Health Сare Committee
Saint-Petersburg's city executive board
State Health Care Institution
Children's City Hospital #1
198205, 14 Avangardnaya Str., Saint-Petersburg
Tel: 735-16-91; fax 735-99-98, e-mail: offica@dgb.spb.ru
Health Certificate # 0302241
Case report # 204
Blood type A2(II)Rh+
BCG-M – no
Inoculation against hepatitis – no
Neonatal screening – January 23, 2012
Daniil Ustinov, date of birth – January 4, 2012 was in departments number 39 and 10
(department of neonatal resuscitation and pathology) from January 6, 2012 to May 5, 2012 with
the following diagnosis:
Gestation: 26/27 weeks. ELBW.
Infantile asphyxia.
Subependymal hemorrhage, intraventricular hemorrhage 1.
Necrotizing enterocolitis.
Ileal stenosis, obturative intestinal obstruction.
Cholestasis syndrome.
I type respiratory distress syndrome.
Patent ductus arteriosus.
New form of bronchopulmonary dysplasia, chronization period, moderately grave disease
course, respiratory failure 0-1.
Retinopathy of prematurity, 0-1 degree.
Premature babies anemia.
Surgery:
January 11, 2012. Closure of ductus arteriosus.
January 18, 2012. Resection of the part of small intestine, double enterostomy.
March 23, 2012. Perianal fistula closure.
Anamnesis: Mother is 26 years old. Blood group A(II) Rh+.
Complications from pregnancy on the background of the chronic pyelonephritis, biliary dyskinesia, chronic
gastritis, vegetative-vascular dystonia (a hypotonic type).
First labor, at the 26/27 week of gestation. Breech presentation.
First period- 2h 30m, second period- 5m, 5m
The Apgar score-3/5
Сritically ill patient since postnatal state due to the respiratory distress, dismaturity and prematurity.
Intubation and mechanical ventilation was performed immediately. Curosurf was injected via the
endotracheal tube.
Stable hemodynamics. Enteral tube feeding.
Tests without any significant features.
Receiving treatment: intravenous therapy, antibiotic injection (ampicillin, gentamicin), vikasolum.
The patient was transferred to the intensive therapy unit of a City Children's Hospital No.1 in 3 days after
delivery.
At the admission to the hospital there was irregular atelectasis in the X-ray image.
Bronchogram. Significantly reduced pneumatization of the intestinal loops.
Additionally injected one more dose of the Curosurf via the endotracheal tube.
Heart US: patent ductus arteriosus, with left-right flow.
Head scan: Subependymal hemorrhage- IVH1, Periventricular leukomalacia.
At the 7th day ductus arteriosus flow remains current, it is hemodynamically significant.
At the 8th day was carried out surgical ductus arteriosus closure.
Staging mechanical ventilation.
Since the admission to the hospital patient has not been fed.
To the 10th day gastric retention and stool retention appeared.
Contrast X-ray examination and surgeon examination were performed.
Acute surgical pathology excluded. Course of the necrotizing enterocolitis. Follow up of the patient.
To the 15th day stool retention remained, mild abdominal distention presented.
At the check X-ray examination, the contrast medium was in the extended intestinal loops.
Medical report: obturation intestinal obstruction. The surgical interference is urgent.
January 18, 2012 (15th day) Laparotomy was undertaken. Stenosis of the ileum terminal portion with thick
intestinal discharges was revealed at the surgical interference.
Intestine is extended above the stenosis. The patient underwent resection of 6 cm. And double enterestomy
was placed at 5 cm from ileocecal angle.
Histology: The gut wall is formed correctly.
The bowel movement passed via the stoma to the third day after surgery.
Erythropoietin (minimum dose) was used after 19 days of delivery. The bowel movement passed through
the stoma was thick. Neurosonography was without decline.
Extubation attempts were made at 24th day, but failed. Re-intubation was performed.
By first month of the neonatal period: weight – 993
Slow growth of Erythropoietin dose.
O2 addiction. A series of X-ray examination revealed atelectasis diffuse decrease.
Final extubation was made in the first month 5d after delivery. The patient transferred to the non-invasive
ventilation. Also apneic spells were registered. From the first month 10d was transferred to O2 funnel.
Enteral nutrition is almost complete.
Neurosonography: IVH resorption was done without CSF circulation damage.
Examined by ophthalmologist: PH 1-2 degree.
By the second month of the neonatal period: weight – 1240, head size – 29cm, chest volume – 14cm.
Since the admission to the hospital, in the blood examination significant inflammatory changes with improvement
have been revealed.
The maximum bilirubin amounted 191, with the cholestasis growing (direct bilirubin, enzymes increase).
Intensive care treatment: intubation of trachea, PT, PN, antibiotic therapy (ampicillin + gentamicin, meronem,
vancomycin, ciplox, amikacin, diflucan), diuretics, euphyllinum, instenon, proserinum, inhalation with berodual +
budesonidum. Hemotransfusion A(II)Rh+#5
At the age of 2 months and 4 days the child was transferred to the Department of Neonatal Pathology.
Infant’s condition at the department is severe, relatively stable. Moderate oxygen dependency.
According to chest X-Ray, airiness of lungs improved.
Unable to increase enteral feeding volume because of periodic abdominal distention and hard stool coming from
the stoma.
Retinopathy without disease progression.
Neurosonography: post-hypoxic ventricular dilatation.
Against the background of a stable condition at the age of 2 months and 19 days – enterostomy closure. Terminal
parts coming to stoma were resected, direct anastomosis performed.
Extubated in 3 days after surgery, cannulas applied, oxygen funnel then.
Defecation in three days after surgery. Enteral feeding started in 6 days after surgery. Antibiotic therapy
intensified because of paraclinical changes increase.
In 10 days after surgery returned to the department.
Stable condition at the department. Oxygen independent. Feeding volume increased. Improvement according to
laboratory tests.
By 3 months: weight = 1740 gr, head circumference = 30.5 cm, chest circumference = 26.5 cm.
By 4 months feeding volume was continuously increased, sucks partially. Hydrops syndrome with
hypoproteinemia.
At 3 months and 6 days hemotransfusion A(II)Rh+ for the purpose of substitution.
At 3 months and 7 days without intubation of trahea.
Chest X-Ray: bronchopulmonary dysplasia.
Since 3 months and days 13 –no antibiotic therapy.
Cholestasis and Hydrops syndrome diminish. Weight curve positive.
Oculist: process stabilization.
By 4 months: weight = 2310 gr, head circumference = 33.5 cm, chest circumference = 29.5 cm.
Additional tests:
1. NSG: brain is structured. MS =36, MD=37, Vld=14, Vlg=10, V3 =2. DCM 2-3mm. Liquor flows
are free.
2. Ultrasound of abdomen, kidneys: No organic pathology, diffuse liver parenchymal change
3. Ophtalmologist: (RetCam.) Retinopathy of prematurity (ROP) I-II stage, active phase (180С).
4. Audio screening: otoacoustic emission was not detected.
5. Chest X-ray (control as of May 2): lungs hyperinflation, lung pattern increase.
6. Blood Test as of May 3:
НBG 106, RBC 3.86, WBC. 6.2. NE 25. EOS 2. MON 11. LYM 59, PLT 321.
7. Urine and feces analysis - normal.
8. Feces cultures for dysentery organisms and EPEC(enteropathogenic e.coli) - negative.
9. Biochemical blood test: ALT-35, AST-66, Billirubin 22-7-15, BUN-2, К-5.2, Na-136, Са-1.27, Glucose
3.7.
10. Sulkovich test: 2.
Treatment: ( #10 dept.)
1.
2.
3.
4.
5.
6.
7.
8.
Antibacterial therapy: sulperacef, amikacin, ciplox, diflucan.
Infusion therapy.
Verospiron,
Dicynone.
Ursofalk.
Aquadetrim, polyvitamins, maltofer.
Inhalations: berodual + budesonidum.
Physiatrics, massage.
Was discharged at the age of 4 months and 1 day with the weight of 2310 g.
Condition is satisfactory. Sucks from feeding bottle, severe aerophagy. Belches from time to
time. Moderate weight gain.
Fixes eyes, follows, laud sound reaction “+”. Muscle tone and reflexes are in accordance
with gestation term.
Rosy skin. Heart sounds rhythmic loud clear at rate 140 bpm.
No rales, rough respiration, respiratory rate 60 per minute. Abdomen soft, a little swelled.
Liver 2 sm. spleen “edge”. Stool is yellow-green, almost always after stimulation. Testicles in
scrotum. Scrotal hydrocele. Penile edema. Profuse urination.
Recommendations:
1.
2.
3.
4.
Follow-up with pediatrician, neurologist.
Feeding with “Humana MCT” + “Alfare” (1:1) 60 ml 7-8 times a day.
Weight gain control.
Orally: -ursofalk 1 ml (2 weeks);
- polyvitamins 1 powder 2 times a day (for 1 month), (prescription handed);
-maltofer 3 drops 1 time a day (for 1 month);
-aquadetrim 1 drop 1 time a day under Sulkovich test control.
5. Inhalations: berodual 2 drops+ budesonidum 250 mcg- 1 ml 0.9% NaCl 2 times a day
(for 1 month).
6. Pulmonologist examination in a month + chest X-Ray. Policlinic department of
Raukhfus Hospital. +7(812)717-25-04. +7(812)717-25-04. Starevskaya S.V.
7. Neurologist examination in a month - NSG.
8. Surgeon examination in a month. Children's City Hospital #1. O.N. Novopoltseva
9. Orthopaedist at 5-6 months with Ultrasound of hip joints.
10. .Ophtalmologist after 2weeks. Policlinics of Children's City Hospital #1.
11. Ultrasound of abdomen and kidneys in 2 months.
12. Vaccination cancelled for two months.
May 5, 2012
Tel. (10 dept.) 735 90 03
No quarantine in the department.
Head of Department – O.A. Solovieva ~
Pediatrist – I.S. Sorokina
Surgeon – O.N. Novopoltseva