1. PERINATAL/NICU CONFERENCE Monthly Statistics Report February 2014 Khlaire D. Pioquinto PERINATAL/NICU CONFERENCE Monthly Statistics Report February 2014 Khlaire D. Pioquinto, MD 3 rd Year Resident – Pediatrics Paolo Augusto U. Campos, MD 3 rd Year Resident – Obstetrics and Gynecology THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the Department of Pediatrics

2. TOTAL BIRTHS

3. Total Births, February 2014 ACCORDING TO AGE OF GESTATIONNUMBER Term129 Preterm21 Postterm1 TOTAL LIVE BIRTHS151

4. Total Births, February 2014 ACCORDING TO PLACE OF PRENATAL CARENUMBER Registered151 Non-registered0 TOTAL LIVE BIRTHS151

5. Total Births, February 2014 ACCORDING TO AGE OF GESTATIONNUMBER Term130 Preterm21 Postterm1 TOTAL LIVE BIRTHS151

6. Total Births, February 2014 ACCORDING TO PLACE OF PRENATAL CARENUMBER Registered151 Non-registered0 TOTAL LIVE BIRTHS151

7. NURSERY ADMISSIONS

8. January 2014 vs February 2014

9. February 2013 vs February 2014

10. Deliveries by Levels

11. Admission to NICU Referral FromNo. of Patients Roomed In (Inborn transfer)1 Discharged (Inborn Readmission) 3 Discharged (Outborn Admission)0 Total4

12. NICU Isolation No. of Patients Inborn Transfer1 Inborn Readmission2 Direct admission1 Outborn Admission1 Total5

13. NEONATAL MORBIDITIES

14. Neonatal Morbidities, January 2014 NUMBER OF NEONATAL MORBIDITIES35 Incidence among total live births230 per 1000 LB Delivered from Normal Mothers20 (57%) Delivered from High Risk Mothers15 (43%)

15. Top 5 Conditions Occurring Among High Risk Mothers, February2014

16. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA - 1

17. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA - 2

18. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA – 2 Prematurity – 7 Low birth weight - 1 LGA – 2 Prematurity – 7 Low birth weight - 1

19. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 LGA – 1 Prematurity – 1 LGA – 1 Prematurity – 1

20. Top 5 Maternal Conditions Associated with Neonatal Morbidities, February 2014 Prematurity 1

21. CONGENITAL ANOMALIES

22. NEONATES WITH 1 minute APGAR <=6

23. Neonates with APGAR <=6, February 2014 NUMBER OF NEONATES WITH APGAR < 7 3 Incidence among total live births in 1000 LB Delivered from low risk mothers 2 Delivered from high risk mothers 1

24. R.R.G 39, G2P1 (0-1-0-1), 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 143/79, HR 96, RR 18, 37.5C SE: pooling of clear amniotic fluid IE: 2cm, 50%, floating, (-) BOW s/p PBE Male APGAR 3, 6, 7 830 g MT 28 weeks AGA CASE 1: APGAR 3, 6, 7

26. K.T.G 33, G2P1 (1-0-0-1), 37 1/7 CC: for repeat CS G1- 2011, CS for breech Past Medical/Personal/Social History/Family History: U/R 100/70, HR 82, RR 18, 36.6C FHT: 140’s bpm SE: not done IE: soft closed CTG: not done s/p RCS, cord prolapse Male APGAR 0, 8, 9 2485 g MT 37 AGA CASE 2: APGAR 0, 8, 9

27. Case: RCG Maria Ellaine Grace K. Uy, MD, MBA

28. Pertinent Data: RCG RCG Delivered via Scheduled Repeat Cesarean Section 33 year old G2P2 (2002) AOG: 37 1/7 weeks MT: 37 AGA Apgar Score: 0,8,9 Anthropometrics: BW= 2485 grams BL= 46 cm HC= 32 cm CC= 30 cm AC= 27 cm

29. Pertinent History Maternal History: No BP elevations, maternal illness during pregnancy Past Medical History: Allergic to fish sauce Family History: Diabetes OB History: G1- 2011- PCS for Breech- LFT- Male- TMC- No FMC G2: Present Pregnancy Personal Social: College graduate, Works as a manager, no vices

30. 1 minute 3 minutes 5 minutes COLOR011 HEART RATE 012 REFLEX IRRITABILITY 022 MUSCLE TONE 022 RESPIRATION022 Drying and Stimulation, PPV, Chest Compressions HR at 60’s, still Acrocyanotic. PPV continued

31. Physical Examination: RCG Had good cry and activity Clear amniotic fluid Flat and open fontanelles Good air entry, no retractions Regular cardiac rhythm, HR at 150 bpm Soft Abdomen Grossly male genitalia Full pulses

32. Diagnosis: RCG Term Baby Boy, AGA, AS 0,9

33. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 6th HOL - Able to latch with good suck - No vomiting - Active - No cyanosis - No jittering - T: 36.7, HR 143, RR: 44 - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Term Baby Boy - Encourage breastfeeding - For BP and O2 sat on all extremities - For circumcision

34. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 8th HOL - With good suck - No vomiting - Active - No cyanosis - No jittering - T: 36.6, HR 141, RR: 42 - RU: 71/57, LU: 70/44, RL: 73/49, LL: 76/42 - 02 sat: 100% - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Term Baby Boy - Encourage breastfeeding - For rooming in - For circumcision

35. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 1st DOL - With good suck - No vomiting - Active - No cyanosis - No jittering - T: 36.5, HR 138, RR: 40 - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Minimal bleeding on surgical site - Term Baby Boy - s/p Circumcison - Encourage breastfeeding

36. Course in the NICU: RCG SubjectiveObjectiveAssessmentPlan - 2nd DOL - With good suck - Regular UO and BM - No vomiting - Active - No cyanosis - No jittering - T: 36.5, HR 138, RR: 40 - Good air entry, no retractions - Good cardiac tone - Soft abdomen - Term Baby Boy - s/p Circumcison - May go home

37. M.L.T 27, G1P0, 40 3/7 CC: uterine contractions Past Medical/Personal/Social History: U/R Family History:U/R 111/78, HR 80, RR 18, 37C SE: not done IE: 7cm, 80%, St-2, (+) BOW CTG: Category 1 trace s/p OFE Male APGAR 4, 9, 9 2970 g MT 39 AGA CASE 3: APGAR 4, 9, 9

38. NEONATAL MORBIDITIES WITH APGAR >=7

39. M.S.F. 30, G2P0 (0-0-1-0), 39 5/7 CC: watery vaginal discharge Past Medical/Personal/Social History: U/R Family History:U/R 128/77, HR 86, RR 16, 37.5C SE: pooling of clear AF IE: 2cm, 50%, St-3, (-) BOW CTG: Category 1 trace s/p NSD Male APGAR 8, 9 3265 g MT 39 AGA CASE 4: Pulmonary Hypertension

40. M.G.B. 41, G2P1 (1-0-0-1), 28 2/7 weeks CC: left breast pain, elevated blood pressure Past Medical/Personal/Social History: (+) Chronic hypertensive for 24 years; Invasive ductal CA, left breast, Stage IV Family History: (+) Hypertension/DM 150/90, HR 88, RR 18, 36C Left breast mass measuring 24 x 14 cm IE: not done CTG: Reactive s/p planned PCS, Myomectomy, Incision biopsy L breast Female APGAR 9, 9 1250 g MT 30 AGA CASE 5: Prematurity, Invasive Ductal CA

41. JPB Born on February 14, 2014 Live preterm baby girl Delivered via Scheduled Primary Cesarean Section for Maternal Condition (Breast Cancer) 41 y/o G2P2 (1102) 28 5/7 weeks AOG BW 1250 g BL 38 cm HC 26 cm CC 23 cm AC 21 cm MT 30, AGA AS 9,9

42. Delivery Apgar 1 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing Apgar 5 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing Immediately placed in a food grade plastic bag O2 saturation: >85% Newborn care was rendered

43. Problem List: Respiratory Distress Syndrome Infection Apnea of Prematurity Hyperbilirubinemia of Prematurity

44. 1. Respiratory Distress Syndrome 2 nd Hour of life SubjectiveObjectiveAssessmentPlan Grunting Spontaneous breathing No cyanosis 20 minutes after No improvement of the grunting RR 60 Fair air entry Subcostal, intercostal and suprasternal retraction T/C Respiratory Distress Syndrome, Prematurity Hook to nasal CPAP Oxacillin, Cefotaxime, Amikacin Intubation done Surfactant therapy (4ml) given Umbilical catheterization

45. VBG pHpCO2PO2HCO3O2BE 7.32861.745.132.376.35.3Compensated Respiratory Acidosis Chest Xray Consider Hyaline Membrane Disease, cannot totally rule out Neonatal Pnemonia Blood Culture No Growth (7 days) CBC HgbHctWBCBandNeuLympMonEosPlt 151457.944842512394nRBC /100 WBC HGT82

47. Problem 2: Hyperbilirubinemia 1 st day of life SubjectiveObjectiveAssessmentPlan Intubated FiO2 40% RR 35 PIP 14 PEEP 3.8 s/p surfactant therapy Mother had a would culture: Heavy growth of S. aureus: sensitive to all except Penicillin VS: HR 144, RR 65, T 36.9 O2 sat 98% Jaundice to upper chest Good air entry, subcostal, intercostal, suprasternal retractions Good cardiac tone Soft abdomen Full pulses Respiratory Distress Syndrome vs Neonatal Pneumonia, Sepsis, unspecified, Hyperbilirubinemi a, unspecified Labs: Bilirubin Levels, CRP, Chest Xray, Hgt Single Overhead Phototherapy Oxacillin, Cefotaxime, Amikacin

48. Bilirubin Levels TotalDirectIndirect 5.210.384.92 Chest Xray Consider Hyaline Membrane Disease, with interval improvement in the Lung Status CRP 0.21 mg/dl HGT152 VBG pHpCO2PO2HCO3O2BE 7.35459.828.433.250.36.6Compensated Respiratory Acidosis

50. VBG pHpCO2PO2HCO3O2BE 7.2455.7332426-3.0Respiratory Acidosis Chest Xray unchanged bilateral lung opacities consistent with resolving hyaline membrane disease Blood Culture No growth for 24 hrs HgbHct 12637 HGT92 Urinalysis RBCWBCEpithelialCastBacteria 2561014 NaKiCal 1394.9139 Bilirubin Levels TotalDirectIndirect 4.540.384.22LRZ

52. 16 th day of life SubjectiveObjectiveAssessmentPlan Intubated FR 8 FiO2 20 RR 20 PIP 10 PEEP 4 iT 0.5 No desaturations VS: HR 141, RR 52, T 37 O2 sat 100% Pink Good air entry, shallow subcostal retractions Good cardiac tone Soft abdomen Full pulses Apnea, Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemi a, unspecified, resolved Labs: Blood gas Nasal CPAP  intubation Aminophylline decreased to every 12 hours Meropenem 24 mg IV every 12 hrs (20 mg/kg/dose)

53. VBG pHpCO2PO2HCO3O2BE 7.26163.435.728.457.9-0.2Respiratory Acidosis

54. Current Diagnosis Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified, Resolved

55. DISTRIBUTION OF BIRTHS February 2014

56. Distribution of Deliveries According to Birthweight

57. Classification Based on Best Score ClassificationSGAAGALGAGrand Total Preterm 121123 Term 011115126 Post Term 0011 Grand Total 113217150

58. Small for Gestational Age Infants, February 2014 NUMBER OF SGA NEONATES 1 Incidence among total live births 6/1000 LB Delivered from normal mothers 0 Delivered from high risk mothers 1 A. Maternal factors1 Gestational Hypertension B. Fetal Factors 0 C. Unknown factor 0

59. Large for Gestational Age Infants, February 2014 NUMBER OF LGA NEONATES 17 Incidence among total livebirths 110 /1000 LB Delivered from normal mothers 8 Delivered from high risk mothers 9 A. Maternal factors Gestational diabetes mellitus Hypertension 1313 B. Fetal Factors Fetal Macrosomia 1

60. DISTRIBUTION OF BIRTHS ACCORDING TO GESTATIONAL AGE ON DELIVERY

61. Distribution of Births According to AOG on Delivery Livebirths = 151

62. Weight vs MT Wt (grams)<2828-2930-3132-3334-3536-36 6/737-3940-42> 42Grand Total 499 and below 0000000000 500-599 0000000000 600-999 1 000000001 1000-1499 00 221 00005 1500-1999 000 122 0005 2000-2499 0000 244 0010 2500-2999 00000 1513 055 3000-3499 000000 506 056 3500-3800 000000 93 012 >3800 000000 42 06 Grand Total 102357118140150 * MT of 1 patient cannot be determined

63. Weight vs LMP BW RANGE <2828-2930-3132-3334-3536-36 6/737-3940-42> 42 Grand Total 499 and below 0000000000 500-5990000000000 600-9991000000001 1000-14990221000005 1500-19990010310005 2000-249900005230010 2500-29990000224110055 3000-3499000002495056 3500-3800000000103013 >38000000004116 Grand Total 1231107107191151

64. Weight vs Best Score Wt (grams)<2828-2930-3132-3334-3536-36 6/737-3940-42> 42Grand Total 499 and below 0000000000 500-599 0000000000 600-999 1000000001 1000-1499 0121100005 1500-1999 0001220005 2000-2499 00004330010 2500-2999 0000124210055 3000-3499 000000516057 3500-3800 00000093013 >3800 0000004206 Grand Total 112289107210151

65. Preterm Delivery, February 2014 NUMBER OF PRETERM NEONATES 17 Incidence among total livebirths 150 in 1000 LB Delivered from low risk mothers 3 Delivered from high risk mothers 14

66. ROOMING IN AND BREASTFEEDING RATES

67. Rooming-in Rate Rooming-in rate – 125/135 (92.6%) – 16 patients are not eligible

68. Breastfeeding rate LevelPureMixedFormula only NoneDonorTotal Level I (N =23) Roomed-in (N =40) 491220063 Level II (N = 71) 353240071 Level III (N = 16) 2821316 Isolation (N =1) 100001 Grand Total 8752803150 N (Total deliveries) = 151 JCI: 92.80% (exclusively BF/Term NB -exclusions) BFHI: 92.86% (exclusively BF + w/medical indications of not BF/total no of live births)

69. GENERAL INDICES OF PERINATAL DEATH

70. Neonatal Mortality, February 2014 NUMBER OF MORTALITIES1 Incidence among total live births 6 per 1000 LB PERINATAL MORTALITY RATE Crude Perinatal Mortality Rate 1 mortality / 151 total births 6 per 1000 TB Corrected Perinatal Mortality Rate 0 non-lethal mortalities+0 stillbirth /151 total births

71. MORTALITY CASE

72. R. M.V. 35, G2P1 (1-0-0-1), 39 3/7 CC: uterine contractions Past Medical/Personal and Social History: U/R Family History: (+) Colon and Lung Ca, (+) Hypertension, (+) Diabetes 120/77, HR 80, RR 20, 37C IE: 5-6cm, 80%, St-2, (+) BOW CTG: Category 1 trace s/p NSD Male APGAR 0 3010 g CASE 6: Mortality Case RMV

73. Admitting CTG

74. Tracing upon arrival at LR, prior CEA

75. Tracing after CEA

76. CTG tracing after AROM

78. CTG tracings prior to transfer to DR

79. FHT tracing at DR (supine)

80. FHT tracing at DR (Left lateral decub)

81. FHT tracing (Prepping to Baby out)

82. Mortality Case: RV Term Baby Boy NSD 35 y.o. G2P2 (2002) 39 3/7 weeks AOG Anthropometrics: – BW 3120g BL 53cm HC 34cm CC 31cm AC 30cm – AGA

83. Upon delivery Pale, not breathing, limp Drying and stimulation 30s Limp, pale, not breathing, HR 0 Positive pressure ventilation 1 minute Limp, pale, not breathing, HR 0 PPV continued, prepared for Endotracheal intubation 2 minutes Limp, pale, not breathing, HR 0 Chest compressions started Endotracheal intubation, bag-tube ventilation

84. 5 mins Limp, pale, not breathing, HR 0 Ventilation/Compression continued Epinephrine/ET 0.1mg/kg/dose every 3mins 8 mins Limp, pale, not breathing, HR 40s Ventilation/Compression continued 15 mins Limp, pale, not breathing, HR 50s Umbilical vein cannulation  Epinephrine/UVC at 0.01mg/kg/dose 20 mins Limp, pale, not breathing, HR 50s ET tube placement reevaluated – not in place ET tube reinserted 25 mins Limp, pale, not breathing, HR 180s NICU Transfer

85. Apgar Score 1 st 5 th 10 th Appearance 000 Pulse001 Grimace 000 Activity 000 Respiration 000 TOTAL001

86. At the NICU Pale, unresponsive BP not appreciated, HR 180, on bag-tube ventilation, T 34C No dysmorphic features Pupils 8-9mm dilated, not reactive to light No spontaneous breathing, Equal chest rise, good air entry both lungs Regular cardiac rhythm, no murmur appreciated Soft abdomen Poor pulses, CRT prolonged

87. Severe hypoxic ischemic encephalopathy, post cardiopulmonary arrest Initial assessment

88. Problems Asphyxia Mixed Metabolic and Respiratory Acidosis 2/8 pH6.604 C0261.2 PO2114.5 HCO36.1 BE-30 O2 sat82.9% Mixed metabolic and respiratory acidosis Hooked to Mechanical Ventilator Correction with NaHCO3 Therapeutic Hypothermia 2/8 6.52 95.6 79 7.8 -30 60% Mixed met and resp acidosis Lactate (4.5-19.82 mg/dL) 223.2 mg/dL Bleeding from puncture sites  discontinued 9 th HOL

89. Problems Shock prob cardiogenic Severe anemia prob sec to hemorrhage HgbHctWBCBandNeutLymphMonoPlt 572042.764541818870 nRBC Cranial Ultrasound Normal PT Control13.3 Patient38.5 % activity0.2 INR3.78 aPTT Control29.3 Patient138 2D Echo PA pressure 50 Right to left shunting (PDA) Underfilled left ventricle Severe tricuspid regurgitation PFO bidirectional PNSS 20mL/kg bolus 2x Dopamine and Dobutamine Drip Blood transfusion ordered but refused PNSS 20mL/kg bolus 2x Dopamine and Dobutamine Drip Blood transfusion ordered but refused

90. Problems Infection HgbHctWBCBandNeutLymphMonoPlt 572042.764541818870 nRBC Blood culure and sensitivity No growth CRP (NV 0-0.5mg/dL) 0.01mg/dL Ampicillin 50mg/kg/dose Gentamicin 4mg/kg/day Ampicillin 50mg/kg/dose Gentamicin 4mg/kg/day

91. 10hrs and 30 mins Patient expired 10 th hour of life Still unresponsive On mechanical ventilator On Dopamine and Dobutamine Drip DNR signed

92. INTRACTABLE METABOLIC ACIDOSIS SECONDARY TO MULTIORGAN DYSFUNCTION SECONDARY TO PERINATAL ASPHYXIA Final Diagnosis

93. Learning Points Adequate communication between teams Regular and proper evaluation of adequacy of resuscitation

94. THANK YOU!!!

95. PERINATAL ASPHYXIA

96. Condition of impaired gas exchange that leads to fetal hypoxemia and hypercardbia Occurs during the 1 st and 2 nd stage of labor In term infants, 90% pccur in antepartum or intrapartum period as a result of impaired gas exchange across the pacenta Postpartum – secondary to pulmonary, cardiovascular, neurologic abnormalities

97. Hypoxic-Ischemic Encephalopathy Abnormal neurobehavioral state in which the predominant pathogenic mechanism is impaired cerebral blood flow Suspected if: – AS 5minutes – FHR <60 bpm – Prolonged (>1hr) acidosis – Seizures within the first 24-48hrs after birth – Burst-suppression patten EEG Cloherty J. Manual of Neonatal care, 6 th ed