THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the

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

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 %)

Total Births, February 2014ACCORDING TO AGE OF GESTATION NUMBER

Term 129 Preterm 21 Postterm 1

TOTAL LIVE BIRTHS 151

85%

14%

1%

TermPretermPostterm

Total Births, February 2014ACCORDING TO PLACE OF PRENATAL CARE NUMBERRegistered 151Non-registered 0TOTAL LIVE BIRTHS 151

Total Births, February 2014ACCORDING TO AGE OF GESTATION NUMBER

Term 130 Preterm 21 Postterm 1

TOTAL LIVE BIRTHS 151

86%

14%

TermPretermPostterm

Total Births, February 2014ACCORDING TO PLACE OF PRENATAL CARE NUMBERRegistered 151Non-registered 0TOTAL LIVE BIRTHS 151

NURSERY ADMISSIONS

January 2014 vs February 2014

Deliveries0

50

100

150

200

250

200

151

JanuaryFebruary

February 2013 vs February 2014

Total Deliveries0

50

100

150

200173

151

Feb-13Feb-14

Deliveries by Levels

42%

47%

11% 1%

N= 151

Level ILevel 2Level 3Isolation

Admission to NICU ReferralFrom No. of Patients

Roomed In (Inborn transfer) 1

Discharged (Inborn Readmission)

3

Discharged (Outborn Admission) 0

Total 4

NICU IsolationNo. of Patients

Inborn Transfer 1

Inborn Readmission 2

Direct admission 1

Outborn Admission 1

Total 5

NEONATAL MORBIDITIES

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%)

Top 5 Conditions Occurring Among High Risk Mothers, February2014

BANIAE

Anemia

HPN

DM

UTI

0 2 4 6 8 10 12 14 16 18

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


BANIAE

Anemia

HPN

DM

UTI

0 2 4 6 8 10 12 14 16 18

LGA - 2


BANIAE

Anemia

HPN

DM

UTI

0 2 4 6 8 10 12 14 16 18

LGA – 2Prematurity – 7

Low birth weight - 1


BANIAE

Anemia

HPN

DM

UTI

0 2 4 6 8 10 12 14 16 18

LGA – 1Prematurity – 1


BANIAE

Anemia

HPN

DM

UTI

0 2 4 6 8 10 12 14 16 18

Prematurity 1

CONGENITALANOMALIES

NEONATES WITH1 minute APGAR <=6

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

• 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

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

Anthropometrics

• BW 830g• BL 32 cm• HC 24 cm• CC 21 cm• AC 18

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

APGAR SCORE (5th minute) = 6SIGN 0 1 2Heart rate Absent Below 100 Over 100Respiratory effort


Good, crying

Muscle tone


Active motion


No response



Completely pink

Positive Pressure Ventilation

APGAR SCORE (10th minute) = 7SIGN 0 1 2Heart rate Absent Below 100 Over 100Respiratory effort


Good, crying

Muscle tone


Active motion


No response



Completely pink

Free Flow O2Thermoregulation

Admitting Impression

• Extreme Prematurity, Very Low Birth Weight Sepsis Unspecified

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

PROBLEMS

• 1. Prematurity• 2. Sepsis• 3. Pneumonia• 4. Apnea • 5. Jaundice• 6. Anemia

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

• 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

Problem 2: Sepsis

• Diagnostics:– CBC– CRP– Blood culture

• Patient was started on the following medications:– Ampicillin– Amikacin

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)

Problem 3: Pneumonia

• Pneumonia in the left lower lung

• UVC at level of T7 to T8

Start Cefotaxime

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

• Progressing Pneumonia with Consolidation, bilateralAntibiotics Shifted to Meropenem

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

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

Problem 5: Apnea

First hour of life

Awake ActiveNo desaturations

T 37 HR 130 RR 49 O2 sats 97


Prematurity

Sepsis Unspecified

Start Aminophylline

2nd day of life

Awake ActiveEpisodes of desaturations and bradycardia

T 37 HR Less than 100 O2 sats 70s


Apnea of Prematurity

Continue Aminophylline

Stimulation during periods of apnea

11th day of life





Ambubagging

EG7

Chest Xray

O2 support

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

• Progressing Pneumonia with Consolidation

11th day of life





For intubationMech Vent settings:FiO2 60PIP 18PEEP 4RR 50iT 0.45

Repeat CBC and EG7

Shift IV antibiotics to Meropenem

Cranial Ultrasound

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

Cranial Ultrasound

• Intraventricular and Germinal Matrix Hemorrhage (Grade II intracranial hemorrhage)

Awake ActiveEpisodes of desaturation

T 37C HR 130 O2 sats 95-100%


t/c Bronchopulmonary Dysplasia

Mech Vent settings adjusted accordingly

Start Dexamethasone

13th to 17th day of life

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

Hgb HctPre transfusion 82 24

Hgb HctPost Transfusion 127 37

• Diagnosis:• Extreme Prematurity, Very Low Birth Weight,

Sepsis Unspecified, Neonatal Pneumonia, Apnea of Prematurity, t/c Bronchopulmonary Dysplasia

•THANK YOU

• 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


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

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

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

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

Diagnosis: RCG

• Term Baby Boy, AGA, AS 0,9

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



- 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 cardiac tone

- Soft abdomen

- Term Baby Boy


- For rooming in

- For circumcision



- 1st DOL- With good

suck- No vomiting- Active- No cyanosis- No jittering

- T: 36.5, HR 138, RR: 40


- Good cardiac tone

- Soft abdomen

- Minimal bleeding on surgical site

- Term Baby Boy

- s/p Circumcison




- 2nd DOL- With good

suck- Regular UO

and BM- No vomiting- Active- No cyanosis- No jittering

- T: 36.5, HR 138, RR: 40


- Good cardiac tone

- Soft abdomen

- Term Baby Boy

- s/p Circumcison

- May go home

• 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


• 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

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

APGAR (1 min)

APGAR (5 min)

Diagnosis

• Term baby Boy

Plan

• Admit to level 2 for observation• Start feeding

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


5st minute of life AcrocyanoticHR 120GrimaceGood cryGood muscle tone

Term baby boy ThermoregulateFree flowing oxygenAdmit to Level 2


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

NEONATAL MORBIDITIES WITH APGAR >=7

• 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

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

Maternal History:- PROM 18 hours prior to delivery

Ob History:- G1 – 2008, abortion at 7 weeks s/p D&C

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

Diagnosis

• Term baby Boy

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


3rd hour of life RR 76ActiveGood cry and activity, retractions, gruntingGr 2/6 systolic murmurSoft abdomenFull pulses


- CBC, CRP- Hgt- Chest xray to

rule out Pneumonia

- Hook to O2 at 3 LPM

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

CXR


8th hour of life HR 139 RR 61 T 37.4 O2 sat 100% 3LPM


- Decrease O2 support at 1LPM


9th hour of life Desaturations as low at 70% at 1LPM


- Increase O2 support at 2LPM

- For 2d Echo to determine cardiac pathology

- Give midazolam for sedation


12th hour of life Desaturations as low at 70% at 1LPM


- For Intubation


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

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

CXR


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


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


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


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


- FiO2 50- RR 40- PIP 16- PEEP 4- SIMV- Increase


- Avoid vigorous suctioning

- For VBG, Na, K, Ical, DBIB


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



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


- FiO2 35- RR 25- PIP 15- PEEP 4- SIMV- Increase


- Transfer to isolette



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


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


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

PERSISTENT PULMONARY HYPERTENSION

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

Typically seen in:

• Full term or post term infants

• 37-41 weeks gestational age

• within the first 12-24 hours after birth.

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.

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.

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.

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.

Later developments

• Within a few hours after birth– tachypnea– retractions– systolic murmur– mixed acidosis, hypoxemia, hypercapnia

• CXR– mild to moderate cardiomegaly– decreased pulmonary vasculature

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)

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

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

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.

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

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

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

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

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.

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.

• 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

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

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

Problem List:

• Respiratory Distress Syndrome• Infection• Apnea of Prematurity• Hyperbilirubinemia of Prematurity

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

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

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

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


7.354 59.8 28.4 33.2 50.3 6.6 Compensated Respiratory Acidosis

VBG


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

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)

VBG


7.261 63.4 35.7 28.4 57.9 -0.2 Respiratory Acidosis

Current Diagnosis

Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild

Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified,

Resolved

DISTRIBUTION OF BIRTHS

February 2014

Distribution of Deliveries According to Birthweight

88%

11%

1%

AGALGASGA

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

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

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

DISTRIBUTION OFBIRTHS ACCORDING

TO GESTATIONALAGE ON DELIVERY

Distribution of Births According to AOG on Delivery

Livebirths = 151

85%

14%

1%

TermPretermPostterm

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

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

ROOMING IN ANDBREASTFEEDING

RATES

Rooming-in Rate

• Rooming-in rate– 125/135 (92.6%)

– 16 patients are not eligible

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

GENERAL INDICESOF PERINATAL DEATH

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

MORTALITY CASE

• 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

Admitting CTG

Tracing upon arrival at LR, prior CEA

Tracing after CEA

CTG tracing after AROM

CTG tracings prior to transfer to DR

FHT tracing at DR (supine)

FHT tracing at DR (Left lateral decub)

FHT tracing (Prepping to Baby out)

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

NICU Transfer

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

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

Severe hypoxic ischemic encephalopathy, post cardiopulmonary arrest

Initial assessment

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

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

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

INTRACTABLE METABOLIC ACIDOSIS SECONDARY TO MULTIORGAN DYSFUNCTION SECONDARY TO PERINATAL ASPHYXIA

Final Diagnosis

Learning Points

• Adequate communication between teams• Regular and proper evaluation of adequacy of

resuscitation

THANK YOU!!!

PERINATAL ASPHYXIA

• 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

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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