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Case of the Year Lyn Callaghan Advanced Neonatal Nurse Practitioner Wishaw General Hospital.

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Presentation on theme: "Case of the Year Lyn Callaghan Advanced Neonatal Nurse Practitioner Wishaw General Hospital."— Presentation transcript:

1 Case of the Year Lyn Callaghan Advanced Neonatal Nurse Practitioner Wishaw General Hospital

2 Background Baby boy born by SVD at 40+2 weeks Spontaneous onset of labour No Infection risks Crash Call at delivery due to Shoulder Dystocia Baby born in good condition Apgars 9/1 9/5 Mum’s second baby Healthy pregnancy Blood Group 0 Negative Anti D during pregnancy

3 Newborn Examination Baby now 15 hours of age – Breast feeding well – Passed urine and meconium Mother – no concerns Midwife – feels baby intermittently tachypnoeic On examination – Pale – No respiratory distress – Normal tone – Normal examination – Note baby becomes tachypnoeic on handling – Heart rate +/- 150 when settled

4 Do you think anything is wrong with the baby? What do you think it could be? What do you do next?

5 What happened next? Chased Cord bloods Repeated FBC and bilirubin Informed mum of rationale At Birth – Hb 15.5 HCT 0.56, WCC 19.0, Plat 204, Retics 5.5% – Bili 24. – Blood Group O pos – DCT Negative At 15 hrs of age – Hb 8.2 HCT 0.23, WCC 20.1, Plat 143, Retics 7.1%. – Bili 28


7 Admit to NNU Repeat FBC, Partial sepsis screen, DCT, Coagulation Chest x-ray – normal Echo – normal structure Baby examines well – Pale – Tachypnoeic – Tachycardia – Mean BP normal At 17 hrs of age – Hb 5.1, HCT 0.19, WCC 22, Plat 98. Retics 8.2% – Bili 29 – CRP <6 – Coag mildly deranged – Blood Group O pos – DCT Neg

8 Stabalisation TUT Platlet transfusion FFP CRUSS Abdominal X-ray Abdominal Scan Progress By 21hrs of age baby developed abdominal tenderness and guarding Differential diagnosis – Haemorrhage – ? Bowel – ?Liver Transferred to Surgical Centre MRI Confirmed Diagnosis

9 Haemangioma of Liver Can cause Heart failure Anaemia Thrombocytopenia Treatment Corticosteroids Embolization Hepatic Artery Ligation Liver Resection

10 Congenital Hepatic Haemangioma Hepatic tumours account for 1-5% of all Paediatric tumours Hepatic Haemangioma is the third most commonest tumour of childhood Occasionally diagnosed on antenatal scan Often never detected – Rarely present as large abdominal mass – Cardiac failure due to massive atreriovenous shunting – Jaundice from compression of bile ducts – GI Bleeding – Fever/illness resembling systemic inflammatory process

11 What is a haemangioma? A vascular birthmark caused by abnormal blood vessels in or under the skin Most common benign tumour of the vascular endothelium in infancy Can occur anywhere outside and inside of the body

12 What are the common types found on the newborn examination? What do we tell the parents?

13 Salmon Patch Stork Bite/Mark Angels Kiss

14 Salmon Patch Pink maculae Dilated superficial capillaries Commonly seen at nape of the neck, mid forehead and upper eyelids Most common vascular malformation Usually fades within a year

15 Strawberry Haemangioma Bright red and sharply demarcated

16 Strawberry Haemangioma Bright red vascular tumour Dilated mass of capillaries Usually protrudes above the skin Can appear anywhere on the body Can start as a flat red superficial lesion Can increase in size over next year

17 Strawberry Haemangioma Usually, growth is complete and involution has commenced by twelve months. Half of all infantile haemangioma have completed involution by age five. 70% by age seven, and most of the remainder by age twelve In more severe cases haemangioma may leave residual tissue damage.

18 Strawberry Haemangioma Complications Psychological Haemangioma near the eyes, nose, mouth, or on throat may interfere with vital functions and therefore require removal Some may – break down and ulcerate – Bleed Rarely can cause heart failure if large and blood being diverted into the excess blood vessels Lesions next to bone can also cause erosion of the bone

19 Strawberry Haemangioma Treatment Oral corticosteriods – Smaller lesions sometimes injected Propranalol Timolol gel Interferon Vincristine Surgical removal Pulsed dye laser – For very early flat lesions

20 Port Wine Stain Nevus Flammeus Usually present at birth and on face, but can occur anywhere Permanent capillary angioma Does not blanch with pressure

21 Port Wine Stain Grows in proportion to general growth Early stains are usually flat and pink – as child matures colour can deepen to a dark red or purple colour In adulthood can become bumpy and raised

22 Port Wine Stain Complications If over forehead and upper lip Sturge Weber Syndrome must be excluded Spine abnormalities Varicose veins Psychological Eye problems is on eyelid or next to eye

23 Port Wine Stain Treatment Some may improve over time Laser treatment – variable results depending on skin colour – Works best in young children – Works best on smaller stains Skin camouflage still common treatment – Some provided free on NHS Support Groups – Birthmark Support Group – British Association of Skin Camouflage – Changing Faces

24 Mongolian Blue Spot Congenital Dermal Melanocytosis Benign, flat birthmark Irregular borders and shape Commonest colour is blue, but can also be blue-grey, blue-black or deep brown Normally disappears by 3 - 5 yrs of age Almost certainly by puberty Important to document on record Prevalent among – Mongolians – Asians – Malay – Polynesians – East African – Latin Americans – Turkish

25 Questions/Discussion

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