1. PERINATAL/NICU CONFERENCE Monthly Statistics Report February 2014 Khlaire D. Pioquinto PERINATAL/NICU CONFERENCE Monthly Statistics Report February 2014 Khlaire D. Pioquinto, MD 3 rd Year Resident – Pediatrics Paolo Augusto U. Campos, MD 3 rd Year Resident – Obstetrics and Gynecology THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the Department of Pediatrics

2. TOTAL BIRTHS

3. Total Births, February 2014 ACCORDING TO AGE OF GESTATIONNUMBER Term129 Preterm21 Postterm1 TOTAL LIVE BIRTHS151

4. Total Births, February 2014 ACCORDING TO PLACE OF PRENATAL CARENUMBER Registered151 Non-registered0 TOTAL LIVE BIRTHS151

5. Total Births, February 2014 ACCORDING TO AGE OF GESTATIONNUMBER Term130 Preterm21 Postterm1 TOTAL LIVE BIRTHS151

6. Total Births, February 2014 ACCORDING TO PLACE OF PRENATAL CARENUMBER Registered151 Non-registered0 TOTAL LIVE BIRTHS151

7. NURSERY ADMISSIONS

8. January 2014 vs February 2014

9. February 2013 vs February 2014

10. Deliveries by Levels

11. Admission to NICU Referral FromNo. of Patients Roomed In (Inborn transfer)1 Discharged (Inborn Readmission) 3 Discharged (Outborn Admission)0 Total4

12. NICU Isolation No. of Patients Inborn Transfer1 Inborn Readmission2 Direct admission1 Outborn Admission1 Total5

13. NEONATAL MORBIDITIES

14. Neonatal Morbidities, January 2014 NUMBER OF NEONATAL MORBIDITIES35 Incidence among total live births230 per 1000 LB Delivered from Normal Mothers20 (57%) Delivered from High Risk Mothers15 (43%)

15. Top 5 Conditions Occurring Among High Risk Mothers, February2014

16. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA - 1

17. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA - 2

18. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA – 2 Prematurity – 7 Low birth weight - 1 LGA – 2 Prematurity – 7 Low birth weight - 1

19. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA – 1 Prematurity – 1 LGA – 1 Prematurity – 1

20. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 Prematurity 1

21. CONGENITAL ANOMALIES

22. NEONATES WITH 1 minute APGAR <=6

23. Neonates with APGAR <=6, February 2014 NUMBER OF NEONATES WITH APGAR < 7 3 Incidence among total live births in 1000 LB Delivered from low risk mothers 2 Delivered from high risk mothers 1

24. R.R.G 39, G2P1 (0-1-0-1), 25 1/7 weeks CC: watery vaginal discharge Past Medical: G1 – NSD at 33 weeks AOG Personal/Social History: U/R Family History: (+) Hypertension, Asthma, Diabetes 143/79, HR 96, RR 18, 37.5C SE: pooling of clear amniotic fluid IE: 2cm, 50%, floating, (-) BOW s/p PBE Male APGAR 3, 6, 7 830 g MT 28 weeks AGA CASE 1: APGAR 3, 6, 7

26. Birth History Baby Boy Live, preterm Delivered via Normal Spontaneous Delivery 39 y/o (G2P2) (0202) 25 4/7 weeks AOG MT: 26 weeks, AGA

27. Anthropometrics BW 830g BL 32 cm HC 24 cm CC 21 cm AC 18

28. APGAR SCORE (1 st minute) = 3 SIGN012 Heart rateAbsentBelow 100Over 100 Respiratory effort AbsentSlow, irregular Good, crying Muscle tone LimpSome flexion of extremities Active motion Response to catheter in nostril (tested after oropharynx is clear) No response GrimaceCough or sneeze ColorBlue, paleBody pink, extremities blue Completely pink Positive Pressure Ventilation

29. APGAR SCORE (5 th minute) = 6 SIGN012 Heart rateAbsentBelow 100Over 100 Respiratory effort AbsentSlow, irregular Good, crying Muscle tone LimpSome flexion of extremities Active motion Response to catheter in nostril (tested after oropharynx is clear) No response GrimaceCough or sneeze ColorBlue, paleBody pink, extremities blue Completely pink Positive Pressure Ventilation

30. APGAR SCORE (10 th minute) = 7 SIGN012 Heart rateAbsentBelow 100Over 100 Respiratory effort AbsentSlow, irregular Good, crying Muscle tone LimpSome flexion of extremities Active motion Response to catheter in nostril (tested after oropharynx is clear) No response GrimaceCough or sneeze ColorBlue, paleBody pink, extremities blue Completely pink Free Flow O2 Thermoregulati on

31. Admitting Impression Extreme Prematurity, Very Low Birth Weight Sepsis Unspecified

32. PLANS Insert UVC O2 support via nasal cannula at 2 lpm Diagnostics: – CBC, CRP – Blood Culture – Hgt – CXR Therapeutics: – IVF at TFR 80 – IV antibiotics (Ampicillin, Amikacin) – Aminophylline

33. PROBLEMS 1. Prematurity 2. Sepsis 3. Pneumonia 4. Apnea 5. Jaundice 6. Anemia

34. Problem 1: Prematurity Thermoregulation: – The patient was placed in an isollette and wrapped in plastic to keep thermoregulated. – Temperature maintained at 36.5-37.5C

35. Feedings: – Upon delivery patient was on NPO, IVF started at TFR 80 – Aminosteril started – On the 3rd day of life, NGT was inserted and patient was started on Glucose water then Breast milk

36. Problem 2: Sepsis Diagnostics: – CBC – CRP – Blood culture Patient was started on the following medications: – Ampicillin – Amikacin

37. HgbHctWBCBandNeuLymMonEosPlt 116351928016026261 CRP 0.04 Blood Culture: No growth (7 days)

38. Problem 3: Pneumonia Pneumonia in the left lower lung UVC at level of T7 to T8 Start Cefotaxime

39. 11 th day of life Awake Active Persistent desaturations T 37C HR less than 100 O2 sats 40s- 50s Pink Minimal effort on respiration No alar flaring sounds Regular cardiac rhythm Full pulses Apnea Probably secondary to progressing Pneumonia or Electrolyte Imbalance Ambubaggin g EG7 Chest Xray O2 support

40. Progressing Pneumonia with Consolidation, bilateral Antibiotics Shifted to Meropenem

41. Problem 4: Jaundice 2 nd day of life Awake Active No desaturations T 37.1 HR 140 RR 49 O2 sats 96 Generalized Jaundice No alar flaring Good air entry Harsh breath sounds Regular cardiac rhythm Full pulses Prematurity Sepsis Unspecified Hyperbilirubin emia Unspecified Start double phototherap y

42. Problem 4: Jaundice 4 th day Awake Active T 37 HR 130 RR 50 O2 sats 98 Pink No alar flaring Good air entry Harsh breath sounds Regular cardiac rhythm Full pulses Prematurity Sepsis Unspecified Hyperbilirubin emia Unspecified, resolved Phototherap y discontinued

43. Problem 5: Apnea First hour of life Awake Active No desaturations T 37 HR 130 RR 49 O2 sats 97 Generalized Jaundice No alar flaring Good air entry Harsh breath sounds Regular cardiac rhythm Full pulses Prematurity Sepsis Unspecified Start Aminophylli ne

44. 2 nd day of life Awake Active Episodes of desaturations and bradycardia T 37 HR Less than 100 O2 sats 70s Generalized Jaundice No alar flaring Good air entry Harsh breath sounds Regular cardiac rhythm Full pulses Apnea of Prematurity Continue Aminophylli ne Stimulation during periods of apnea

45. 11 th day of life Awake Active Persistent desaturations T 37C HR less than 100 O2 sats 40s- 50s Pink Minimal effort on respiration No alar flaring sounds Regular cardiac rhythm Full pulses Apnea Probably secondary to progressing Pneumonia or Electrolyte Imbalance Ambubaggin g EG7 Chest Xray O2 support

46. pH7.198 pCO274.4 pO280 HCO329 BE1 SO292 Na119 K4.7 Ical133 Hgb82 Hct24 Na correction with NaCl incorporation

47. Progressing Pneumonia with Consolidation

48. 11 th day of life Awake Active Persistent desaturations T 37C HR less than 100 O2 sats 40s- 50s Pink Minimal effort on respiration No alar flaring sounds Regular cardiac rhythm Full pulses Apnea Probably secondary to progressing Pneumonia or Electrolyte Imbalance For intubation Mech Vent settings: FiO2 60 PIP 18 PEEP 4 RR 50 iT 0.45 Repeat CBC and EG7 Shift IV antibiotics to Meropenem Cranial Ultrasound

49. pH7.387 pCO232.3 pO242.9 HCO319.4 BE SO2 Hgb91 Hct27 WBC14.6 Neutrophils70 Lymphocytes23 Monocytes2 Eosinophils0 Platelet422

50. Cranial Ultrasound Intraventricular and Germinal Matrix Hemorrhage (Grade II intracranial hemorrhage)

51. Awake Active Episodes of desaturation T 37C HR 130 O2 sats 95- 100% Pink Minimal effort on respiration No alar flaring sounds Regular cardiac rhythm Full pulses t/c Bronchopulm onary Dysplasia Mech Vent settings adjusted accordingly Start Dexamethas one 13 th to 17 th day of life

52. 12 th day of life T 36.5 HR 150 RR 53 O2 sats 95 Pale skin No alar flaring Harsh breath sounds Regular cardiac rhythm Full pulses Prematurity Sepsis Unspecified Apnea of Prematurity Anemia PRBC for transfusion Problem 6: Anemia

53. HgbHct Pre transfusion 8224 HgbHct Post Transfusion 12737

54. Diagnosis: Extreme Prematurity, Very Low Birth Weight, Sepsis Unspecified, Neonatal Pneumonia, Apnea of Prematurity, t/c Bronchopulmonary Dysplasia

55. THANK YOU

56. K.T.G 33, G2P1 (1-0-0-1), 37 1/7 CC: for repeat CS G1- 2011, CS for breech Past Medical/Personal/Social History/Family History: U/R 100/70, HR 82, RR 18, 36.6C FHT: 140’s bpm SE: not done IE: soft closed CTG: not done s/p RCS, cord prolapse Male APGAR 0, 8, 9 2485 g MT 37 AGA CASE 2: APGAR 0, 8, 9

57. Pertinent Data: RCG RCG Delivered via Scheduled Repeat Cesarean Section 33 year old G2P2 (2002) AOG: 37 1/7 weeks MT: 37 AGA Apgar Score: 0,8,9 Anthropometrics: BW= 2485 grams BL= 46 cm HC= 32 cm CC= 30 cm AC= 27 cm

58. Pertinent History Maternal History: No BP elevations, maternal illness during pregnancy Past Medical History: Allergic to fish sauce Family History: Diabetes OB History: G1- 2011- PCS for Breech- LFT- Male- TMC- No FMC G2: Present Pregnancy Personal Social: College graduate, Works as a manager, no vices

59. 1 minute 3 minutes 5 minutes COLOR011 HEART RATE 012 REFLEX IRRITABILITY 022 MUSCLE TONE 022 RESPIRATION022 Drying and Stimulation, PPV, Chest Compressions HR at 60’s, still Acrocyanotic. PPV continued

60. Physical Examination: RCG Had good cry and activity Clear amniotic fluid Flat and open fontanelles Good air entry, no retractions Regular cardiac rhythm, HR at 150 bpm Soft Abdomen Grossly male genitalia Full pulses

61. Diagnosis: RCG Term Baby Boy, AGA, AS 0,9

62. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 6th HOL - Able to latch with good suck - No vomiting - Active - No cyanosis - No jittering - T: 36.7, HR 143, RR: 44 - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Term Baby Boy - Encourage breastfeeding - For BP and O2 sat on all extremities - For circumcision

63. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 8th HOL - With good suck - No vomiting - Active - No cyanosis - No jittering - T: 36.6, HR 141, RR: 42 - RU: 71/57, LU: 70/44, RL: 73/49, LL: 76/42 - 02 sat: 100% - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Term Baby Boy - Encourage breastfeeding - For rooming in - For circumcision

64. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 1st DOL - With good suck - No vomiting - Active - No cyanosis - No jittering - T: 36.5, HR 138, RR: 40 - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Minimal bleeding on surgical site - Term Baby Boy - s/p Circumcison - Encourage breastfeeding

65. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 2nd DOL - With good suck - Regular UO and BM - No vomiting - Active - No cyanosis - No jittering - T: 36.5, HR 138, RR: 40 - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Term Baby Boy - s/p Circumcison - May go home

66. M.L.T 27, G1P0, 40 3/7 CC: uterine contractions Past Medical/Personal/Social History: U/R Family History:U/R 111/78, HR 80, RR 18, 37C SE: not done IE: 7cm, 80%, St-2, (+) BOW CTG: Category 1 trace s/p OFE Male APGAR 4, 9, 9 2970 g MT 39 AGA CASE 3: APGAR 4, 9, 9

67. Boy T Delivered via NSD via outlet forceps extractions 27 y/o G1P1 (1001) at 40 3/7 weeks AOG, MT 39 AS 4,9 BW: 2970g BL: 51cm HC: 33 CC: 32 ½ AC: 33 ½

68. Physical exam Molding Flat and fontanelles Hyperemic right conjunctiva, (+) forceps mark and hematoma, right cheek Good air entry Good cardiac tone Soft abdomen Full pulses

69. APGAR (1 min)

70. APGAR (5 min)

71. Diagnosis Term baby Boy

72. Plan Admit to level 2 for observation Start feeding

73. Course in the ward SOAP 1 st minute of life Delivered via NSD outlet forceps extraction Acrocyanotic HR 110 Grimace No cry Limp Term baby boyDrying Stimulation Free flowing oxygen

74. Course in the ward SOAP 5 st minute of lifeAcrocyanotic HR 120 Grimace Good cry Good muscle tone Term baby boyThermoregulate Free flowing oxygen Admit to Level 2

75. Course in the ward SOAP 6 th hour of life Tolerated feedings Active No episodes of cyanosis With urine output and meconium passage Molding Hyperemic right conjunctivae Forceps mark and hematoma on right cheek Good air entry Good cardiac tone Soft abdomen Full pulses Term baby boyObservation at Level 2

76. NEONATAL MORBIDITIES WITH APGAR >=7

77. M.S.F. 30, G2P0 (0-0-1-0), 39 5/7 CC: watery vaginal discharge Past Medical/Personal/Social History: U/R Family History:U/R 128/77, HR 86, RR 16, 37.5C SE: pooling of clear AF IE: 2cm, 50%, St-3, (-) BOW CTG: Category 1 trace s/p NSD Male APGAR 8, 9 3265 g MT 39 AGA CASE 4: Pulmonary Hypertension

78. Festijo Boy S.F Delivered via NSD 32 y/o G2P1 (1011) 39 5/7 weeks AOG, MT 39 AGA AS 8,9 BW 3265g BL 49cm HC 36cm CC 33cm AC 30cm

79. Maternal History: -PROM 18 hours prior to delivery Ob History: -G1 – 2008, abortion at 7 weeks s/p D&C

80. Pertinent PE Caput Good cry and activity Clear amniotic fluid Flat and open fontanelles Good air entry, no retractions Grade 1-2 systolic murmur Soft abdomen Grossly male genitalia with urine output Full pulses

81. Diagnosis Term baby Boy

82. Course in the Wards SOAP 2 nd hour of life Cyanosis HR 150 RR 50s O2 sat 70% at room air Good cry and activity Adynamic precordium gr 2/6 systolic murmur at left parasternal border Full pulses Persistent Pulmonary Hypertension vs Cyanotic Heart disease Sepsis, unspecified -Refer to Neonatologist -Refer to Pediatric cardiologist -Hook IV line -Hyperoxia test -Start antibiotics -Transfer to level 3

83. Course in the Wards SOAP 3 rd hour of lifeRR 76 Active Good cry and activity, retractions, grunting Gr 2/6 systolic murmur Soft abdomen Full pulses Persistent Pulmonary Hypertension vs Cyanotic Heart disease Sepsis, unspecified -CBC, CRP -Hgt -Chest xray to rule out Pneumonia -Hook to O2 at 3 LPM

84. ABG6LPM pH7.287 pCO231.4 pO292.8 HCO315 O296% BE-10.3 HgbHctWBCBandsNeuLymMonEosPlt 1845521.12702161190 CRP = 0.02 mg/dL Hgt = 115 Bcs: No growth after 7 days

85. CXR

86. Course in the Wards SOAP 8 th hour of lifeHR 139 RR 61 T 37.4 O2 sat 100% 3LPM Persistent Pulmonary Hypertension vs Cyanotic Heart disease Sepsis, unspecified -Decrease O2 support at 1LPM

87. Course in the Wards SOAP 9th hour of lifeDesaturations as low at 70% at 1LPM Persistent Pulmonary Hypertension vs Cyanotic Heart disease Sepsis, unspecified -Increase O2 support at 2LPM -For 2d Echo to determine cardiac pathology -Give midazolam for sedation

88. Course in the Wards SOAP 12th hour of lifeDesaturations as low at 70% at 1LPM Persistent Pulmonary Hypertension vs Cyanotic Heart disease Sepsis, unspecified -For Intubation

89. Course in the Wards SOAP 12th hour of life s/p intubation Fr 3.5 Level 10 Good and equal air entry Soft abdomen Full pulses Persistent Pulmonary Hypertension; Pneumonia -Mech ventilation settings -FiO2 100 -PIP 20 -PEEP 6 -IT 0.4 -RR 70 -For HGT -Insert UVC -Shift antibiotics to Cefotaxime

90. ABG6LPM2/18 1 hr post intubation pH7.2877.346 pCO231.444.6 pO292.897.9 HCO31524.4 O296%96.9 BE-10.3-1.2 2d Echo: Elevated estimated right ventricular and pulmonary pressures; flattened interventricular septum and TR het of 61 mmHg (systolic BP of 71 mmHg) + right atrial pressure Moderate right ventricular dilation Mild ventricular hypertrophy Good biventricular systolic function Large bidirectional PDA No pericardial effusion

91. CXR

92. Course in the Wards SOAP 2 nd day of life Intubated NPO No desaturations No cyanosis T 37.1 RR 71 Jaundice Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA; Sepsis, unspecified -Reinsert OGT -Start breastmilk feeding 3ml every 3 hours -Start phototherapy -Revise mech vent -FiO2 100 -RR 60 -Itime 0.5 -PIP 18 -PEEp 5

93. ABG6LPM2/18 1 hr post intubation 2/19 FiO2 100 PEEP 5, PIP 20 RR 60 pH7.2877.3467.397 pCO231.444.654.3 pO292.897.946.6 HCO31524.433.3 O296%96.981.8 BE-10.3-1.27.7 2/19 Crea0.57 iCal0.98 Na135 K3.7

94. Course in the Wards SOAP 3rd day of life Intubated Tolerates 3ml of milk via OGT No desaturations No cyanosis HR 118-145 RR 60-74 BP 61-72/29-45 O2 sat 96-100% Jaundice to chest Good air entry Good cardiac tone Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Hyperbilirubinemia, unspecified; Sepsis, unspecified -Mech vent settings: -FiO2 70 -RR 60 -PIP 16 -PEEP 4 -Increase feedings to 5ml every 3 hours

95. Course in the Wards SOAP 4th day of life Intubated Tolerates 5ml of milk via OGT No desaturations No cyanosis RR 58-73 O2 sat 94-100% No alar flaring Jaundice to chest Shallow subcostal retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA; Hyperbilirubinemia, unspecified; Sepsis,unspecified -Mech vent settings: -FiO2 50 -RR 40 -PIP 16 -PEEP 4 -SIMV -Increase feedings to 10ml every 3 hours -Avoid vigorous suctioning -For VBG, Na, K, Ical, DBIB

96. ABG6LPM2/18 1 hr post intubation 2/19 FiO2 100 PEEP 5, PIP 20 RR 60 2/21 FiO2 40 PEEP 4 PIP 16 RR 30 pH7.2877.3467.3977.352 pCO231.444.654.356.8 pO292.897.946.642.8 HCO31524.433.331.5 O296%96.981.874.8 BE-10.3-1.27.75.1 2/192/21 Crea0.57 iCal0.981.33 Na135 K3.74.4 Total Bilirubin14.49 LIRZ Direct Bilirubin0.73 Indirect Bilirubin14.08

97. Course in the Wards SOAP 5th day of life Intubated Tolerates 10ml of milk via OGT No desaturations No cyanosis RR 51-62 HR 125-151 O2 sat 92-96% Jaundice to face No alar flaring Shallow subcostal retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified Hyperbilirubinemia, unspecified -Mech vent settings: -FiO2 35 -RR 25 -PIP 15 -PEEP 4 -SIMV -Increase feedings to 15ml every 3 hours -Transfer to isolette

98. Course in the Wards SOAP 6th day of life Intubated Tolerates 15ml of milk via OGT No desaturations No cyanosis RR 58-71 HR 108-145 O2 sat 92-96% Light Jaundice to face No alar flaring Shallow subcostal retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified Hyperbilirubinemia -For extubation -Hook to CPAP

99. Course in the Wards SOAP 7 th -11 th day of life CPAP Tolerates 30ml of milk via OGT No desaturations No cyanosis RR 48-64 HR 110-152 O2 sat 95-100% Light Jaundice to chest No alar flaring No retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified Hyperbilirubinemia -Continue feedings -Possible weaning off CPAP

100. Course in the Wards SOAP 12-15 th day of life Tolerates 30ml of milk via OGT No desaturations No cyanosis RR 48-55 HR 110-152 O2 sat 95-100% No alar flaring No retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified, resolved Hyperbilirubinemia, resolved -Continue feedings

101. PERSISTENT PULMONARY HYPERTENSION

102. Definition Persistent Fetal Circulation (PFC) Pulmonary hypertension resulting in severe hypoxemia secondary to right-to-left shunting through the foramen ovale and ductus arteriosus in the absence of structural heart disease

103. Typically seen in: Full term or post term infants 37-41 weeks gestational age within the first 12-24 hours after birth.

104. In Utero Fetal gas exchange occurs through the placenta instead of the lungs. PVR > SVR causes blood from the right side of the heart to bypass the lungs through the ductus arteriosus and foramen ovale.

105. Fetal Shunts Ductus arteriosus – R-L shunting of blood from pulmonary artery to the aorta bypasses the lungs. – Usually begins to close 24-36 hours after birth. Foramen ovale – Opening between left and right atria. – Closes when there is an increased volume of blood in the left atrium.

106. At Birth First breath – Decrease in PVR – Increase in pulmonary blood flow and PaO 2 Circulatory pressures change with the clamping of the cord. – SVR >PVR allowing lungs to take over gas exchange. – If PVR remains higher blood continues to be shunted and PPHN develops.

107. Signs of PPHN Infants with PPHN are born with Apgar scores of 5 or less at 1 and 5 minutes. Cyanosis may be present at birth or progressively worsen within the first 12-24 hours.

108. Later developments Within a few hours after birth – tachypnea – retractions – systolic murmur – mixed acidosis, hypoxemia, hypercapnia CXR – mild to moderate cardiomegaly – decreased pulmonary vasculature

109. Pulmonary Vasculature Pulmonary vascular bed of newborn is extremely sensitive to changes in O 2 and CO 2. Pulmonary arteries appear thick walled and fail to relax normally when exposed to vasodilators. Capillaries begin to build protective muscle. (remodeling)

110. Diagnosis Hyperoxia Test Place infant on 100% oxyhood for 10 minutes. – PaO 2 > 100 mmHg parenchymal lung disease – PaO 2 = 50-100 mmHg parenchymal lung disease or cardiovascular disease – PaO 2 < 50 mmHg fixed R-L shunt cyanotic congenital heart disease or PPHN

111. Hyperoxia Test (cont.) If fixed R-L shunt – need to get a preductal and postductal arterial blood gases with infant on 100% O 2. Preductal- R radial or temporal artery Postductal- umbilical artery – If > 15 mmHg difference in PaO 2 then ductal shunting – If < 15 mmHg difference in PaO 2 then no ductal shunting

112. Treatment Goals: – To maintain adequate oxygenation. These babies are extremely sensitive Handling them can cause a decrease in PaO 2 and hypoxia Crying also causes a decrease in PaO 2 Try to coordinate care as much as possible – To maintain neutral thermal environment to minimize oxygen consumption.

113. Mechanical Ventilation TCPLV (Time cycled pressure limited ventilation) may be used with PPHN. Want to use low peak inspiratory pressures Monitor PaO 2 and PaCO 2 with a transcutaneous monitor

114. Hyperventilation Hyperventilation helps promote pulmonary vasodilation Respiratory Alkalosis- decrease PAP to level below systemic pressures to improve oxygenation by helping to close the shunts – Try to keep pH =7.5 and PaCO 2 = 25-30 – Alkalizing agents - sodium bicarbonate or THAM

115. Hyperventilation (cont.) Babies often become agitated when they are hyperventilated May need to administer muscle relaxants and sedation – usually given pancuronium and morphine pancuronium- q 1-3 hours IV at 0.1-0.2 mg/kg morphine- continuous infusion 10 micrograms/kg/hr

116. Nitric Oxide (NO) Potent pulmonary vasodilator – decrease pulmonary artery pressure – increase PaO 2 Does not cause systemic hypotension NO more effective in PPHN babies without lung disease Baby must be weaned slowly off NO or may have rebound hypertension

117. Effects of NO NO is metabolized to nitrogen dioxide (NO 2 ) which can cause acute lung injury. NO 2 is potentially toxic. NO reacts with hemoglobin to form methemoglobin.

118. Outcome PPHN may last anywhere from a few days to several weeks. Mortality rate is 20-50%. – Decreased by HFOV and NO – Decreased by ECMO Babies treated with hyperventilation may develop sensorineural hearing loss.

119. M.G.B. 41, G2P1 (1-0-0-1), 28 2/7 weeks CC: left breast pain, elevated blood pressure Past Medical/Personal/Social History: (+) Chronic hypertensive for 24 years; Invasive ductal CA, left breast, Stage IV Family History: (+) Hypertension/DM 150/90, HR 88, RR 18, 36C Left breast mass measuring 24 x 14 cm IE: not done CTG: Reactive s/p planned PCS, Myomectomy, Incision biopsy L breast Female APGAR 9, 9 1250 g MT 30 AGA CASE 5: Prematurity, Invasive Ductal CA

120. JPB Born on February 14, 2014 Live preterm baby girl Delivered via Scheduled Primary Cesarean Section for Maternal Condition (Breast Cancer) 41 y/o G2P2 (1102) 28 5/7 weeks AOG BW 1250 g BL 38 cm HC 26 cm CC 23 cm AC 21 cm MT 30, AGA AS 9,9

121. Delivery Apgar 1 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing Apgar 5 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing Immediately placed in a food grade plastic bag O2 saturation: >85% Newborn care was rendered

122. Problem List: Respiratory Distress Syndrome Infection Apnea of Prematurity Hyperbilirubinemia of Prematurity

123. 1. Respiratory Distress Syndrome 2 nd Hour of life SubjectiveObjectiveAssessmentPlan Grunting Spontaneous breathing No cyanosis 20 minutes after No improvement of the grunting RR 60 Fair air entry Subcostal, intercostal and suprasternal retraction T/C Respiratory Distress Syndrome, Prematurity Hook to nasal CPAP Oxacillin, Cefotaxime, Amikacin Intubation done Surfactant therapy (4ml) given Umbilical catheterization

124. VBG pHpCO2PO2HCO3O2BE 7.32861.745.132.376.35.3Compensated Respiratory Acidosis Chest Xray Consider Hyaline Membrane Disease, cannot totally rule out Neonatal Pnemonia Blood Culture No Growth (7 days) CBC HgbHctWBCBandNeuLympMonEosPlt 151457.944842512394nRBC /100 WBC HGT82

126. Problem 2: Hyperbilirubinemia 1 st day of life SubjectiveObjectiveAssessmentPlan Intubated FiO2 40% RR 35 PIP 14 PEEP 3.8 s/p surfactant therapy Mother had a would culture: Heavy growth of S. aureus: sensitive to all except Penicillin VS: HR 144, RR 65, T 36.9 O2 sat 98% Jaundice to upper chest Good air entry, subcostal, intercostal, suprasternal retractions Good cardiac tone Soft abdomen Full pulses Respiratory Distress Syndrome vs Neonatal Pneumonia, Sepsis, unspecified, Hyperbilirubinemi a, unspecified Labs: Bilirubin Levels, CRP, Chest Xray, Hgt Single Overhead Phototherapy Oxacillin, Cefotaxime, Amikacin

127. Bilirubin Levels TotalDirectIndirect 5.210.384.92 Chest Xray Consider Hyaline Membrane Disease, with interval improvement in the Lung Status CRP 0.21 mg/dl HGT152 VBG pHpCO2PO2HCO3O2BE 7.35459.828.433.250.36.6Compensated Respiratory Acidosis

129. VBG pHpCO2PO2HCO3O2BE 7.2455.7332426-3.0Respiratory Acidosis Chest Xray unchanged bilateral lung opacities consistent with resolving hyaline membrane disease Blood Culture No growth for 24 hrs HgbHct 12637 HGT92 Urinalysis RBCWBCEpithelialCastBacteria 2561014 NaKiCal 1394.9139 Bilirubin Levels TotalDirectIndirect 4.540.384.22LRZ

131. 16 th day of life SubjectiveObjectiveAssessmentPlan Intubated FR 8 FiO2 20 RR 20 PIP 10 PEEP 4 iT 0.5 No desaturations VS: HR 141, RR 52, T 37 O2 sat 100% Pink Good air entry, shallow subcostal retractions Good cardiac tone Soft abdomen Full pulses Apnea, Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemi a, unspecified, resolved Labs: Blood gas Nasal CPAP  intubation Aminophylline decreased to every 12 hours Meropenem 24 mg IV every 12 hrs (20 mg/kg/dose)

132. VBG pHpCO2PO2HCO3O2BE 7.26163.435.728.457.9-0.2Respiratory Acidosis

133. Current Diagnosis Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified, Resolved

134. DISTRIBUTION OF BIRTHS February 2014

135. Distribution of Deliveries According to Birthweight

136. Classification Based on Best Score ClassificationSGAAGALGAGrand Total Preterm 121123 Term 011115126 Post Term 0011 Grand Total 113217150

137. Small for Gestational Age Infants, February 2014 NUMBER OF SGA NEONATES 1 Incidence among total live births 6/1000 LB Delivered from normal mothers 0 Delivered from high risk mothers 1 A. Maternal factors1 Gestational Hypertension B. Fetal Factors 0 C. Unknown factor 0

138. Large for Gestational Age Infants, February 2014 NUMBER OF LGA NEONATES 17 Incidence among total livebirths 110 /1000 LB Delivered from normal mothers 8 Delivered from high risk mothers 9 A. Maternal factors Gestational diabetes mellitus Hypertension 1313 B. Fetal Factors Fetal Macrosomia 1

139. DISTRIBUTION OF BIRTHS ACCORDING TO GESTATIONAL AGE ON DELIVERY

140. Distribution of Births According to AOG on Delivery Livebirths = 151

141. Weight vs MT Wt (grams)<2828-2930-3132-3334-3536-36 6/737-3940-42> 42Grand Total 499 and below 0000000000 500-599 0000000000 600-999 1 000000001 1000-1499 00 221 00005 1500-1999 000 122 0005 2000-2499 0000 244 0010 2500-2999 00000 1513 055 3000-3499 000000 506 056 3500-3800 000000 93 012 >3800 000000 42 06 Grand Total 102357118140150 * MT of 1 patient cannot be determined

142. Weight vs LMP BW RANGE <2828-2930-3132-3334-3536-36 6/737-3940-42> 42 Grand Total 499 and below 0000000000 500-5990000000000 600-9991000000001 1000-14990221000005 1500-19990010310005 2000-249900005230010 2500-29990000224110055 3000-3499000002495056 3500-3800000000103013 >38000000004116 Grand Total 1231107107191151

143. Weight vs Best Score Wt (grams)<2828-2930-3132-3334-3536-36 6/737-3940-42> 42Grand Total 499 and below 0000000000 500-599 0000000000 600-999 1000000001 1000-1499 0121100005 1500-1999 0001220005 2000-2499 00004330010 2500-2999 0000124210055 3000-3499 000000516057 3500-3800 00000093013 >3800 0000004206 Grand Total 112289107210151

144. Preterm Delivery, February 2014 NUMBER OF PRETERM NEONATES 17 Incidence among total livebirths 150 in 1000 LB Delivered from low risk mothers 3 Delivered from high risk mothers 14

145. ROOMING IN AND BREASTFEEDING RATES

146. Rooming-in Rate Rooming-in rate – 125/135 (92.6%) – 16 patients are not eligible

147. Breastfeeding rate LevelPureMixedFormula only NoneDonorTotal Level I (N =23) Roomed-in (N =40) 491220063 Level II (N = 71) 353240071 Level III (N = 16) 2821316 Isolation (N =1) 100001 Grand Total 8752803150

148. GENERAL INDICES OF PERINATAL DEATH

149. Neonatal Mortality, February 2014 NUMBER OF MORTALITIES1 Incidence among total live births 6 per 1000 LB PERINATAL MORTALITY RATE Crude Perinatal Mortality Rate 1 mortality / 151 total births 6 per 1000 TB Corrected Perinatal Mortality Rate 0 non-lethal mortalities+0 stillbirth /151 total births

150. MORTALITY CASE

151. R. M.V. 35, G2P1 (1-0-0-1), 39 3/7 CC: uterine contractions Past Medical/Personal and Social History: U/R Family History: (+) Colon and Lung Ca, (+) Hypertension, (+) Diabetes 120/77, HR 80, RR 20, 37C IE: 5-6cm, 80%, St-2, (+) BOW CTG: Category 1 trace s/p NSD Male APGAR 0 3010 g CASE 6: Mortality Case RMV

152. Admitting CTG

153. Tracing upon arrival at LR, prior CEA

154. Tracing after CEA

155. CTG tracing after AROM

157. CTG tracings prior to transfer to DR

158. FHT tracing at DR (supine)

159. FHT tracing at DR (Left lateral decub)

160. FHT tracing (Prepping to Baby out)

161. Mortality Case: RV Term Baby Boy NSD 35 y.o. G2P2 (2002) 39 3/7 weeks AOG Anthropometrics: – BW 3120g BL 53cm HC 34cm CC 31cm AC 30cm – AGA

162. Upon delivery Pale, not breathing, limp Drying and stimulation 30s Limp, pale, not breathing, HR 0 Positive pressure ventilation 1 minute Limp, pale, not breathing, HR 0 PPV continued, prepared for Endotracheal intubation 2 minutes Limp, pale, not breathing, HR 0 Chest compressions started Endotracheal intubation, bag-tube ventilation

163. 5 mins Limp, pale, not breathing, HR 0 Ventilation/Compression continued Epinephrine/ET 0.1mg/kg/dose every 3mins 8 mins Limp, pale, not breathing, HR 40s Ventilation/Compression continued 15 mins Limp, pale, not breathing, HR 50s Umbilical vein cannulation  Epinephrine/UVC at 0.01mg/kg/dose 20 mins Limp, pale, not breathing, HR 50s ET tube placement reevaluated – not in place ET tube reinserted 25 mins Limp, pale, not breathing, HR 180s NICU Transfer

164. Apgar Score 1 st 5 th 10 th Appearance 000 Pulse001 Grimace 000 Activity 000 Respiration 000 TOTAL001

165. At the NICU Pale, unresponsive BP not appreciated, HR 180, on bag-tube ventilation, T 34C No dysmorphic features Pupils 8-9mm dilated, not reactive to light No spontaneous breathing, Equal chest rise, good air entry both lungs Regular cardiac rhythm, no murmur appreciated Soft abdomen Poor pulses, CRT prolonged

166. Severe hypoxic ischemic encephalopathy, post cardiopulmonary arrest Initial assessment

167. Problems Asphyxia Mixed Metabolic and Respiratory Acidosis 2/8 pH6.604 C0261.2 PO2114.5 HCO36.1 BE-30 O2 sat82.9% Mixed metabolic and respiratory acidosis Hooked to Mechanical Ventilator Correction with NaHCO3 Therapeutic Hypothermia 2/8 6.52 95.6 79 7.8 -30 60% Mixed met and resp acidosis Lactate (4.5-19.82 mg/dL) 223.2 mg/dL Bleeding from puncture sites  discontinued 9 th HOL

168. Problems Shock prob cardiogenic Severe anemia prob sec to hemorrhage HgbHctWBCBandNeutLymphMonoPlt 572042.764541818870 nRBC Cranial Ultrasound Normal PT Control13.3 Patient38.5 % activity0.2 INR3.78 aPTT Control29.3 Patient138 2D Echo PA pressure 50 Right to left shunting (PDA) Underfilled left ventricle Severe tricuspid regurgitation PFO bidirectional PNSS 20mL/kg bolus 2x Dopamine and Dobutamine Drip Blood transfusion ordered but refused PNSS 20mL/kg bolus 2x Dopamine and Dobutamine Drip Blood transfusion ordered but refused

169. Problems Infection HgbHctWBCBandNeutLymphMonoPlt 572042.764541818870 nRBC Blood culure and sensitivity No growth CRP (NV 0-0.5mg/dL) 0.01mg/dL Ampicillin 50mg/kg/dose Gentamicin 4mg/kg/day Ampicillin 50mg/kg/dose Gentamicin 4mg/kg/day

170. 10hrs and 30 mins Patient expired 10 th hour of life Still unresponsive On mechanical ventilator On Dopamine and Dobutamine Drip DNR signed

171. INTRACTABLE METABOLIC ACIDOSIS SECONDARY TO MULTIORGAN DYSFUNCTION SECONDARY TO PERINATAL ASPHYXIA Final Diagnosis

172. Learning Points Adequate communication between teams Regular and proper evaluation of adequacy of resuscitation

173. THANK YOU!!!

174. PERINATAL ASPHYXIA

175. Condition of impaired gas exchange that leads to fetal hypoxemia and hypercardbia Occurs during the 1 st and 2 nd stage of labor In term infants, 90% pccur in antepartum or intrapartum period as a result of impaired gas exchange across the pacenta Postpartum – secondary to pulmonary, cardiovascular, neurologic abnormalities

176. Hypoxic-Ischemic Encephalopathy Abnormal neurobehavioral state in which the predominant pathogenic mechanism is impaired cerebral blood flow Suspected if: – AS 5minutes – FHR <60 bpm – Prolonged (>1hr) acidosis – Seizures within the first 24-48hrs after birth – Burst-suppression patten EEG Cloherty J. Manual of Neonatal care, 6 th ed