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Aside

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(Image courtesy of http://www.sciencedirect.com/science/article/pii/S0022346803008698)

During my training, I was lucky to witness a case of hydrops fetalis undergo a rare form of management done in our institution.

During the prenatal course, the obstetrician noted the baby to have hydrops fetalis. Serial ultrasound established the diagnosis and at the time the baby was nearing birth, the condition persisted.

As in my previous articles, hydrops means the generalized swelling of a fetus. The skin becomes edematous and very taut, disabling a good expansion of the chest when breathing. The pleural space, where the lungs float is also filled with fluids, compressing the lungs. So once the lungs becomes occupied by air after birth, there will be difficulty of the lungs to expand. The pericardial cavity, which the heart occupies, may also be fluid filled. Abdominal cavity may also contain fluid, termed ascites. At least 2 of these 3rd spaces must be involved before diagnosis could be entertained in an individual.

On the baby’s latest ultrasound, it was noted that the right lung has pleural effusion, the left lung was spared. In order to manage the baby optimally at birth, a pre-natal conference among all parties involved in the delivery of the baby was called – the perinatologist, neonatologist, and pediatric surgeon, to discuss how the delivery process will take place. At that time that this was done, the unang yakap was still in conception so it was not employed in this particular delivery.

The perinatologist wanted to employ EXITextrauterine intrapartum treatment. This means that the treatment will happen when the baby is out of the uterus but is still within the confines of the delivery procedure (umbilical cord remains uncut).

1.The baby was delivered via emergency section. He was brought out of the uterus, the umbilical cord still connected to the placenta.

2. The pediatric surgeon inserted a needled through the right pleural space, drained fluid as much. (The purpose of doing this is to allow maximum expansion of the lungs when it gets aerated; the fluid, if not evacuated, will limit the expansion of the lungs leading to poor tidal volume, lesser oxygenation of the blood, which will aggravate the already compromised baby).

3. Umbilical cord was then cut and baby was handed to the neonatology team.

4. Neonatologist then intubated the baby.

5. Chest x-ray was done to document the level of the tip of the endotracheal tube, check how much of the fluid was drained, and check how expanded the lung after the procedure.

In short, the procedure was successful. We were able to ventilate the baby afterwards. Baby however had other pressing problems, and as expected he when through persistent pulmonary hypertension, or persistent fetal circulation. PPHN or PFC usually results from a thickening of the walls of the arterioles/capillaries that surround the lung alveoli. Because of this thickness, oxygen travels slowly from the alveolar space into the bloodstream, thus leading to lesser oxygenation of the blood. PPHN can be primary (no identifiable cause) or secondary (a result or effect of another primary disorder). In this case, if the baby, who has hydrops fetalis, also has PPHN, it would only mean than the hydrops was a chronic disorder that it has affected the development of the lung tissue and vessels. If the PPHN was primary, then the arterioles and capillaries are thick to begin with, and there’s no way to reverse this anymore. If it is secondary, it means that the arterioles or capillaries have thinned out for postnatal life but then became thicker as a response to/result of an insult/injury. Despite proper ventilation and support given to the baby, he succumbed to PPHN after several days.

EXIT…?

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Swollen Misfortune

Recent PostsSwollen MisfortuneEarly Marriages, Adolescents and

via Swollen Misfortune.

 
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Posted by on May 31, 2012 in neonates, Pregnancy, Specific Disorders

 

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Swollen Misfortune

Few weeks ago, someone sent me an SMS seeking an appointment. She is a first-time pregnant woman who wants to discuss the results of her second ultrasound findings. She told me her baby was found out to have hydrops and she wants to hear my opinion. Well, that was kinda flattering, but the person she really needed to see is a perinatologist (an obstetrician who subspecialized on very problematic pregnancies, and this pregnancy is one example). Nevertheless, being a neonatologist myself, I may also be able to give her my piece, though on a limited span.

I saw her after few days, together with her mother, and before they sat, she handed me the ultrasound findings. It’s true, the baby was visualized to be hydropic (generalized swelling) on ultrasound. As I shifted my eyes from the ultrasound result to her face, she was already on the verge of tears. You can see there the longing to hear a different opinion, that perhaps the ultrasound result was erroneous, that the baby will still become normal eventually. But I am not someone who will nurture that false hopes she was brewing. I told her that a single ultrasound finding is not definitive. The baby has to be serially monitored and the best person to do this better be a perinatologist. She heeded and went straight to the perinatologist immediately after we ended our conversation.

Few days ago, while attending to the delivery of a baby whose placenta separated totally from the uterus, I was notified that the mother with a hydropic baby was scheduled for cesarean delivery at seven in the evening of the same day. I asked why the preterm termination of pregnancy, the resident reckoned the mother already began to have abdominal cramps (labor pains). This was the 26th week of pregnancy (panic mode alerted! Baby is extremely premature). If baby was premature, then there’s not much problem; if hydropic, there’s not much problem. But if you combine both prematurity and hydrops, that’s too much of a trouble. I almost swallowed my testicles that rushed up my throat upon hearing the news of imminent delivery later in the day.

The operation commenced. Upon opening the uterus, the amniotic fluid was so voluminous. This must be stretching the uterus beyond limits that prompted it to contract and expel the baby. After almost four liters of amniotic fluid was siphoned, the baby was next. The baby’s feet was first to be delivered. It looks big for a 26 weeks old baby, more like that of a 34 weeks. Then the body followed. There was almost difficulty of delivering the baby as the abdomen was too distended and tense, and so was the head. The skin was so taut from abdomen to the face, his lips were almost like a fish mouth in appearance. Generally, the baby looks like a victim of drowning. She was gasping for air. I immediately intubated her to assist her breathing as her chest will have difficulty in rising.

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I took picture of the baby and showed it to the mother as I can’t let baby have skin-to-skin contact with the mother, while the nurse rushed baby to the incubator at the adjacent nursery. I provided mechanical ventilatory support but the baby wasn’t improving much. I showed baby after attending to her immediate needs to her lola. I asked them to provide surfactant that may help baby get better, but they were reluctant as they think it is an extraordinary measure anymore to do heroic measures. They were already resigned that the baby will not make it; and if ever, will grow up impaired.

Maybe I was wrong to ever ask them to procure some medicine, or they were right all along not to continue providing baby’s needs. I did some work-ups to help me identify the probable cause of baby’s hydrops. Hydrops is usually called by a problematic baby’s heart. Because of it’s inability to pump blood well, the fluid gets retained and thus explains why the baby’s entire body swells, including body cavities damming up with fluids. Another most common cause of hydrops is anemia of severe degree. Because of anemia, the body lacks adequate oxygen delivery. Baby’s heart now have to work more than double time to cope up with the body’s demand (just like in a congestive heart failure), and likewise ending up generally swollen. For this particular baby, her blood work-up showed a very, marked anemia. I wish I could do further test and identify what could be the cause of the anemia but then I was limited. I could transfuse blood to reverse the condition, it could have been easy. But there was a major road block. Parents are Jehovah’s Witnesses. (Oh, I was doomed.., nothing further).

Five hours from birth, baby’s condition still never improved. Her heart already showed declining function… The heartbeat and oxygen saturation keeps on falling… her color started to turn darker… I asked them if they have some practice of baptizing baby or a minor before death, they said it was up to them to pray for the baby. I respected their religious view. Six hours from birth, baby finally succumbed.

 
 

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