Tag Archives: respiratory distress syndrome
This is a retro-blog.
I remember one patient who was referred to me for neonatal care. It was about 4 years ago. A mother had to deliver prematurely by cesarean section because of premature rupture of membrane and uncontrolled uterine contractions.. Baby was 28 weeks gestational age. There was no more room for control of labor, and preparing the baby’s lungs for eventual delivery; the cesarean section had to be done outright. Both parents were employed at that time, so I thought there was no problem about financial resources.
Again, as for all babies being born prematurely, he needed to be administered surfactant. It was night time, banks were closed so there’s no way the father can tender cash at that time. I told him to go to another hospital, secure surfactant with my name as guarantor and sign a waiver for them to pay for the drug in 24 hours. The medicine was released to him and thus I was able to administer it immediately.
(Image courtesy of www.nhlbi.nih.gov/health/health-topics/topics/pda/)
Baby was already being weaned from the respirator, when a new problem arose, a patent ductus arteriosus. This posed a threat as it increased the volume of blood that goes to the lungs for oxygenation and predisposing to a chronic problem: bronchopulmonary dysplasia. Oral medication given via tube to treat the problem. Then another problem set in: persistent pulmonary hypertension and renal insufficiency bordering renal failure, plus signs of systemic infection showing. I did some double volume blood exchange transfusion here besides giving respective medicines.
Baby’s persistent pulmonary hypertension responded to sildenafil. After the exchange transfusion, baby started urinating. Then the murmur disappeared. However, it took a some time to wean the baby off from the respirator because of one problem: baby developed bronchopulmonary dysplasia. I had to give cocktail of medications. Finally baby was weaned off from the respirator and was extubated but still dependent on oxygen support. There were even times when after extubation and when his BPD would exacerbate, it would require some hourly aerosolization to open up his distal airways.
When baby was almost two months, he was then discharged from the hospital, free from oxygen support, feeding well, and gaining weight daily. Due to big hospital bill, they asked if it is okay for them to sign a promisory note for their payment of my professional fee. Should I say no? I never proposed any condition at all. I just called the hospital to give my approval. They also partially paid their hospital bill.
One week from discharge, they followed up at the clinic. Few days after that, the hospital declared bankruptcy and closed. Then, my fear came true. They disappeared and never came back. They never at least had the courtesy to tell me that they can’t pay my professional fee. Nada! Boom! Ba-bye! I had their number. Sometimes I ask my secretary to remind them, but then they just say they will come to no avail. Then I recall how was I attending to that baby before, I had no car then. I would wait for a cab to visit the baby. Then during early mornings, I had to walk for about 10-15 minutes going to the main road to hail a cab to go back home. And then this is what I deserve.
The perks of a neonatologist. Other colleagues surely do have their own stories and could be worse than this.
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…
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.
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.
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.
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.
Premature baby, 25 weeks gestation, was referred to my service immediately only after he was delivered, as the mother arrived in the hospital in active labor already. With all my might, I drove hastily to attend to him as the first few minutes is very critical for baby’s survival – their breathing, their temperature regulation more importantly. Gladly, their referral was, baby is on 100% oxygen saturation with low flow oxygen via his nasal catheter.
Arriving at the NICU, I immediately attended to his needs. His x-ray showed a severe form of surfactant deficiency. Talked to the dad and explained the condition of the baby. He needed surfactant badly. Unfortunately, resources are limited, he cannot provide it as he recently resigned from work and no one else can provide support that very instant. Baby had to make do with mere ventilatory support… but with risks…
The first 24 hours of preterm was essentially unremarkable, he was stable. In fact, on the 25th to 30th hour of life, I began weaning off the ventilatory support. (amazing) But on the 36th hour of life, he started deteriorating. Ventilatory support had to be increased to the point of a peak inspiratory pressure at 40 cmH20. This was the only setting that he became stable… (but with a PRIZE!) When I noticed that he was stable, I decided to go home and have my dinner. But upon arriving at home, I got a distress call that his heart rate suddenly fell. It was gut-wrenching feeling… I immediately ordered x-ray while I rushed back to the hospital (a 10 minute drive without traffic for an amateur driver like me). Lo and behold, he had pneumothorax on both lungs! Not just pneumothorax, but TENSION pneumothorax. There was a point of rupture somewhere along the baby’s lungs where air escaped from into the chest cavity. The air leak kept on increasing volume, on an enclosed space, thus compressing the lungs like a tin can, as well as the heart. This compression disables the heart to pump blood effectively thus causing decrease in the strength of pulses, blood pressure, faint/distant heart tones.
(Not the actual patient. Photo courtesy of http://images.mitrasites.com/wallpaper/pneumothorax.html)
I immediately inserted needle onto the chest of the baby, both sides, after proper preparation and giving baby analgesics, to drain the air from the chest, to stop compressing on the lungs and heart. But… it was not enough. There was continuous exodus of air, and the baby’s heart beat and oxygenation has not improved significantly; I thought that the air leak must be so large that’s causing continuous egress of air.
Needle thoracentesis. (Image courtesy of http://gtranatomy.blogspot.com/2011/04/blogation-numero-cuatro.html). Of course, this was done with baby lying supine though.
Chest tube thoracostomy. (Image courtesy of http://www.medicalexhibits.com/medical_exhibits.php?exhibit=05001_02X&query=chest%20tube%20placement%20technique%20placing%20thoracostomy%20tube)
I called in the pediatric surgeon to insert a bigger tube to help drain the chest of air. This was indeed a pulse-raising scenario. Had I a heart condition, I could already have chest pain or maybe heart attack at that instant, that was how tension-filled the NICU was at that moment.
But… after all our concerted, heroic efforts to save the baby, he continued to deteriorate. We resuscitated him, but he didn’t make it. When the parents came in, the mother hugged me, crying. It was heart-breaking scenario, as baby was their first…
When all things were settled, I finally bid them everyone. I went to an open fast-food chain to buy myself a dinner. It was midnight. Then I drove back home, to rest… because in a few hours time, I have a scheduled CS delivery to attend to.