1. CASE DISCUSSION Legaspi, Luis Ontok, Abdul-Aziz Payumo, Edelissa
Pelayo, May Angela
Rodriguez, Melissa
Samson, Edgardo

3. HISTORY

4. Identifying Data Baby Boy J.C. Full Term, 37 weeks by P.A.
2600 g, appropriate for G.A.
Cephalic presentation
Repeat low-segment C.S.
23 year old, G2P2

5. Maternal Obstetrical History
OB Index: G2P2 (2002)
Previous Pregnancy:
Date:
Sex: Male
BW: kg
Place: Perpetual Help Hospital
Delivery Type: 1o Low-segment C.S.
AOG: Full Term
Complications: Cephalopelvic Disroportion

6. Antenatal History LMP: September 04, 2008 Prenatal Checkups: 2 at PGH
Medications Taken: None
Illnesses/Infection: None
Alcohol/Tobacco Use: None

7. Labor Onset of Uterine Activity: Spontaneous
Intensity of Contractions: Moderate
Membrane Status: Intact
Analgesia: None

8. Delivery Mode: Abdominal Amniotic Fluid: Slightly Meconium Stained
Analgesia: Subarachnoid Block

9. History of Present Illness
Limp, HR 60’s, acrocyanotic, with no response
(+) grimace, HR 50’s, acrocyanotic, some flexion
Thermoregulation
Suctioning
Tactile stimulation
Some flexion, HR 100, (+) grunting, (+) grimace, acrocyanotic
PPV
(+) crying, acrocyanotic, active, HR 130s, RR 50-60
Given blow by O2
Stimulation
(+) grunting, (+) retractions
Weaned off from O2
NICU 3
Placed on O2 support via 10 lpm

10. Immediate Neonatal Period
APGAR Score: 5, 9
Resuscitation:
Supplementary O2 10 LPM via hood
Positive Pressure-Ventilation

11. Family History (-) Hypertension (-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Blood Dyscrasias

12. PHYSICAL EXAMINATION

13. PHYSICAL EXAM GENERAL APPEARANCE: limp, in respiratory distress
VITAL SIGNS:
T: 36.6oC HR: 130 bpm RR: 50 cpm
Wt: 2600 g Lt: 49 cm HC: 32.5 cm
CC: 31 cm AC: 28 cm

14. PHYSICAL EXAM
SKIN:
acrocyanotic, (-) lesions, (+) cracking, rare veins
HEAD:
(-) molding, (-) cephalhematoma, both fontanels flat and soft, (-) overlapping sutures, BT: 8cm, BP: 9cm, SOB: 9cm, OF: 10.5cm, OM: 11.5cm
EYES:
(-) discharges, anicteric sclerae, both pupils equally reactive to light

15. PHYSICAL EXAM EARS: (-) low-set ears, formed, firm with instant recoil
MOUTH:
(-) circumoral cyanosis, (-) cleft lip, formed tongue,
(-) cleft palate
CHEST/LUNGS:
barrel-shaped, (+) subcostal & intercostal retractions, raised areola with 3-4 mm bud, (+) grunting, (-) tachypnea

16. PHYSICAL EXAM
HEART:
adynamic precordium, (-) thrills, normal rate, regular rhythm, (-) murmur
ABDOMEN:
globular but not distended, nonpalpable liver
UMBILICUS:
translucent, (-) meconium stained, 2 arteries & 1 vein
BACK:
lanugo with bald areas, (-) dimpling, straight spine

17. PHYSICAL EXAM GENITALIA:
both testes descended, scrotum with good rugae
ANUS:
patent, (+) passage of meconium
EXTREMITIES:
(-) polydactyly, (-) hip dislocation, plantar crease over anterior 2/3, equally strong & palpable pulses
NEUROLOGIC EXAM:
(+) moro reflex, (+) sucking reflex, (+) grasping reflex

18. PRIMARY IMPRESSION

19. Primary Working Impression
Meconium Pneumonitis
Full term 37 weeks by PA 2600 grams AGA cephalic presentation delivered by repeat LSCS, AS 5,9

20. MECONIUM PNEUMONITIS (+) history of meconium staining
baby received non-vigorous, HR 60s, poor muscle tone, with no response
(+) tachypnea
(+) grunting
(+) retractions

21. DIFFERENTIAL DIAGNOSIS

22. DIFFERENTIALS Differential Rule-in Rule-out Hyaline Membrane Disease
(+)tachypnea
(+) grunting
(+)retractions
-rare in term neonates
-mother not GDM
-worsens / peaks at hours
Transient Tachypnea of the Newborn
-usually follows uneventful normal FT SVD or cesarean section
-Early onset tachypnea with or without retractions
(+) expiratory grunting
-cyanosis relieved by minimal 02
-with rapid recovery in 3 days
-PE: lungs clear w/o rales or rhonchi
-benign, self-limited course

23. Meconium Aspiration Syndrome (+) history of meconium staining
Neonatal Pneumonia
(+)tachypnea
(+) grunting
(+)retractions
(+) cyanosis
Pre-natal history suggests infection
-usually predisposed by pre-mature labor, PROM, increased IE
-CBC usually: neutropenia, leukocytosis
-cannot be fully ruled-out
Meconium Aspiration Syndrome
(+) history of meconium staining
-baby received non-vigorous, HR 60s, poor muscle tone, with no response
Neonatal Sepsis
Respiratory distress
Cannot be fully ruled out

24. COURSE IN THE WARD

25. Catcher’s Area
Born at PGH Nursery on May 7, 2009 with APGAR score 5, 9
Started on Piperacillin-Tazobactam (75mkd) 195 mg IV q12
Started on Amikacin (15mkd) 40 mg IV OD

26. Catcher’s Area Piptazo
Combination antibiotic containing the extended-spectrum penicillin and the B-lactamase inhibitor tazobactam
Amik
An aminoglycoside With synergistic effect with B-lactams

27. Catcher’s Area Labs: Venoclysis started with D10W (80) @ 9cc/hr
CBC with PC Na, K, Cl, Ca,
Blood typing CXR APL
ABG Blood C/S
Venoclysis started with D10W 9cc/hr
NPO, Hgt q8
O2 support at 10 lpm/hood

28. NICU

29. On Admission Admitted at NICU 3 on May 7, 2009
Received with fair pulses BP 30-40/20’s
Given total of 50 cc/kg PNSS IV bolus, BP improved to 40-50/30’s but still with fair pulses
Started on 10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D5W 23.1cc)
UVC inserted

30. On Admission 50 cc/kg PNSS IV bolus To increase BP
10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D5W 23.1cc)
Maintenance bp

31. On Admission
Due to persistent desaturation (O2 sats 80’s), patient intubated with MV settings 100%, 18/3, RR 60 LT 0.4
O2 sats improved to %
ABGs ordered
D10W increased to run for 10 cc/hour
STAT NaHCO3 5 meqs given

32. On Admission NaHCO3 5 meqs To counteract metabolic acidosis
MV settings 100%, 18/3, RR 60 LT 0.4 ?

33. ABG 05/07/09 23:10 100% O2 hood Respiratory AcidosispH 
pCO2 
pO2 
HCO3 
BEb
-8.2
O2sat
91.40%
Respiratory Acidosis
Decrease Ventilation
Hypoxemia

34. ABG ABG 05/08/09 00:18 S/P INTUBATION 100% 18/3 60 0.4pH 
pCO2 N
pO2
188.00
HCO3 
BEb
-8.5
O2sat
99.50%
Metabolic Acidosis
NaHCO3 5 meqs

35. ABG ABG 05/08/09 06:51 AFTER CORRECTION 100% 18/3 60 0.4 pH 7.407 N
pCO2 
pO2
146.00
HCO3 
BEb -5
O2sat
99.30%

36. Complete Blood Count Component 05/07/09 Reference Range Unit WBC 5.56
5.0 – 30.0
X109/L
RBC
3.74
4.0 – 6.0
X1012/L
HGB
129
g/L
HCT
0.386
0.370 – 0.540
MCV
103.2
80.0 – 100.0 Fl
MCH
34.5
27.0 – 31.0 Pg
MCHC
334
320 – 360
RDW
17.2
11.0 – 16.0 %
Platelet
227
150 – 450
NRBC
2/100

37. Complete Blood Count Complete Blood Count Component 05/07/09
Reference Range
Unit
Neutrophil
0.697
0.500 – 0.700 %
Lymphocyte
0.182
0.200 – 0.500
Monocyte
0.101
0.020 – 0.090
Eosinophil
0.016
0.000 – 0.060
Basophils
0.004
0.000 – 0.020
Stab
Metamyelocyte
Myelocyte
Promyelocyte
Blast
Atypical Lymphocyte

38. Electrolytes Test 05/09/09 05/12/09 Units Normal Values Calcium 1.60
1.92
mmol/L
2.12 – 2.52
Sodium
143
140 –
Potassium
3.9
4.3
3.50 – 5.10
Chloride
108
106
98.00 –

39. 1st HD, 1st DOL
PWI: FT 37 weeks PA, 2600g, AGA, ceph, repeat LSCS, LBB, AS 5,9; Neonatal Pneumonia vs MAS; PPHN precaution r/o sepsis
MV settings maintained
IVF shifted to D10IMB Ca 10cc/hr

40. 1st HD, 1st DOL
D10IMB Ca 10cc/hr
To correct hypocalcemia

41. 1st HD, 1st DOL Decrease RR to 50 then decrease by 2 q2 until 30
Decrease FiO2 by 5 q2 until 60%

42. ABG
ABG
05/08/ : % 18/ pH
7.468
pCO2
14.40
pO2
191.00
HCO3
10.50
BEb
-9.8
O2sat
99.80%
Dec. RR to 50  then dec by 2 O2 til 30
Dec.. FiO2 by 5 O2 til 60%

43. Babygram 5/08/09 (1st hospital day)
Pneumonia, both inner lung zones

44. 2nd HD, 2nd DOL MV setting at 80%, 18/3, 44, 0.4 ABGs ordered
Once FiO2 60%, may start feeding with 5cc EBM q3/OGT with SAP

45. 2nd HD, 2nd DOL
Start feeding 5cc EBM as ordered, if tolerated 3x, start increments: increase 5cc every feeding until 30cc
MV setting: 60% 18/
Wean FiO2 by 5 q2 til 21%
Wean RR by 2 q2 til 10
Extract ABGs at RR=10

46. ABG ABG 05/09/09 09:32 WEANING 80% 18/3 44 0.4 pH 7.360 pCO2 32.70 pO2
149.00
HCO3
18.40
BEb
-5.1
O2sat
99.20%

47. 3rd HD, 3rd DOL Prepare for extubation Prepare O2 hood FiO2 30%
MV settings at 21%, 18/3, 14, 0.4
Revise inotropes: Dopamine 0.5cc + D5W 23.5 cc to run at 1cc/hour then consume then discontinue

48. 3rd HD, 3rd DOL S/P Extubation Placed on O2 hood FiO2 30%
Racemic epinephrine nebulization started to continue 2 more doses 15 minutes apart

49. 3rd HD, 3rd DOL Patient noted to be jaundiced up to thighs
For TB DB IB
Increase feeding to 35cc q3/OGT

50. 3rd HD, 3rd DOL For CPT with proper shields Dopamine discontinued
NCPAP 30% PEEP 5
ABGs
Noted vomiting with feeding; abdomen soft but distended
Feeding decreased to 30cc

51. ABG ABG Maintain now 05/11/09 04:13 S/P EXTUBATION 30% pH 7.324 N pCO2
pO2
84.00
HCO3 N
BEb
-4.7
O2sat
95.60%
Maintain now

52. 4th HD, 4th DOL Increased feeding to 35cc TB DB IB noted
Maintained on phototherapy
PWI: FT 37 wks by PA, 2600 g, AGA, cephalic, delivered via primary LSCS, LBG, AS 5,9; Neonatal pneumonia; Hyperbilirubinemia no set-up

53. Bilirubin Test 05/11/09 05/12/09 Units Normal Values TB 16.1 14.6
umol/L
17.00 – DB
0.0
0.00 – 10.00 IB
10.00 –

54. 4th HD, 4th DOL
13cc of feeding residual noted; no abdominal distention
Feeding deferred
Wean FiO2 by 5 q2 until 21%
Coffee-ground noted

55. 4th HD, 4th DOL NPO Start Famotidine 1mg IV q12
Give Vit K 2mg slow IV push
ABGs ordered at 25% PEEP 5

56. ABG ABG 05/11/09 17:00 25% 18/3 60 0.4 pH 7.329 pCO2 40.80 pO2 68 HCO3
05/11/ : % 18/ pH
7.329
pCO2
40.80
pO2 68
HCO3
21.80
BEb
-3.5
O2sat
92.40

57. Babygram 05/11/09 (4th hospital day) S/P Extubation
Atelectasis, Right Upper Lobe
Atelectasis/Consolidation, Medial Segment of R Lower Lobe

58. 5th HD, 5th DOL
PWI: FT, 37 wks by PA, 2600g, AGA, cephalic, rpt LSCS, LBG, AS 5,9; neonatal pneumonia; hyperbilirubinemia with no set-up; rule out nosocomial sepsis
Still with jaundice and coffee ground material

59. 5th HD, 5th DOL For repeat CBC with PC, blood CS, eletrolytes
To start Ceftazidime (50mkd) 130mg IV q12h
NPO
IVF revised to: D10IMB Ca 13cc/hr
Please put patient on right side up

60. Complete Blood Count Complete Blood Count Component 05/07/09 05/12/09
Reference Range
Unit
WBC
5.56
24.42
5.0 – 30.0
X109/L
RBC
3.74
3.66
4.0 – 6.0
X1012/L
HGB
129
122
g/L
HCT
0.386
0.358
0.370 – 0.540
MCV
103.2
97.8
80.0 – 100.0 Fl
MCH
34.5
33.3
27.0 – 31.0 Pg
MCHC
334
341
320 – 360
RDW
17.2
17.3
11.0 – 16.0 %
Platelet
227
142
150 – 450
NRBC
2/100 1

61. Complete Blood Count Complete Blood Count Component 05/07/09 05/12/09
Reference Range
Unit
Neutrophil
0.697
0.77
0.500 – 0.700 %
Lymphocyte
0.182
.07
0.200 – 0.500
Monocyte
0.101
0.10
0.020 – 0.090
Eosinophil
0.016
0.006
0.000 – 0.060
Basophils
0.004
0.000 – 0.020
Stab
Metamyelocyte
Myelocyte
Promyelocyte
Blast
Atypical Lymphocyte

62. MECONIUM ASPIRATION SYNDROME

63. Meconium-stained amniotic fluid may be aspirated during labor and delivery, causing neonatal respiratory distress. Because meconium is rarely found in the amniotic fluid prior to 34 weeks' gestation, meconium aspiration chiefly affects infants at term and postterm.

64. 3 major constituents of meconium:
Intestinal secretions
mucosal cells
solid elements of swallowed amniotic fluid are the 3 major solid constituents of meconium.
Water - major liquid constituent, (85-95%)

65. Meconium Aspiration Syndrome
Factors that promote meconium passage in utero include:
placental insufficiency,
maternal hypertension,
preeclampsia,
oligohydramnios, and
maternal drug abuse, especially of tobacco and cocaine.

66. Pathophysiology
In utero meconium passage results from neural stimulation of a mature GI tract and usually results from fetal hypoxic stress. As the fetus approaches term, the GI tract matures, and vagal stimulation from head or cord compression may cause peristalsis and relaxation of the rectal sphincter leading to meconium passage.

67. Pathophysiology
Meconium directly alters the amniotic fluid, reducing antibacterial activity and subsequently increasing the risk of perinatal bacterial infection. Meconium is irritating to fetal skin, thus increasing the incidence of erythema toxicum.

68. Pathophysiology
However, the most severe complication of meconium passage in utero is aspiration of stained amniotic fluid before, during, and after birth.

69. Pathophysiology
Aspiration induces hypoxia via 4 major pulmonary effects: 1. airway obstruction 2. surfactant dysfunction 3. chemical pneumonitis

70. Pathophysiology 1. Airway obstruction
Complete obstruction - atelectasis.
Partial obstruction - ball-valve effect.
Hyperdistention of the alveoli occurs from airway expansion during inhalation and airway collapse around inspissated meconium in the airway, causing increased resistance during exhalation.

71. Pathophysiology
2. Surfactant dysfunction free fatty acids of the meconium (eg, palmitic, stearic, oleic), have a higher minimal surface tension than surfactant Meconium strip it from the alveolar surface, resulting in diffuse atelectasis.

72. Pathophysiology
3. Chemical pneumonitis Enzymes, bile salts, and fats in meconium irritate the airways and parenchyma, causing a release of cytokines results in a diffuse pneumonia that may begin within a few hours of aspiration.

73. History
Presence of meconium in amniotic fluid is required to cause meconium aspiration syndrome (MAS), but not all neonates with meconium-stained fluid develop meconium aspiration syndrome. The presence of thick particulate meconium in the amnionic fluid increases the likelihood of prenatal aspiration. Green urine may be observed in newborns with meconium aspiration syndrome less than 24 hours after birth. Meconium pigments can be absorbed by the lung and can be excreted in urine.

74. Clinical Manifestations
Cyanosis
End-expiratory grunting
Alar flaring
Intercostal retractions
Tachypnea
Barrel chest in the presence of air trapping
Auscultated rales and rhonchi (in some cases)
Yellow-green staining of fingernails, umbilical cord, and skin may be observed.

75. Factors that promote the passage of meconium in utero :
Placental insufficiency
Maternal hypertension
Preeclampsia
Oligohydramnios
Maternal drug abuse, especially of tobacco and cocaine
Maternal infection/chorioamnionitis
Fetal gasping secondary to hypoxia
Inadequate removal of meconium from the airway prior to the first breath
Use of positive pressure ventilation (PPV) prior to clearing the airway of meconium

76. Laboratory Studies Acid-base status
Metabolic acidosis from perinatal stress is complicated by respiratory acidosis from parenchymal disease and persistent pulmonary hypertension of the newborn (PPHN).
ABG measurement of pH, partial pressure of carbon dioxide (pCO2), partial pressure of oxygen (pO2), and continuous measurement of oxygenation by pulse oximetry are necessary for appropriate management.

77. Laboratory Studies
Serum electrolytes: Obtain sodium, potassium, and calcium concentrations when the infant with MAS aged 24 hours because the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and acute renal failure are frequent complications of perinatal stress.

78. Laboratory Studies CBC count
In utero or perinatal blood loss, as well as infection, contributes to postnatal stress.
Hemoglobin and hematocrit levels must be sufficient to ensure adequate oxygen-carrying capacity.
Neutropenia or neutrophilia with left shift of the differential may indicate perinatal bacterial infection.

79. Chest Findings
gross overaeration of the lungs and bilateral nodular infiltrates
The nodular infiltrates represent areas of patchy or focal alveolar atelectasis and the overaerated spaces in between, compensatroy, focal alveolar overdistension

80. Management
When aspiration occurs, intubation and immediate suctioning (tracheal suctioning) of the airway can remove much of the aspirated meconium
No clinical trials justify suctioning based on the consistency of meconium. Do not perform the following harmful techniques in an attempt to prevent aspiration of meconium-stained amniotic fluid:
Squeezing the chest of the baby
Inserting a finger into the mouth of the baby

81. guidelines for management of the baby exposed to meconium
The American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee
If the baby is not vigorous (defined as minimal or absent respiratory effort, poor muscle tone, or heart rate <100 beats/min):
Use direct laryngoscopy, intubate, and suction the trachea immediately after delivery.
Suction for no longer than 5 seconds.
If no meconium is retrieved, do not repeat intubation and suction.
If meconium is retrieved and no bradycardia is present, reintubate and suction.
If the heart rate is low, administer positive pressure ventilation and consider suctioning again later.

82. Medical Care
If the baby is vigorous (defined as good respiratory effort, crying, good muscle tone, and heart rate >100 beats/min):
Do not electively intubate.
Clear secretions and meconium from the mouth and nose with a bulb syringe or a large-bore suction catheter.
In either case: The remainder of the initial resuscitation steps should ensue and include drying, stimulating, repositioning, and administering oxygen as necessary.

83. Continued care in the NICU
Maintain an optimal thermal environment
Minimal handling
Sedation - to decrease agitation
Continue respiratory care. Oxygen therapy via hood or positive pressure is crucial in maintaining adequate arterial oxygenation. If mechanical ventilation is required, make concerted efforts to minimize the mean airway pressure and to use as short an inspiratory time as possible. Oxygen saturations should be maintained at 90-95%.

84. Continued care in the NICU
Surfactant therapy
For treatment of persistent pulmonary hypertension of the newborn (PPHN), inhaled nitric oxide is the pulmonary vasodilator of choice
Pay careful attention to systemic blood volume and blood pressure. Volume expansion, transfusion therapy, and systemic vasopressors are critical in maintaining systemic blood pressure greater than pulmonary blood pressure, thereby decreasing the right-to-left shunt through the patent ductus arteriosus.

85. Complications
chronic lung disease
infections

86. Prognosis Most with complete recovery of pulmonary function
Intrapartum events initiating the meconium passage may cause the infant to have long-term neurologic deficits:
CNS damage,
seizures,
mental retardation, and
cerebral palsy.

87. HYPERBILIRUBINEMIA

88. HYPERBILIRUBINEMIA
Yellow color usually results from accumulation of unconjugated, nonpolar, lipid-soluble bilirubin pigment in the skin
May be due in part to deposition of pigment from conjugated bilirubin
Elevated levels of indirect, unconjugated bilirubin potentially neurotoxic

89. HYPERBILIRUBINEMIA Unconjugated hyperbilirubinemia factors:
Increase load of bilirubin to be metabolized by liver
Hemolytic anemia, polycythemia, shortened red cell life, increased enterohepatic circulation, infection
Damaged or reduced the activity of the transferase enzyme or other related enzymes
Genetic deficiency, hypoxia, infection, thyroid deficiency
Blocked transferase enzyme
Absence or decreased amounts of enzyme or reduced bilirubin uptake by liver cells
Genetic defect, prematurity

90. HYPERBILIRUBINEMIA
Jaundice appearing after the 3rd day and within the 1st week suggests bacterial sepsis or urinary tract infection
Other causes: syphilis, toxoplasmosis, CMV, enterovirus

91. HYPERBILIRUBINEMIA
Regardless of the cause, goal of therapy is to prevent indirect-reacting bilirubin related neurotoxicity
Tx: phototherapy and exchange therapy

92. THANK YOU!