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Tag Archives: small for gestational age

My First Case of Congenital Cytomegalovirus Infection

I have this opportunity to demystify an infant’s case of long standing jaundice…

The mother’s prenatal course was apparently unremarkable, save for gestational diabetes that was controlled. The mother cannot remember any other symptoms such as flu-like illness, skin rashes, nor was she hypertensive during the prenatal period. Baby was delivered via repeat cesarean section, small for gestational age. He stayed quite long in the hospital because of infection. He was purely breastfeeding. His newborn metabolic screening result was normal. I was not the attending then.

At home, baby was quite fuzzy and irritable. Baby has been being attended to by the original neonatologist. He was jaundiced. In cases of purely breastfed babies, sometimes jaundice can be expected to last for about 3 months but the intensity is not that much compared to that during the first week of life. His stool color was still yellow. He developed umbilical hernia. The skin texture was fine; tongue was normal in size; hair was not coarse; there was no hypotonia; nor was there any constipation (something that is a remarkable findings among babies with hypothyroidism). Baby was worked up for possible hypothyroidism. Thyroid function test was normal. They were advised to go to a pediatric endocrinologist for evaluation.

Mother brought baby to my clinic for second opinion. I saw the laboratory result, it was normal. But what is puzzling is the jaundice that was quite intense. I could not evaluate baby well, especially the abdomen, because he is irritable. I advised mother that baby needs further test and treatment thus they agreed to be confined in the hospital.

I repeated the thyroid function test, it was normal. That reassured me baby has no congenital hypothyroidism which is one dreaded condition a baby can have because of life dependency on thyroid hormones for better quality of life and to attenuate whatever cognitive impairment it has already caused. I still called up an endocrinologist friend to confirm my understanding of baby’s thyroid function test result and she agreed baby is not a case of metabolic disorder.

I treated the baby as a case of sepsis pending work up results. Ultrasound of the abdomen showed the liver is enlarged, the biliary tree is intact. I am not afraid that this baby has biliary atresia which is another “lethal” condition that usually leads to baby’s death in a slow fashion.

Liver enzyme, alkaline phosphate and bilirubin were all elevated (it was a direct hyperbilirubinemia). I started the baby on ursodeoxycholic acid to help eliminate the bilirubin that could also cause inflammation of the liver cells.

After a week in the hospital, baby’s jaundice has significantly decreased and yet the direct hyperbilirubinemia (50%) was still persistent, and alkaline phosphatase level was still significantly elevated. I have discharged baby with instruction to undergo karyotyping and TORCH screening as I haven’t ascertained yet what was causing the baby’s jaundice.

A week later, mother brought back the results of baby’s tests. Karyotyping was NORMAL (thank God). On the other hand, TORCH panel revealed (+) IgM and IgG for cytomegalovirus. I referred the baby immediately to an ophthalmologist for chorioretinitis screening, and to a pediatric infectious disease specialist for further management. CT Scan of the head showed that there were periventricular calcifications near the parietal areas of the brain.

Baby is still jaundiced although the intensity is no longer that dark. He is on supportive treatment.

He will undergo repeat head CT scan as well as chorioretinitis screening one month after the first.

 
 

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Foul: SC SQAOs RH LAW

(photo courtesy of www.pogsinc.org)

(photo courtesy of http://www.pogsinc.org)

UN resident representative described the Philippines as the “worst performer” in Asia as far as achievement of Millenium Development Goals (MDG) are concerned. This, as far as lowering of child mortality, decreasing maternal morbidity and mortality as well as HIV prevention are concerned.

These three are included in the Responsible Parenthood and Reproductive Law that was already signed, implementing rules and regulations signed as well, but put on hold by the “status quo ante order” issued by the Supreme Court on March 19, 2013.

This law went through hurdles for about 16 years before being finally passed by the 15th Congress. It aims to empower people by making them a responsible parent. By this, it will allow parents to determine the number of their offspring they can responsibly have – those that they can feed, vaccinate, send to school and be a responsible citizens of the country. This can be achieved through sexuality education, which will be taught while the children are young, and employment of safe and acceptable contraceptive methods, depending on the couple’s choice, heightened HIV education and awareness especially to population at risk.

Recently, there was a scandal about an adolescent college student who claimed her life after, bottom line, cannot afford to pay her tuition. They are 4 siblings and yet the father cannot afford her tuition fee. And how does this relate to the RH Law? I am not saying the father is irresponsible. BUT, had he considered that he could only afford to rear one or two children, providing all their needs, then his daughter wouldn’t have suffered this problem at such a young and tender age. He could still have his brilliant daughter this very minute with him.

I am the eldest of 4 children. My parents used pills and condoms. We don’t own a house and we had been renting up to this date. When I was about to enter the school of medicine, the 4 of us were already simultaneously going to college. With my father’s income, he couldn’t afford to send us altogether. He talked to me that he cannot afford my tuition. If he would, my other siblings wont be able to enrol. I on the other hand has graduated from college already, so perhaps I could already work and save up for my tuition. I was heartbroken as my aspiration of being a physician was imperiled. I won’t be graduating with my batch mates. I felt it was so unfair for me. I was selfish as I didn’t want to trash my dreams to happen at the right time that I want it to, and without considering my other siblings’ welfare too. But my selfishness was my motivation and determination to find myself a scholarship that can fuel my ambition. My youngest sister as well was able to secure a scholarship for her. So basically, my father was only supporting two of my other siblings as far as tuition and miscellaneous fees are concerned. It was very very difficult time. Sometimes we have to make do with our meager allowance. But one thing I salute my parents for was that we were never delayed in paying our tuition. My parents didn’t want as much as possible for us to be delayed from graduating. They didn’t want as much as possible for us to be working scholars in order for us to afford college. As much as possible, they wanted to shoulder the entire burden of sending us to college as it is their obligation to do so. They believed it was was their duty and responsibility. My parents admitted that they won’t be able to give us land, house or any property for inheritance but our education that will help us build our own future. Now, if my parents who practiced family planning were still hard up to give us good and quality education, how much more for those who had not?

I am aware of that it will be a long time before the concrete effects of RH Law will be experienced by our fellowmen. But delaying it or even preventing it from being implemented, considering our country’s situation right now, is a violation of our rights to access to reproductive health care. We need an immediate tangible effect such as in the following case.

Small for Gestational Infant

A mother conceived, she was hypertensive even at the early stages of her pregnancy. After reaching 20 weeks, her blood pressure all the more shoot up. Even with medical care from a private obstetrician, still the blood pressure wasn’t adequately controlled. At 36 weeks, she came to the hospital in active labor. The baby’s heart beat was erratic and had to be delivered immediately, or else we will lose the baby.

The baby came out without spontaneous breath and crying, and the heart beat was very slow. He had to be resuscitated, a tube was inserted into his trachea to assist him breathing. He was small for his age of 36 weeks, with respect to his weight, length and head circumference (an indirect indicator of brain growth). This only means that the baby was chronically “undernourished” inside the mother’s uterus that’s why all of his anthropometric measurements were below normal.

Adequate blood glucose and oxygen supply from the placenta to the baby is necessary for optimum brain and body growth. Normal or good glucose level stimulates the production of more insulin-like growth factor 2, which is responsible for increasing the number of neurons and oligodendrocytes, and increasing the communications between neurons through dendrites and axon. An increased communication between these two parts of neurons leads to faster transmission of signals. Bottom line, intelligent kid. The opposite, “bobo.” I am not saying this is always the case but the risk, a very high risk at that, to being one is undeniably there.

So this baby already suffered an injury biochemically and physiologically inside the womb, even if he was born alive. So it’s true no mother died in this case. It’s true, no baby died in this case. But the impact of the chronic uncontrolled hypertension to the baby’s brain, IS permanent, and may be debilitating. This thing is still happening among our pregnant mothers, even if they are under the care of able obstetricians. But what about those who have no access to obstetricians? And mind you, this is just one aspect of issues surrounding a pregnant woman. There are more other pressing equally important concerns.

One anti-RH bill argues that there is no more need for RH law as there is already an existing Magna Carta Law for Women. Let me throw back the question to you. With the MCW in place, how come, we still have this high incidence of maternal morbidity and death? With the MCW in place, how come we are not achieving the millenium development goals? And what about HIV which is not included in the MCW, neonates? With the SQAO against implementation of the RH Law, aren’t we not endangering further our poor constituents? Is it right to issue this SQAO at this time?

 

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Does Physical Abuse To Pregnant Mother Affect The Baby?

Did you know that physical violence to a pregnant woman can cause intrauterine growth restriction (retardation)? Strange as it may sound, yes, physical abuse of a pregnant woman can indeed to several perinatal complications. Worse the fetus may be dead by the time he is born.

This was the topic during the first day of the convention I attended, though I failed to catch the first part of the talk. What struck me was the slide showing a strong association between violence towards pregnant woman and adverse outcome of the baby.

With that, I searched for any articles online, any study on physical violence and its adverse effect among pregnant women. I found a study conducted in Canada, but it is a large scale one involving 4750 study population. Independent variable (cause) studied was the physical abuse, which may have occurred even as early as before pregnancy. The dependent variables (outcome/effect) were presence of antenatal (before birth) hemorrhages, intrauterine growth retardation, and perinatal death (death between 20 weeks of pregnancy until 7 days after delivery). The study has shown that there is higher risk for occurrence of antenatal hemorrhage, intrauterine growth retardation and perinatal death among abused pregnant women.

(Reference: Patricia A. Janssen, PhD,a,c,d Victoria L. Holt, PhD,a Nancy K. Sugg, MD, MPH,b Irvin Emanuel, MD,a Cathy M, Critchlow, PhD,a and Angela D Henderson, PhDd/  Intimate partner violence and adverse pregnancy outcomes: A population-based study. Am J Obstet Gynecol 2003;188:1341-7.)

The speaker in the lecture explained why physical abuse restricts the growth of the fetus. Abuse causes the woman to be stressed. During stress, there is a release of stress hormones and substances, including epinephrine (otherwise known as adrenaline). This causes an rise on the resistive index at the level of the umbilical vessels.

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(http://www.fetal.com/IUGR/treatment.html)

During ultrasonography, the sonologist can focus on the umbilical cord and obtain the resistance index on the blood flow that goes to the baby. (Resistance index is almost similar also to the resistance along an electric wire; the higher the resistance, the lesser the output in the end). If the resistance index is increasing, it means to say that blood flow through the umbilical cord going to the baby is decreasing. Because of lack of blood supply, the baby receives less nutrition and oxygen– the basic baby’s requirement for rapid growth in utero. As a result, baby ends up smaller than expected for his age of gestation.

The chronic the stress of the mother is, the worse the fetal outcome. And as I have previously stated, worst case scenario may end up in fetal death, not from the physical trauma but from the reversal of blood flow to the fetus due to very high resistance index.

(Will include the lecturer’s name later when I get hold of my program).

 
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Posted by on October 2, 2012 in neonates, Physical Abuse, Pregnancy

 

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Blood Sugar and the Developing Brain

A woman should be physically well and prepared before getting pregnant. Having either a low or high body mass index (BMI) is harmful to the developing fetus as both can lead to fetal undernutrition, among other else. Onset of this problem earlier than 20th weeks gestational age is already considered chronic episode, but the exact onset cannot be pin-pointed unless serial monitoring of the fetus development is done.

At birth, there are three anthropometric parameters that are important to be measured: the weight, length and the head circumference. These are then plotted against the baby’s age in weeks at the Lubchenco chart to determine if the baby’s measurement fall’s with accepted or normal range.

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(Photo courtesy: http://www.merckmanuals.com)

The baby is then classified as small, appropriate or large for gestational age. Small for gestational age, SGA are those babies whose measurements (especially weight and head circumference) falls below the 10th %ile; large for gestational age, LGA, are those whose measurements fall above the 90th %ile; and appropriate for gestational age, AGA, are those whose measurements fall within the 10-90th %ile rank. Of the extremes, the SGAs are more common. There are various causes of SGA according to onset of the insult. Chronic onset usually happens when the insult started before the 20th gestational age, and this usually brings about a symmetric type where all measurement (weight, head circumference and length) fall below the 10 %ile line. Causes include chronic maternal hypertension and congenital infections with syphilis, toxoplasma, cytomegalovirus and rubella. If the insult occurred after the 20th gestational age, usually it is only the weight that gets affected bringing about an asymmetric type, but with sparing of the brain (hence it is also known as brain-sparing SGA). Such is what happens during cases of hypertensive disorders during the latter half of pregnancy. Common denominators of these would be a decrease in blood flow from the maternal circulation to the developing baby via the placenta-umbilical cord complex.

Maternal glucose influx into the fetus is very significant to the brain development. It should be understood that brain cells and red blood cells are the only body cells that do not require insulin to imbibe glucose from the circulating blood; they uptake glucose without help, and thus is dependent on the concentration of blood glucose. Normal level of blood glucose then should be maintained as adequate amount of glucose is an important determinant in the production of insulin-like growth factor (IGF), a significant factor in brain development. IGF is responsible in increasing the number of neurons and oligodendrocytes, as well as in increasing the arborization (connections) between axons and dendrites. (It has been established that the more arborizations between neurons, the faster the communication and thus the transmittal of information from one neuron to another, besides the effect of myelin sheath surrounding these structures). Inability therefore to sustain normal supply to brain cells for a long duration will significantly adversely affect the neuro-developmental outcome of the fetus, including his cognitive development. As even if the baby has inherited the genes to be genius but if this environmental factor in his development prevails, then it nullifies his potential of being genius at the end.

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(Photo courtesy: http://athletics.wikia.com)

If many mothers are nutritionally unprepared (whether because there’s too many children or there’s lack of adequate spacing between child births, among other else) before conceiving a child, would you then wonder why their children end up academically INADEQUATES in most cases? 

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A mother gave birth to a baby who was small for gestational age few days ago. Initially I was called in because the baby was reported as preterm, as based on ultrasound measurements. It turned out that the baby was near term at 36 weeks, but small for gestational age. I had the baby roomed-in with the mother after establishing that the baby seemed fine, except that I had to monitor the blood sugar. Initially the values were all normal so there was the plan to discharge the baby together with the mother. But on the day of supposed discharge, that’s when low blood sugar of the baby already occurred. Afraid of the risk of aggravating what might have already transpired already inside the uterus, I immediately had intravenous fluid administered to the baby. The grandmother was asking me what milk formula would be best to give so that this will not happen. I told her that oral feeding alone won’t resolve the problem, thus I stuck to breastfeeding still. With the help of iPad as visual aid (thanks to technology), I explained to the mother the consequences of low blood sugar to the developing brain. I emphasized that given the opportunity to correct possible adverse effect, as much as possible I didn’t baby to end up “bobo.”

IVF then helped normalize the blood sugar values. Every time I get a normal value, I try to decrease the rate at which the IVF was being infused, maintaining or increasing it back if the blood sugar dips below the accepted cut off value. Only at the seventh day of life did  the baby tolerate pure oral feedings and was thus given the clearance to go home.

 
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Posted by on April 22, 2012 in neonates

 

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