APPLE SARASWATI Multi-speciality Hospital 27 ½ weeks preterm Neonate 614 gm birth weight 90 days in NICU 15 days on invasive ventilatory support Read the survival story of a 27 ½ weeks preterm Neonate with a 614 gms birth weight. A 27 ½ weeks, preterm Neonate born to a primi mother was shifted to NICU department of Apple Saraswati Hospital. Maternal and Obstetric history : 21 years old primi mother, K/c/o acquired heart disease on atenolol & penidura prophylaxis. Mother was closely followed during the pregnancy by a team of Gynecologists and Cardiologist. Patient had Rheumatic heart disease with moderate MS, mild AS with moderate AR & mild PH. (patient had undergone balloon mitral valvotomy 2 years back). She has been advised not to conceive again considering her compromised cardiac status. Birth History. Baby was delivered by LSCS, birth weight was 614 gm & cried immediately after birth. In view of ELBW/PT, (Extremely low birth weight / Pre term) baby was transferred to NICU of Apple Saraswati Hospital. On admission, baby had mild distress and intermittent grunting for which baby was taken on CPAP. Arterial Blood Gas analysis was suggestive of mild metabolic acidosis with hypoxia & chest X ray was normal. Baby’s respiratory distress settled over 24 hours. CPAP was discontinued. Baby was maintaining well in room air. In view of SGA (IUGR) baby was kept NBM & total parenteral nutrition was started from day 1. Feeds were slowly introduced on day 4 and stepped up slowly. Baby was approximately all right till Day 9. On day 10 of life, baby was on 40% feeds. Baby had distended abdomen with decreased level of consciousness. There were dilated bowel loops seen on X ray abdomen erect. There were brownish gastric aspirates, & serum electrolytes were Na+ - 106, K+-4.4, Haemogram was normal & Neurosonogram was within normal limits .Baby was kept NBM. Abdomen was tens within next 12 hours. Baby had frank Necrotising enterocolitis (NEC) on day 11 with pneumatosis intestinalis and fixed dilated loops. X-Ray showing Pulmonary haemorrhage - White Arrow & evidence of Necrotising enterocolitis (NEC) - Yellow Arrow On day 11 of life baby develop thrombocytopenia and her oxygen requirement increased. Arterial Blood Gas analysis revealed metabolic acidosis with hypoxia. Baby was electively ventilated on day 11. Platelet transfusion were given in view of thrombocy topenia (Platelet count 30,000/cmm). Inspite of platelet transfusion baby had pulmonary heamorrhage and ventilator requirement increased. Baby was ventilated from day 11 to day 18 of life, she was transfused with 4 RDPS, 1FFP and 1PCV. Baby was extubated and taken on CPAP on the day 18 of life. CPAP was continued for 10 days and slowly weaned off. Baby was kept NBM from day 11 to day 20 of life. On day 21 baby recovered form Necrotising enterocolitis (NEC) & was started on minimum feeds 0.5ml, 4 hourly EBM. Feeds were gradually increased to full feeds on day 30 of life. From day 30 of life upto day 80 of life baby was tolerating feeds well and was accepting wati spoon feeds well and started gaining weight. Baby’s weight on discharge was 1408 grams. Baby was screened for retinopathy of prematurity and OAEC. C h o l e s t a t i c J a u n d i c e : - Ye l l o w i s h discolouration of the skin and mucous membrane was noted on day of life 35, which gradually increased & stool – intermittently was clay coloured. Serum Bilirubin was suggestive of direct hyperbilirubinemia (Total 20mg/dl, Direct 15mg/dl) with normal Ultrasound abdomen & normal gall bladder. Serum SGPTwas normal. TORCH panel was negative, Thyroid function was normal ,metabolic screeningwas also normal. Baby was treated with Multivitamins, Medium chian Triglycerides, (Neonatal hepatitis probably secondary to TPN) and with conservative treatment. Baby was recovered completely and on discharge serum Bilirubin was Total 8mg/dl, Direct 5mg/dl Symptomatic Hyponatremia – Hyponatremia is one of the common electrolyte disturbance in NICU. In this baby there was severe symptomatic hyponatremia probably secondary to NEC. Baby became comatose within 12 hours. Initially we suspected IVH but Neurosonogram was showing only cerebral oedema and no bleed, baby was treated with 3% Nacl/ Hypertonic saline over next 48 hours and baby improved dramatically neurologically. Hydrocephalus - During routing monitoring we noticed on day 35 of life that there is abrupt rise on head circumference. Neurologically baby was normal except apnea. Anterior fontenelle was bulging. Neurosonogram was done which revealed moderate communicating hydrocephalus which was treated by serial aspiration of CSF by lumbar puncture. Consequently hydrocephalus slowly regressed. 25 Bed, Level IV NICU 01 High frequency & 05 advanced Ventilators Round the clock availability of experienced & highly skilled Neonatal Intensivists Trained Medical Officers & Paramedical staff Bedside Echocardiography, Ultrasonography, ABG analysis Isolation ward for septic neonates In house Diagnostic facilities viz, Pathology Lab, Video EEG, CT & MRI Scan, Digital X-Ray Neonatal ICU Ambulance equipped with Neonatal ventilator PANEL OF CONSULTANTS NEONATAL & PAEDIATRIC INTENSIVISTS PAEDIATRICIANS DR. VYANKATESH TARKASBAND (DIXIT) DR. DHANANJAY PATIL MD(PAEDIATRICS) – KEM HOSPITAL MUMBAI FELLOWSHIP IN PAEDIATRIC CRITICAL CARE (ISCCM) – WADIA CHILDREN'S HOSPITAL, MUMBAI MD(PAEDIATRICS), DCH, FCPS, FELLOWSHIP IN PAEDIATRIC RESPIRATORY MEDICINE KEM HOSPITAL MUMBAI DR. AMOL GIRWALKAR DR. PREETI SAGAONKAR FELLOWSHIP IN NEONATAL CRITICAL CARE - PUNE MBBS, DCH. NEONATAL & PAEDIATRIC SURGERY DR. PRAKASH VICHARE MD(PAEDIATRICS), DCH. DR. SANTOSH PATIL MS, Mch (Paediatric Surgery) FIAGES PAEDIATRIC NEUROSURGERY DR. NARESH BIYANI MS, DNB (General Surgery) Mch (Neurosurgery), DNB (Neurosurgery) APPLE SARASWATI MULTI-SPECIALITY HOSPITAL 804, 805/2, Circuit House-Kadamwadi Road, Kolhapur - 416 003 0231-2688888 www.applesaraswati.com