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Extern Conference. Thursday 27 th September 2007. History. A preterm AGA 8 days old male infant with complaint of jaundice. History.

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Extern Conference


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    1. Extern Conference Thursday 27th September 2007

    2. History • A preterm AGA 8 days old male infant with complaint of jaundice

    3. History • PI : the patient was born at 35+6 weeks of gestational age (on 14th sep 07) by spontaneous vertex delivery, with birth weight 2610 gm AGA, HC 32 (P3-10 ) cm and body length 48 cm(P3-10). Apgar scores were 10,10 at 1&5 minutes, respectively. Prenatal history was normal.

    4. Maternal history • His mother is 15-years old. G1P0A0. First ANC at GA 26 weeks x 4 times. Her blood group is B with Rh positive. Blood serology was all negative. Hct 35%, MCV 90 • No family history of hematologic disease • She came to the hospital with premature contraction, no PROM.

    5. History • On the 2nd date of birth ,he developed visible jaundice. Physical examination was unremarkable. GA 36 weeks by Ballard’s score. ABO and Rh blood types of the patient and his mother revealed no incompatibility. G-6-PD enzyme was normal. Coombs’ test was negative. Blood smear showed no hemolysis. Reticulocyte count was 7.22

    6. History • At thattime, phototherapy was started and continued for 4 days. The microbilirubin was declined. He was discharged home on 18thsep 07, the 5th day of birth. • BW was 2560 gm on the discharged day.

    7. History • After discharge home (DOL 3D21HR), he was given only breast feeding, about 10 times per day, 20 minutes each feed. Frequency of urination was 10 times per day, yellowish color. Frequency of defecation was 3-4 times per day, yellowish color

    8. History • On the admission day (DOL=7), his mother brought him to Siriraj hospitalto follow up his jaundice clinical. He had no fever, active but still icteric.

    9. History • Diet : breast feeding only • Immunization : HBV , BCG at birth • No history of neonatal jaundice in family

    10. Physical examination • V/S : T 37c, BP 55/35mmHg ,RR 54/min, PR 141/min • BW 2470 gm HC 32 cm BL 48 cm • GA : active, mildly pale, marked jaundice, no petechiae or rash, no dyspnea. • HEENT : no cephalhematoma, no macroglossia, no tongue tie, AF 2x3 cm ,PF 1x1 cm Eyes : no cataract ,cornea clear • CVS : normal s1 and s2, no murmur • RS : normal breath sound, no adventitious sound.

    11. Physical examination • Abdomen : soft, no distention, bowel sound positive, liver and spleen can’t be palpated. • CNS : normal reflexes, normal muscle tone

    12. Problem list • Maternal teenage pregnancy • Preterm AGA male infant, NL, BW 2610 g , Apgar 10,10 • History of visible jaundice on 2nd day of life with phototherapy treatment for 4 days • Recurrent visible jaundice on DOL 7

    13. Neonatal jaundice • A yellow discoloration of the skin, mucous membrane, and sclera in the first 4 weeks of life after birth. • Neonatal jaundice is visible when total serum bilirubin exceeds 5 mg/dl

    14. Common disease in neonatal jaundice

    15. Pathology • Bilirubin production • Hemolysis • Extravasation • Bilirubin conjugation • Impaired hepatic function • Bilirubin excretion • Biliary tract obstruction • Intestinal obstruction • Increase enterohepatic circulation

    16. In this patient • DDX • Hemolytic jaundice • Breast feeding jaundice

    17. Investigation • CBC with slide • TB/DB/MB • reticulocyte count • TSH • Coombs’ test • G6PD • Blood group normal

    18. Investigation (21/9/07) • The blood examination was performed. • Microbilirubin : 21.4 mg/dL. • TB : 26.2 • DB : 2.5 • CBC : Hb 9.8 Hct 27.4% WBC 9440 (N 46% L 49% M 3% E 2%) Plt 484000 • MCV 83 RDW 18.1 anisocytosis 1+ poikilocytosis 1+ • reticulocyte count 3.11 (0.1-1.3) • TSH 3.08 mcu/ml (0-18)

    19. Review blood smear • Normochromic normocytic RBC • Anisocytosis 2+ , poikilocytosis 1+, polychromasia few spherocyte 2+ • WBC no band form • Platelets adequate

    20. Problem list • Maternal teenage pregnancy • Preterm AGA male infant, NL, BW 2610 g , Apgar 10,10 • History of visible jaundice on 2nd day of life with phototherapy treatment for 4 days • Recurrent visible jaundice on DOL 7 • anemia

    21. Directhyperbilirubinemia Indirecthyperbilirubinemia Neonatal jaundice • Neonatal hepatitis • - Intrauterine infection • Biliary atresia • Sepsis • etc Coombs’ Test ,Blood types Negative Positive • Dx:Isoimmunization • Rh • ABO • Other Hemoglobin or Hct Low or normal High

    22. Hemoglobin or Hct Low or normal High Coombs’ test negative • Dx: Polycythemia • Maternal-fetal transfusion • Twin-twin transfusion • Delay cord clamping • Intrauterine hypoxia Reticulocyte count High Normal RBC morphology Dx:-Physiologic jaundice -Extravascular blood in body tissue -Increase enterohepatic circulation -Breast milk jaundice -Hypothyroidism -Metabolic errors -Hormone+drugs Abnormal Non-specific Diagnostic Dx : -RBC abnormality -Hemoglobinopathy -Enzyme deficiency -Hemolysis-DIC /sepsis Dx: -Spherocytosis -Elliptocytosis -Stomatocytosis -Pyknocytosis

    23. DDx • Hemolytic jaundice • Breast feeding jaundice

    24. DDx • Hemolytic jaundice

    25. Most likely diagnosis • Indirect hyperbilirubinemia from hemolysis -HS -Thalassemia

    26. Treatment • Goals • Prevention of kernicterus • Treatment of underlying conditions • Maintenance of hydration and nutrition • Interventions • Intensive Phototherapy • Exchange transfusion

    27. Phototherapy • Indication for early phototherapy • Bilirubin rising faster than 0.5mg/dL/hr or 5mg/dL/d • Persistent, severe metabolic or respiratory acidosis • Sepsis • Sick VLBW infants • Indication for phototherapy in infants >35 weeks gestation AAP: Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks Gestation, July 2004

    28. In this case

    29. Exchange transfusion • Indication in infants 35 weeks gestation or more

    30. In this patient Double phototherapy Hct/MB : 32/22.2 4 hours Hct/MB : 32/22.7 Pre-transfusion : Hct/MB 21/15.4 Exchange transfusion Post-transfusion : Hct/MB 31/8.9

    31. Exchange transfusion • Action • Replacement of the neonate’s blood with donor blood that has normal level of serum bilirubin • Mechanism: removes bilirubin and antibodies from circulation and correct anemia • Most beneficial to infants with hemolysis • Generally never used until after intensive phototherapy attempted

    32. Exchange transfusion • Indication • Intensive phototherapy fails • TB exceed the level indicated in guideline • Despite intensive phototherapy for 6 hrs • Signs of acute bilirubin encephalopathy

    33. Principle of exchange transfusion • Two-volume exchange (160 ml/kg) • Push-pull method (5 ml/kg/2-3min) • Time 60-90 min • In case of blood group incompatibility , choose bl gr. which compatible with both mom and baby.

    34. Complication

    35. Progression

    36. Progression

    37. Plan of management • Continue breast feeding • Consult hematologist to find out the cause of hemolytic anemia -Inclusion body test : negative -Hb typing : pending • Observe clinical of kernicterus

    38. Complication of neonatal jaundice • Acute bilirubin encephalopathy • The acute manifestations of bilirubin toxicity in the 1st week after birth. • Early phase: lethargic and hypotonic • Intermediate phase: stupor, irritability, high pitched cry fever, hypertonia • Advance phase: Retrocollis-opisthotonos, shrill cry, apnea, coma, sometimes seizure and death • Kernicterus • The chronic and permanent clinical sequelae of bilirubin toxicity

    39. Discharge • Assessment before discharge • Predischarge bilirubin • Use nomogram to determine risk zone • Assessment of risk factors

    40. Discharge • Assessment before discharge • Predischarge bilirubin • Use nomogram to determine risk zone • Assessment of risk factors

    41. Follow-up Care • Plan based on • Age in hours at discharge • Risk of excessive hyperbilirubinemia • Availability and reliability of follow-up

    42. Follow-up Care • Timing of follow-up

    43. Follow-up Care • Follow up assessment should include • Body weight, % change from BW, adequacy of intake, the pattern of voiding and stooling, presence or absence of jaundice • Clinical judgment should be used to determine the need for a bilirubin measurement. • If there is any doubt about the degree of jaundice. Blood testing should be done.

    44. Follow-up Care • Some harmful advice and beliefs have to be changed. All health personnel should not advise parents to supplement water or dextrose water to newborns or expose newborns to sunlight.

    45. Follow-up Care • Parents should be educated and provided with adequate educational materials at discharge regarding jaundice, feeding adequacy and symptoms to watch for, the risks of untreated hyperbilirubinemia, and the need for close follow-up of their infants after discharge

    46. THANK YOU