission to NICU ReferralFrom No. of Patients
Roomed In (Inborn transfer) 1
Discharged (Inborn Readmission)
3
Discharged (Outborn Admission) 0
Total 4
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NICU IsolationNo. of Patients
Inborn Transfer 1
Inborn Readmission 2
Direct admission 1
Outborn Admission 1
Total 5
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NEONATAL MORBIDITIES
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Neonatal Morbidities, January 2014NUMBER OF NEONATAL MORBIDITIES 35Incidence among total live births 230 per 1000 LBDelivered from Normal Mothers 20 (57%)Delivered from High Risk Mothers 15 (43%)
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Top 5 Conditions Occurring Among High Risk Mothers, February2014
BANIAE
Anemia
HPN
DM
UTI
0 2 4 6 8 10 12 14 16 18
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Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014
BANIAE
Anemia
HPN
DM
UTI
0 2 4 6 8 10 12 14 16 18
LGA - 1
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Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014
BANIAE
Anemia
HPN
DM
UTI
0 2 4 6 8 10 12 14 16 18
LGA - 2
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Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014
BANIAE
Anemia
HPN
DM
UTI
0 2 4 6 8 10 12 14 16 18
LGA – 2Prematurity – 7
Low birth weight - 1
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Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014
BANIAE
Anemia
HPN
DM
UTI
0 2 4 6 8 10 12 14 16 18
LGA – 1Prematurity – 1
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Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014
BANIAE
Anemia
HPN
DM
UTI
0 2 4 6 8 10 12 14 16 18
Prematurity 1
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CONGENITALANOMALIES
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NEONATES WITH1 minute APGAR <=6
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Neonates with APGAR <=6, February 2014
NUMBER OF NEONATES WITH APGAR < 7 3
Incidence among total live births in 1000 LB
Delivered from low risk mothers2
Delivered from high risk mothers 1
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• R.R.G• 39, G2P1 (0-1-0-1), 25 1/7
weeks• CC: watery vaginal discharge• Past Medical: G1 – NSD at
33 weeks AOG• Personal/Social History: U/R• Family History: (+)
Hypertension, Asthma, Diabetes
• 143/79, HR 96, RR 18, 37.5C• SE: pooling of clear
amniotic fluid• IE: 2cm, 50%, floating, (-)
BOW• s/p PBE• Male
APGAR 3, 6, 7830 gMT 28 weeks AGA
CASE 1: APGAR 3, 6, 7
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Birth History
• Baby Boy • Live, preterm• Delivered via Normal Spontaneous Delivery• 39 y/o (G2P2) (0202)• 25 4/7 weeks AOG• MT: 26 weeks, AGA
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Anthropometrics
• BW 830g• BL 32 cm• HC 24 cm• CC 21 cm• AC 18
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APGAR SCORE (1st minute) = 3SIGN 0 1 2Heart rate Absent Below 100 Over 100Respiratory effort
Absent Slow, irregular
Good, crying
Muscle tone
Limp Some flexion of extremities
Active motion
Response to catheter in nostril (tested after oropharynx is clear)
No response
Grimace Cough or sneeze
Color Blue, pale Body pink, extremities blue
Completely pink
Positive Pressure Ventilation
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APGAR SCORE (5th minute) = 6SIGN 0 1 2Heart rate Absent Below 100 Over 100Respiratory effort
Absent Slow, irregular
Good, crying
Muscle tone
Limp Some flexion of extremities
Active motion
Response to catheter in nostril (tested after oropharynx is clear)
No response
Grimace Cough or sneeze
Color Blue, pale Body pink, extremities blue
Completely pink
Positive Pressure Ventilation
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APGAR SCORE (10th minute) = 7SIGN 0 1 2Heart rate Absent Below 100 Over 100Respiratory effort
Absent Slow, irregular
Good, crying
Muscle tone
Limp Some flexion of extremities
Active motion
Response to catheter in nostril (tested after oropharynx is clear)
No response
Grimace Cough or sneeze
Color Blue, pale Body pink, extremities blue
Completely pink
Free Flow O2Thermoregulation
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Admitting Impression
• Extreme Prematurity, Very Low Birth Weight Sepsis Unspecified
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PLANS• Insert UVC• O2 support via nasal cannula at 2 lpm• Diagnostics:
– CBC, CRP– Blood Culture– Hgt– CXR
• Therapeutics:– IVF at TFR 80– IV antibiotics (Ampicillin, Amikacin)– Aminophylline
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PROBLEMS
• 1. Prematurity• 2. Sepsis• 3. Pneumonia• 4. Apnea • 5. Jaundice• 6. Anemia
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Problem 1: Prematurity
• Thermoregulation:– The patient was placed in an isollette and
wrapped in plastic to keep thermoregulated.– Temperature maintained at 36.5-37.5C
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• Feedings:– Upon delivery patient was on NPO, IVF started at
TFR 80– Aminosteril started– On the 3rd day of life, NGT was inserted and
patient was started on Glucose water then Breast milk
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Problem 2: Sepsis
• Diagnostics:– CBC– CRP– Blood culture
• Patient was started on the following medications:– Ampicillin– Amikacin
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Hgb Hct WBC Band Neu Lym Mon Eos Plt
116 35 19 2 80 16 02 6 261
CRP 0.04
Blood Culture: No growth (7 days)
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Problem 3: Pneumonia
• Pneumonia in the left lower lung
• UVC at level of T7 to T8
Start Cefotaxime
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11th day of life
Awake ActivePersistent desaturations
T 37C HR less than 100 O2 sats 40s-50s
PinkMinimal effort on respirationNo alar flaringsoundsRegular cardiac rhythmFull pulses
Apnea Probably secondary to progressing Pneumonia or Electrolyte Imbalance
Ambubagging
EG7
Chest Xray
O2 support
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• Progressing Pneumonia with Consolidation, bilateralAntibiotics Shifted to Meropenem
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Problem 4: Jaundice
2nd day of life
Awake ActiveNo desaturations
T 37.1 HR 140 RR 49 O2 sats 96
Generalized JaundiceNo alar flaringGood air entryHarsh breath soundsRegular cardiac rhythmFull pulses
Prematurity
Sepsis Unspecified
Hyperbilirubinemia Unspecified
Start double phototherapy
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Problem 4: Jaundice
4th day
Awake Active
T 37 HR 130 RR 50 O2 sats 98
PinkNo alar flaringGood air entryHarsh breath soundsRegular cardiac rhythmFull pulses
Prematurity
Sepsis Unspecified
Hyperbilirubinemia Unspecified, resolved
Phototherapy discontinued
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Problem 5: Apnea
First hour of life
Awake ActiveNo desaturations
T 37 HR 130 RR 49 O2 sats 97
Generalized JaundiceNo alar flaringGood air entryHarsh breath soundsRegular cardiac rhythmFull pulses
Prematurity
Sepsis Unspecified
Start Aminophylline
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2nd day of life
Awake ActiveEpisodes of desaturations and bradycardia
T 37 HR Less than 100 O2 sats 70s
Generalized JaundiceNo alar flaringGood air entryHarsh breath soundsRegular cardiac rhythmFull pulses
Apnea of Prematurity
Continue Aminophylline
Stimulation during periods of apnea
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11th day of life
Awake ActivePersistent desaturations
T 37C HR less than 100 O2 sats 40s-50s
PinkMinimal effort on respirationNo alar flaringsoundsRegular cardiac rhythmFull pulses
Apnea Probably secondary to progressing Pneumonia or Electrolyte Imbalance
Ambubagging
EG7
Chest Xray
O2 support
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pH 7.198
pCO2 74.4
pO2 80
HCO3 29
BE 1
SO2 92
Na 119
K 4.7
Ical 133
Hgb 82
Hct 24
Na correction with NaCl incorporation
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• Progressing Pneumonia with Consolidation
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11th day of life
Awake ActivePersistent desaturations
T 37C HR less than 100 O2 sats 40s-50s
PinkMinimal effort on respirationNo alar flaringsoundsRegular cardiac rhythmFull pulses
Apnea Probably secondary to progressing Pneumonia or Electrolyte Imbalance
For intubationMech Vent settings:FiO2 60PIP 18PEEP 4RR 50iT 0.45
Repeat CBC and EG7
Shift IV antibiotics to Meropenem
Cranial Ultrasound
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pH 7.387
pCO2 32.3
pO2 42.9
HCO3 19.4
BE
SO2
Hgb 91
Hct 27
WBC 14.6
Neutrophils 70
Lymphocytes 23
Monocytes 2
Eosinophils 0
Platelet 422
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Cranial Ultrasound
• Intraventricular and Germinal Matrix Hemorrhage (Grade II intracranial hemorrhage)
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Awake ActiveEpisodes of desaturation
T 37C HR 130 O2 sats 95-100%
PinkMinimal effort on respirationNo alar flaringsoundsRegular cardiac rhythmFull pulses
t/c Bronchopulmonary Dysplasia
Mech Vent settings adjusted accordingly
Start Dexamethasone
13th to 17th day of life
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12th day of life T 36.5 HR 150 RR 53 O2 sats 95
Pale skinNo alar flaringHarsh breath soundsRegular cardiac rhythmFull pulses
PrematuritySepsis UnspecifiedApnea of Prematurity
Anemia
PRBC for transfusion
Problem 6: Anemia
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Hgb HctPre transfusion 82 24
Hgb HctPost Transfusion 127 37
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• Diagnosis:• Extreme Prematurity, Very Low Birth Weight,
Sepsis Unspecified, Neonatal Pneumonia, Apnea of Prematurity, t/c Bronchopulmonary Dysplasia
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•THANK YOU
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• K.T.G• 33, G2P1 (1-0-0-1), 37
1/7• CC: for repeat CS• G1- 2011, CS for breech• Past
Medical/Personal/Social History/Family History: U/R
• 100/70, HR 82, RR 18, 36.6C• FHT: 140’s bpm• SE: not done• IE: soft closed• CTG: not done
• s/p RCS, cord prolapse • Male• APGAR 0, 8, 9• 2485 g• MT 37 AGA
CASE 2: APGAR 0, 8, 9
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Pertinent Data: RCG
• RCG• Delivered via Scheduled Repeat Cesarean Section • 33 year old G2P2 (2002)• AOG: 37 1/7 weeks• MT: 37 AGA• Apgar Score: 0,8,9
• Anthropometrics:• BW= 2485 grams• BL= 46 cm• HC= 32 cm• CC= 30 cm• AC= 27 cm
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Pertinent History
• Maternal History: No BP elevations, maternal illness during pregnancy
• Past Medical History: Allergic to fish sauce
• Family History: Diabetes
• OB History: • G1- 2011- PCS for Breech- LFT- Male- TMC- No
FMC• G2: Present Pregnancy
• Personal Social: College graduate, Works as a manager, no vices
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1 minute 3 minutes 5 minutes
COLOR 0 1 1
HEART RATE 0 1 2
REFLEX IRRITABILITY 0 2 2
MUSCLE TONE 0 2 2
RESPIRATION 0 2 2
Drying and Stimulation, PPV, Chest
Compressions
HR at 60’s, still Acrocyanotic. PPV continued
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Physical Examination: RCG
• 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• Full pulses
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Diagnosis: RCG
• Term Baby Boy, AGA, AS 0,9
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Course in the NICU: RCG
Subjective Objective Assessment Plan
- 6th HOL- Able to latch
with good suck
- No vomiting- Active- No cyanosis- No jittering
- T: 36.7, HR 143, RR: 44
- Good air entry, no retractions
- Good cardiac tone
- Soft abdomen
- Term Baby Boy
- Encourage breastfeeding
- For BP and O2 sat on all extremities
- For circumcision
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Course in the NICU: RCG
Subjective Objective Assessment Plan
- 8th HOL- With good
suck- No vomiting- Active- No cyanosis- No jittering
- T: 36.6, HR 141, RR: 42
- RU: 71/57, LU: 70/44, RL: 73/49, LL: 76/42
- 02 sat: 100%
- Good air entry, no retractions
- Good cardiac tone
- Soft abdomen
- Term Baby Boy
- Encourage breastfeeding
- For rooming in
- For circumcision
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Course in the NICU: RCG
Subjective Objective Assessment Plan
- 1st DOL- With good
suck- No vomiting- Active- No cyanosis- No jittering
- T: 36.5, HR 138, RR: 40
- Good air entry, no retractions
- Good cardiac tone
- Soft abdomen
- Minimal bleeding on surgical site
- Term Baby Boy
- s/p Circumcison
- Encourage breastfeeding
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Course in the NICU: RCG
Subjective Objective Assessment Plan
- 2nd DOL- With good
suck- Regular UO
and BM- No vomiting- Active- No cyanosis- No jittering
- T: 36.5, HR 138, RR: 40
- Good air entry, no retractions
- Good cardiac tone
- Soft abdomen
- Term Baby Boy
- s/p Circumcison
- May go home
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• M.L.T• 27, G1P0, 40 3/7• CC: uterine contractions• Past
Medical/Personal/Social History: U/R
• Family History:U/R
• 111/78, HR 80, RR 18, 37C• SE: not done• IE: 7cm, 80%, St-2, (+) BOW• CTG: Category 1 trace
• s/p OFE• Male
APGAR 4, 9, 92970 gMT 39 AGA
CASE 3: APGAR 4, 9, 9
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• Boy T• Delivered via NSD via
outlet forceps extractions
• 27 y/o G1P1 (1001) at 40 3/7 weeks AOG, MT 39
• AS 4,9
• BW: 2970g• BL: 51cm• HC: 33• CC: 32 ½• AC: 33 ½
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Physical exam
• Molding• Flat and fontanelles• Hyperemic right conjunctiva, (+) forceps mark
and hematoma, right cheek• Good air entry• Good cardiac tone• Soft abdomen• Full pulses
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APGAR (1 min)
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APGAR (5 min)
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Diagnosis
• Term baby Boy
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Plan
• Admit to level 2 for observation• Start feeding
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Course in the wardS O A P
1st minute of lifeDelivered via NSD outlet forceps extraction
AcrocyanoticHR 110GrimaceNo cryLimp
Term baby boy DryingStimulationFree flowing oxygen
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Course in the wardS O A P
5st minute of life AcrocyanoticHR 120GrimaceGood cryGood muscle tone
Term baby boy ThermoregulateFree flowing oxygenAdmit to Level 2
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Course in the wardS O A P
6th hour of lifeTolerated feedingsActiveNo episodes of cyanosisWith urine output and meconium passage
MoldingHyperemic right conjunctivaeForceps mark and hematoma on right cheekGood air entryGood cardiac toneSoft abdomenFull pulses
Term baby boy Observation at Level 2
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NEONATAL MORBIDITIES WITH APGAR >=7
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• M.S.F.• 30, G2P0 (0-0-1-0), 39
5/7• CC: watery vaginal
discharge• Past
Medical/Personal/Social History: U/R
• Family History:U/R
• 128/77, HR 86, RR 16, 37.5C• SE: pooling of clear AF• IE: 2cm, 50%, St-3, (-) BOW• CTG: Category 1 trace
• s/p NSD• Male
APGAR 8, 93265 gMT 39 AGA
CASE 4: Pulmonary Hypertension
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Festijo
• Boy S.F• Delivered via NSD• 32 y/o G2P1 (1011)• 39 5/7 weeks AOG, MT
39 AGA• AS 8,9
• BW 3265g• BL 49cm• HC 36cm• CC 33cm• AC 30cm
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Maternal History:- PROM 18 hours prior to delivery
Ob History:- G1 – 2008, abortion at 7 weeks s/p D&C
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Pertinent PE
• Caput• Good cry and activity• Clear amniotic fluid• Flat and open fontanelles• Good air entry, no retractions• Grade 1-2 systolic murmur• Soft abdomen• Grossly male genitalia with urine output• Full pulses
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Diagnosis
• Term baby Boy
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Course in the WardsS O A P
2nd hour of lifeCyanosis
HR 150 RR 50s O2 sat 70% at room airGood cry and activityAdynamic precordium gr 2/6 systolic murmur at left parasternal borderFull pulses
Persistent Pulmonary Hypertension vs Cyanotic Heart diseaseSepsis, unspecified
- Refer to Neonatologist
- Refer to Pediatric cardiologist
- Hook IV line- Hyperoxia test- Start antibiotics- Transfer to level
3
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Course in the WardsS O A P
3rd hour of life RR 76ActiveGood cry and activity, retractions, gruntingGr 2/6 systolic murmurSoft abdomenFull pulses
Persistent Pulmonary Hypertension vs Cyanotic Heart diseaseSepsis, unspecified
- CBC, CRP- Hgt- Chest xray to
rule out Pneumonia
- Hook to O2 at 3 LPM
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ABG 6LPM
pH 7.287
pCO2 31.4
pO2 92.8
HCO3 15
O2 96%
BE -10.3 Hgb Hct WBC Bands Neu Lym Mon Eos Plt
184 55 21.1 2 70 21 6 1 190
CRP = 0.02 mg/dL
Hgt = 115
Bcs: No growth after 7 days
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CXR
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Course in the WardsS O A P
8th hour of life HR 139 RR 61 T 37.4 O2 sat 100% 3LPM
Persistent Pulmonary Hypertension vs Cyanotic Heart diseaseSepsis, unspecified
- Decrease O2 support at 1LPM
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Course in the WardsS O A P
9th hour of life Desaturations as low at 70% at 1LPM
Persistent Pulmonary Hypertension vs Cyanotic Heart diseaseSepsis, unspecified
- Increase O2 support at 2LPM
- For 2d Echo to determine cardiac pathology
- Give midazolam for sedation
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Course in the WardsS O A P
12th hour of life Desaturations as low at 70% at 1LPM
Persistent Pulmonary Hypertension vs Cyanotic Heart diseaseSepsis, unspecified
- For Intubation
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Course in the WardsS O A P
12th hour of lifes/p intubation
Fr 3.5Level 10Good and equal air entrySoft abdomenFull pulses
Persistent Pulmonary Hypertension;Pneumonia
- Mech ventilation settings
- FiO2 100- PIP 20- PEEP 6- IT 0.4- RR 70- For HGT- Insert UVC- Shift antibiotics
to Cefotaxime
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ABG 6LPM 2/181 hr post intubation
pH 7.287 7.346
pCO2 31.4 44.6
pO2 92.8 97.9
HCO3 15 24.4
O2 96% 96.9
BE -10.3 -1.2
2d Echo: Elevated estimated right ventricular and pulmonary pressures; flattened interventricular septum and TR het of 61 mmHg (systolic BP of 71 mmHg) + right atrial pressureModerate right ventricular dilationMild ventricular hypertrophyGood biventricular systolic functionLarge bidirectional PDANo pericardial effusion
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CXR
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Course in the WardsS O A P
2nd day of lifeIntubatedNPONo desaturationsNo cyanosis
T 37.1 RR 71JaundiceGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDA;Sepsis, unspecified
- Reinsert OGT- Start breastmilk
feeding 3ml every 3 hours
- Start phototherapy
- Revise mech vent
- FiO2 100- RR 60- Itime 0.5- PIP 18- PEEp 5
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ABG 6LPM 2/181 hr post intubation
2/19 FiO2 100 PEEP 5, PIP 20 RR 60
pH 7.287 7.346 7.397
pCO2 31.4 44.6 54.3
pO2 92.8 97.9 46.6
HCO3 15 24.4 33.3
O2 96% 96.9 81.8
BE -10.3 -1.2 7.7
2/19
Crea 0.57
iCal 0.98
Na 135
K 3.7
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Course in the WardsS O A P
3rd day of lifeIntubatedTolerates 3ml of milk via OGTNo desaturationsNo cyanosis
HR 118-145RR 60-74BP 61-72/29-45O2 sat 96-100%Jaundice to chestGood air entryGood cardiac toneSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAHyperbilirubinemia, unspecified;Sepsis, unspecified
- Mech vent settings:
- FiO2 70- RR 60- PIP 16- PEEP 4- Increase
feedings to 5ml every 3 hours
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Course in the WardsS O A P
4th day of lifeIntubatedTolerates 5ml of milk via OGTNo desaturationsNo cyanosis
RR 58-73O2 sat 94-100%No alar flaringJaundice to chestShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDA;Hyperbilirubinemia, unspecified;Sepsis,unspecified
- Mech vent settings:
- FiO2 50- RR 40- PIP 16- PEEP 4- SIMV- Increase
feedings to 10ml every 3 hours
- Avoid vigorous suctioning
- For VBG, Na, K, Ical, DBIB
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ABG 6LPM 2/181 hr post intubation
2/19 FiO2 100 PEEP 5, PIP 20 RR 60
2/21 FiO2 40 PEEP 4 PIP 16 RR 30
pH 7.287 7.346 7.397 7.352
pCO2 31.4 44.6 54.3 56.8
pO2 92.8 97.9 46.6 42.8
HCO3 15 24.4 33.3 31.5
O2 96% 96.9 81.8 74.8
BE -10.3 -1.2 7.7 5.1
2/19 2/21
Crea 0.57
iCal 0.98 1.33
Na 135 135
K 3.7 4.4
Total Bilirubin 14.49 LIRZ
Direct Bilirubin 0.73
Indirect Bilirubin 14.08
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Course in the WardsS O A P
5th day of lifeIntubatedTolerates 10ml of milk via OGTNo desaturationsNo cyanosis
RR 51-62HR 125-151O2 sat 92-96%Jaundice to faceNo alar flaringShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia, unspecified
- Mech vent settings:
- FiO2 35- RR 25- PIP 15- PEEP 4- SIMV- Increase
feedings to 15ml every 3 hours
- Transfer to isolette
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Course in the WardsS O A P
6th day of lifeIntubatedTolerates 15ml of milk via OGTNo desaturationsNo cyanosis
RR 58-71HR 108-145O2 sat 92-96%Light Jaundice to faceNo alar flaringShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia
- For extubation- Hook to CPAP
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Course in the WardsS O A P
7th-11th day of lifeCPAPTolerates 30ml of milk via OGTNo desaturationsNo cyanosis
RR 48-64HR 110-152O2 sat 95-100%Light Jaundice to chestNo alar flaringNo retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia
- Continue feedings
- Possible weaning off CPAP
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Course in the WardsS O A P
12-15th day of lifeTolerates 30ml of milk via OGTNo desaturationsNo cyanosis
RR 48-55HR 110-152O2 sat 95-100%No alar flaringNo retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecified, resolvedHyperbilirubinemia, resolved
- Continue feedings
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PERSISTENT PULMONARY HYPERTENSION
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Definition
• Persistent Fetal Circulation (PFC)• Pulmonary hypertension resulting in severe
hypoxemia secondary to right-to-left shunting through the foramen ovale and ductus arteriosus in the absence of structural heart disease
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Typically seen in:
• Full term or post term infants
• 37-41 weeks gestational age
• within the first 12-24 hours after birth.
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In Utero
• Fetal gas exchange occurs through the placenta instead of the lungs.
• PVR > SVR causes blood from the right side of the heart to bypass the lungs through the ductus arteriosus and foramen ovale.
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Fetal Shunts
• Ductus arteriosus– R-L shunting of blood from pulmonary artery to
the aorta bypasses the lungs.– Usually begins to close 24-36 hours after birth.
• Foramen ovale– Opening between left and right atria.– Closes when there is an increased volume of blood
in the left atrium.
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At Birth
• First breath– Decrease in PVR– Increase in pulmonary blood flow and PaO2
• Circulatory pressures change with the clamping of the cord.– SVR >PVR allowing lungs to take over gas
exchange.– If PVR remains higher blood continues to be
shunted and PPHN develops.
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Signs of PPHN
• Infants with PPHN are born with Apgar scores of 5 or less at 1 and 5 minutes.
• Cyanosis may be present at birth or progressively worsen within the first 12-24 hours.
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Later developments
• Within a few hours after birth– tachypnea– retractions– systolic murmur– mixed acidosis, hypoxemia, hypercapnia
• CXR– mild to moderate cardiomegaly– decreased pulmonary vasculature
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Pulmonary Vasculature
• Pulmonary vascular bed of newborn is extremely sensitive to changes in O2 and CO2.
• Pulmonary arteries appear thick walled and fail to relax normally when exposed to vasodilators.
• Capillaries begin to build protective muscle. (remodeling)
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Diagnosis
• Hyperoxia Test• Place infant on 100% oxyhood for 10 minutes.
– PaO2 > 100 mmHg parenchymal lung disease– PaO2= 50-100 mmHg parenchymal lung disease
or cardiovascular disease– PaO2 < 50 mmHg fixed R-L shunt cyanotic
congenital heart disease or PPHN
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Hyperoxia Test (cont.)
• If fixed R-L shunt – need to get a preductal and postductal arterial
blood gases with infant on 100% O2.• Preductal- R radial or temporal artery• Postductal- umbilical artery
– If > 15 mmHg difference in PaO2 then ductal shunting
– If < 15 mmHg difference in PaO2 then no ductal shunting
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Treatment
• Goals:– To maintain adequate oxygenation.
• These babies are extremely sensitive• Handling them can cause a decrease in PaO2 and
hypoxia• Crying also causes a decrease in PaO2
• Try to coordinate care as much as possible– To maintain neutral thermal environment to
minimize oxygen consumption.
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Mechanical Ventilation
• TCPLV (Time cycled pressure limited ventilation) may be used with PPHN.
• Want to use low peak inspiratory pressures • Monitor PaO2 and PaCO2 with a
transcutaneous monitor
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Hyperventilation
• Hyperventilation helps promote pulmonary vasodilation
• Respiratory Alkalosis- decrease PAP to level below systemic pressures to improve oxygenation by helping to close the shunts– Try to keep pH =7.5 and PaCO2 = 25-30– Alkalizing agents - sodium bicarbonate or THAM
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Hyperventilation (cont.)
• Babies often become agitated when they are hyperventilated
• May need to administer muscle relaxants and sedation– usually given pancuronium and morphine
• pancuronium- q 1-3 hours IV at 0.1-0.2 mg/kg• morphine- continuous infusion 10 micrograms/kg/hr
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Nitric Oxide (NO)
• Potent pulmonary vasodilator– decrease pulmonary artery pressure– increase PaO2
• Does not cause systemic hypotension• NO more effective in PPHN babies without
lung disease• Baby must be weaned slowly off NO or may
have rebound hypertension
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Effects of NO
• NO is metabolized to nitrogen dioxide (NO2) which can cause acute lung injury.
• NO2 is potentially toxic.• NO reacts with hemoglobin to form
methemoglobin.
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Outcome
• PPHN may last anywhere from a few days to several weeks.
• Mortality rate is 20-50%.– Decreased by HFOV and NO– Decreased by ECMO
• Babies treated with hyperventilation may develop sensorineural hearing loss.
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• M.G.B.• 41, G2P1 (1-0-0-1), • 28 2/7 weeks• CC: left breast pain,
elevated blood pressure• Past
Medical/Personal/Social History: (+) Chronic hypertensive for 24 years; Invasive ductal CA, left breast, Stage IV
• Family History: (+) Hypertension/DM
• 150/90, HR 88, RR 18, 36C• Left breast mass measuring
24 x 14 cm• IE: not done• CTG: Reactive • s/p planned PCS,
Myomectomy, Incision biopsy L breast
• FemaleAPGAR 9, 91250 gMT 30 AGA
CASE 5: Prematurity, Invasive Ductal CA
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JPB
• Born on February 14, 2014
• Live preterm baby girl• Delivered via Scheduled
Primary Cesarean Section for Maternal Condition (Breast Cancer)
• 41 y/o• G2P2 (1102) • 28 5/7 weeks AOG
• BW 1250 g• BL 38 cm• HC 26 cm• CC 23 cm• AC 21 cm• MT 30, AGA• AS 9,9
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Delivery
• Apgar 1 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing
• Apgar 5 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing
• Immediately placed in a food grade plastic bag• O2 saturation: >85%• Newborn care was rendered
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Problem List:
• Respiratory Distress Syndrome• Infection• Apnea of Prematurity• Hyperbilirubinemia of Prematurity
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1. Respiratory Distress Syndrome 2nd Hour of life
Subjective Objective Assessment Plan•Grunting•Spontaneous breathing•No cyanosis
20 minutes after•No improvement of the grunting
•RR 60•Fair air entry•Subcostal, intercostal and suprasternal retraction
T/C Respiratory Distress Syndrome, Prematurity
•Hook to nasal CPAP•Oxacillin, Cefotaxime, Amikacin
•Intubation done•Surfactant therapy (4ml) given•Umbilical catheterization
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VBG
pH pCO2 PO2 HCO3 O2 BE
7.328 61.7 45.1 32.3 76.3 5.3 Compensated Respiratory Acidosis
Chest Xray Consider Hyaline Membrane Disease, cannot totally rule out Neonatal Pnemonia
Blood Culture
No Growth (7 days)
CBC
Hgb Hct WBC Band Neu Lymp Mon Eos Plt
151 45 7.9 4 48 42 5 1 239 4nRBC/100 WBC
HGT 82
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Problem 2: Hyperbilirubinemia1st day of life
Subjective Objective Assessment Plan•Intubated•FiO2 40%•RR 35•PIP 14•PEEP 3.8•s/p surfactant therapy•Mother had a would culture: Heavy growth of S. aureus: sensitive to all except Penicillin
•VS: HR 144, RR 65, T 36.9 O2 sat 98%•Jaundice to upper chest•Good air entry, subcostal, intercostal, suprasternal retractions •Good cardiac tone•Soft abdomen•Full pulses
Respiratory Distress Syndrome vs Neonatal Pneumonia, Sepsis, unspecified, Hyperbilirubinemia, unspecified
•Labs: Bilirubin Levels, CRP, Chest Xray, Hgt
•Single Overhead Phototherapy
•Oxacillin, Cefotaxime, Amikacin
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Bilirubin Levels
Total Direct Indirect
5.21 0.38 4.92
Chest Xray Consider Hyaline Membrane Disease, with interval improvement in the Lung Status
CRP 0.21 mg/dl
HGT 152
VBG
pH pCO2 PO2 HCO3 O2 BE
7.354 59.8 28.4 33.2 50.3 6.6 Compensated Respiratory Acidosis
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VBG
pH pCO2 PO2 HCO3 O2 BE
7.24 55.7 33 24 26 -3.0 Respiratory Acidosis
Chest Xray unchanged bilateral lung opacities consistent with resolving hyaline membrane disease
Blood Culture
No growth for 24 hrs
Hgb Hct
126 37HGT 92
Urinalysis
RBC WBC Epithelial Cast Bacteria
2 5 61 0 14
Na K iCal139 4.9 139
Bilirubin Levels
Total Direct Indirect
4.54 0.38 4.22 LRZ
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16th day of lifeSubjective Objective Assessment Plan
•Intubated•FR 8•FiO2 20•RR 20•PIP 10•PEEP 4• iT 0.5•No desaturations
•VS: HR 141, RR 52, T 37 O2 sat 100%•Pink•Good air entry, shallow subcostal retractions•Good cardiac tone•Soft abdomen•Full pulses
Apnea, Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemia, unspecified, resolved
•Labs: Blood gas
•Nasal CPAP intubation
•Aminophylline decreased to every 12 hours
•Meropenem 24 mg IV every 12 hrs (20 mg/kg/dose)
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VBG
pH pCO2 PO2 HCO3 O2 BE
7.261 63.4 35.7 28.4 57.9 -0.2 Respiratory Acidosis
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Current Diagnosis
Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild
Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified,
Resolved
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DISTRIBUTION OF BIRTHS
February 2014
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Distribution of Deliveries According to Birthweight
88%
11%
1%
AGALGASGA
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Classification Based on Best ScoreClassification SGA AGA LGA Grand Total
Preterm1 21 1 23
Term0 111 15 126
Post Term0 0 1 1
Grand Total1 132 17 150
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Small for Gestational Age Infants, February 2014
NUMBER OF SGA NEONATES 1 Incidence among total live births 6/1000 LB Delivered from normal mothers 0 Delivered from high risk mothers 1
A. Maternal factors 1 Gestational Hypertension B. Fetal Factors 0 C. Unknown factor 0
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Large for Gestational Age Infants, February 2014
NUMBER OF LGA NEONATES 17 Incidence among total livebirths 110 /1000 LB Delivered from normal mothers 8 Delivered from high risk mothers 9
A. Maternal factors Gestational diabetes mellitus Hypertension
13
B. Fetal Factors Fetal Macrosomia 1
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DISTRIBUTION OFBIRTHS ACCORDING
TO GESTATIONALAGE ON DELIVERY
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Distribution of Births According to AOG on Delivery
Livebirths = 151
85%
14%
1%
TermPretermPostterm
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Weight vs Best ScoreWt (grams) <28 28-29 30-31 32-33 34-35 36-36 6/7 37-39 40-42 > 42 Grand
Total
499 and below 0 0 0 0 0 0 0 0 0 0
500-599 0 0 0 0 0 0 0 0 0 0
600-999 1 0 0 0 0 0 0 0 0 1
1000-1499 0 1 2 1 1 0 0 0 0 5
1500-1999 0 0 0 1 2 2 0 0 0 5
2000-2499 0 0 0 0 4 3 3 0 0 10
2500-2999 0 0 0 0 1 2 42 10 0 55
3000-3499 0 0 0 0 0 0 51 6 0 57
3500-3800 0 0 0 0 0 0 9 3 0 13
>3800 0 0 0 0 0 0 4 2 0 6
Grand Total 1 1 2 2 8 9 107 21 0 151
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Preterm Delivery, February 2014
NUMBER OF PRETERM NEONATES 17 Incidence among total livebirths 150 in 1000 LB
Delivered from low risk mothers3
Delivered from high risk mothers 14
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ROOMING IN ANDBREASTFEEDING
RATES
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Rooming-in Rate
• Rooming-in rate– 125/135 (92.6%)
– 16 patients are not eligible
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Breastfeeding rate
Level Pure Mixed Formula only None Donor Total
Level I (N =23)
Roomed-in (N =40)
49 12 2 0 0 63
Level II (N = 71) 35 32 4 0 0 71
Level III (N = 16) 2 8 2 1 3 16
Isolation (N =1) 1 0 0 0 0 1
Grand Total87 52 8 0 3 150
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GENERAL INDICESOF PERINATAL DEATH
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Neonatal Mortality, February 2014
NUMBER OF MORTALITIES 1Incidence among total live births 6 per 1000 LB
PERINATAL MORTALITY RATE Crude Perinatal Mortality Rate 1 mortality / 151 total births
6 per 1000 TB
Corrected Perinatal Mortality Rate 0 non-lethal mortalities+0 stillbirth /151 total births
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MORTALITY CASE
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• R. M.V.• 35, G2P1 (1-0-0-1), 39
3/7• CC: uterine contractions• Past Medical/Personal
and Social History: U/R• Family History: (+) Colon
and Lung Ca, (+) Hypertension, (+) Diabetes
• 120/77, HR 80, RR 20, 37C• IE: 5-6cm, 80%, St-2, (+)
BOW• CTG: Category 1 trace
• s/p NSD• Male
APGAR 03010 g
CASE 6: Mortality Case RMV
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Admitting CTG
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Tracing upon arrival at LR, prior CEA
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Tracing after CEA
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CTG tracing after AROM
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CTG tracings prior to transfer to DR
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FHT tracing at DR (supine)
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FHT tracing at DR (Left lateral decub)
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FHT tracing (Prepping to Baby out)
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Mortality Case: RV
• Term Baby Boy• NSD • 35 y.o. G2P2 (2002) • 39 3/7 weeks AOG• Anthropometrics:
– BW 3120g BL 53cm HC 34cm CC 31cm AC 30cm– AGA
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NICU Transfer
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Apgar Score
1st 5th 10th
Appearance 0 0 0
Pulse 0 0 1Grimace 0 0 0
Activity 0 0 0
Respiration 0 0 0
TOTAL 0 0 1
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At the NICU
• Pale, unresponsive • BP not appreciated, HR 180, on bag-tube ventilation,
T 34C• No dysmorphic features• Pupils 8-9mm dilated, not reactive to light• No spontaneous breathing, Equal chest rise, good air
entry both lungs• Regular cardiac rhythm, no murmur appreciated• Soft abdomen• Poor pulses, CRT prolonged
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Severe hypoxic ischemic encephalopathy, post cardiopulmonary arrest
Initial assessment
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Problems• Asphyxia• Mixed Metabolic and Respiratory Acidosis
2/8
pH 6.604
C02 61.2
PO2 114.5
HCO3 6.1
BE -30
O2 sat 82.9%
Mixed metabolic and respiratory acidosis
Hooked to Mechanical VentilatorCorrection with NaHCO3Therapeutic Hypothermia
2/8
6.52
95.6
79
7.8
-30
60%
Mixed met and resp acidosis
Lactate (4.5-19.82 mg/dL)
223.2 mg/dL
Bleeding from puncture sites discontinued9th HOL
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Problems• Shock prob cardiogenic• Severe anemia prob sec to hemorrhage
Hgb Hct WBC Band Neut Lymph Mono Plt
57 20 42.7 6 45 41 8 188 70 nRBC
Cranial UltrasoundNormal
PT Control 13.3 Patient 38.5 % activity 0.2 INR 3.78aPTT Control 29.3 Patient 138
2D EchoPA pressure 50Right to left shunting (PDA)Underfilled left ventricleSevere tricuspid regurgitationPFO bidirectional
PNSS 20mL/kg bolus 2xDopamine and Dobutamine DripBlood transfusion ordered but refused
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Problems
• InfectionHgb Hct WBC Band Neut Lymph Mono Plt
57 20 42.7 6 45 41 8 188 70 nRBC
Blood culure and sensitivity
No growth
CRP (NV 0-0.5mg/dL)
0.01mg/dL
Ampicillin 50mg/kg/doseGentamicin 4mg/kg/day
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INTRACTABLE METABOLIC ACIDOSIS SECONDARY TO MULTIORGAN DYSFUNCTION SECONDARY TO PERINATAL ASPHYXIA
Final Diagnosis
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Learning Points
• Adequate communication between teams• Regular and proper evaluation of adequacy of
resuscitation
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THANK YOU!!!
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PERINATAL ASPHYXIA
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• Condition of impaired gas exchange that leads to fetal hypoxemia and hypercardbia
• Occurs during the 1st and 2nd stage of labor• In term infants, 90% pccur in antepartum or
intrapartum period as a result of impaired gas exchange across the pacenta
• Postpartum – secondary to pulmonary, cardiovascular, neurologic abnormalities
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Hypoxic-Ischemic Encephalopathy
• Abnormal neurobehavioral state in which the predominant pathogenic mechanism is impaired cerebral blood flow
• Suspected if:– AS <=3 at >5minutes– FHR <60 bpm– Prolonged (>1hr) acidosis– Seizures within the first 24-48hrs after birth– Burst-suppression patten EEG
Cloherty J. Manual of Neonatal care, 6th ed
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