Perinatology Conference

January- May 2010

Nursery Census
January May, 2010

Number of Live Births and Neonatal Deaths

80 Number of Total Deliveries 70 60 50 40 30 20 10 January Number of Deaths 1 Number of Live Births 58 0 February 1 66 March 4 49 April 1 49 May 0 54

Total number of deliveries from January to May, 2010 =283

Nursery Census
January May, 2010

Number of Preterm, Fullterm and Postterm Deliveries

80 70 60 50 40 30 20 10 0 Postterm Fullterm Preterm Number of Deliveries

January 0 55 4

February 0 60 7

March 0 45 8

April 0 42 8

May 0 52 2

Total number of deliveries from January to May, 2010 =283

Nursery Census
January May, 2010

Vital Statistics
Preterm Crude Birth Rate/ Prematurity Rate
Term Crude Birth Rate

Formula
No. of Preterm Deliveries/Total No. of Deliveries x1,000

In 1,000 population

7/283 x1,000

24.7

No. of Fullterm Deliveries/Total No. of Deliveries x1,000

276/283 x1,000

975.2

Preterm Crude Death Rate

Preterm Case Fatality Rate Perinatal Mortality Rate

No. of Preterm Deaths/Total No. of Deaths x1,000

No. of Preterm deaths/Total No. of Preterm Deliveries x1,000 No. of deaths [fetal death >28wk gest + death <7d]/Total No. of Live Births + No. of Fetal Deaths x1,000

7/7 x1,000
7/29 x1,000 3/283 x1,000

1,000
241.3 10.6

Total number of deliveries from January to May, 2010 =283

CAUSES OF PREMATURITY
January Infant of Diabetic Mother Severe Preeclampsia February Twin Pregnancy Preeclampsia March Chronic Hypertension Hyperthyroidism April Twin Pregnancy Infant of Diabetic Mother May Gestational Hypertension Premature Rupture of Membranes

Placenta previa totalis

Infant of Diabetic Mother

Premature Rupture of Membranes Hydrops Fetalis

Infant of Diabetic Mother

Twin Pregnancy

Premature Rupture of Membranes

Severe Preeclampsia

Tracheoesophageal fistulaesophageal atresia

Nursery Census
January May, 2010

Mode of Delivery
80 70 60 50 40 30 20 10 0
January Abdominal Vaginal Assisted Vaginal Spontaneous 17 1 41 Number of Deliveries

Februar y 25 1 41

March 23 2 28

April 25 0 25

May 18 0 36

Total number of deliveries from January to May, 2010 =283

INDICATIONS OF ABDOMINAL MODE OF DELIVERY

January Repeat CS February Nonreassurrin g Fetal Heart Rate Transverse Lie March Arrest of Cervical Dilatation Preeclampsiauncontrolled Repeat CS April Breech May Repeat CS

Arrest of Descent Severe Preeclampsia

Twin Pregnancy Protracted Labor

Nonreassuring Fetal Heart Rate Arrest of Descent

Twin Pregnancy

Transverse Lie

Repeat CS

Frank breech

Nonreassurrin g Fetal Heart Rate

Placenta previa Repeat CS Severe Preeclampsia

Failure of Induction

Placenta Previa Totalis

Cephalopelvic Disproportion; Big Baby

Nonreassuring Fetal Heart Rate

Nursery Census
January May, 2010

Gender of Neonates
80 70 60 50 40 30 20 10 0

Number of Deliveries

January Ambiguous 0 Female 25 Male 34

February 0 34 33

March 0 24 29

April 0 23 27

May 0 28 26

Total number of deliveries from January to May, 2010 =283

Nursery Census
January May, 2010

Number of Small-, Appropriate-, and Large for Gestational Age Deliveries

80 70 60 50 40 30 20 10 0 LGA AGA SGA Number of Deliveries

January 3 51 5

February 2 61 4

March 0 49 4

April 2 44 4

May 0 52 2

Total number of deliveries from January to May, 2010 =283

Nursery Census
January May, 2010

Distribution of Neonates According to Adequacy of Weight for Age

Preterm
N

Fullterm
% N 13 % 51.1

Postterm
N %

SGA

24.1

AGA
LGA

19
1

65.5
3.44

235
6

92.5
2.36

Neonatal Survival & Mortality According to Weight vs Pediatric Aging

January May, 2010

BW(gm)
<25
500 501-750 751-1000 1001-1250 1251-1500 1501-1750 1751-2000 2001-2500 2501-2750 2751-3000 3001-3500 3501-4000 >4000

Gestational Age (weeks)

26-27 28-29 30-31 32-33 34-35 36-37 38-40 41-42 >42

2 1 1 1 1 2

1
3 1

1
4 3 2 13 10

1
23 43 1

8(1)
1 4

71
63 8

1
8 3

Total number of deliveries from January to May, 2010 =283

Causes of Sepsis
Based on Culture Results January Blood CS: - Acinetobacter
lwoffii

February Blood CS:

-Staphylococcus auricularis (2) -Staphylococcus epidermidis (1)

March Blood CS:

-Enterobacter agglumerans

April Blood CS:

Staphylococcus epidermidis - Streptococcus heamolyticus - Gram (+) Cocci

May Blood CS: -Staphylococcus

epidermidis

Blood CS: - Klebsiella pneumoniae

TACS: Staphylococcus epidermidis

TACS:
- Staphylococcus epidermidis - Stenotrophomonas maltophilia -Enterobacter aerogenes

Eye Discharge CS:

- Enterococcus faecalis

Stool CS:
-Gram (+) Cocci -Escherichia coli

Nursery Census
January May, 2010

Mortality According to Postnatal Age

Preterm
N

Fullterm
N %

Postterm
N %

Early Neonatal Death <48 hrs >48 hrs 7 days Late Neonatal Death 7 -21 days 28 days
2 4 1

57 14.2

28.5

Mortality
January B. D.
46 days old

26wks, 650g, AGA, Cephalic, Neonatal Sepsis; Neonatal 1LTCS, AS2,3,7 Pneunomia; s/p Surfactant Instillation; s/p Intubation; s/pUmbilical Catheterization
Hydrops fetalis; Neonatal Sepsis,considered; s/p Intubation

Februar B. S. 29 wks, 2.3kg, LGA, 2hrs old Cephalic, 1LTCS, AS1,3 y March
B. S.
64hrs old

24-25wks, 600g, SGA, Cephalic, Hyaline Membrane Disease; 1LTCS, AS1,3,6, 1st of Twin Neonatal Sepsis; s/p Intubation 25wks, 450g, SGA, Transverse Lie, 1LTCS, AS0,2,3, 2nd of Twin Hyaline Membrane Disease; Neonatal Sepsis; s/p Intubation

B.S.
41hrs old

Mortality
March B. T.
54 days old

30wks, 1.55kg, AGA, Cephalic, Emergency CS, AS9,9

Tracheo-esophageal Fistula with Esophageal Atresia; Neonatal Sepsis; Neonatal Pneumonia; GERD gr4; Bronchopulmonary Dysplasia; s/p Open thoracotomy, ligation of Distal TEF, Tube Gastrostomy; s/p Open toracotomy, Primary Repair TEF-EA; s/p Tracheostomy; s/p IV Cutdown Neonatal Sepsis; Perinatal Asphyxia, Severe HypoxicIschemic Encephalopathy; Herniation syndrome, secondary; Intracranial Hemorrhage, considered Severe Hyaline Membrane Disease; Neonatal Sepsis,

B.E.
46 hrs old

33(36)wks, 3kg, LGA(AGA), Cephalic, Emergency CS, Thickly Meconium-Stained

April

G. Q 4hrs.

26-27wks, 725g, AGA, Cephalic, 1LTCS, AS8,9

Baby Boy E Newborn Male La Paz, Iloilo City

PRENATAL HISTORY:
2 days prior to delivery
(+) Decrease in fetal movement (-) Consult (-) Medication

Morning prior to admission

(+) further decrease in fetal movement
Consult Admission

Emergency Ceasarean Section

(Poor Fetal Variability)

NATAL/POSTNATAL HISTORY:
APGAR Score Criteria Color Mnemonic 0 1 2 Appearance All blue, palePink body, All pink
blue extremities

Heart rate

Pulse

Absent None

< 100 beats/min Grimace

> 100 beats/min Sneeze, cough

Reflex response Grimace to nasal catheter/tactile stimulation Muscle tone Activity Respiration Respiration

Limp

Absent

Some Active flexion of extremities Irregular, Good, crying slow

*A total score of 710 at 5 min is considered normal; 46, intermediate; and 03,
low.

1st Min= 0

NATAL/POSTNATAL HISTORY:
Thickly meconium stained, pale, limp and bradycardic
Tracheal aspiration minimal meconium aspirate

Limp and bradycardic

Tracheal intubation O2 at 10 lpm Continuous ambubagging

NATAL/POSTNATAL HISTORY:
APGAR Score Criteria Color Mnemonic 0 1 2 Appearance All blue, palePink body, All pink
blue extremities

APGAR Score 0 1 2
All blue, pale Pink body, blue All pink extremities

Heart rate

Pulse

Absent None

< 100 beats/min Grimace

> 100 beats/min Sneeze, cough

Absent

< 100 beats/min > 100 beats/min

Reflex response Grimace to nasal catheter/tactile stimulation Muscle tone Activity Respiration Respiration

None

Grimace

Sneeze, cough

Limp

Absent

Some Active Limp flexion of extremities Irregular, Good, crying Absent slow

Some flexion of Active extremities Irregular, slow Good, crying

*A total score of 710 at 5 min is considered normal; 46, intermediate; and 03,
low.

1st Min= 0

After 5 Min= 2

Admission to NICU

FAMILY HISTORY:
(-) Hypertension (-) Bronchial asthma (-) Diabetes mellitus (-) Food and Drug Allergy

PHYSICAL EXAMINATION:
Vital Signs: CR: 50140s RR: Continuous ambubagging at 60 cpm Temp: 35.8 36.4C Anthropometrics: Weight: 3 kg Length: 51 cm Head circumference: 37 cm Chest circumference: 31 cm Abdominal circumference: 31 cm

PHYSICAL EXAMINATION:
General survey:
Limp with poor muscle tone and activity, poor cry and pallor

Skin:
No petechiae, rashes or birth marks

HEENT:
Bulging and tense fontanels with alar flaring No caput succedaneum, molding or cephalhematoma No eye discharges No cleft lips, gums or palate

PHYSICAL EXAMINATION:
Chest:
No asymmetry or deformities Good air entry but with rales Normal cardiac rate and regular rhythm

Abdomen:
Globular, soft abdomen No masses or organomegaly noted Normoactive bowel sounds

Extremities:
Good peripheral pulses; No fractures noted

Anus:
Patent

NEUROLOGIC EXAMINATION:
GCS score/Best Response: 3 Cranial nerve: I- Not elicited II- 3-4mm pupils, isocoric, sluggishly reactive to light III, IV, VI- Not elicited V, VII- Absent corneal reflex, No facial asymmetry VIII- Not elicited IX, X- Absent gag reflex XI, XII- Not elicited Reflexes: Absent deep tendon reflexes Motors: Absent Meningeals: No meningeals Clonus: Negative

B A L L A R D S C O R E
17

ADMITTING IMPRESSION:
Preterm, 36 weeks by Ballard score, 3 kg birth weight, Large for Gestational Age, delivered Cephalic via Primary Ceasarean Section, Thickly meconium-stained

Early Neonatal Sepsis, considered

Perinatal Asphyxia, considered

Intubated Continuous ambubagging FiO2: 100% Minimal bloodRR: 60 cpm

streaked drainage O2 saturations: 97-98%

NPO
CBG q6 228mg/dL

CBC Day of Umbilical vein admission VBG Day of cannulation Hgb 5.7 admissio Hct 17.1 n D10W at 80cc/kg WBC 26.3 pH 7.438 NRBC 2 pCO2 18.1 Seg 66 pO2 58 Stb 22 HCO3 12.3 Lym 5 O2 sat 92.7 Eos 5 B.E. -9.6 Mon Meta 1 Myelo 1 Platelet 242 (m)

Blood Type A+

Chest x-ray: - Essentially negative cardio-pulmonary findings - s/p Endotracheal tube and orogastric tube insertion - X-ray of the abdomen is suggested for further evaluation

Ampicillin Ceftazidime

Limp
No spontaneous breathing

No spontaneous eye opening

O2 saturations: 99-100%

Blood-streaked vomitus

Prolonged bleeding on previous IV sites

Beginning jaundice up to the abdomen Blood-streaked vomitus Pupils 2-3 mm anisocoric, sluggishly reactive to light Flexion of toes Hypotonia

Protime CBC

Day VBG of7hrs Post- 7h Adm admission 7.438 transfusio 7.341 Clotting time pH 14.5se pCO2 c 18.1 n 21.7 Hgb 5.7 pO2 78%58 9.6 156 Prothrombin activity Hct 17.1 30.4 11.8 HCO3 12.3 INR O2 sat 1.33 18.9 99.4 WBC 26.3 92.7 NRBC 202 B.E. 39.4 -9.6 58 -13.1 APTT Seg 66 48 control Stb 22 32.5 16 Lym 5 28 Eos 5 1 Mon 4 Meta 1 3 Myelo 1 Cranial UTZ Platelet 242 (m) 192 (m)

Limp No spontaneous breathing No spontaneous eye opening Anisocoria (L-pinpoint;R-23mm) sluggishly reactive to Pediatric Neurologist light Hypotonic ..Severe Hypoxic-Ischemic
Encephalopathy..

O2 saturation: 99-100% Pale Tense fontanels Flexion of toes upon stimulation Brownish with blood streak secretion per OGT

..Herniation syndrome, secondary, t/c Intracranial Hemorrhage..

Phenobarbital standby

Limp Hypotonic No spontaneous breathing No spontaneous eye opening

24h S. electrolytes Na 130 K 3.4 Ca 1.41 BUN 5.72 Ca Crea 90.81 O2 saturation: 99-100% Glucona te Bilirubin Levels Deepening and Total Bilirubin 9.26 progression of jaundice Direct Bilirubin 0.81 up to the thighs Indirect Bilirubin 8.55

Limp Hypotonic No spontaneous breathing No spontaneous eye opening O2 saturation: 49-55% Bradycardia (CR: 7220bpm) Pallor Jaundice

Fundoscopic exam: (-) ROR Tortuous vessels with hemorrhages

D N R
BCS: No growth

Clinical Staging of Posthypoxic Encephalopathy

Factor Duration Level of consciousness Muscle tone Stage I (Mild) < 24 h Hyperalertness and irritability Normal Stage II (Moderate) Stage III (Severe) 214 days Hours to weeks Lethargy Deep stupor or coma Hypotonia or Flaccidity proximal limb weakness Increased Depressed or absent Present Absent Weak Incomplete Exaggerated Overreactive Absent Absent Absent Reduced or absent

Tendon reflexes Myoclonus Complex reflexes Sucking Moro response Grasping Oculocephalic (doll's eye)

Increased Present Active Exaggerated Normal to exaggerated Normal

Adapted from Sarnat HB, Sarnat MS: Neonatal encephalopathy following fetal distress. Archives of Neurology 33:696705, 1975.

Clinical Staging of Posthypoxic Encephalopathy

Factor Autonomic function Pupils Respiration Heart rate Seizures EEG Stage I (Mild) Stage II (Moderate) Stage III (Severe)

Dilated Regular Normal or tachycardic None Normal

Constricted Variable in rate and depth, periodic Low resting < 120 beats/min Common (70%) Low voltage, periodic or paroxysmal, epileptiform activity 5% 20%

Variable or fixed Irregular apnea Bradycardia Uncommon Periodic or isoelectric

Risk of death Risk of severe handicap

< 1% < 1%

> 60% > 70%

Adapted from Sarnat HB, Sarnat MS: Neonatal encephalopathy following fetal distress. Archives of Neurology 33:696705, 1975.

Final Diagnosis: Respiratory Failure Perinatal Asphyxia, Severe HypoxicIschemic Encephalopathy Herniation Syndrome, Secondary t/c Intracerebral Hemorrhage Preterm, LGA Sepsis, Early onset

(Adapted from Neonatal Resuscitation Textbook, ed. 5. American Academy of Pediatrics and American Heart Association, Appendix, p. 62, 2006.)

FIGURE 1. Algorithm for the suggested evaluation of a term newborn with hyperbilirubinemia. Information from jaundice and hyperbilirubinemia in the newborn. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of pediatrics. 16th ed. Philadelphia: Saunders, 2000:51128.