Neonatal Arrhythmia

Birth History ARB Delivered via STAT Primary Cesarean Section for arrest in cervical dilatation 25 year old G1P1 (1001) AOG: 38 5/7 weeks MT: 39 AGA Apgar Score: 9,9 Anthropometrics: BW= 2890 grams BL= 47 cm HC= 35 cm CC= 32 cm AC= 27 cm

Maternal History: 1st Trimester, Cough and Colds, no medications given Past Medical History: Breast cyst, Left, s/p Excision(2012) Family History: Hypertension OB History: present pregnancy Personal Social: College graduate, housewife, no vices

Upon Delivery Good cry and activity, no cyanosis Clear amniotic fluid Flat and open fontanelles Good air entry, no retractions Irregular cardiac rhythm, HR 140 bpm, no murmur (skipped beats, 10 -13x per minute) Soft Abdomen Grossly normal female genitalia Full pulses

Initial Impression Term Baby Girl r/o Cardiac Pathology

Transfer to Level 3 of care hook to cardiac monitor PLAN: Transfer to Level 3 of care hook to cardiac monitor Refer to a pediatric cardiologist Hook to cardiac monitor BP and oxygen saturations on all extremities

Course in the NICU Subjective Objective Assessment Plan 3rd HOL Good suck, cry, and activity Able to latch T: 36.8, HR 146, RR: 44 No cyanosis, no alar flaring Good air entry, no retractions Irregular cardiac rhythm, with 1-2 skipped beats/minute Full pulses Live term baby girl r/o cardiac pathology Monitor vital signs every hour Hook to cardiac monitor BP and O2 sats on all extremities Watch out for 25-30 skipped beats/minute

Oxygen saturations on all extremities: 100% Stable vital signs BP on all extremities: Oxygen saturations on all extremities: 100% 61/31 63/38 65/30 61/35

Course in the NICU Subjective Objective Assessment Plan 10th HOL Good suck, cry, and activity Tolerates 10-15ml of milk feedings T: 37, HR 122, RR: 44 No cyanosis, no alar flaring Good air entry, no retractions Irregular cardiac rhythm, with 2-5 skipped beats/minute Full pulses Live term baby girl r/o cardiac patholog Bed side 2D-echo EG-7

2D echo Cardiology remarks: PFO 4.2mm Left to right shunt Trivial mitral regurgitation PDA 1.8 continuous blow Normal transitional circulation; no arrhythmia Cardiology remarks: Common incidental finding in newborns Structural abnormality ruled out No signs of heart failure noted Refer for >5 skipped beats per minute

EG7 results: Na: 138 mmo/L K: 4.3 mmo/L iCal: 1.21 mmo/L Hct: 47% pH: 7.37 pCO2: 47 mmHg pO2: 38mmHg (80-105) HCO3: 27 mmo/L TCO2: 28 mM Beecf: 2 mM sO2: 69% (95-98) tHB: 16 g/dL

Course in the NICU Subjective Objective Assessment Plan 24th HOL Good suck, cry, and activity Tolerates 10-15ml of milk feedings every 2 hours T: 36,5, HR 148, RR: 56 No cyanosis, no alar flaring Good air entry, no retractions Regular cardiac rhythm, no skipped beats Full pulses Live term baby girl Rooming in

Course in the NICU Subjective Objective Assessment Plan Day 2 of life Good suck, cry, and activity Breastfeeding T: 36,5, HR 148, RR: 56 No cyanosis, no alar flaring Good air entry, no retractions Regular cardiac rhythm, no skipped beats Full pulses Live term baby girl May go home For ECG - Normal

Neonatal Arrhythmias Arrhythmias in fetuses and newborns are relatively common -- up to 90% of newborns and 1% to 3% of pregnancies Life-threatening arrhythmias are uncommon

Almost all arrhythmias fall into one of three categories irregular tachycardic bradycardic

Arrhythmias are found in 1–5% of newborns during the first 10 days of life Most are premature supraventricular beats that will disappear during the first month of life The development of symptoms depends on the rate and duration of the arrhythmia tachyarrhythmia - 240–300bpm Bradyarrhythmia - <100bpm

Normal Newborn ECG

Sinus Pause

Sinus Arrhythmia

Sinus pauses from 800 to 1,000 msec may occur in healthy newborns Such pauses usually are followed by escape beats from the atria or the atrioventricular (AV) junction Pauses of more than 2 seconds are considered abnormal

Possible causes: oversedation, (drugs passed through the placenta) hypothermia central nervous system abnormalities increased intracranial pressure increased vagal tone obstructive jaundice hypothyroidism