Diaphragmatic plication for phrenic nerve paralysis following obstructed labour in a neonate: A case report Naqvi Sayyed EH*, Beg Mohammed H, Haseen Azam, Abqari Shaad, Khan Ghazanfer Department of Cardiothoracic Surgery & paediatrics, JN Medical College, AMU, Aligarh Presented by: Dr S. Ehtesham H. Naqvi MS, MCh CTVS, DNB CTVS Assistant professor CTVS, JN Medical College, AMU, Aligarh

Phrenic nerve paralysis following obstructed labour: An overview Etiology: usually excessive lateral hyperextension of the neck during obstructed labour Incidence: 1:1000- 1:10,000 Most cases unilateral, more common on the right side. If excessive stretching of C3-C5 nerve ,simultaneous occurrence of brachial plexus palsy (most common Erbs’ Palsy) : 75% of cases. Risk factors: Abnormal presentations (Breach, shoulder, face), Cephalo- pelvic disproportions, Forceps interventions

Phrenic nerve paralysis following obstructed labour: An overview Usual presentation Unilateral involvement: respiratory difficulty, incidental X ray finding Bilateral involvement :severe respiratory failure presenting as cyanosis in neonatal period. Examination reduced respiratory movements, bowel sounds in the chest (eventration), paradoxical respiratory indrawing of abdominal musculature. Investigations X ray Chest, Fluoroscopy, USG Chest, CECT Chest

Phrenic nerve paralysis following obstructed labour: Management ??? Unilateral Asymptomatic: Conservative Unilateral with respiratory distress: positive pressure ventilation, conservative/elective diaphragmatic plication at one month Neonatal diaphragmatic plication Indications: Bilateral paralysis, inability to wean from ventilator, bowel complications, prevention of lung collapse, hypoplasia Schwartz MZ, Filler RM. Plication of the diaphragm for symptomatic phrenic nerve paralysis. J Pediatr Surg. 1978; 13:259–63 De Vries TS, Koens BL, Vos A. Surgical treatment of diaphragmatic eventration caused by phrenic nerve injury in the newborn. J Pediatr Surg. 1998; 33:602–5

CASE REPORT Presentation 25 days male baby weighting 3.2 kg Full term Breech delivery at some private hospital. history of the usage of delivery forceps. difficulty in breathing and laboured breast feeding Abnormal posture of right arm since birth Examination Room air saturation 90-95%. No cyanosis, CVS system WNL Respiratory movements diminished on right side, Indrawing of right upper abdomen with respiration. Breath sounds diminished in right lower chest. Erb's arm palsy on the right side.

INVESTIGATIONS Fluoroscopy: paradoxical movements of right diaphragm INVESTIGATIONS Fluoroscopy: paradoxical movements of right diaphragm. Normal left dome of diaphragm Echocardiography: Structurally normal heart X ray Chest

MANAGEMENT Risk, benefits of Neonatal diaphragmatic plication measured. Plan for postoperative ventilatory management. Discussion with the parents. Surgical Procedure: Posterolateral Thoracotomy through right 8th intercoastal space with plication of diaphragm Peroperative findings: Lax right hemidiaphragm raised up to mid thoracic levels Collapsed right lung Colon occupying supra hepatic space

PEROPERATIVE FINDINGS

OUTCOMES Extubated on the next morning of surgery Discharged on day 7 of surgery No wound infection At discharge: room air saturation 99- 100%, no tachypnea, no difficulty in feeding

MESSAGE Early plication in cases of congenital phrenic nerve palsy may benefit in terms of: Improvement of ventilation and reduction in respiratory complaints Growth of lung during the developmental phase Possible prevention of gastrointestinal complications However more number of patients need to be reviewed to support the assumption.