RAJARAJESWARI MEDICAL COLLEGE & HOSPITAL

KAMBIPURA, MYSORE ROAD, KENGERI HOBLI, BANGALORE-560074. PH-22733272

DEPT OF NEONATOLOGY
Name: B/O PRATIBHA OUTBORN BABY
Age/sex: 16 D/MALE
Unit: NICU, Unit 4 IP NO: 37686
Address: #32, MUNIYAPPA COMPOUND, ROBIN THEATRE, KENGERI UPANAGAR BENGALURU
Date of admission: 19/12/22 Date of discharge from NICU: 05/01/23
Date of birth: 19/12/22 Time of Birth: 6:00PM
In charge doctor: DR.SAHANA
DR.VENKATESHMURTHY
DR.NAMRATHA

DIAGNOSIS: TERM (38+5) / MALE / 1.88KG / LBW / SGA / SYMMETRIC IUGR / BORN TO RH
NEGATIVE MOTHER/BABY CRIED AFTER TUBE AND MASK VENTILATION / RESPIRATORY
DISTRESS – SUSPECTED MECONIUM ASPIRATION / SYMPTOMATIC HYPOGLYCEMIA /
NEONATAL SEIZURES / SUSPECT SEPSIS / NEONATAL HYPERBILIRUBUNEMIA /LATE ONSET
THROMBOCYTOPENIA/

Maternal details: 26 years aged mother with obstetric index of G2P1L1 with 9 month of amenorrhea with breech
presentation
LMP- 23/03/2022
EDD- 30/12/2022
Mother blood group: AB NEGATVE.
Obstetrics History:
P1: 3 Years / Female / LSCS (oligohydramnios) / 1.6kgs / NICU admission for 20 days in view of prematurity
P2: present pregnancy
1st trimester
Spontaneous conception
Upt: done at 1 ½ months of amenorrhea
Folic acid supplementation taken
Dating & NT scan done
No h/o spotting PV
No h/o fever with rashes, PV bleed, radiation or drug exposure
2nd trimester
Quickening felt at 5MOA
2 doses of Inj. TT taken
Iron and Calcium supplements taken
Anomaly scan normal
No H/O headache or visual disturbances
No Pedal edema
3rd trimester
Appreciated fetal movements well
Taken Iron and Calcium supplements continued
Last trimester obstetric scan showed a growth lag of 40 days suggestive of fetal growth restriction.
Doppler study showed with decreased diastolic blood flow in the MCA and Umbilical arteries suggesting evidence of
fetoplacental insufficiency.

Mother blood group: AB NEGATIVE

Blood group baby: AB POSITIVE
Married life – 3 years, Consanguinity: NON-CONSANGUINOUR MARRIAGE
Mode of delivery: EMERGENCY LSCS (i/v/o oligohydramnios and breech presentation)

Baby details: A Single, live, term, male baby born via LSCS (oligohydramnios/breech) with birth weight of 1.88 kgs,
delivered at a private hospital at Bangalore. Baby didn’t cry at birth and hence, baby was intubated and bag and mask
given for 1 minute following which baby cried and tone and colour improved. Baby was put on oxygen mask and was
shifted to RRMCH for further management and care.
Date of birth: 19/12/2022 Time of Birth: 6:00PM
Birth weight: 1.88 kg
Length- 47 cm
Head circumference: 32 cm
APGAR score: No documentation noted.

Physical examination on arrival at NICU.

Heart rate: 164bpm
Respiratory Rate: 90cpm
SPO2: 93% on room air
CRT: <3seconds
P.Vol: Good
BP: 90/70 mmHg
GRBS: 115 mg/dl

Head to toe exam:

Head- normal
Fontanelle- AF: open and wide
Eyes- normal
Ears: Normal
Nose - normal
Oral cavity- normal
Chest: Normal in shape- Retractions noted
Abdomen: Normal in shape
Digits- 10+10
Hip-normal
Limbs: Normal
Skin-normal
Genitalia - male type, both testes present in the scrotum
Spine – normal
Anus -Patent

Systemic examination:
Respiratory system: Bilateral air entry present and equal, subcostal retractions and intercostal retractions noted.
Grunting noted. Respiratory distress score of 3(Downes score) at admission
CVS: S1S2 heard, no murmurs, all peripheral pulses felt with good pulse volume
Per abdomen: Soft, bowel sounds present
CNS: normal tone, normal reflexes

INVESTIGATIONS:
CBC 19/12 21/12 24/12 25/12
TSH 14.36
Hb 19.0 20.9 16.7 17.2 FT4 2.75
RBC 5.67 6.36 5.16 5.4 BU 12 1.0
WBC 12.11 10.8 15.6 9.4 SC 0.8 1.0
HCT 56.6 59.5 48.2 50.6 UA 6.8 3.6
MCV 99.8 93.6 93.4 93.7
TB DB AST ALT ALP TP ALB
MCH 33.5 32.9 35 31.9
19/12 3.4 0.7 59 7 209 4.7 3.3
MCHC 33.6 35.1 35 34
21/12 12.1 0.9 66 13 141 4.3 3.0
PLTs 16400 75000 30000
23/12 1.1 0.3 43 14 162 4.0 25
DLC 58/34 68/20 62/22
CRP Neg 6+ 24+
SE 19/12 21/12 24/12 25/12 28/12
S.SODIUM 140 138 136 136
S.POTASSIUM 5.6 5 6.7 5.9
S.CHLORIDE 108 107 110 110
CALCIUM 9.3 9.6

COURSE IN THE NICU:

26 year old G2P1L1 delivered a single live term 38+5 male baby via emergency LSCS i/v/o breech presentation and
baby didn’t cry at birth, baby cried after tube and mask ventilation following which baby was extubated and put on
low flow O2 and given iv bolus and shifted to RRMCH,NICU. On arrival to NICU ,baby had respiratory
distress(DOWNE’S score of 3) with Heart rate of 140bpm,Respiratory rates of 90 cpm ,good pulse volume and
,SPO2 -93% on room air, BP of 96/66(70)mmhg.

RESPIRATORY SYSTEM:
In view of respiratory distress (with tachypnea (90 cpm),grunt with stethoscope intercostal retractions,subcostal
retractions and nasal flaring being present) baby was put on CPAP support with FI02:40%PEEP 5,Baby was
monitored.As the distress settled by day 3 baby was weaned off to room air from CPAP and baby was maintaining
saturation on room air.
CARDIOVASCULAR SYSTEM:
The baby was maintaining HR, BP, appropriate for gestation age, till day 5 of life. On day 6 of life baby had an acute
life threatening event with GRBS 36 with cyanosis, gasping, nil cardiac, absent pulses; baby was resuscitated and was
put on invasive mode of mechanical ventilation. Baby was put on inotrope support that was gradually tapered and
stopped over 24 hours.GIR correction was started for hypoglycemia. Baby was weaned off from ventilatory support to
low flow oxygen on day 10 of life and on day 14 of life baby was weaned off from oxygen supplementation to room
air. The baby was hemodynamically stable with stable heart rates and blood pressure now.
PER ABDOMEN:
The baby was kept NPO on day1 and started on IV Fluids 10% dextrose. On day 2 baby was started on feeds that
were gradually upgraded. On day 5 in view of an acute life threatening event, baby being on mechanical ventilation,
baby was kept NPO, IV FLUIDS started with continued GIR correction. By day 7 of life baby was started on tube
feeds, that were graded up gradually and IV fluids were tapered and stopped. Now baby is on DBF + Extrapalladai
feeds and is tolerating feeds well.
CENTRAL NERVOUS SYSTEM:
On day 6 of life baby had abnormal involuntary movements of both upper limbs and lower limbs – neonatal seizures
and hence baby was given loading dose of INJ.PHENOBARBITONE and was then continued on maintenance doses
of INJ.PHENOBARBOTONE. On day 8 of life INJ.PHENOBARBITONE was stopped and was started on Syrup
LEVITERACETAM that was being continued. No further episodes of seizures/abnormal movements noted. The baby
had hypertonia initially that had improved gradually. Now the baby is alert, active, with normal tone in all limbs and
with normal neonatal reflexes.
NEONATAL HYPERBILIRUBINEMIA:
On Day 2 of life Trans cutaneous bilirubinometry showed a value of 9mg/dl and hence phototherapy started and was
given for 1 day .Post phototherapy serum bilirubin levels were within normal limits
SUSPECTED SEPSIS:
Baby was started on first line antibiotics AUGMENTIN & NETILMICIN and continued for 3 days. Day 3 septic
screening showed CRP of 6 and hence antibiotics were upgraded to INJ CEFOPERAZOE+SULBACTAM &
AMIKACIN. On day 7 with repeat CRP of +24 antibiotics were upgraded to MEROPENEM & VANCOMYCIN that
were given for 13 days and stopped.

TREATMENT GIVEN IN NICU-

1. INJ. AUGMENTIN IV BD X 3 DAYS
2. INJ. NETILMYCIN IV OD X 3 DAYS
3. INJ. CALCIUM GLUCONATE 3ML IV TID X 3 DAYS
4. INJ MEROPENEM MG IV
5. INJ VANCOMYCIN MG
6. INJ AMIKACIN IV
7. INJ PHENOBARBITONE
8. INJ LASIX
9. SYP LEVIPIL
10. SYP DOMSTAL

ADVICE ON DISCHARGE FROM NICU:

1. ON DEMAND DIRECT BREAST FEEDING + EXTRA PALLADA FEEDS FOLLOWED BY BURPING
AFTER EACH FEED.
2. TO IMMUNIZE WITH BIRTH DOSE OF BCG,OPV,HEPATITIS B INJECTION ON FOLLOWUP
3. ULTRA D3 ROPS (400 IU /1ML ) UPTILL 1 YEAR OF AGE
4. SYP OSSOPAN D 2.5 ML TID FOR 3 MONTHS
5. SYP DOMSTAL 0.4ML TID FOR 3 DAYS
6. SYP LEVIPIL 0.2ML BD TO CONTINUE TILL REVIEW
7. TO GET MRI – BRAIN AND EEG ON FOLLOWUP.
8. TO REVIEW AT HIGHRISK BABY CLINIC ON 09-01-2023.

NICU INCHARGE – DR. SAHANA

DR. VENKATESH MURTHY D.V.
DR.NAMRATHA

NICU RESIDENTS: DR. KIRAN,/DR.NAVYA/DR.SHILPA

DR. KUNAL/DR. LAVANYA
DR.SHARWANI/DR.NITESH