CHAPTER II

CASE REPORT

The case neonate girl resided in Semarang Regency, Central Java, under medical
record number C777008. The patient came to the hospital and admitted on September
18th 2019. Patient with is reffered from Diponegoro National hospital because of severe
asphyxia.

History of illness

Based on the anamnesis with the parents and information from patient’s medical record,
a female baby was born on 18 th of September 2019 from G1P0A0 mother, 24 years of
age with 37 weeks of pregnancy and had regular antenatal check-up by the obstetrician.
There was no history of sick, no history of hypertension, no history of diabetes mellitus,
no history of asthma, no history of heart disease, no history of fever with rash. Non-
prescribed drugs and traditional herbal medicine were not taken. The baby was born by
sectio caesarea, because of fetal distress and intra uterine growth restriction, there was
little amount of green amniotic fluid, sectio caesarea done in Diponegoro National
hospital. The baby not cried immediately, bluish of his extremities. The record of Apgar
score is 1-2-3. Based on that score, resuscitation done, intubated and refer to Kariadi
General Hospital. His birth weight was 1750 grams.

Figure 1. Clinical appearance

Table 1. Laboratory Finding

Examination Normal Unit 19/09/ 21/09/ 26/09/ 30/09/ 16/01/

19 2019 2020 2019 20
Hematology

Hb 13,6 – 19,0 gr/dL 13,2 9,6 14,7 14,6 10,6

Ht 44 – 62 % 37.1 27,4 40,6 43,5 32,5
Erytrocyte 2,1 – 5,3 10^6/uL 3.08 2,92 3,93 4,0 3,45
MCH 24,0 – 34,0 pg 39,6 32,9 37,4 36,7 30,7
 MCV 83 – 110 fl 120,5 93,8 103,3 109,3 94,2
MCHC 29,0 – 36,0 g/dL 32.9 35 36,2 33,6 32,6
Leukocyte 3,6 – 11 10^3/uL 13,4 6,3 6,4 4,3 8,5
Platelet 150 – 400 10^3/uL 32 232 11 53 376
RDW 11,6 – 14,8 % 23.7 24,9 24,2 25,9 14,1

Random 80-160 mg/dL 89

blood glukose
Total bilirubin 15 – 39 mg/dL 9,8
Direct 0,6 – 1,3 mg/dL 1,22
bilirubin
Indirect 0,2-0,8 mg/dl 8,58
bilirubin
Calcium 2,12-2,52 Mmol/L 1,82 2,40
Sodium 136 – 145 mmol/L 129 141
Potasium 3,5 – 5,1 mmol/L 2,6 4,5
Chloride 98 – 107 mmol/L 90 104

Table 3. Blood Gas Analysis Finding

Examination Normal Unit 18/09/ 19/09/
19 19

Temp C 34,2 36,6

FIO2 % 100 80
pH 7,37-7,45 7,19 7,382
pCO2 35-45 mmHg 30,4 32,2
pO2 83 – 108 mmHg 71,8 116,3
PH(T) 7,35-7,45 7,227 7,387
pCO2 (T) mmHg 26,9 31,6
pO2 (T) mmHg 59,4 113,8
HCO3- 22-36 Mmol/L 11,7 19,3
TCO2 Mmol/L 12,6 20,3
Eecf mg/dL -16,7 -6,0
BE (B) -2-3 mg/dL -14,5 -4,3
 SO2c 95-100 % 90,6 98,5
A-aDO2 Mmol/L 636,6 426,1
RI mmol/L 8,9 3,7

Table 2. Imunoserology Finding (19/09/19)

TSH 0,51- uIU/mL 10,5
4,94 9

Free T4 10,6 – Pmol/L 11,6

19,4 5

Blood culture (23/09/2019)

There
Anti is no bacteria growth in the
Negative=<4,0 specimen
IU/m 0

Figure 1. Genetic Examination 15 th October 2019

Diagnostic Impression :There is no structural abnormality in chromosome in
metaphase phase, there is an addition one chromosome in 21, meet the criteria of down
syndrome.

Figure 2. Chest X-Ray 18 th September 2019

Diagnostic Impression :Endo tracheal tube inserted with the distal end as high as
vertebrae thoracal 12, cardiomegaly, no infiltrate in lung. Abdomen within normal limit
Figure 2. Head USG 19 th September 2019
Diagnostic Impression: hyperechoic lesion in caudothalamic groove dextra and
sinistra region and intraventricular lateral dextra -> suspect germinal matrix
hemorrhage.
Figure 3. Chest X-Ray 22 th September 2019

Diagnostic Impression :Cardiomegaly, ifiltrate in lung like in neonatal pneumonia.,

right pleural effusionAbdomen within normal limit.

Figure 4. Abdomen USG 22 th September 2019

Diagnostic Impression :Mild Hepatomegly with normal parenkim, no enlargement in
intra and extra hepatal bile duct, no choledocal cyst, Vesica velea relative small
(preprandial 1,36, post prandial 1,12), there is no trieangular cord sign, there is unclear
biliary atresia based on USG
Figure 5. Chest X-Ray 23 th September 2019

Diagnostic Impression :Cardiomegaly, ifiltrate in lung,Right pleural effusion slightly

decrease Abdomen within normal limit, neonatal pneumonia

Figure 6. Echocardiography on 1st November 2019

- Situs colitus, AV-VA concordance
- All four pulmonary venous estuaries normal
 - Balance heart chamber
- Secundum Atrial septal defect  0,597 cm L yo R shunt
- VSD PMO  0,575 cm, L yo R shunt
- AV valve morphology and semilunar normal
- Left aorta arch, CoA (-), PD (-)
- Normal LV systolic function with LVEF 87,2%
- Minimal pericardial effusion

Diagnostic Impression: Moderate Secundum ASD, Perimembran VSD with moderate

outlet, mild pericardial effusion

Figure 7. Head USG 2nd November 2019

Diagnostic Impression :There is no subependymal, intraventricular, and brain
parenkim hemorrage, there is no ventrikel enlargement.

History of Family illness

There was no family history of congenital disease including congenital heart disease, no
family with down syndrome.

Figure 5. Pedigree
Social and economical background

Her father graduated from bachelor of nursery and works as nurse. Her mother
graduated from bachelor of nursery, before worked as a nurse, but now only a
housewife. Monthly income is ± IDR 3.000,000,-. Hospitalization fee was paid with
insurance (JKN non PBI).

Sosial and economical status: enough

Nutritional History

From nutritional history, the baby received breastmilk 8 times/ day

Treatmen BW Intake Quantity

t day
1 1750 Delay Delay
2 1750 Delay Delay
3 1750 Delay Delay
4 1750 Breastmilk through OGT 8x1ml
5 1750 Breastmilk through OGT 8x1ml

6 2035 Breastmilk through OGT 8x1ml

7 2035 Breastmilk through OGT 8x32ml
8 2100 Breastmilk through OGT 8x32ml
9 2190 Breastmilk through OGT 8x32ml
10 2045 Breastmilk through OGT 8x32ml
11 2045 Breastmilk through OGT 8x32ml
12 2045 Breastmilk through OGT 8x32ml
13 2070 Breastmilk through OGT 8x32ml
14 2070 Breastmilk through OGT 8x32ml
15 2070 Breastmilk through OGT 8x30ml
16 1955 Breastmilk through OGT 8x30ml
 17 1810 Breastmilk through OGT 8x30ml
18 1810 Breastmilk through OGT 8x31ml

Vaccination History
Baby do not receive Hb0 immunization.
Interpretation: Incomplete vaccination history

Perinatal History
This child was born form G1P0A0 mother, 24 years of age with 37 weeks of pregnancy
and had regular antenatal check-up by the obstetrician. There was no history of sick, no
history of hypertension, no history of diabetes mellitus, no history of asthma, no history
of heart disease, no history of fever with rash. Non-prescribed drugs and traditional
herbal medicine were not taken. The baby was born by sectio caesarea, because of
fetal distress and intra uterine growth restriction, there was little amount of green
amniotic fluid, sectio caesarea done in Diponegoro National hospital. The baby not cried
immediately, bluish of his extremities. The record of Apgar score is 1-2-3. His birth
weight was 1750 grams.

Growth History and Developmental History

History of birth weight 1750 gr, body length 40 cm, chest circumference 28 cm, head
circumference 30 cm. Weight 3 months ago 2200 gr and current weight 3300 gr.
Anthropometry a neonate girl at born

Body weight: 1,750 kg

length: 40 cm
Head circumference : 30 cm
Figure 6. Fenton Chart for girl
Impression :

 Cross-sectional : low birth weight, short stature, microcephal

Physical Examination

Vital sign blood pressure 66/44 mm/hg, Pulse 95 x/minute, respiratory rate 32 x/minute,
Temperature 34,1 °C, body weight 1750 gr.On her head there was no bulging
fontanella, microcephal, dismorphic face, anemic palpebral conjungtiva, no jaundice
sclera, pupils were isochor, 3 mm in right and left pupil diameter, pupillary light reflex is
normal, there was nasal flaring, no sianotic mouth, an endo tracheal tube inserted,
number 3, insertion depth 8 cm, oral mucosa was not pale, the pharynx wasn’t show
hyperemia, there is no enlargement and hyperemia of the tonsils on her neck, no
limfonodi enlargement, no nuchal rigid. Chest examination revealed simetric when static
and dynamic, there was suprasternal, subcostal retraction, reduction in vesiculer basic
sound, no ronchi, and no crackles in both lung. From heart examination, data obtain that
the cardiac apex doesn’t shift to lateral and there was normal s1-s2 heart sound, no
murmur. The abdomen was flat, supple, bowel sound (+) normal, spleen and liver were
not palpable, bleeding through umbilical infusion. Extremities looked pale, cold, no
edema, capillary refill time was >2 second, there was no muscle wasting. There was
cutis mammorata. Physiologic reflex in upper and lower extremities were normal, no
pathological reflexes, no clonus, and tonus were normal. There were no meningeal sign.
Examination in cranial nerves revealed olfactorius nerve (N.I) was normal, pupillary
reflex (N.II and N.III) normal, eye movement (N III,IV, and VI) was free to all direction,
naso labial sulcus was simetric (N.VII), swallowing was good (N.IX and X) tongue was
simetric ( N. XII), Trigeminal nerve (N.V), vestibulocolear (N.VIII) and accessory nerve
(N.XI) was normal.

Based on the anamnesis, physical and supporting examination, in the emergency room
patient diagnosed by severe respiratory distress, neonatal aterm (37 week), Low birth
weight (1750 gram), shock observation, clinical down syndrome. Patient treated with O 2
VTP FiO2 100% flow 10 lpm, D 10 % infusion 120/5ml/hours (GIR 4,7), Dobutamin Drip
10 mcg/Kg BW/minute, intravein injection of ampicillin 80 mg/12 hours, Gentamicin
7mg/24 jam, Ca glukonas 0,8 ml/12 hours, patient progammed to check routine blood
check, blood gas analysis, and babygram

In NICU, condition of the patient the patient presented look pale and weak, irregular
breath, and cutis marmorata. From patient vital status, the result of blood pressure
66/44 with MAP 52, Heart rate 78x/minute,respiratory rate 26x/ minute, pulse can’t be
feel, temperature 32,4°C, Sp O2 52 %. There was sub costal retraction, no sign of
infection. Patient was shock with acral coldness, normal heart sound, there is no
additional sound. Bleeding in umbilical vein since patient admitted in emergency room,
no vomit, no seizure. The patient was diagnosed by severe respiratory distress,
neonatal aterm (37 minggu), low birth weight (1750 gram), IUGR, clinically down
syndrome, post severe asphyxia, shock observation.Patient treated with O 2 PC-AC +
VG RR 60 PEEP 7 Vt 7 Ti 0,4 Pmax 30 FiO2 100 %, D 10 % 120/5ml/jam (GIR 4,7),
dobutamin drip 10 mcg/kgBW/minute, Intravein injection ampicillin 80 mg/12 hours,
gentamicin 7 mg/24 hours, Ca Gluconas 0,8 ml/12 hours. Patient progammed to check
routine blood check, blood gas analysis, babygram.

First day and second day of admission, the patient presented look pale and weak,
irregular breath, and cutis marmorata. From patient vital status, the result of blood
pressure 66/44 with MAP 52, Heart rate 78x/minute,respiratory rate 26x/ minute, pulse
can’t be feel, temperature 32,4°C, Sp O 2 52 %. There was sub costal retraction, no sign
of infection. Patient was shock with acral coldness, normal heart sound, there is no
additional sound. Bleeding in umbilical vein since patient admitted in emergency room,
no vomit, no seizure. The patient was diagnosed by severe respiratory distress,
neonatal aterm (37 minggu), low birth weight (1750 gram), IUGR, clinically down
syndrome, post severe asphyxia, shock observation. The patient treated by O 2, VM PS-
AC +VG RR 60 PEEP 7 volume 7 Ti 0,4 Pmax 30 FiO 2 100%, D 10 %
infusion120ml/5ml/ hours with GIR 4,7, dobutamin drip 10 mcq/kgBW/minute, Ampicillin
80mg/12 hours IV, Gentamicin 7mg/24 hours, Ca glukonas 0,8 ml/12 hours. The patient
was planned to routine blood check, babygram, BGA, keep the temperature in infant
warmer 34 °C.

Third day of admission, The patient presented cutis marmorata and hard distend
abdomen. From patient vital status, the result of blood pressure 49/25 with MAP 33,
Heart rate 129x/minute,respiratory rate 65x/ minute, pulse can’t be feel, temperature
36,5°C, Sp O2 90%. There was sub costal retraction, there is no fever but leukositosis
(leukosit 13.400) is found. Patient was shock with acral coldness, normal heart sound,
there is no additional sound. No bleeding (Hb 12,2 mg/dl, Ht 37,1,trombosit 32.000), no
vomit, no seizure. The patient was diagnosed by severe respiratory distress, neonatal
aterm (37 minggu), low birth weight (1750 gram), IUGR, clinically down syndrome, post
severe asphyxia, shock observation. The patient treated by O 2, VM PC-AC +VG RR 40
PEEP 6 volume 7 45%, D 40 % infusion24ml +NaCl 3% (2Meq) 10 ml and D 10 %
infusion 212ml +KCl otsu (2Meq) 5 ml ith GIR 5, dobutamin drip 10 mcq/kgBW/minute,
Ampicillin 80mg/12 hours IV, Gentamicin 7mg/24 hours, Ca glukonas 0,8 ml/12 hours.

Fourth and fifth day of admission, The patient presented cutis marmorata, hard distend
abdomen, vomit two times, and dyspneu. From patient vital status, the result of blood
pressure 63/44 with MAP 51, Pulse regular, Heart rate 130x/minute, respiratory rate
57x/ minute, temperature 36,5°C, Sp O 2 90%. There was sub costal retraction, there is
no fever but leukositosis (leukosit 13.400 in 4 th and 6.700 in 5th) is found. Patient wasn’t
shock, normal heart sound, there is no additional sound. No bleeding, no vomit, breast
feeding 8 times per day, no seizure. The patient was diagnosed by severe respiratory
distress, neonatal aterm (37 minggu), low birth weight (1750 gram), IUGR, clinically
down syndrome, post severe asphyxia, shock observation. The patient treated by O 2,
VM PC-AC +VG RR 40 PEEP 6 volume 7 45%, D 40 % infusion24ml +NaCl 3% (2Meq)
10 ml and D 10 % infusion 212ml +KCl otsu (2Meq) 5 ml ith GIR 5, aminosteril 6 %i
nfusion 58/2,4/hours, dobutamin drip 10 mcq/kgBW/minute, Ampicillin 80mg/12 hours
IV, Gentamicin 7mg/24 hours, Ca glukonas 0,8 ml/12 hours. The patient was planned to
routine blood check, electrolyte, calcium, ureum, creatinine. Total bilirubin, direct
bilirubin, CRP, Ft4, TSHs, cromosom check, and target of MAP is >38.

Sixth and seventh day of admission, The patient presented dyspneu with the RR was
62x/minute and SpO2 , from the baby gram show an effusion on right pleura. Based on
routine blood check the trombosit was 15.000. The result of TSH was elevated and
there decrease on T4. So we treated the patient with euthyrax 17 mcq/24
hours,cefotaxime replace ampicillin, cefotaxime was gifted intravenously 100mg/12
hours. Blood culture checked to this patient.head USG is repeat in next 2 weeks.

Eleventh until fourteenth day of admission, The patient presented no dyspneu, no vomit,
and improvement of swelling. From patient vital status, the result of blood pressure
61/44 with MAP 44, Pulse regular, Heart rate 147x/minute,respiratory rate 55x/ minute,
temperature 36,5°C, Sp O2 90%. There was no abnormality in thorax, there is no
leukositosis (leukosit 6.400 in 8th day). Trombositopenia (trombosit 11.000 in 8 th
day),Patient wasn’t shock, Breast feeding 20 ml- 25 ml/ 8 hours. The patient was
diagnosed by severe respiratory distress, neonatal aterm (37 minggu), low birth weight
(1750 gram), IUGR, clinically down syndrome, post severe asphyxia, post shock,
improvement in right pleural effusion, and trombositopenia. The patient treated by O 2,
VM PC-AC +VG RR 40 PEEP 5 volume 7 30%, D 15 % + electrolit that consist of (D 40
% infusion 41 ml +NaCl 3% (2Meq) 10 ml and D 10 % infusion 131 ml +KCl otsu (2Meq)
5 ml with GIR 5), aminosteril 6 % infusion 100/4,1/hours, cefotaxime 100mg/12 hours
IV, Gentamicin 8mg/24 hours, Euthyrax 17 mcg/ day The patient was planned to
echocardiography.

Fourteenth and fifteenth day of admission, patient was transferred to high risk baby
ward. No fever, vomit, and dyspneu, Patient was conccious, with vital sign HR 140
x/menit, RR 40 x/menit, Sp O2 97 %. There is a face dimorphic, no anemic conjunctiva,
no nasal flare, no sianotic in mouth, thorax within normal limit, and no cold acral in
extremity. This patient was diagnosed by mild respiratory distress, neonatal aterm (37
minggu), low birth weight (1750 gram), IUGR, clinically down syndrome, post severe
asphyxia, post shock, improvement in right pleural effusion, and trombositopenia.
Patient used O2 nasal canule 1 lpm, aff infus in 15 day of admission, patient still use
euthyrax 17 mcg/ day. Patient intake is 30 ml/3 hours. The patient progammed to
discharge.