Legaspi, Luis
Ontok, Abdul-Aziz
Payumo, Edelissa
Pelayo, May Angela
Rodriguez, Melissa
Samson, Edgardo
Baby Boy J.C.
• Full Term, 37 weeks by P.A.
• 2600 g, appropriate for G.A.
• Cephalic presentation
• Repeat low-segment C.S.
• 23 year old, G2P2
•
•
•
OB Index: G2P2 (2002)
Previous Pregnancy:
Date:
2007
Sex:
Male
BW:
2.7 kg
Place:
Perpetual Help Hospital
Delivery Type: 1o Low-segment C.S.
AOG:
Full Term
Complications: Cephalopelvic Disroportion
•
LMP: September 04, 2008
•
Prenatal Checkups: 2 at PGH
•
Medications Taken: None
•
Illnesses/Infection: None
•
Alcohol/Tobacco Use: None
•
Onset of Uterine Activity: Spontaneous
•
Intensity of Contractions: Moderate
•
Membrane Status: Intact
•
Analgesia: None
•
Mode: Abdominal
•
Amniotic Fluid: Slightly Meconium Stained
•
Analgesia: Subarachnoid Block
(+) grimace, HR 50’s,
acrocyanotic, some
flexion
• Thermoregulation
• Suctioning
• Tactile stimulation
• Thermoregulation
• Suctioning
• Tactile stimulation
• PPV
Some flexion, HR 100,
(+) grunting, (+)
grimace, acrocyanotic
(+) crying,
acrocyanotic, active,
HR 130s, RR 50-60
• Given blow by O2
• Stimulation
• Thermoregulation
• Weaned off from
O2
(+) grunting, (+
retractions
•
•
APGAR Score: 5, 9
Resuscitation:
 Supplementary O2 10 LPM via hood
 Positive Pressure-Ventilation
•
(-) Hypertension
•
(-) Diabetes Mellitus
•
(-) Bronchial Asthma
•
(-) Blood Dyscrasias
•
GENERAL APPEARANCE:
limp, in respiratory distress
•
VITAL SIGNS:
T: 36.6oC
HR: 130 bpm RR: 50 cpm
Wt: 2600 g Lt: 49 cm
HC: 32.5 cm
CC: 31 cm AC: 28 cm
•
SKIN:
acrocyanotic, (-) lesions, (+) cracking, rare veins
•
HEAD:
(-) molding, (-) cephalhematoma, both fontanels flat
and soft, (-) overlapping sutures, BT: 8cm, BP:
9cm, SOB: 9cm, OF: 10.5cm, OM: 11.5cm
•
EYES:
(-) discharges, anicteric sclerae, both pupils equally
reactive to light
•
EARS:
(-) low-set ears, formed, firm with instant recoil
•
MOUTH:
(-) circumoral cyanosis, (-) cleft lip, formed tongue,
(-) cleft palate
•
CHEST/LUNGS:
barrel-shaped, (+) subcostal & intercostal retractions, raised
areola with 3-4 mm bud, (+) grunting, (-) tachypnea
•
HEART:
adynamic precordium, (-) thrills, normal rate, regular
rhythm, (-) murmur
•
ABDOMEN:
globular but not distended, nonpalpable liver
•
UMBILICUS:
translucent, (-) meconium stained, 2 arteries & 1 vein
•
BACK:
lanugo with bald areas, (-) dimpling, straight spine
•
GENITALIA:
both testes descended, scrotum with good rugae
•
ANUS:
patent, (+) passage of meconium
•
EXTREMITIES:
(-) polydactyly, (-) hip dislocation, plantar crease over
anterior 2/3, equally strong & palpable pulses
•
NEUROLOGIC EXAM:
(+) moro reflex, (+) sucking reflex, (+) grasping reflex
•
Meconium Pneumonitis
•
Full term 37 weeks by PA 2600 grams
AGA cephalic presentation delivered
by repeat LSCS, AS 5,9
(+) history of meconium staining
 baby received non-vigorous, HR
60s, poor muscle tone, with no
response
 (+) tachypnea
 (+) grunting
 (+) retractions

Differential
Rule-in
Rule-out
Hyaline Membrane Disease
(+)tachypnea
(+) grunting
(+)retractions
-rare in term neonates
-mother not GDM
-worsens / peaks at 48-36
hours
Transient Tachypnea of the
Newborn
-usually follows uneventful
normal FT SVD or cesarean
section
-cyanosis relieved by
minimal 02
-with rapid recovery in 3
days
-PE: lungs clear w/o rales or
rhonchi
-benign, self-limited course
-Early onset tachypnea with
or without retractions
(+) expiratory grunting
Neonatal Pneumonia
(+)tachypnea
(+) grunting
(+)retractions
(+) cyanosis
Pre-natal history
suggests infection
-usually predisposed by
pre-mature labor, PROM,
increased IE
-CBC usually:
neutropenia, leukocytosis
-cannot be fully ruled-out
Meconium Aspiration
Syndrome
(+) history of
meconium staining
-baby received nonvigorous, HR 60s, poor
muscle tone, with no
response
(+)tachypnea
(+) grunting
(+)retractions
-cannot be fully ruledout
Neonatal Sepsis
Respiratory distress
Cannot be fully ruled
•
Born at PGH Nursery on May 7,
2009 with APGAR score 5, 9
•
Started on Piperacillin-Tazobactam
(75mkd) 195 mg IV q12
Started on Amikacin (15mkd) 40 mg
IV OD
•
Piptazo
Combination antibiotic
containing the extendedspectrum penicillin and
the B-lactamase inhibitor
tazobactam
Amik
An aminoglycoside With
synergistic effect with Blactams
•
Labs:
• CBC with PC
• Blood typing
• ABG
•
•
•
Na, K, Cl, Ca,
CXR APL
Blood C/S
Venoclysis started with D10W (80) @
9cc/hr
NPO, Hgt q8
O2 support at 10 lpm/hood
NICU
•
Admitted at NICU 3 on May 7, 2009
•
Received with fair pulses BP 30-40/20’s
•
Given total of 50 cc/kg PNSS IV bolus, BP
improved to 40-50/30’s but still with fair pulses
•
Started on Dopamine @ 10mcg/kg/min to run
for 1cc/hour (Dopamine 0.9cc + D5W 23.1cc)
•
UVC inserted
50 cc/kg PNSS IV bolus
To increase BP
Dopamine @ 10mcg/kg/min
Maintenance bp
to run for 1cc/hour (Dopamine
0.9cc + D5W 23.1cc)
•
•
•
•
•
Due to persistent desaturation (O2 sats
80’s), patient intubated with MV settings
100%, 18/3, RR 60 LT 0.4
O2 sats improved to 98-100%
ABGs ordered
D10W increased to run for 10 cc/hour
STAT NaHCO3 5 meqs given
NaHCO3 5 meqs
To counteract metabolic
acidosis
MV settings 100%, 18/3, RR 60 ?
LT 0.4
05/07/09
hood
23:10
100% O2
pH
7.189

pCO2
51.20

pO2
76.00

HCO3
19.80

BEb
-8.2
O2sat
91.40%
Respiratory Acidosis
Decrease Ventilation
Hypoxemia
ABG
05/08/09
0.4
00:18
S/P INTUBATION 100%
18/3
pH
7.252

pCO2
39.70
N
pO2
188.00
HCO3
17.70
BEb
-8.5
O2sat
99.50%
 Metabolic Acidosis
NaHCO3 5 meqs

60
ABG
05/08/09
60 0.4
06:51
AFTER CORRECTION
100%
pH
7.407
N
pCO2
28.00

pO2
146.00
HCO3
17.80
BEb
-5
O2sat
99.30%

18/3
Component
05/07/09
Reference Range
Unit
WBC
5.56
5.0 – 30.0
X109/L
RBC
3.74
4.0 – 6.0
X1012/L
HGB
129
120-180
g/L
HCT
0.386
0.370 – 0.540
MCV
103.2
80.0 – 100.0
Fl
MCH
34.5
27.0 – 31.0
Pg
MCHC
334
320 – 360
g/L
RDW
17.2
11.0 – 16.0
%
Platelet
227
150 – 450
X109/L
NRBC
2/100
Complete Blood Count
Component
05/07/09
Reference Range
Unit
Neutrophil
0.697
0.500 – 0.700
%
Lymphocyte
0.182
0.200 – 0.500
%
Monocyte
0.101
0.020 – 0.090
%
Eosinophil
0.016
0.000 – 0.060
%
Basophils
0.004
0.000 – 0.020
%
Stab
Metamyelocyt
e
Myelocyte
Promyelocyte
Blast
Atypical
Lymphocyte
%
Test
05/09/09
05/12/09
Units
Normal
Values
Calcium
1.60
1.92
mmol/L
2.12 –
2.52
Sodium
143
140
mmol/L
136.00 –
145.00
Potassiu
m
3.9
4.3
mmol/L
3.50 –
5.10
Chloride
108
106
mmol/L
98.00 –
107.00
•
PWI: FT 37 weeks PA, 2600g, AGA,
ceph, repeat LSCS, LBB, AS 5,9;
Neonatal Pneumonia vs MAS; PPHN
precaution r/o sepsis
•
MV settings maintained
•
IVF shifted to D10IMB Ca 300 @
10cc/hr
D10IMB Ca 300 @ 10cc/hr
To correct hypocalcemia
•
Decrease RR to 50 then decrease by 2
q2 until 30
•
Decrease FiO2 by 5 q2 until 60%
ABG
05/08/09
17:00 100%
18/3
pH
7.468
pCO2
14.40
pO2
191.00
HCO3
10.50
BEb
-9.8
O2sat
99.80%
60 0.4
Dec. RR to 50  then dec by 2 O2 til
30
Dec.. FiO2 by 5 O2 til 60%
Pneumonia, both inner lung zones
•
MV setting at 80%, 18/3, 44, 0.4
•
ABGs ordered
•
Once FiO2 60%, may start feeding
with 5cc EBM q3/OGT with SAP
•
•
•
•
•
Start feeding 5cc EBM as ordered, if
tolerated 3x, start increments:
increase 5cc every feeding until 30cc
MV setting: 60% 18/5 26 0.4
Wean FiO2 by 5 q2 til 21%
Wean RR by 2 q2 til 10
Extract ABGs at RR=10
ABG
05/09/09
44 0.4
09:32
WEANING
80%
pH
7.360
pCO2
32.70
pO2
149.00
HCO3
18.40
BEb
-5.1
O2sat
99.20%
18/3
•
Prepare for extubation
•
Prepare O2 hood FiO2 30%
•
MV settings at 21%, 18/3, 14, 0.4
•
Revise inotropes: Dopamine 0.5cc +
D5W 23.5 cc to run at 1cc/hour then
consume then discontinue
•
S/P Extubation
•
Placed on O2 hood FiO2 30%
•
Racemic epinephrine nebulization
started to continue 2 more doses
15 minutes apart
•
Patient noted to be jaundiced up to
thighs
•
For TB DB IB
•
Increase feeding to 35cc q3/OGT
•
•
•
•
•
•
For CPT with proper shields
Dopamine discontinued
NCPAP 30% PEEP 5
ABGs
Noted vomiting with feeding;
abdomen soft but distended
Feeding decreased to 30cc
ABG
05/11/09
04:13
S/P EXTUBATION
30%
pH
7.324
N
pCO2
38.60
N
pO2
84.00
HCO3
20.30
BEb
-4.7
O2sat
95.60%
Maintain now
N
•
•
•
•
Increased feeding to 35cc
TB DB IB noted
Maintained on phototherapy
PWI: FT 37 wks by PA, 2600 g, AGA,
cephalic, delivered via primary LSCS,
LBG, AS 5,9; Neonatal pneumonia;
Hyperbilirubinemia no set-up
Test 05/11/09 05/12/0 Units
9
TB
16.1
14.6
umol/L
DB
IB
0
16.1
0.0
14.6
Normal Values
17.00 – 180.00
umol/L 0.00 – 10.00
umol/L 10.00 – 180.00
•
13cc of feeding residual noted; no
abdominal distention
•
Feeding deferred
•
Wean FiO2 by 5 q2 until 21%
•
Coffee-ground noted
•
NPO
•
Start Famotidine 1mg IV q12
•
Give Vit K 2mg slow IV push
•
ABGs ordered at 25% PEEP 5
ABG
05/11/09
17:00 25%
18/3
pH
pCO2
60 0.4
7.329
40.80
pO2
68
HCO3
21.80
BEb
-3.5
O2sat
92.40
Atelectasis, Right Upper Lobe
Atelectasis/Consolidation, Medial Segment of R Lower
Lobe
•
PWI: FT, 37 wks by PA, 2600g, AGA,
cephalic, rpt LSCS, LBG, AS 5,9;
neonatal pneumonia;
hyperbilirubinemia with no set-up; rule
out nosocomial sepsis
•
Still with jaundice and coffee ground
material
•
•
•
•
•
For repeat CBC with PC, blood CS,
eletrolytes
To start Ceftazidime (50mkd) 130mg IV
q12h
NPO
IVF revised to: D10IMB Ca 400 @ 13cc/hr
Please put patient on right side up
Complete Blood Count
Compone
nt
05/07/09
05/12/09
Reference
Range
Unit
WBC
5.56
24.42
5.0 – 30.0
X109/L
RBC
3.74
3.66
4.0 – 6.0
X1012/L
HGB
129
122
120-180
g/L
HCT
0.386
0.358
0.370 – 0.540
MCV
103.2
97.8
80.0 – 100.0
Fl
MCH
34.5
33.3
27.0 – 31.0
Pg
MCHC
334
341
320 – 360
g/L
RDW
17.2
17.3
11.0 – 16.0
%
Platelet
227
142
150 – 450
X109/L
NRBC
2/100
1
Complete Blood Count
Component 05/07/09
05/12/09
Reference
Range
Unit
Neutrophil
0.697
0.77
0.500 – 0.700
%
Lymphocyt
e
0.182
.07
0.200 – 0.500
%
Monocyte
0.101
0.10
0.020 – 0.090
%
Eosinophil
0.016
0.006
0.000 – 0.060
%
Basophils
0.004
0.000 – 0.020
%
Stab
Metamyelo
cyte
Myelocyte
Promyelocy
te
Blast
Atypical
%
Meconium-stained amniotic fluid may be
aspirated during labor and delivery,
causing neonatal respiratory distress.
Because meconium is rarely found in the
amniotic fluid prior to 34 weeks'
gestation, meconium aspiration chiefly
affects infants at term and postterm.
3 major constituents of meconium:
1. Intestinal secretions
2. mucosal cells
3. solid elements of swallowed amniotic
fluid are the 3 major solid constituents
of meconium.
Water - major liquid constituent, (8595%)
Factors that promote meconium passage in
utero include:
•
placental insufficiency,
•
maternal hypertension,
•
preeclampsia,
•
oligohydramnios, and
•
maternal drug abuse, especially of
tobacco and cocaine.
In utero meconium passage results from
neural stimulation of a mature GI tract
and usually results from fetal hypoxic
stress. As the fetus approaches term,
the GI tract matures, and vagal
stimulation from head or cord
compression may cause peristalsis and
relaxation of the rectal sphincter leading
to meconium passage.
Meconium directly alters the amniotic
fluid, reducing antibacterial activity and
subsequently increasing the risk of
perinatal bacterial infection.
Meconium is irritating to fetal skin, thus
increasing the incidence of erythema
toxicum.
However, the most severe complication
of meconium passage in utero is
aspiration of stained amniotic fluid
before, during, and after birth.
Aspiration induces hypoxia via 4 major
pulmonary effects:
1. airway obstruction
2. surfactant dysfunction
3. chemical pneumonitis
1. Airway obstruction
Complete obstruction - atelectasis.
Partial obstruction - ball-valve effect.
Hyperdistention
of the alveoli occurs
from airway expansion during inhalation
and airway collapse around inspissated
meconium in the airway, causing
increased resistance during exhalation.
2. Surfactant dysfunction
free fatty acids of the meconium (eg,
palmitic, stearic, oleic), have a higher
minimal surface tension than surfactant
Meconium strip it from the alveolar
surface, resulting in diffuse atelectasis.
3. Chemical pneumonitis
Enzymes, bile salts, and fats in
meconium irritate the airways and
parenchyma, causing a release of
cytokines
results in a diffuse pneumonia that may
begin within a few hours of aspiration.
Presence of meconium in amniotic fluid is
required to cause meconium aspiration
syndrome (MAS), but not all neonates with
meconium-stained fluid develop meconium
aspiration syndrome. The presence of thick
particulate meconium in the amnionic fluid
increases the likelihood of prenatal aspiration.
Green urine may be observed in newborns with
meconium aspiration syndrome less than 24
hours after birth. Meconium pigments can be
absorbed by the lung and can be excreted in
urine.
•Cyanosis
•End-expiratory grunting
•Alar flaring
•Intercostal retractions
•Tachypnea
•Barrel chest in the presence of air trapping
•Auscultated rales and rhonchi (in some cases)
•Yellow-green staining of fingernails, umbilical
cord, and skin may be observed.
– Placental insufficiency
– Maternal hypertension
– Preeclampsia
– Oligohydramnios
– Maternal drug abuse, especially of tobacco and
cocaine
– Maternal infection/chorioamnionitis
– Fetal gasping secondary to hypoxia
– Inadequate removal of meconium from the airway
prior to the first breath
– Use of positive pressure ventilation (PPV) prior to
clearing the airway of meconium
Acid-base status
• Metabolic acidosis from perinatal stress is
complicated by respiratory acidosis from
parenchymal disease and persistent pulmonary
hypertension of the newborn (PPHN).
• ABG measurement of pH, partial pressure of
carbon dioxide (pCO2), partial pressure of
oxygen (pO2), and continuous measurement of
oxygenation by pulse oximetry are necessary for
appropriate management.
Serum electrolytes:
Obtain sodium, potassium, and calcium
concentrations when the infant with MAS
aged 24 hours because the
syndrome of inappropriate secretion of
antidiuretic hormone (SIADH) and
acute renal failure are frequent
complications of perinatal stress.
CBC count
• In utero or perinatal blood loss, as well as
infection, contributes to postnatal stress.
• Hemoglobin and hematocrit levels must be
sufficient to ensure adequate oxygen-carrying
capacity.
• Neutropenia or neutrophilia with left shift of the
differential may indicate perinatal bacterial
infection.
gross overaeration of the lungs and
bilateral nodular infiltrates
 The nodular infiltrates represent areas
of patchy or focal alveolar atelectasis
and the overaerated spaces in
between, compensatroy, focal alveolar
overdistension

When aspiration occurs, intubation and
immediate suctioning (tracheal
suctioning) of the airway can remove
much of the aspirated meconium
No clinical trials justify suctioning based
on the consistency of meconium. Do not
perform the following harmful
techniques in an attempt to prevent
aspiration of meconium-stained
amniotic fluid:
• Squeezing the chest of the baby
• Inserting a finger into the mouth of the baby
The American Academy of Pediatrics Neonatal
Resuscitation Program Steering Committee
 If the baby is not vigorous (defined as minimal or absent
respiratory effort, poor muscle tone, or heart rate <100
beats/min):
 Use direct laryngoscopy, intubate, and suction the trachea
immediately after delivery.
 Suction for no longer than 5 seconds.
 If no meconium is retrieved, do not repeat intubation and
suction.
 If meconium is retrieved and no bradycardia is present,
reintubate and suction.
 If the heart rate is low, administer positive pressure ventilation
and consider suctioning again later.
 If the baby is vigorous (defined as good respiratory
effort, crying, good muscle tone, and heart rate >100
beats/min):
 Do not electively intubate.
 Clear secretions and meconium from the mouth and nose
with a bulb syringe or a large-bore suction catheter.
 In either case: The remainder of the initial
resuscitation steps should ensue and include drying,
stimulating, repositioning, and administering oxygen
as necessary.
• Maintain an optimal thermal environment
• Minimal handling
• Sedation - to decrease agitation
• Continue respiratory care. Oxygen therapy via hood
or positive pressure is crucial in maintaining
adequate arterial oxygenation. If mechanical
ventilation is required, make concerted efforts to
minimize the mean airway pressure and to use as
short an inspiratory time as possible. Oxygen
saturations should be maintained at 90-95%.
• Surfactant therapy
• For treatment of persistent pulmonary hypertension of
the newborn (PPHN), inhaled nitric oxide is the pulmonary
vasodilator of choice
• Pay careful attention to systemic blood volume and blood
pressure. Volume expansion, transfusion therapy, and
systemic vasopressors are critical in maintaining
systemic blood pressure greater than pulmonary blood
pressure, thereby decreasing the right-to-left shunt
through the patent ductus arteriosus.
1.
2.
chronic lung disease
infections
Most with complete recovery of pulmonary
function
Intrapartum events initiating the meconium
passage may cause the infant to have longterm neurologic deficits:
 CNS damage,
 seizures,
 mental retardation, and
 cerebral palsy.
 Yellow
color usually results from
accumulation of unconjugated,
nonpolar, lipid-soluble bilirubin
pigment in the skin
 May be due in part to deposition of
pigment from conjugated bilirubin
 Elevated levels of indirect,
unconjugated bilirubin potentially
neurotoxic
 Unconjugated hyperbilirubinemia factors:
 Increase load of bilirubin to be metabolized
by liver
 Hemolytic anemia, polycythemia, shortened red
cell life, increased enterohepatic circulation,
infection

Damaged or reduced the activity of the
transferase enzyme or other related
enzymes
 Genetic deficiency, hypoxia, infection, thyroid
deficiency


Blocked transferase enzyme
Absence or decreased amounts of enzyme
or reduced bilirubin uptake by liver cells
 Genetic defect, prematurity
 Jaundice
appearing after the 3rd day
and within the 1st week suggests
bacterial sepsis or urinary tract
infection
 Other causes: syphilis, toxoplasmosis,
CMV, enterovirus
 Regardless
of the cause, goal of
therapy is to prevent indirect-reacting
bilirubin related neurotoxicity
 Tx: phototherapy and exchange
therapy
THANK YOU!