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DISCUSSION
Cries : Weak
Heart rate : 150x/minutes
Respiratory rate : 42x/minutes
Temperature : 36,6ºC
Cyanosis (-)
Dyspneu (-)
Icteric (-)
Bodylength : 47 cm
Birth weight : 2800 gram
Head circumference : 34 cm
Specific Examination:
Head : Nose: Nasal flaring (-), grunting (-)
Thorax : Chest retraction (-), Heart: heart sound I and II Normal, There’s
no murmur, Lungs: Normal vesicular and no ronchi
Abdomen : Flat, supple, bowel movement (+), umbilical cord normal
Extremity : Inspection: cycling motion of the leg was observed,
there’s no congenital defect
Genitalia: Anus: (+), meconium (+)
No Terms Clarifications
1. Cycling motion Sign of neonatal seizure, caused by sudden
abnormal and excessive electrical activity in the
brain.
2. Breech presentation Fetus in longitudinal line with the buttocks or
Dyspneu (-)
Icteric (-)
Bodylength : 47 cm
Birth weight : 2800 gram
Head circumference : 34 cm
5. Specific Examination:
Head : Nose: Nasal flaring (-), grunting (-)
Thorax : Chest retraction (-), Heart: heart sound I and II Normal,
There’s no murmur, Lungs: Normal vesicular and no ronchi
Abdomen : Flat, supple, bowel movement (+), umbilical cord normal
Extremity : Inspection: cycling motion of the leg was observed,
there’s no congenital defect
Genitalia : Anus: (+), meconium (+)
Synthesis:
Seizures are paroxysmal alterations in neurologic function
caused by excessive synchronous depolarization of neurons
Synthesis:
A neonate with mild HIE may present with absent rooting
and sucking reflexes initially. However, rooting and sucking
remained inadequate for breastfeeding well into the first week of
the participant’s life. An absent rooting reflex may not impact an
infant’s feeding functionally, but short sucking bursts may be
related to swallowing difficulties. Cerebral depression may cause
reduced alertness and a lower level of consciousness in infants
(Genna et al., 2013). In this study, it appears that state regulation
Cause Frequency
Hypoxic-ischaemic encephalopathy 30-53%
Intracranial haemorrhage 7-17%
Cerebral infarction 6-17%
Cerebral malformation 3-17%
Meningitis/septicemia 2-14%
Metabolic
Hypoglycaemia 0,1-5%
Hypocalcaemia, hypomagnesaemia 4-22%
Hypo-/hypernatremia 3-4%
Inborn errors of metabolism (such as pyridoxine dependency,
folinic-acid responsive seizures, glucose transporter defecr,
non-ketotic hyperglycinaemia, proprionic aciduria)
Kern icterus
1%
Maternal drug withdrawal 4%
Idiopathic 2%
Benign idiopathic neonatal seizures 1%
Neonatal epileptic syndromes
Congenital infections
Source: Pressler, 2003
Synthesis:
According to Kosim, et al (2008), the etiology of neonatal
seizures are:
- Asphyxia
Perinatal asphyxia causes hypoxic-ischemic
encephalopathy and is an important neurological problem
in the neonatal period, and causes neurological sequelae
later on. Intrauterine asphyxia is the most common cause of
hypoxic-ischemic encephalopathy. This is because
hypoxemia occurs, lack of oxygen to brain tissue. Both of
these conditions can occur together, one can be more
dominant but the ischemic factor is the most important
factor compared to hypoxemia.
- Intracranial Trauma and Bleeding
Trauma and intracranial bleeding usually occur in
large infants born to mothers with primiparous pregnancies.
This occurs during prolonged labor, difficult labor caused
by fetal position abnormalities in the uterus or precipitous
birth before the uterine cervix opens wide enough. In low
birth weight babies with a body weight of <1500 grams
usually bleeding occurs preceded by asphyxia. Intracranial
hemorrhage can occur in the arachnoid, subdural, and
intraventricular spaces or brain parenchyma.
- Infection
In newborns infection can occur in the uterus, during
labor, or immediately after birth. Infections in the uterus
occur due to primary maternal infections such as
toxoplasmosis, rubella, cytomegalovirus, and herpes.
During labor or immediately after birth, the baby can be
infected by the herpes simplex virus, Coxsackie virus, E.
Colli, and Streptococcus B which can cause encephalitis
and meningitis.
- Metabolic Disorder
Metabolic disorders that cause seizures in newborns
are disorders of metabolism of glucose, calcium,
magnenisum, electrolytes, and amino acids. This metabolic
disorder is present in 73% of newborns with brain damage.
Reduced glucose levels from normal values are the most
common cause of metabolic disorders in newborns. Various
conditions of metabolic disorders associated with seizures
in neonates are:
Hypoglycemia: Hypoglycemia in newborns is when in the
first three days after birth, blood sugar levels are less than
20 mg% in under-month infants or less than 30 mg% in
term infants on examination of blood sugar levels 2 times in
a row, and less than 40mg% in infants over 3 days.
Hypoglycemia often occurs in small babies during
pregnancy, babies of mothers with diabetes, or babies with
severe diseases such as asphyxia and sepsis.
Hypocalcaemia: Hypocalcaemia is rarely the sole cause of
neonatal seizures. usually hypocalcemia is accompanied by
other disorders, such as hypoglycemia, hypomagnersemia,
or hypophosphatemia. The diagnosis of hypocalcemia is
when the blood calcium level is less than 7 mg%.
Hypocalcemia occurs early in infants with low birth weight,
- Clonic seizures
Synthesis:
Neonatal seizures can be classified into four categories:
subtle, clonic, tonic, or myoclonic. Subtle seizures are more
common in premature infants and manifest most often as ocular
phenomena (tonic horizontal eye deviation with or without eye
jerking, sustained eye opening with ocular fixation), oral-buccal-
lingual movements (chewing or tongue thrusting), or “bicycling”
or stepping movements of the lower extremities. Subtle seizures
are not consistently associated with EEG changes (Krakauer and
Carter, 2012).
- Clonic Seizures
Consist of slow (1-3 /minute) rhythmic jerking
movements of the extremities. They may be focal or
multi-focal. Each movement is composed of a rapid
phase followed by a slow one.
Changing the position or holding the moving limb does
not suppress the movements. They are commonly seen
in full-term neonates >2500 grams
There is no loss of consciousness and they are
associated with focal trauma, infarction or metabolic
disturbances.
- Myoclonic Seizures
Focal myoclonic seizures typically involve the flexor
muscles of the extremities.
Multi-focal myoclonic seizures present as asynchronous
twitching of several parts of the body.
Generalized myoclonic seizures present as massive
flexion of the head and trunk with extension or flexion
of the extremities. They are associated with diffuse
CNS pathology.
- Subtle (Fragmentary) Seizures
Usually occurs in association with other types of seizures
and may manifest with:
Stereotypic movements of the extremities such as
bicycling or swimming movements.
Deviation or jerking of the eyes with repetitive
blinking.
Drooling, sucking or chewing movements.
Apnea or sudden changes in respiratory patterns.
Rhythmic fluctuations in vital signs.
Synthesis:
Both clinical and laboratory studies demonstrate that
seizures early in life can result in permanent behavioral
abnormalities and enhance epileptogenicity. In experimental
rodent models, the consequences of seizures are dependent upon
age, etiology, seizure duration, and frequency. Recurrent seizures
in immature rats result in long-term adverse effects on learning
and memory. These behavioral changes are paralleled by changes
in brain connectivity, dendritic morphology, excitatory and
Synthesis:
Extracellular accumulation of excitatory amino acids
(mainly glutamate) due to increased release as well as impaired
uptake; this causes the overactivation of neuronal glutamate
receptors, mainly the N-methyl-D-aspartate (NMDA) receptor,
which results in an excessive intracellular influx of calcium
(Antonucci et al., 2014).
The resulting intracellular calcium accumulation has the
following effects: (a) activation of celldegrading enzymes
(lipases, phospholipases, proteases and endonucleases); (b)
production of oxygen free radicals through activation of
Xanthine oxidase, increased prostaglandin synthesis, and
activation of Nitric Oxide (NO) synthase (Antonucci et al.,
2014).
Neonatal circulation
With the infant’s first breath and exposure to increased
oxygen levels, there is an increased blood flow to the lungs
Newborn Reflexes
One of the neonate’s greatest strengts is a full set of useful
reflexes. A reflex is an involuntary and automatic response to a
stimulus.
Development
Name Response Significance
and course
Survival reflex
Breathing Repetitive inhalation Provides oxygen and
Permanent
reflex and expiration expel carbon dioxide
Eye-blink Closing or blinking Protect the eyes from
Permanent
reflex the eyes bright lights, adapt visual
Constriction of pupils
Pupilary reflex Protect against bright
to bright;dilatation to Permanent
lights
dark
Disappears
Rooting reflex over the first
Turning the head in
few weeks of
the direction of a
life and is Orients baby to the breast
tactile (touch)
replaced by
stimulus to the cheek
voluntary
head turning.
Sucking on object
Sucking reflex Allows baby to take in
placed (or taken ) into Permanent
nutrients
the mouth
Swallowing Allows baby to take in
Swallowing Permanent
reflex nutrients
Primitive reflexes
Usually
Its presence at birth and
Fanning and then disappears
disappearance in the first
curling the toes when within the
Babinsky reflex year are an indication of
the bottom of the foot first 8 months
normal neurogical
is stroked to 1 year of
development
life
Disappears in
first 3-4 Its presence at birth and
Curling of the fingers
months and is later disappearance in the
Palmar around object (such a
then replaced first year are an
grasping reflex finger) that touch the
by a indication of normal
baby’s palm
voluntary neurogical development
grasp
Moro reflex A loud noise or The arm Its presence at birth and
sudden change in the movements later disappearance are an
position of the baby’s and arching indication of normal
head will cause the of the back neurological development
baby to throw his or disappear
her arms outward, over the first
arch the back, and 4-6 months;
then bring the arms however, the
toward each other as child
if to hold onto continues to
something. react to
unexpected
noises or a
loss of bodily
support by
showing a
startle reflex
(which does
not
disappear).
An infant immersed
in water will display,
active movements of
the arms and legs and
involuntarily hold his Disappears in Its presence at birth and
Swimming
or her breath (thus the first 4-6 later disappearance are an
reflex
giving the body months. indication of normal
buoyancy); this neurological development
swimming reflex will
keep an infant afloat
for some time,
allowing easy rescue.
Disappears in
the first 8 Its presence at birth and
Infants held upright weeks unless later disappearance are an
so that their feet the infant has indication of normal
Stepping reflex
touch a flat surface regular neurological
will step as if to walk. opportunities development.
practice this
response.
Synthesis:
According to Kotaska et al (2009) For a woman with
suspected breech presentation, pre- or early labour ultrasound
should be performed to assess type of breech presentation, fetal
growth and estimated weight, and attitude of fetal head. If
ultrasound is not available, Caesarean section is recommended.
The contraindications to labour include cord presentation, fetal
growth restriction or macrosomia, any presentation other than a
frank or complete breech with a flexed or neutral head attitude,
clinically inadequate maternal pelvis, and fetal anatomy
incompatible with vaginal delivery. Vaginal breech delivery can
be offered when the estimated fetal weight is between 2500 g and
4000 g.
Ultimately, if the obstetrical operator is not experienced or
comfortable with vaginal breech deliveries, cesarean
delivery may be the best choice. Unfortunately, with the
dwindling number of experienced obstetricians who still perform
vaginal breech deliveries and who can teach future generations of
obstetricians, this technique may soon be lost due to attrition.
reported at 1 minute and 5 minutes after birth for all infants, and
at 5-minute intervals thereafter until 20 minutes for infants with a
score less than 7. The Apgar score provides an accepted and
convenient method for reporting the status of the newborn infant
immediately after birth and the response to rescucitation if
needed. However, it has been inappropriately used to predict
individual adverse neurologic outcome. The purpose of this
statement is to place the Apgar score in its proper perspective
(American Academy of Pediatrics, 2015).
An Apgar score that remains 0 beyond 10 minutes of age
may, however, be useful in determining whether continued
resuscitative efforts are indicated because very few infants with
an Apgar score of 0 at 10 minutes have been reported to survive
with normal neurologic outcome. In line with this, the 2011
Neonatal Resuscitation Program guidelines state that “if you can
confirm that no heart rate has been detectable for at least 10
minutes, discontinuation of resuscitative efforts may be
appropriate (American Academy of Pediatrics, 2015).
Abortion 0 no abortion
- 39 weeks pregnant normal, no premature
- Breech presentation malpresentation
4. Physical Examination
Activity : Hypoactive
Sucking response : Weak
Cries : Weak
Heart rate : 150x/minutes
Respiratory rate : 42x/minutes
Temperature : 36,6ºC
Cyanosis (-)
Dyspneu (-)
Icteric (-)
Bodylength : 47 cm
Birth weight : 2800 gram
Head circumference : 34 cm
a. What is the interpretation and mechanism of pathological
finding on physical examination?
Answer:
The interpretation of physical examination on table 2.3 below.
5. Specific Examination:
Head : Nose: Nasal flaring (-), grunting (-)
Thorax : Chest retraction (-), Heart: heart sound I and II Normal,
There’s no murmur, Lungs: Normal vesicular and no ronchi
Abdomen : Flat, supple, bowel movement (+), umbilical cord normal
Extremity : Inspection: cycling motion of the leg was observed,
there’s no congenital defect
Genitalia : Anus: (+), meconium (+)
a. What the interpretation and mechanism of the pathological
finding on specific examination?
Answer:
The interpretation of specific examination on table 2.4 below.
Extremity
Inspection: cycling motion of No cycling motion Seizure (Subtle)
the leg was observed
No congenital defect
Genitalia Normal
Anus (+) (+)
Meconium (+)
Synthesis:
- Phenorbarbital
Mechanism of Action Depresses sensory and motor cortex,
cerebellum Antiseizure activity occurs primarily where GABA
mediates neurotransmission Hypnotic effects of barbiturates
result from activity at GABA receptor in the polysynaptic
midbrain reticular formation (controls CNS arousal) Off-label
use for hyperbilirubinemia: Phenobarbital induces glucuronyl
transferase and hepatic bilirubin-binding Y-protein to lower
serum bilirubin concentrations (Sheth, 2017).
Absorption Bioavailability: 70-90% Onset: 5 min (IV)
Duration: 4-6 hr (IV/IM) Peak plasma time: 8-12 hr Therapeutic
plasma concentration: 10-40 mcg/mL; may require 3-4 weeks of
treatment to achieve therapeutic levels Distribution Protein
Answer:
Quo ad vitam: dubia ad bonam
Quo ad fungsionam: dubia ad bonam
Quo ad sanationam: dubia ad bonam
12. How does the competences of general practitioner for this case?
Answer:
The competences of general practicioner for this case is 3B (KKI,
2012).
Synthesis:
General practitioner be able to make a clinical diagnosis based on
physical examination and examination additional checks requested by
doctors such as lab or x-ray examination. Doctors can decide and give
preliminary therapy, and refer to a specialistrelevant (emergency case).
2.6 Conclusion
Two days old baby boy sluggish to breastfeed and a frequent “cycling”
motion on the legs due to suffering from neonatal seizure with history of
neonatal asphyxia.
Asphyxia
Hypoxia
Seizure
Cycling
motion