Presentation on theme: "Case of the Year Lyn Callaghan Advanced Neonatal Nurse Practitioner"— 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 labourNo Infection risksCrash Call at delivery due to Shoulder DystociaBaby born in good conditionApgars 9/1 9/5Mum’s second babyHealthy pregnancyBlood Group 0 NegativeAnti D during pregnancy
3 Newborn Examination Baby now 15 hours of age Mother – no concerns Breast feeding wellPassed urine and meconiumMother – no concernsMidwife – feels baby intermittently tachypnoeicOn examinationPaleNo respiratory distressNormal toneNormal examinationNote baby becomes tachypnoeic on handlingHeart 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 rationaleAt BirthHb 15.5 HCT 0.56, WCC 19.0, Plat 204, Retics 5.5%Bili 24.Blood Group O posDCT NegativeAt 15 hrs of ageHb 8.2 HCT 0.23, WCC 20.1, Plat 143, Retics 7.1%.Bili 28
7 Repeat FBC, Partial sepsis screen, DCT, Coagulation Admit to NNURepeat FBC, Partial sepsis screen, DCT, CoagulationChest x-ray – normalEcho – normal structureBaby examines wellPaleTachypnoeicTachycardiaMean BP normalAt 17 hrs of ageHb 5.1, HCT 0.19, WCC 22, Plat 98. Retics 8.2%Bili 29CRP <6Coag mildly derangedBlood Group O posDCT Neg
8 By 21hrs of age baby developed abdominal tenderness and guarding StabalisationProgressTUTPlatlet transfusionFFPCRUSSAbdominal X-rayAbdominal ScanBy 21hrs of age baby developed abdominal tenderness and guardingDifferential diagnosisHaemorrhage? Bowel?LiverTransferred to Surgical CentreMRI Confirmed Diagnosis
9 Haemangioma of Liver Can cause Treatment Heart failure Anaemia ThrombocytopeniaCorticosteroidsEmbolizationHepatic Artery LigationLiver Resection
10 Congenital Hepatic Haemangioma Hepatic tumours account for 1-5% of all Paediatric tumoursHepatic Haemangioma is the third most commonest tumour of childhoodOccasionally diagnosed on antenatal scanOften never detectedRarely present as large abdominal massCardiac failure due to massive atreriovenous shuntingJaundice from compression of bile ductsGI BleedingFever/illness resembling systemic inflammatory process
11 What is a haemangioma?A vascular birthmark caused by abnormal blood vessels in or under the skinMost common benign tumour of the vascular endothelium in infancyCan 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?
14 Salmon Patch Pink maculae Dilated superficial capillaries Commonly seen at nape of the neck, mid forehead and upper eyelidsMost common vascular malformationUsually fades within a year
15 Strawberry Haemangioma Bright red and sharply demarcated
16 Strawberry Haemangioma Bright red vascular tumourDilated mass of capillariesUsually protrudes above the skinCan appear anywhere on the bodyCan start as a flat red superficial lesionCan 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 twelveIn more severe cases haemangioma may leave residual tissue damage.
18 Strawberry Haemangioma Complications PsychologicalHaemangioma near the eyes, nose, mouth, or on throat may interfere with vital functions and therefore require removalSome maybreak down and ulcerateBleedRarely can cause heart failure if large and blood being diverted into the excess blood vesselsLesions next to bone can also cause erosion of the boneThe vast majority of hemangiomas are not associated with complications. Hemangiomas may break down on the surface, called ulceration. If the ulceration is deep, significant bleeding may occur in rare occasions. Ulceration on the deeper area can be painful and problematic. If a hemangioma develops in thelarynx, breathing can be compromised. A hemangioma can grow and block one of the eyes, causing an occlusionamblyopia. Very rarely, extremely large hemangiomas can cause high-output heart failure due to the amount of blood that must be pumped to excess blood vessels. Lesions adjacent to bone can also cause erosion of the bone
19 Strawberry Haemangioma Treatment Oral corticosteriodsSmaller lesions sometimes injectedPropranalolTimolol gelInterferonVincristineSurgical removalPulsed dye laserFor very early flat lesions Hogeling M et al. (August 2011). "A randomized controlled trial of propranolol for infantile hemangiomas".Pediatrics 128 (2): e259–e266. doi: /peds PMID
20 Port Wine Stain Nevus Flammeus Usually present at birth and on face, but can occur anywherePermanent capillary angiomaDoes not blanch with pressureA vascular lesion – capillary malformation in the skinDoes not disappear over timeAlso associated more rarely with Klipper Trenaunay Syndrome
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 colourIn adulthood can become bumpy and raised
22 Port Wine Stain Complications PsychologicalEye problems is on eyelid or next to eyeIf over forehead and upper lip Sturge Weber Syndrome must be excludedSpine abnormalitiesVaricose veinsIf the port-wine stain is around the eye or on the eyelid, a referral may be made to an optometrist or ophthalmologist for a test of the ocular pressures in that eye. If swelling occurs in the port-wine stain, it may cause vision problems,glaucoma, or blindness.1 in 10 babies born with a port wine stain on the face will have problems with the eye or the brainThe majority of children have no complicationsBrain abnormalities: are an uncommon association with port-wine stains of the face. This is due to extensive blood vessel abnormalities in the brain (the Sturge-Weber syndrome). Epilepsy and other problems may then develop.
23 Port Wine Stain Treatment Some may improve over timeLaser treatmentvariable results depending on skin colourWorks best in young childrenWorks best on smaller stainsSkin camouflage still common treatmentSome provided free on NHSSupport GroupsBirthmark Support GroupBritish Association of Skin CamouflageChanging FacesGenerally, the paler the port-wine stain, the greater the chance of excellent results.The laser can cause an unpleasant stinging. Therefore, younger children usually have laser treatment under a general anaesthetic or with sedation. Local anaesthetic is normally sufficient for older children and adults.Up to ten treatments are needed depending on the size. Treatments are given about eight weeks apart. It is best to have completed all sessions before a child reaches the age of 5 years.There may be pain, bruising and swelling over the treated area for a while after each session.If lasers don't work, surgery is sometimes required
24 Mongolian Blue Spot Congenital Dermal Melanocytosis Benign , flat birthmarkIrregular borders and shapeCommonest colour is blue, but can also be blue-grey, blue-black or deep brownNormally disappears by yrs of ageAlmost certainly by pubertyImportant to document on recordPrevalent amongMongoliansAsiansMalayPolynesiansEast AfricanLatin AmericansTurkishThe Mongolian spot is a congenital developmental condition exclusively involving the skin. The blue colour is caused by melanocytes, melanin-containing cells, that are usually located in the epidermis but are in the deeper region of the skin known as the dermis in the location of the spot. Usually, as multiple spots or one large patch, it covers one or more of the lumbosacral area (lower back), the buttocks, sides, and shoulders. It results from the entrapment ofmelanocytes in the lower half to two-thirds of the dermis during their migration from the neural crest to the epidermis during embryonic development.The condition is unrelated to sex; male and female infants are equally predisposed to Mongolian spotThe Mongolian spot is referred to in the Japanese idiom shiri ga aoi (尻が青い), meaning "to have a blue butt", which is a reference to immaturity or inexperience. In Mexico, where its name is the "green butt" (Spanish: rabo verde) it is referred to as la patada de Cuauhtémoc, meaning "Cuauhtémoc's kick". In Korea, it is thought that the Mongolian spot is the bruise formed when Samshin halmi (Korean: 삼신할미), a shaman spirit to whom people pray around child birth, has beaten in order for a baby to go out from his or her mother.In the comedy manga series Joshiraku written by Kōji Kumeta, as well as in its anime adaptation, the character Marii Buratei is known to have a Mongolian spot. In one sketch, a westerner notices the spot and mistakes it for child abuse, blaming "barbarian Japanese" and taking Marii to "safety" abroad, against her wishes.