1. Ｒ1 歐宗頴
2016/11/04
case discussion

2. case demography Name: 阮Ｏ嬌之子, 1786xxxx Age: 7-day-old, PMA: 34wks
Gender: boy
Admission: 2016/10/19
Chief complaint:
Lethargy and poor feeding since 7d/o

3. prenatal history lower abdominal pain
G4P2AA2
Maternal: 34y/o, GDM(-), PIH(-), preeclampsia(-)
Level II sonography: normal
HBsAg(-), HBeAg(-), VDRL(-), HIV(-), Rubella IgG(+)
Amniocentesis: not performed
GBS: not performed
lower abdominal pain
preterm premature rupture of membrane
Tocolysis with Yutopar, betamethasone, Cefazolin
10/16
32+5wk
10/19
GA33wk
NST: severe variable deceleration
emergent Cesarean section

4. Clinical course G4P2, GA33wk, C/S due to variable deceleration
10/19
G4P2, GA33wk, C/S due to variable deceleration
BBW: 2008g(25-50th)
BL: 44cm(50%)
HC: 33cm(25-50%)
Apgar score: 6 (hypotonia)
subcostal retraction, desaturation(70%)

5. 10/19

7. Clinical course temperature instability off incubator GA33wk, C/S, AGA
10/19
10/24
temperature instability
off incubator
GA33wk, C/S, AGA
fetal distress with TTN
Ampicillin & Gentamicin for 3 days
trophic feeding with SSC20 since 12th hr

8. Clinical course temperature instability off incubator 14:30 Calcitriol
10/19
10/24
10/25
GA33+6wk
temperature instability
off incubator
14:30 Calcitriol
GA33wk, C/S, AGA
fetal distress with TTN
Ampicillin & Gentamicin for 3 days
trophic feeding with SSC20 since 12th hr

9. Clinical course temperature instability temperature instability
10/19
10/24
10/25
GA33+6wk
temperature instability
temperature instability
off incubator
14:30 Calcitriol
GA33wk, C/S, AGA
fetal distress with TTN
Night-
Lethargy, poor feeding
Fever(-), Irritability(-)
Apnea(-), Bradycardia(-), Desaturation(-), Tachypnea(-)
N/V(-), Stool passage change(-), Bloody stool(-)
Physical examination:
Fontanelle bulging(-)
Abdomen: soft and flat(28cm), normoactive bowel sounds, tenderness(-),
mass(-), hepatospelnomegaly(-), rigidity(-), hernia(-)
Muscle tone: flaccid, poor sucking, focal weakness(-)

10. Clinical course Neosure 303 95 temperature instability off incubator
10/19
10/24
10/25
GA33+6wk
temperature instability
off incubator
Night-
Lethargy, poor feeding
GA33wk, C/S, AGA
fetal distress with TTN
trophic feeding with SSC20 since 12th hr
Neosure
303
235
195
155
115 95
SSC20 35 75
150
120
100 40 60 80
20cc/kg/d +6
GA34wk

13. 10/26 16:00

14. Impression
Necrotizing enterocolitis, stage IA
hypocalcemia, suspect insufficient intake related
prematurity, GA33wks
respiratory distress, favor TTN

15. Clinical course temperature instability off incubator 14:30 Calcitriol
10/19
10/24
10/25
GA33+6wk
temperature instability
off incubator
14:30 Calcitriol
GA33wk, C/S, AGA
fetal distress with TTN
Night-
Lethargy, poor feeding
10/26
GA34wk
NPO
Ceftriaxone
Amikacin
Metronidazole
Night-
Lethargy recovery

16. 10/26 16:00
10/26 23:30

17. segmental dilated small loops favor reflex ileus
10/27 13:00
10/27 21:30
segmental dilated small loops
favor reflex ileus
segmental bowel wall swelling

18. Clinical course temperature instability off incubator 14:30 Calcitriol
10/19
10/24
10/25
GA33+6wk
temperature instability
off incubator
14:30 Calcitriol
GA33wk, C/S, AGA
fetal distress with TTN
Night-
Lethargy, poor feeding
10/26
GA34wk
10/30
11/02
35wk
NPO
Ceftriaxone
Amikacin
Metronidazole
trophic feeding with neosure
54cc/kg/d
Night-
Lethargy recovery

19. diagnosis
Necrotizing enterocolitis, stage IA
hypocalcemia, suspect insufficient intake related
prematurity, GA33wks
respiratory distress, favor TTN

20. necrotizing enterocolitis
discussion

21. necrotizing enterocolitis
introduction
necrotizing enterocolitis
one of the most common gastrointestinal emergencies in the newborn
inflammation
invasion of enteric gas forming organisms
dissection of gas into the muscularis and portal venous system

22. pneumomatosis

23. unspecific feeding intolerance
Vital signs change, lethargy
OB(+)
bloody stool
ileus
pneumomatosis

24. Vital signs change, lethargy
OB(+)
bloody stool
ileus
Absence bowel sounds
pneumomatosis
mild acidosis
thrombocytopenia
ascites
portal vein gas

25. Vital signs change, lethargy OB(+) bloody stool ileus
Absence bowel sounds
pneumomatosis
mild acidosis
thrombocytopenia
ascites
portal vein gas
Unstable Vital Signs, DIC, neutropenia
peritonitis
pneumoperitoneum

28. 2016 Oct. 16

32. Take home message Risk factors for NEC unspecific presentation
early recognition, early intervention
prophylaxis

33. thanks for your attention

35. CCr 18 FeNa 0.3% (1-FeP) 84% FeCa 0.72% Albumin 3.1 BUN 4 Cr 0.62 Ccr
136 K
4.9
cCa
7.8 P
10.2 Mg
1.6
ALK-P
149
AMON 31
CRP
<7
CCr 18
FeNa
0.3%
(1-FeP)
84%
FeCa
0.72%