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Ooops!

I was once called for a referral. A few days old preterm baby having seizures that occurred within the first few hours of life. Baby was having seizures despite the anti-convulsant that was already given. The baby was already referred to a neurologist before I stepped into the picture. Baby was worked up and his electrolytes showed low sodium (112). (The normal level is 135 – 145; if the value is lower than 135, that’s considered hyponatremia. If value is less than 125, baby can have seizure that will not be controlled by anticonvulsant until the problem is corrected). In this case, it seems the most likely cause of seizure was identified. Thus, the immediate thing for me to do was to correct this abnormality and hope that it will eventually stop the seizures.

So after 48 hours, the sodium level was already raised to near normal. The good thing was, seizure already stopped. So I guess the baby’s urgent problem was resolved.

The question that bothered us was, why did the baby have severe hyponatremia? It is a rule of thumb that the electrolyte picture of a baby within 48hrs from birth generally reflects that of the mother. Unless that baby also has a congenital abnormality such as in cases of congenital adrenal hyperplasia (CAH). The baby in this case did not have physical signs highly suggestive of CAH, and the newborn screening eventually was normal, so this as the cause was easily ruled out. So, this made me then thought of the mother’s electrolyte status.

I interviewed the mother when she visited her baby at the NICU. I asked her if she was on prolonged intravenous fluid administration, if she was taking medications. She revealed she was on prolonged furosemide “maintenance.” This was given by an internist she consulted. BINGO! Seems I nailed the culprit with mere few questions. So I went on further with my interview. I asked why was she on prolonged furosemide intake. She said, she consulted the internist because she had edema (swelling) of both her lower legs. I further asked, “at what months of pregnancy did she notice the onset of edema, of hypertension. She did not know she was pregnant then when she had that consultation. Then my next question was, “is your menstrual cycle irregular?” And she replied YES! I was then flabbergasted and felt sorry for the mother, most especially for the baby. Why?

Let me reconstruct the story for a clearer understanding. Here was a woman with irregular menstrual cycle. She became pregnant but was not able to realize it because of her irregular schedule. Then later in the pregnancy, she developed edema of both lower extremities. She consulted an internist because of the latter, who also incidentally discovered she was hypertensive. The internist did not know the patient was pregnant; he did not do pregnancy test nor abdominal ultrasound. Pregnancy was remote from his consideration, thus he did not do these tesst… even if the woman was already showing signs of PREECLAMPSIA. So he gave furosemide. But since the edema was unresolving, she kept on taking the drugs. Few days ago, she was having abdominal pain. She saw another doctor, an OB-Gyn, who requested for an ultrasound. HALLELUJAH of all hallelujahs, she was indeed PREGNANT. And since her blood pressure remained uncontrolled, she was scheduled for emergency CS delivery. Since she was on prolonged furosemide intake, aside from it removing water from the body, furosemide also eliminates electrolytes like sodium and potassium. Since she was already hyponatremic, so was also the baby whose blood supply comes from the mother via the placenta.

The rest of the baby’s course in the neonatal ICU was unremarkable thus I signed out from the service after making sure baby was ready for discharge.

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Post-Hemorrhagic Hydrocephalus

Post-Hemorrhagic Hydrocephalus.

 
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Posted by on July 29, 2012 in Hydrocephalus, neonates, Prematurity

 

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Post-Hemorrhagic Hydrocephalus

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The ventricles. (Image courtesy of http://library.thinkquest.org/28457/csf.shtml)

The brain normally produces cerebrospinal fluid daily via the choroid plexus (a network of vessels) situated over the ventricular system. There are two lateral ventricles, located on each of the brain hemisphere. The fluid from both lateral ventricles enters the 3rd ventricle, then passes through a narrowing, the aqueduct of Sylvius (a common site of obstruction giving rise to obstructive or non-communicating type of hydrocephalus) into the 4th ventricle. From the 4th ventricle, via three openings (foramina of Monroe and Luschka), the CSF empties into the subarachnoid space that covers the entire brain and spinal cord. From the subarachnoid space, the fluid is reabsorbed into the venous system via the arachnoid granulations. Sometimes the latter may also be obstructed by blood clots or fibrosis, such that CSF accumulation leads to the communicating type or non-obstructive type of hydrocephalus.

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Diagram: Cerebrospinal fluid circulation via http://securesignupoffers.net/c/

The Case...
A male preterm infant was delivered and as expected, he had complications on his breathing requiring surfactant administration and ventilatory support. After a few days, baby was being weaned off from oxygen, but was noted to have some fluctuations of his oxygen saturation, necessitating increasing or decreasing of the oxygen by nasal catheter, but not to the degree of using a continuous positive airway pressure or higher mode of delivery. Chest x-ray done during this occasion revealed pneumonia which also prompted shifting of antibiotics when the previous ones didn’t seem to afford relief. It took some time before oxygen was totally weaned off.
The next thing that we were watching on this baby was his weight gain and his transition from gavage feeding (feeding via orogastric tube) to oral or breastfeeding; he can not tolerate to swallow more than 1 mL for quite some time. During these days, it was also noted that the midline suture of his skull was wide and gaping, prompting a consideration of hydrocephalus. Immediately, a cranial ultrasound and referral to pediatric neurologist was done. Ultrasound indeed confirmed the presence of hydrocephalus, communicating type. (It means that the aqueduct of Sylvius is intact and functional, but the arachnoid granulations is the site of obstruction; there is normal rate of production but there is obstruction at the site of reabsorption). This is highly suggestive of a previous intraventricular or germinal matrix bleed.
As a form of treatment, baby was given a loop diuretic, a carbonic anhydrase inhibitor (this inhibits carbonic anhydrase, the rate limiting enzyme in the production of CSF), and serial lumbar puncture to drain CSF as much as possible, every 2 – 3 days. Of course, we provided some analgesics to the baby prior to the puncture to minimize or eliminate pain. And since we did not observe drastic increase in the head circumference of baby, we decided to stop doing the serial taps after two weeks but kept a close eye on the circumference monitoring.
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Lumbar puncture. (image courtesy of http://residency.pediatrics.med.ufl.edu/resources/policy-manual/rotations/rotation-goals-objectives/night-shift-inpatient-wards/lumbar-puncture-instructions/)
We patiently waited until baby was able to tolerate being fed per orem. He was then discharged after almost 2 months being in the hospital. He was still on medications, on frequent head circumference monitoring. The mother was also taught how to measure the head circumference, and was diligent about it. At one occasion, in a span of two weeks, the increase was greater than what was expected, so baby was referred to a neurosurgeon. Parents were advised likelihood of inserting a ventriculo-peritoneal shunt (a tube inserted into the ventricles, then a tract is created underneath the skin from the head to the peritoneal cavity – the space inside the abdominal cavity)
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Ventriculo-peritoneal shunting procedure. (Image courtesy of http://www.khocommunications.com/port%20p5.html)
Fortunately, the neurosurgeon was at bay didn’t do yet the shunting procedure and advised close monitoring. The shunt in itself has a lot of risks, and some common complications include infection and malfunctioning, requiring removal and re-insertion of a new one as the need arises. With the parents close cooperation, the procedure did not ever take place. The baby seem to have improved. His medications were discontinued and thereafter, the head didn’t grow more than expected rate.
 
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Posted by on July 29, 2012 in Hydrocephalus, neonates

 

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Unlucky (Post-Natal Asphyxia)

Disclaimer: This blog is not to solicit your sympathy, but read at your own will.

I had been taking care of this baby, who was born at 25 weeks gestational age. It seems that the mother had been having infection in her uterus that prompted the preterm labor. Studies have already shown the association that inflammatory process in the uterus at the time of pregnancy may also transmit the inflammatory factors to the brain of the fetus, thus the latter is at risk for cerebral palsy, even if he graduates from the neonatal intensive care unit. Another risk that this intra-uterine infection produces is development of bronchopulmonary dysplasia, BPD (otherwise called chronic lung disease of the newborn). BPD is usually considered when a child has a difficulty of tolerating room air (or the baby remains oxygen-dependent) after a certain period of time, when he is already expected to be off from oxygen support. BPD, aside from being a result of an infection, may also be precipitated by other inflammatory processes in the lungs (such as use of mechanical ventilators that induces trauma from volume of introduced air or employed pressure), or volume overload (such as patent ductus arteriosus).

My little baby, seemed to have contracted already BPD by two means: patent ductus arteriosus and inflammation from intrauterine infection prior to his delivery. He was already off from the mechanical ventilator on his seventh day of life, but still cannot tolerate being off completely from oxygen. He was given surfactant immediately within few hours from birth, and early x-ray studies showed clearing of the white ground glass picture that was initially seen after birth. After I extubated (removed the mechanical ventilator) on his seventh day of life, I did an x-ray revealing findings consistent with pneumonia or BPD. Considering the prenatal background of his birth, I was moved to treat his respiratory problem as BPD. Gladly, there were no crises arising from it. What was funny though was that every time he attempts to valsalva/defecate, he desaturates and his heart rate slows down. This makes the nurses panic. I reassured them to assist the baby’s breathing as this could be expected from someone with premature brain. So far, there had been no problem.

On his second week of life, something unexpected happen. During one of the episodes he was doing valsalva, his heart rate slowed down to the point he was unresponsive to the nurse’s maneuver. I was called to the rescue but in five minutes when I arrived, resuscitation was already ongoing, his heart rate was gone. We continued reviving, and after almost an hour, his heart beat came back. Unfortunately, a brain deprived of oxygen of at least five minutes duration is a poor sign.

Yes, baby was revived, but he was not breathing spontaneously already; his breathing depended on the mechanical ventilator. He was also already having seizures as an aftermath. In less than 12 hours from his near death hap, his brain activity already stopped; merely spinal cord reflexes were appreciated. I had the baby referred to a pediatric neurologist, who confirmed the brain’s inactivity. I then talked to the parents and explained the scenario, with full disclosure. After few hours, parents approached me at my office and said they will no longer be aggressive with baby’s care. After his currently medicines will be consumed we will not be refilling/replacing them. Bottomline, if baby’s heartbeat will stop, we will no longer do cardiac pump/massage. This is one of heart-wrenching moments we usually encounter, but it is one reality that we have to accept in our line of profession.

The parents and the relatives talked among themselves what to do with baby. Since baby no longer has a chance of recovering, and is solely dependent of medications and mechanical ventilator to keep him alive, this of course would entail exhaustive financial expenses on their part. Weighing financial resources vs benefit/outcome, it would be a loss-loss scenario on their side. They then decided to terminate aggressive treatment and bring home baby instead, considered in the hospital as HOME/DISCHARGE AGAINST MEDICAL ADVICE.

How does this work? Once parents are able to settle the hospital bill of the baby, the baby is then brought home by the parents. As much as possible, all contraptions are removed from the baby, except the (endotracheal tube) tube that is connected to the respirator. As the baby exits the nursery, the respirator is replaced by a bag-mask apparatus that is connected to a portable oxygen source. A personnel then does the bag-mask ventilation of the baby until he/she is inside the vehicle that will transport him/her home. Then that is the time now that the nurse/physician will remove the tape that secured the endotracheal tube to the patient’s mouth, and pulls it out. Then it will just be a matter of minutes when the heartbeat will stop. (Strictly speaking, it should be the parents who should pull out the endotracheal tube from the baby’s mouth. But to allay the pain their suffering, we [health care providers] instead do it for them.) This is the most painful part of the grieving I think, watching your baby’s last gasp of air until the heart completely stops. Is this considered euthanasia? I’d rather not classify it. Are the parents guilty of “pulling the plug?” No, they had full disclosure and they just had to appropriate and allocate their resources. Was it ethical? Yes, there was full disclosure of the outcome, they had to consider every aspects – their finances; the baby’s outcome– what would he become of if treatment had been aggressive; their custom and tradition, and their elderlies’ advices, before finalizing their decision.

I saw patients at my office for their outpatient consultations and immunization. After my last patient’s vaccination, I heard a loud thud and screaming few seconds when the mother exited the door. It turned out she slipped on a fluid scattered by some irresponsible mammal on the floor. Gladly, the mother held tight onto her 2 months old infant thus was spared from getting hurt. The mother though had her head hit the floor, thus the thud we all heard. We immediately notified the hospital administration about the incident and we brought the mother to the emergency room for consultation and clearance. Meanwhile her baby was left to us. Unfortunately she was hungry. Gladly, the mother gave us milk for the baby to consume. I, my secretary stood as the baby’s nanny while the mother was being attended to at the ER. Baby seems a voracious feeder, I had to find milk while the mom is still being checked. It took almost three hours when the mother was cleared to go home.

 
 

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A Mother’s Request

A Mother’s Request.

 

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A Mother’s Request

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(Photo courtesy of http://www.information-on-surrogacy.com/how-to-give-an-injection.html)

A 32-year old woman lost three fetuses via miscarriages. She didn’t know then why it happened. This time, she’s pregnant for her fourth. This time she was worked-up and diagnosed that she has anti-phospholipid antibody syndrome (APAS). This is a condition where the mother seems to be reacting against her own self, forming blood clots all over her body, including the placenta. To be able to make the pregnancy viable, mother has to be maintained on anti-coagulants during the course of pregnancy – including aspirin (at a certain period only) or daily injections with heparin. Fetus can have growth restriction, mother can have severe hypertension, among other else.

The mother had been having daily aspirin intake to prevent blood clots. However, in the most recent days, it had to be shifted to heparin injections as aspirin seemed not to be working well. Baby’s status had to be monitored daily. When it was noted that baby’s status was deteriorating, though it was a painful and hard decision, baby had to be delivered even if he was premature (with the risk of the baby dying, AGAIN!). Parents are too aggressive for the survival of the baby. They’ve been spending a lot (my guess, more or less a million pesos) just to make this pregnancy successful. Understandable, this will be their first live born baby, after three pregnancy losses.

Baby came out, wrinkled, tiny, with a shrill cry. On the latest ultrasound, it was estimated that baby is 838 grams (classified as extremely low birth weight — babies weighing less than 1000 grams). In the western countries, what they usually do is, within the 1st 15 minutes from birth, they intubate baby, instill surfactant, then provide nasal continuous positive airway pressure respiratory support. I was tempted to do the same. The surfactant was already available. But then I remembered what was more important was baby’s battle with infection. Thus I prioritized baby to undergo skin-to-skin contact with the mother to acquire the latter’s skin bacterial flora that will populate baby’s intestine and trigger his immune system. I can always administer surfactant a little later and it won’t cause the baby too much harm.

While baby was on his mom’s chest, mother was crying loudly. We understood that as cry (not just tears) for joy. After 4 pregnancies, she was finally able to deliver a live born baby. In between sobs, she was asking me to do all my best to take care of baby. That she had been waiting for her own baby…

Suddenly, the toll was on me, I panicked at the expectations of the mom. She repeatedly asked me if baby can lie beside her at their room. That was how she longed for baby. How could I defy her wish when I realized (1) how long they waited for the baby, (2) how much they want to have their own child, (3) how much expenses they incurred to make this pregnancy successful, among other else. Suddenly a lump formed at my throat, making me swallow hard. (And I was burning in fever due to exudative tonsillitis at that time). I told her I will try my utmost skill to make baby survive, as much as possible, with minimal if not no deficit at all.

At 15 minutes, when the baby started to have nasal flaring, that’s when I took baby off from his mother, brought him to the NICU for further care.

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Beinte-Cinco: Quatro

For the past few days, I have been plagued by extremely premature babies for the first time, all 25 weeks gestational age, with different stories embracing each…

UNO…

Parents are well-to-do. They have a business, requiring husband to be out of town. Allegedly, the current pregnancy is not of the husband’s… Mother came in to the labor room, in active phase of labor, meaning, baby is already about to come out. Based on limited data gathered by my resident, mother is about 25 weeks pregnant, had been having diarrhea few hours prior to abdominal pain.

Baby was born, I immediately provided his needs – intubation, mechanical ventilator support, umbilical vascular catheterization. Despite full support, baby’s oxygenation status was never better. Chest x-ray showed collapsed lungs due to sequelae of prematurity. Husband is out of town, the mother’s companions are her employees, who cannot help me with legalities and decision-making.

Then the obstetrician revealed, (as she has the rapport with the mother), that the mother attempted to abort the baby by ingesting some abortifacient. About six hours from birth, the father arrived, but even if he wanted to be aggressive, the baby couldn’t respond anymore to treatment. They then signed a DO NOT RESUSCITATION order. Baby expired after about 12 hours from birth.

DOS…

Both parents are young and unemployed. Mother is 18 years old, father is 22. She came in too to the hospital because of abdominal pain. When at the emergency room, baby’s head was already presenting so she was rushed to the delivery room. I was called in after the baby was delivered so I rushed like an ambulance driver to the hospital. Baby’s urgent needs were provided and then I talked to the father about baby’s condition, what he needs. Unfortunately, even after he has called all possible resources, he wasn’t able to provide the medication baby badly needed.

Baby was only relying on the mechanical ventilatory support. However on the 30th hour of life, he started showing signs of deterioration. His mechanical ventilatory settings were unusually high that eventually led to rupture of both lungs (just as when I left the hospital). I had to rush back to possibly rescue baby. His x-ray revealed rupture of both lungs, with air escaping out but still within chest cavity, thus compressing both the lungs, and the heart. If this were not addressed, baby will die in a few minutes..

I called in a pediatric surgeon to insert tube to drain the air, while I only deed a rescue needle thoracentesis. Alas, after our attempts to rescue baby, he didn’t make it. He expired at about 38 hours from birth.

TRES…

I was informed that there is a pregnant mother, on her 28th week gestational age, for control of labor, but if she will deliver, I will attend to the baby. At least, the baby was older this time (and so I thought)… I instructed then the NICU staff to prepare equipment that baby will need upon delivery. Only two hours after the referral, the phone rang again, calling me now to the delivery room as the baby’s head was already almost out. At least this time, I was already able to have dinner.

I rushed to the hospital and in less than 10 minutes, baby came out. But baby wasn’t looking normal, he was deformed. His head and face were deformed, the abdomen was as large as the head (normally, for a preterm, the head is larger, abdomen and chest are almost the same in diameter), the feet are compressed, looking like club foot. When I was asked what the gender of baby was, I couldn’t commit whether baby is a boy or girl. It seemed like there are scrotal sacs, but empty (which is expected at this gestational age), there was a protrusion that is hard to discern if its penis or clitoris. (In cases where genitalia is ambiguous, we are not obliged to assign a gender until we were able to document it by chromosome (DNA) analysis, so as to avoid mistake in gender assignment). Baby’s skin were also showing red spots highly suggestive that baby has congenital infection, probably german measles or cytomegalovirus. The large abdomen suggests that liver or kidney is enlarged. Whether it is a tumor or a reaction to maternal infection during the course of pregnancy, I could not be certain. Physical assessment also revealed that baby is only 25 weeks, and not 28 weeks as thought of by the mother.

Upon birth also, heart beat was already less than normal, and he was already gasping (an ominous sign of arrest). I already knew that resuscitative efforts in this kind of situation will be otiose. So, I immediately called in the grandmother (as the husband is abroad) and explained how futile resuscitating baby is. We provided comfort care, had baby baptized, and waited for baby to expire.

In retrospect, I learned that at 5 months gestational age, baby’s ultrasound revealed that there was polyhydramnios (excessive amount of amniotic fluid). The placenta was large too, heavier than the baby, also substantiating my suspicion that mother had a lethal form of asymptomatic infection that grossly affected the baby.

After 58 minutes from birth, baby expired.

QUATRO…

It was a Sunday, it was supposed to be lazy day, rest day for me, but for some crazy reason, the world does not want me to fully enjoy my rest days, this day included. I was called in for emergency cesarean delivery at a hospital for the birth of yet again 25 weeks old baby. Baby had to be delivered as the hand is already coming out of the vagina.

Upon arrival at the hospital, the obstetrician and her assistant was already operating on the mother so I barely had time to prepare. Baby came out in few minutes and needed resuscitation as he was not spontaneously crying and breathing. We had to provide bag-mask ventilation but the equipment was dysfunctional. Also, many equipment that baby needs is not available in that hospital so I had to immediately transfer baby to a higher center. The baby is the 2nd child, the 1st child being 13 years old already and parents want the baby to live. What am I to do but to stress myself thus? (evil-grin) 

The ambulance and I rushed to the other hospital in convoy. Again, his needs were provided. This time, I or perhaps the baby was lucky because the father was able to provide that much needed surfactant. Also, the baby’s lungs are not that collapsed compared to the other ones I previously mentioned.

It seemed that the mother has uterine infection as the bag of waters broke one day before she had labor pains. Usually infections at this week of gestation is lethal/deadly to the premature baby.

The baby is currently stable at present, although still requiring mechanical ventilatory support.

 

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