2. Identifying Data Newborn female Filipino Born on November 25, 2013 33 year old G2P2 (2002) 38 6/7 weeks age of gestation based on LMP

3. Maternal history Blood group B+, HbsAg nonreactive 4 th month AOG – had UTI, had fever and cough which was treated with an unrecalled antibiotic for 7 days (+) Family history of an unspecified lung disease Occasional social drinker prior to pregnancy

4. Birth history Spontaneous onset of labor Spontaneous rupture of membranes Vaginal delivery Born full term with AS 9, 9, 39 weeks by MT BW 3.54 kg BL 47 cm

5. 2 nd HOL Non-separation Good suck during latching Good cry and activity RUE: 73/39 LUE: 70/28 RLE: 76/31 LLE: 75/38 HR: 156 RR: 54 T:36.4 Noncyanotic Good air entry, regular cardiac rhythm Full pulses, CRT <2 sec A> Term newborn female

6. 17 th HOL Good suck during latching Good cry and activity With urine output and meconium passage HR: 145 RR: 52 T:36.6 Noncyanotic Good air entry Soft systolic murmur at left parasternal order Full pulses, CRT <2 sec A> Term newborn female, probably in transitional circulation

7. 40 th HOL Good suck during latching Good cry and activity With urine output and meconium passage HR: 140 RR: 40 T:37.3 Wt: 3425 grams (wt loss 115 grams, 3% BW) Noncyanotic Good air entry Grade 2/6 holosystolic murmur at left parasternal border A> Term newborn female, probably in transitional circulation rule out congenital heart disease

8. 43 rd HOL 2D Echocardiography:  4mm ventricular septal defect  2-3mm patent ductus arteriosus with continuous flow  Left sided aortic arch with a juxtaductal coarctation (2mm)  Dilated main pulmonary artery, still R ventricle dominant heart  PA pressure 60 mmHg  CHD; VSD, Coarctation  Small PDA  RV and PA hypertension

9. 48 th HOL Exclusively breastfed with good suck Good cry and activity Adequate urine output and meconium passage HR: 127-146 RR: 42-72 T:37.3 Noncyanotic Good air entry Grade 2-3/6 holosystolic murmur at left parasternal order Fair femoral pulses A> Term newborn female, CHD – VSD, Coarctation

10. NICU Referral Noncyanotic RUE: 88/34, 98% LUE: 91/34, 96% RLE: 67/47, 100% LLE: 63/38, 97% HR: 154 RR: 72 T:37.8 Noncyanotic Good air entry Grade 2-3/6 holosystolic murmur at left parasternal order Fair femoral pulses, left>right A> Term newborn female

11. NICU Referral Feeding with expressed breastmilk continued IVF D10IMB at TFR 90ml/kg/day Diagnostics: CBCPC, Blood C&S, Chest XrayCBCPCBlood C&S Therapeutic: Ampicillin at 101.7 mg/kg/day Gentamicin 3.95 mg/kg/dose Definitive management:  Options:  Open heart surgery: VSD and repair of coarctation  Closed heart surgery: Coarctation repair OR coarctation repair + band

12. Day 4 of life Underwent repair of coarctation and PA banding Procedure:  Extended end-to-end anastomosis, PA banding Intraoperative findings:  Short segment, preductal coarctation approximately 2 mm in diameter  Hypoplastic aortic arch

13. Postoperative Issues: Hypertension  BP range: 97-114 /46-69 mmHg  Nitroglycerine started Assisted ventilation  Commenced during operation  Maintained and gradually weaned from mechanical ventilation  Spontaneous respiratory capability was monitored via pulse oxymeter and blood gasesblood gases  Extubated on day 1 post op

14. Postoperative Issues: Increasing WBC  Afebrile  Chest xray showed presence of bilateral lung opacities  Cefotaxime added to present antibiotics at 50 mg/kg/dose

15. Final Diagnosis Live term baby girl delivered via NSD to a 33 years old G2P2 (2002) 38 6/7 wks AOG by LMP, MT 39 wks, AGA, AS 9,9 Congenital heart disease – Coarctation of the aorta with large ventricular septal defect s/p coarctation of aorta repair (end to end anastomosis), pulmonary artery banding, thoracotomy

16. CBC with platelet count HgbHctWBCBandNeuLymPlt 11/281444414.6--5338304STG 12/011685218.736819165STG 12/061725220.4--5832388-- Blood C&S: No growth after 7 days of incubation

17. Electrolytes NaKiCaMgBUNCrea 11/281414.31.210.8710.60.78 11/291414.40.98 11/301413.90.9111.760.60 12/041425.63.60.42

18. Blood Gases pHpCO2HCO3pO2BEO2 Sat 11/287.4123.615.1132.2-6.798 11/297.2249.620.4177-799 11/297.3735.921.1184.6-2.999 FiO2 – 40% PIP 16 PEEP 6 RR 45 IT 0.4 11/307.3741.423.97995 FiO2 – 21% PIP 14 PEEP 4 RR 20 IT 0.4

19. Thank youThank you