This document summarizes the case of a 3 day old male neonate born at 41 weeks gestation via lower uterine cesarean section with meconium aspiration and respiratory distress since birth. On examination, the baby was tachypneic with generalized convulsions, bulged chest, and weight below the 10th percentile. Investigations revealed perinatal asphyxia, hypoxic ischemic encephalopathy, and meconium aspiration. The diagnosis was term small for gestational age neonate with perinatal asphyxia, hypoxic ischemic encephalopathy, and meconium aspiration. Management included supportive care, antibiotics, anticonvulsants, and follow up.
2. Particulars of the patient
Name: Baby of Tamanna.
Age: 3 days.
Sex: Male.
Address: Laxmipur, Noakhali.
Date of Admission: 26.10.2015.
Date of Examination: 26.10.2015.
3. Chief Complaints
Born after 9 days of expected date of
delivery.
Passage of meconium in utero.
Delayed cry after birth.
Respiratory distress since birth.
4. History of present illness
According to the statement of father, baby was
delivered by LUCS 9 days after the expected date of
delivery with average birth weight. Baby cried about
10 minutes after birth following resuscitation. Baby
had h/o passage of meconium in utero and
developed respiratory distress since birth. He also
had h/o convulsion from 2nd day of life. With these
complaints, the baby was admitted in a local
hospital and then referred to Dhaka Shishu Hospital
for further evaluation and better management.
5. Birth History
Antenatal : Mother, Tamanna, a 20 years old
lady, gravida – 1st , para – 1, was on regular
antenatal check up and was normotensive &
nondiabetic. There was no history of fever
with rash or taking any offending drug during
her pregnancy period. She was immunized
against tetanus and her blood group is B
positive.
6. Birth History (cont..)
Postnatal : Baby cried about 10 minutes after
birth following N-P & O-P suction and physical
stimulation.
Natal : Baby was delivered by LUCS at 41 weeks
of gestational age at 10.00 PM on 24.10.2015 at
hospital due to maternal oligohydramnios. Liquor
was meconium stained.
7. Family History
He is the 1st issue of his non-consanguineous
parents.
Socio-economic History
He came from a low socio-economic family.
Feeding History
Baby was kept nothing per oral.
8. Physical Examination
o Baby was pink with O₂, acyanotic, anicteric,
having generalized convulsion.
o Weight : 2230 gm ( below 10th centile ).
o Length : 47 cm ( just below 10th centile ).
o OFC : 33 cm ( just below 10th centile ).
o Temperature : 99° F.
o CRT ˂ 3 seconds.
o SPO₂ (Pulse oximeter) : 98% with O₂ (5L/min).
9. Cont..
o Fontanelle : Normal, not bulged.
o Face : No dysmorphysm.
o Eye : Pupil size was normal, light reflex was
present.
o Nose : Normal.
o Ear : Normal.
o Oral cavity : Normal.
o Neck : Normal.
10. Cont..
o Respiratory rate : 68/min.
o Chest was bulged, chest movement was
symmetrical on both side, subcostal indrawing
was present.
o Air entry was good and symmetrical in both
side, no added sound.
o Heart rate : 100/min.
o Apex beat was palpable in left 4th intercostal
space just medial to the mid clavicular line, 1st
and 2nd heart sound was audible in all 4 areas,
no murmur.
11. Cont..
o Abdomen : Soft, not distended.
o Umbillicus : Meconium stained.
o Liver : Not palpable.
o Spleen : Not palpable.
o Kidneys : Not ballotable.
o Bowel sound : Present.
o Genitalia : Both testes are in scrotum.
12. Cont..
o Anal opening was patent.
o Spine : Normal.
o Hip joints (both) : Normal.
o Movement of all joints : Normal.
o Muscle tone : Normal.
o Primitive reflexes : Good.
o No visible congenital anomaly.
13. New Ballard Score
Neuromuscular Maturity
Neuromuscular Maturity
Sign
Score
Posture Flexion of hip and limb 3
Square window (Wrist) 30° 3
Arm recoil ˂90˚ 4
Popliteal angle 100° 3
Scarf sign Elbow do not pass midline 4
Heal to ear Up to 90˚ 3
14. New Ballard Score
Physical Maturity
Physical Maturity Sign Score
Skin Superficial peeling 2
Lanugo Mostly bald 4
Planter surface Creases over entire sole 4
Breast Full areola, 5 mm bud 4
Ear Formed and firm, instant
recoil
3
Genitals (male) Testes pendulous, deep
rugae
4
16. Salient feature
Baby of Tamanna, 3 days old male neonate, 1st issue
of his parents, was delivered by LUCS at 41 weeks of
gestational age due to maternal oligohydramnios
and cried about 10 minutes after birth with h/o
meconium aspiration. He developed respiratory
distress since birth and had h/o convulsion. Baby
was tachypnoeic, having generalized convulsion
with bulged chest with good air entry. His primitive
reflexes were normal with good muscle tone. His
weight falls below 10th centile.
17. Provisional Diagnosis
Term (41 weeks) with Small for Gestational
Age with Perinatal Asphyxia with Hypoxic
Ischemic Encephalopathy (ll) with Meconium
Aspiration Syndrome.
18. Investigations
Complete Blood Count :
• Hb%: 16.6 gm/dl
• WBC: Total count: 8,300/cumm
Differential count:
o Neutrophil: 60%
o Lymphocyte: 36%
o Monocyte: 02%
o Eosinophil: 02%
o Basophil : 00%
19. Cont..
o RBC: Macrocytic with normochromic.
o WBC: Shows as distribution.
o Platelet: Normal.
• Platelet : 1,79,000/cumm
• PBF:
23. Final Diagnosis
Term (41 weeks) with Small for Gestational Age
with Perinatal Asphyxia with Hypoxic Ischemic
Encephalopathy (ll) with Meconium Aspiration.
24. Management
A.Counseling.
B.Supportive:
Maintenance of temperature.
Airway clearance by O-P & N-P suction.
Maintenance of breathing by O₂ inhalation @
5L/min.
Maintenance of circulation.
Maintenance of hydration and nutrition : Inf.
10% dextrose in 0.225% NaCl ( 100ml/kg ).
25. Cont..
Inj. Ceftazidime 100 mg/kg/day in 2 divided
doses.
Inj. Amikacin 15 mg/kg/day in 2 divided
doses.
Inj. Phenobarbitone 20mg/kg IV stat.
Inj. Phenobarbitone 5mg/kg/day in 2 divided
doses (maintenance dose).
Inf. 10% Dextrose 2ml/kg IV bolus.
Inj. KT 1ml in each 100 ml IV fluid.
Inj. Dobutamine 5µgm/kg/min.
C.Follow up.
