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 band Plt

160 49 23.7 29 63 06 02 172

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 • 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 fontanellesLight jaundice to abdomen+subcostal retractions, good air entry, rales on both lung fieldsRegular cardiac rhythm, no murmurSoft abdomenFull pulse

Persitent Pulmonary Hypertension

Meconium Aspiration Syndrome

• 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

Day 3 of LifeS O A P

• (+) Fever• Intubated• With

spontaneous respirations

• With ocassional desaturations, no cyanosis

BP 68/27 CR 154 RR 72 O2sats 98% T37.8Flat fontanellesLight jaundice to abdomen+subcostal retractions, good air entry, harsh breath soundsRegular cardiac rhythm, no murmurSoft abdomenFull pulse

Persitent Pulmonary Hypertension

Meconium Aspiration Syndrome

• 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

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 2.12 12.95 High Risk Zone

Chest Xray

Impression: Interval regression of bilateral infiltrates/edema

Day 4 of LifeS 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 fontanellesVery Light jaundice to face+shallow subcostal retractions, good air entry, harsh breath soundsRegular cardiac rhythm, no murmurSoft abdomenFull pulse

Persitent Pulmonary Hypertension

Meconium Aspiration Syndrome

• Midazolam Drip started at 0.5mcg/kg/min

• BCS (Staph. Haemolyticus)

• Transferred to isolation

Day 5 of lifeS O A P

• Intubated• With

spontaneous respirations

• No desaturations, no cyanosis

BP 68/31 CR 167 RR 50 O2sats 94% Flat fontanelsVery Light jaundice to face+subcostal retractions, good air entry, harsh breath soundsRegular cardiac rhythm, no murmurSoft abdomenFull pulse

Persitent Pulmonary Hypertension

Meconium Aspiration Syndrome

• Mech.Vent.Settings adjusted

• Phototherapy discontinued

• Feeding increased and IVF adjusted

• Dobutamine drip discontinued

• Milrinone and Morphine drip decreased

• Midazolam Drip continued

• Lumbar puncture done

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 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 shnting throughthe ductus arteriosus

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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 correctingany predisposingdisease

Hypoglycemia, polycythemia

To improve poor tissue oxygenation

Response unpredictable, transient, and complicated by the adverse effects of drugs or mechanical ventilation

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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)

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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.

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TreatmentExtracorporeal 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

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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.

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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

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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!

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