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passant mohamed

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name
: A.O
weight
:2.44kg
height
:50cm
gender
:
number
:623
GA
:39week
birth date
: 26/7/2015
admission date
: 27/7/2015
past medical history :
1) cyanosis

2) cardiac arrest

3)convulsions
medication history:
1)unasyn

2)claforan

3)dormicum
ampicillin , sulbactam
cefotaxime
midazolam
D
ia
g
n
o
sis:
. PROM

.HIE grade 3

.neonatal sepsis

.respiratory distress

.neonatal pneumonia

.perinatal renal failure

.thrombocytopenia

Premature Rupture of Membranes
PROM
is when
amniotic membranes
rupture
before the course of labor -

This results in intrauterine infection
referred as "
Chorioamnionitis
" - meconium aspiration
and others risks can lead to neonatal sepsis
-
Blood or CSF cultures are required for diagnosis
-Optimal treatment includes:
1)
ampicillin
(100mg/kg/day IV divided every 12 hours for a premature neonate). 2)
Aminoglycosides
usually amikacin at a dose of 15mg/kg/dose q24-48hrs depending on Wt and PNA
*monitor CrCl for renal functions
Important notes to be taken into consideration:
• Infant’s Weight on 26/8  2.44 K.G
• Infant’s Weight on 2/8  2.37 K.G
• Height = 50 cm
• GA = 39 weeks / Full term neonate
• 27/7  Serum Creatinine = 1.32 GFR = 17
• 29/7  Serum Creatinine = 1.4 GFR = 16.1
• 2/8  Serum Creatinine = 0.9 GFR = 25


.Premature rupture of membranes can lead to

hypoxic ischemic encephalopathy (HIE).

, is the brain injury caused by oxygen deprivation to the brain.
The newborn’s body can
compensate for brief periods of depleted oxygen,
but if the asphyxia lasts too long, brain tissue is destroyed.

-It Is defined clinically on the basis of a
constellation of findings
to include a combination of abnormal :
.consciousness
.tone and reflexes
.feeding
.respiration
.seizures

stages
mild
moderate
severe
.
Muscle tone may be increased slightly.
.Transient behavioural abnormalities, such as poor feeding, irritability, or excessive crying or sleepiness,

may be observed
By 3 - 4 days of life, the central nervous system examination findings become normal


.The baby is lethargic, with significant hypotonia
.The grasping, Moro, and sucking reflexes may be sluggish or absent
.The baby may experience occasional periods of apnea
.Seizures may occur within the first 24 hours of life.
.Full recovery within 1 - 2 weeks is possible


.Stupor or
coma
is typical.
.
Breathing
may be irregular, and the baby often requires ventilatory support
.Generalized hypotonia and depressed deep tendon reflexes are common
.Neonatal reflexes (e.g. sucking, swallowing, grasping, Moro) are absent
.Disturbances of ocular motion.
.
Seizures
occur early , The seizures are usually generalized, and their frequency may increase during the 24 - 48 hours after onset.

Managment
.hypothermia — 
Therapeutic hypothermia,
maintained for 72 hours
at 33 to 35°C (91.4 to 95.0°F) and started within the first six hours after delivery, is the only effective
.
neuroprotective therapy
currently available for treatment of neonatal encephalopathy.
Supportive management
 —
 Aside from treatment with hypothermia, suggested the following recommendations:

Evaluate with an EEG
to gather information regarding the treatment and prognosis of neonatal encephalopathy.
identifying seizure activity
in infants with neonatal encephalopathy.
● Arterial blood gases and serum calcium, magnesium, glucose, and electrolytes should be assessed early in the course and as needed. Liver enzymes and serum creatinine are measured to identify injury to other end organs.

Use high frequency ventilation
, nitric oxide, or extracorporeal membrane oxygenation therapies, as available, for infants with persistent pulmonary hypertension
in order to maintain oxygenation.
●Treat seizures with 
phenobarbitone,  phentyoin , or (lorazepam , Midazolam).

Phenobarbitone (Pb)
:It is the drug of choice in neonatal seizures.
The dose is 20 mg/kg/IV slowly over 20 minutes (not faster than 1 mg/kg/min).
If seizures persist after completion of this
loading dose
, additional doses of phenobarbitone 10 mg/kg may be used every 20-30 minutes until a total dose of 40 mg/kg has been given.
The
maintenance dose
of Pb is 3-5 mg/kg/day in 1-2 divided doses, started 12 hours after the loading dose.
●Perform a
lumbar puncture
when there is concern for
intracranial infection
, especially since meningitis can mimic the signs and symptoms of neonatal encephalopathy. Antibiotics are started until infection is ruled out, and
 acyclovir
 is initiated if herpes simplex virus is suspected.
●Replace volume and use
inotropic agents
as required to maintain blood pressure and adequate cerebral perfusion. However, systemic hypertension and volume overload, which can worsen cerebral edema, should be avoided.
respiratory distress
formerly known as

hyaline membrane disease
, is a common problem in

preterm infants.

This disorder is caused primarily by
deficiency of pulmonary surfactant in an immature lung.

Surfactant is not produced in adequate amounts until relatively late in gestation (
34 to 36 wk)
; thus, risk of respiratory distress syndrome (RDS) increases with greater prematurity
Prognosis with treatment is excellent; mortality is < 10% ,
RDS resolves within 4 or 5 days

symptoms
Diagnosis
thrombocytopenia
Neonatal thrombocytopenia is typically defined as a platelet count less than 150,000/microL based upon the definition used in adults.

Causes

Increased destruction
including immune-mediated platelet destruction or consumption.

Decreased production
in the bone marrow.

In the case:

Disseminated intravascular coagulation (DIC)

.systemic process producing both thrombosis and hemorrhage.

.DIC is a complication of an underlying illness that typically includes
sepsis, asphyxia, meconium aspiration, necrotizing enterocolitis, or severe neonatal respiratory distress syndrome
in the neonate.

.clinical presentation of an ill-appearing patient, moderate to severe thrombocytopenia, and the presence of
microangiopathic changes on the peripheral blood smear.

.Confirming laboratory studies include
prolonged prothrombin time, prolonged activated partial thromboplastin time, decreased plasma fibrinogen concentration, and increased fibrin degradation product or D-dimer levels.

treatment

.Treating underlying cause of DIC.
.Transfusions of platelets and fresh frozen plasma .

given to maintain the
platelet count >50,000/microL
 and the prothrombin time within the physiologic range.
Fibrinogen concentration is maintained at >100mg/dL
 with infusion of
cryoprecipitate
.

neonatal sepsis
a clinical syndrome characterized by signs and symptoms of
infection
with or without accompanying bacteremia in the first month of life. It encompasses various systemic infections of the newborn as:
.
septicemia,
.meningitis,
.pneumonia,
.arthritis,
.osteomyelitis and urinary tract infections

classification
-Early onset sepsis (EOS): -Late onset sepsis (LOS):
It appears within the first
72 hours of life
.The source of infection usually is the
maternal genital trac
It usually presents usually
after 72 hours of age
. The source of infection in LOS is either
nosocomial or community acquired
and neonates usually present with septicemia ,pneumonia or meningitis.

managment
-
Supportive:

:
1.
Thermo-neutral environment
to avoid hypo/hyperthermia
2.
Mechanical ventilation
to keep oxygen saturation
3.In case of
hemodynamic instability, IV fluids
should be administered
4
.Volume expansion with crystalloids or colloids
to maintain normal tissue perfusion and blood pressure.
5.
fresh frozen plasma
can be used in case of
anaemia

antimicrobial therapy
initial therapy should include 
ampicillin
 plus an
aminoglycoside. Cefotaxime
 may be added to or substituted for the
aminoglycoside
if meningitis caused by a gram-negative organism is suspected.
therapywith 
ampicillin 
plus 
gentamicin
 or 
ampicillin plus cefotaxime
. If gram-negative meningitis is suspected
,ampicillin, cefotaxime, and an aminoglycoside
may be used.
consider vancomycin if MRSA is suspected

neonatal pneumonia
Pneumonia is an important
cause
of neonatal
infection
and accounts for significant
morbidity and mortality,
especially in developing countries . In these countries, the World Health Organization estimates that almost
800,000 neonatal deaths
occur each year from acute respiratory infections, mostly pneumonia
CLINICAL MANIFESTATIONS :
— 
1-
Early-onset pneumonia
commonly presents with
respiratory distress
beginning at or soon after birth.
Infants may have associated
:lethargy, apnea, tachycardia, and poor perfusion
,
sometimes progressing to
septic shock.
Some infants develop
pulmonary hypertension
. Other signs include
temperature instability, metabolic acidosis, and abdominal distension. None of these signs is specific for pneumonia,
and res
piratory distress also can be caused by noninfectious causes .
2-
Late-onset pneumonia
is marked by
changes in the overall condition of the newborn
and can include nonspecific signs of
apnea, tachypnea, poor feeding, abdominal distention, jaundice, emesis, respiratory distress, and circulatory collapse.


DIAGNOSIS :

Because signs of pneumonia are
nonspecific
, any newborn infant with sudden onset of respiratory distress or other signs of illness should be evaluated for pneumonia and/or sepsis.
Cultures — 
for determination of organism and sensitivity to antibiotics .
Chest radiography
 — The chest radiograph can confirm the clinical diagnosis of pneumonia. But it wont tell us the cause of it
treatment
 Depending on the
severity
of respiratory distress,

initial management
may include
oxygen supplementation
and
mechanical ventilation
, in addition to
empirical antibiotic therapy.

 a frequently used initial regimen for
empiric coverage
is :
1-
Ampicillin
is effective against group B streptococcus, most other strains of streptococci, L. monocytogenes, and some gram-negative bacteria.
2-
gentamicin
also has synergistic activity against many of these organisms .

note:
in our hospital
amikacin
is prefered over

gentamicin
as is it has nearly the same effect but its
nephrotoxicity
although higher than gentamicin but its reversible gentamicin nephrotoxicity is lower but irreversible

infants >3 days old,
 vancomycin plus an aminoglycoside
is the preferred initial therapy .
Amikacin
 has the most activity against
ESBL-producing strains among the aminoglycosides.
The duration of therapy is guided by the infecting pathogen and the response of the patient. The usual treatment course for uncomplicated pneumonia is
10 to 14 days.

Viral infections
 
 Specific agents for the treatment of viral pneumonia are limited. For most viral infections acquired in the perinatal or postnatal period, therapy remains
.
Herpes simplex virus 
— (HSV) pneumonia is suspected,
intravenous acyclovir (60 mg/kg per day in 3 divided doses for 21 days) i
s recommended . HSV pneumonia usually is
fatal
despite treatment .
Respiratory syncytial virus
 — 
Ribavirin
 is the
only
available specific treatment for respiratory syncytial virus (RSV) pneumonia; however, it is generally
not
recommended in infants and young children because efficacy in this population has not clearly been proven. RSV prophylaxis is suggested for high-risk infants (eg, those with chronic lung disease and/or born a
t <29 weeks gestation

Perinatal asphyxia
the most common cause of
AKI
in newborns, which results mostly from
impaired renal perfusion
.

CLINICAL PRESENTATION
:
elevated or rising serum creatinine
(1.32 mg/dl on 27/8)
anuria/oliguria.
Clinical neurological manifestations:

seizures , hypotonia, coma, hypoxic ischemic encephalopathy in the immediate neonatal period
(our patient had history of convulsions)
AKI also may be associated with a number of other laboratory abnormalities including :
hyponatremia, hypocalcemia,
hyperkalemia, hyperphosphatemia,
and acidosis.

Diagnosis:

*is confirmed by either :
a serum creatinine level
>1.5 mg/dL

or
increases by at least
0.2 to 0.3 mg/dL per day.

History:

Neonatal conditions that may be associated with AKI include
.prematurity
.perinatal asphyxia
.respiratory distress syndrome
.sepsis

The initial management of an infant with suspected AKI includes:

.bladder catheterization.
.fluid challenge (
of 10 to 20 mL/kg of isotonic saline given over one to two hours
) except in infants with intravascular volume overload. We can infuse colloid such as
albumin or fresh frozen plasma
, when clearly indicated.
discontinuation of fluids containing
potassium.
readjustment of medications that are renally excreted


Furosemide:
is given for signs of fluid overload.
may cause
Ototoxicity
due to accumulation of furosemide specially when administrated with
aminoglycosides.

Dopamine:
In infants with heart failure or with hypotension that does not respond to volume repletion, dopamine infusion may increase renal blood flow and urine output by raising systemic blood pressure.
Subsequent management
is directed towards the underlying cause of AKI and complications of AKI including: fluid overload, electrolyte abnormalities, and hypertension.

Renal replacement therapy
is considered if fluid and electrolyte balance and adequate nutrition cannot be maintained, despite adequate medical therapy.

medications
.apnea
.cyanosis
.Grunting
.inspiratory stridor
.nasal flaring
.poor feeding
.tachypnea (more than 60 breaths per minute).
There may also be retractions in the intercostal, subcostal, or supracostal spaces

Refrences:

http://www.msdmanuals.com/professional/pediatrics/infections-in-
www.newbornwhocc.org/2014_pdf/Neonatal%20sepsis%202014
http://www.Uptodate.com
(Clinical features, diagnosis, and treatment of neonatal encephalopathy)
(Etiology and pathogenesis of neonatal encephalopathy)
(Management of premature rupture of the fetal membranes at term)
(Neonatal pneumonia)
(Pneumonia in children)

http://cerebralpalsy.org/about-cerebral-palsy/cause/hypoxic-ischemic-encephalopathy/
http://www.sahealth.sa.gov.au/wps/wcm/connect/3beb3b0042abf6c09e57bfad100c470d/Hypoxic+inc+neonatal+hypothermic+neuroprotection_May2014.pdf?MOD=AJPERES&CACHEID=3beb3b0042abf6c09e57bfad100c470d
https://www.health.qld.gov.au/qcg/documents/g_hie5-1.pdf
http://emedicine.medscape.com/article/973501-followup
elraml pediatric hospital protocol

http://www.newbornwhocc.org/2014_pdf/Neonatal%20seizures%202014.pdf
http://www.ilae.org/visitors/centre/documents/Guide-Neonate-WHO.pdf
http://online.lexi.com/lco/action/home
http://www.michigancerebralpalsyattorneys.com/about-cerebral-palsy/causes-and-risk-factors-of-cerebral-palsy/labor-and-delivery-problems/premature-rupture-membranes-prom /

nourhan alaa
mohamed sherif
esraa mohamed
passant mohamed
noura yousry
nada badra
mayar el guishy
nourhan turky
ahmed yehia
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