Case Study Two: A case of prematurity and intrauterine ...



|TM5559: Clinical Tropical Paediatrics |

|Case Study Two: A case of prematurity and intrauterine growth restriction. |

|Samantha Leggett: SN 12494652 |

| |

|8/2/2011 |

Case Study Two

A case of prematurity and Intrauterine Growth Restriction

Female Infant (FI) of AA

DOB: 15-10-2010

Gestation: Thought to be 31 weeks

Birth Weight 1000g

Sociodemographic Details: Family live in Uia Village, Bugati, Madang (approx 1 ½ hours from Madang, 4 Kina/ $1.60 on PMV). Baby is child number seven and Mum (AA) reports that all other children are healthy and that the eldest two are at school. Mum and Dad are both alive and are married and living together. Mum reports that neither she nor her husband has received any education. Neither is formally employed but they have a small market garden which they make a little money from.

Background: Baby’s mother presented to Modilon General Hospital (MGH) on 15-10-10 with a history of 8 hours of labour pains. She had had 3 ante natal visits early in her third trimester and had been advised to make her way to MGH if labour started as she was considered a high risk pregnancy[1].

Findings at Birth: Baby was born by standard vaginal delivery in good condition and her newborn examination revealed no abnormalities. Her Apgar score was 7 at 1 minute with no further assessments documented. She immediately self ventilated in low flow oxygen and no other respiratory concerns are noted.

Initial Comments from doctor:

1) Very Low Birth Weight

2) ? Maternal Illness-Mum looks sick but not talking

3) Severe Prematurity

Initial Management Plan:

48mls/kg/24hours 10% Dextrose Intravenously (IV)

Aminophylline, Na Bicarbonate 8.4%,

XPen, Gentamicin

Keep Warm, Hb/WCC

Medical History including findings on admission (see Appendix A (p.21) for a copy of medical notes):

Baby was admitted to the special Care Nursery directly from the labour ward where it is noted that she was severely premature and was of very low birth weight at just one kilogram (kg).

Respiratory system: Baby has never had any respiratory concerns and has been self ventilating from birth and in room air for the majority of her admission with no apnoeas noted. Aminophylline IV has been being administered throughout her admission.

Circulation (A), thermoregulation (B) and fluid management (C): Few circulatory observations (other than temperature which will be discussed later) are noted in the nursing documentation and nothing at all in the medical notes. A rudimentary fluid balance chart was maintained with some omissions regarding input and no output volumes documented.

(A) On Day 3 (15/10/10) of life baby was noted to be clinically pale with Haemoglobin (Hb) of 11.8 g/dl. A cross match and blood transfusion was ordered and written instructions provided regarding its administration. On seven occasions over the proceeding fifteen days notes are entered regarding ‘chasing’ the cross match and giving the transfusion with a note on 21/10/10 stating that baby ‘looked pale +++’. Baby finally received her blood transfusion of 35mls packed red cells on 02/11/10 after a donation of blood from her father on 01/11/10. Pre-transfusion her Hb was noted to be 7.3 g/dl.

(B) Baby’s first recorded temperature in the Special Care Nursery was noted to be 38.6 degrees Celsius (C) at 06:00 on Day 2 of life. The next time her temperature is documented is at 18:00 that evening and reads 39.5 C. It can be seen from Chart 1 below that baby was only normothermic on what appears to be 9 occasions over 6 separate but non-consecutive days in her first 18 days of life. Her lowest temperature was recorded at 36.3 C and her peak temperature at 40 C. Gaps in the chart represent times when temperatures were not documented.

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(C) Baby was commenced on 48mls/kg/day of 10% Dextrose at birth which was increased to 55mls/kg/day on Day 4 of life. 36mls/kg/day of expressed breast milk (EBM) via naso-gastric tube (NGT) was also requested to be introduced. Total fluids on D4 should have been 90mls/kg/day. On D7 of life baby was still receiving 55mls/kg/day IV and NG feeds had not been commenced. It is noted that baby was active with a soft, non-distended abdomen and bowel sounds present and had regularly passed urine and had her bowels open. On D9 of life it was noted that baby was tolerating EBM via NGT at 5mls every 2 hours. Increased feeding progressed very slowly with no note of why and no note of when IV fluids are discontinued. By D17 of life baby was noted to be tolerating EBM via NGT 20mls every 2 hours (240mls/kg/day) in addition to breastfeeds. NG feeds were increased to 22mls 2 hourly (264mls/kg/day) on D17 of life with additional breastfeeds and were being tolerated at this volume at the point of my examination. Few blood glucose levels are documented but those that are were between 2.6-6 mmols/l.

Jaundice: On 20/10/10, Day 6 of life, baby was noted to be jaundiced and a Serum Bilirubin (SBR) level ordered. The first SBR levels are seen on the results sheet in Appendix B (p.30) on 19/10/10 and are 19.7 mg/dl. It is unclear from the medical and nursing notes when phototherapy was commenced but a medical note was entered on 23/10/10 for phototherapy to keep being decreased and on 26/10/10 to say that baby is out of phototherapy. SBR levels show an increase to 16.1 mg/dl on 29/10/10 and a subsequent downward trend to 8.2 mg/dl by 02/11/10. No further phototherapy is documented.

Weight gain: The graph below illustrates baby’s weight trend during her admission with a maximum loss of 13% of her birth weight. Gaps represent days that no weight was documented.

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Neurological status: Baby is noted to be active from birth, breastfeeding early on and no neurological concerns are noted.

Family: Baby’s Mum (AA) remained in hospital with her throughout and took an active role in her care with baby’s Dad visiting when he could. AA seemed quiet and withdrawn and indicated a strong desire to return to her family and Uia village. She expressed concern that she was unable to look after the rest of her family while she was at the hospital, and for being unable to earn money in order to feed her family or afford the elder two children’s school fees. She said that the children’s father and her mother were looking after the house and garden. When questioned regarding her own health she stated that she had felt unwell throughout this pregnancy but that she felt much better since the baby had been born.

My examination:

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I examined FI of AA on 02/11/10 (D19 of life) and my findings were as follows:

Using the Dubowitz Scoring system [1] which has been validated for use in Melanesian infants [2] and with assistance from one of my fellow students, I ascertained baby’s age to be of around 34 weeks gestation ((38* 0.2642)+24.595). This would translate to a gestational age at birth of about 31 weeks which fits in with AA’s obstetric history.

Baby had recently been moved into an incubator from under a radiant warmer after receiving her blood transfusion and was self ventilating in room air with SpO2 >95% and no signs of respiratory distress. The incubator temperature was set at 35 degrees and baby was warm to touch. General findings were unremarkable, all observations being within expected limits [3] and as documented (no pre or post blood transfusion observations had been documented). Her abdomen was soft, bowel sounds were present and no liver edge or spleen were palpable.

To comment on her general condition Baby was very thin, her skin and lips were dry and her eyes were a little oedematous. When awake she was alert, looking around and handled well. She had a naso gastric tube in situ and during my visit to the unit Mum had baby out of the incubator and was putting her to the breast. The breast was offered for 15 minutes and then AA gave EBM via the NGT. Additionally, baby was not covered or wrapped in any way when out of the incubator.

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Preterm birth and low birth weight: definitions, determinants and consequences

Infants born with a low birth weight (LBW) can be divided into two categories- those born too soon and those born too small. Preterm infants (37 weeks gestation) who, despite having adequate time to grow are born too small and weigh ................
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