R.R.G 39, G2P1 ( ), 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 CASE 1:

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

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

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

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

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 Thermoregulation

Admitting Impression Extreme Prematurity, Very Low Birth Weight Sepsis Unspecified

UVC inserted 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

PROBLEMS 1. Prematurity 2. Sepsis 3.. Respiratory (Pneumonia and Apnea) 4. Jaundice 5. Anemia

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

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

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

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

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

Problem 3. Respiratory (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 Aminophylline

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 Aminophylline Stimulation during periods of apnea

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 Ambubagging EG7 Chest Xray O2 support

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

Progressing Pneumonia with Consolidation

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

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

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

Awake Active Episodes of desaturation T 37C HR 130 O2 sats % Pink Minimal effort on respiration No alar flaring sounds Regular cardiac rhythm Full pulses t/c Bronchopulmonary Dysplasia Mech Vent settings adjusted accordingly Start Dexamethasone 13 th to 17 th day of life

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 Hyperbilirubinemia Unspecified Start double phototherapy

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 Hyperbilirubinemia Unspecified, resolved Phototherapy discontinued

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

HgbHct Pre transfusion 8224 HgbHct Post Transfusion 12737

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

THANK YOU