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Premature Infant

(A case of premature infant diagnosed with G6PD and its management)

By JYOTI RANI TASOOD,Department of Pediatrics,TSMU


Outline
•Introduction

•History / Events

•Clinical Problems

•Pathophysiology

•Medical Management
- Oxygen Therapy
- Blood Investigations
- Phototherapy
- Nutrition
Introduction

The premature neonate (gestation 25/52 +6 days) is a 6 days old,


Chinese male and weighs 815grams at birth.

The mother has premature rupture of membrane (PROM) 5 days


before delivery, chorioamnionitis and pyrexia.

He was admitted to neonatal ICU on 18/1/08 due to apnoea at birth,


infection complications and extremely low birth weight. He
appeared jaundice and was diagnosed with G6PD.
History/ Events
Mother’s history

Age: 28 years old

Race/ Occupation: Georgian/ Housewife

Past Medical History: Nil

Past Surgical History: Left Ureter operation more


than 10 years ago

Blood Group: 0 +

Drug Allergy: Sulphur Drugs


Antenatal / Intrapartum Problems:

•Premature Labour 25/52 + 6 days

•Infection

•Pyrexia (Temperature 38.3C)

•Membrane Rupture 18/11/2018@ 0300hrs


Labour History

Onset: 18/11/2018 0200hrs

Delivery Time: 18/11/2018 0507 hrs

Nature of liquor: clear

Anaesthesia/ Analgesia: Entonox

Mode of delivery: Spontaneous Vaginal

Resuscitation:
•Oxygen/ Stimulation
•Bag and Mask

Apgar Score: 7 (1 min) 8 (5 min)


Neonate Record

Sex: Male

Birth Weight: 815 gm

Head Circumference: 24 cm

Length: 34 cm

Passed Urine: No

Passed Meconium : No
Neonate Record
Cord Blood for:

•G6PD
•FT4/ TSH
•IgM
•ABO/ Rh/ DCT

Drugs Given
•Vitamin K 1 gm ( Vitamin K is administered prophylactically
to prevent a transient deficiency of coagulation factors II, VII, IX and X.
Dosage is 0.5mg to 1 mg IM up to 1 hour after birth. )

•Gentamicin 2 mg

•Ampillicin 40 mg
Physical Examination upon Birth
Head Normal Liver Normal
Fontanelles Normal Spleen Normal
Face Normal Kidneys Normal
Eyes Left eye fixed; Right eye partially fixed Hips Normal
Ear Normal Back Normal
Nose Normal Genitalia Normal
Neck Normal Anus Sacral Dimple
Skin Normal Limbs Normal
Mouth Normal Activity Normal
Palate Normal Posture Normal
Heart Normal Tone Normal
Femoral Pulse Normal Moro’s Normal
Reflex
Lungs Normal Grasp Normal
Abdomen Normal Traction Normal
Umbilicus/ Normal Cry Normal
Cord
Clinical Problems
Clinical Problems

Maternal

1. Premature Ruptured of membrane (PROM) more than 24 hrs


• Placental Histology: E Coli

2. Clinical chorioamnionitis
Chorioamnionitis is a condition in which the chorion and amnion (the
membranes that surround the fetus) and the amniotic fluid (in which the fetus
floats) are infected by bacteria. This can lead to infection in both the mother
and fetus, and, in most cases means the fetus has to be delivered as soon as
possible.

3. Pyrexia
• Temperature Maximum: 38.3C
• Covered with PO EES 800mg BD then IV EES(erythromycin
ethyl succinate)
Clinical Problems

Neonate

1. Prematurity
•IM Betamethasone X2 completed
2. Premature Rupture of membrane

3. Apnea of Premature
•Covered with IV Caffeine Citrate

4. Glucose-6-phosphate dehydrogenase (G6PD)


deficiency

5. Early Neonatal Jaundice


•Serum Bilirubin 71 at 15 hrs of life
Clinical Problems

6. Hyper glycaemia
•Reflo 125 158 140 ( normal range : 65 – 125 mg/ dl)
•Urine Sugar 1+
•Piggy back with ½ strength normal saline

•Hyperglycemia occur in preterm neonate who is having


total parenteral nutrition. It may also be an early sign of
sepsis
Clinical Problems
7. Hypernatremia
•Na 152
Hypernatremia is defined as a serum sodium greater than 150mmol/L.
Newborn infants, particularly preterm ones, rapidly become dehydrated
and hypernatramia if fluid intake is reduced or abnormal losses occur
where water loss exceeds sodium loss.

1. Reduced renal excretion. The newborn kidney is less efficient at


excreting excess salt than water, and so hypernatraemia is more
likely in very immature infants than in older children.

2. Excessive water loss. The lack of keratin in the skin of very tiny
babies causes excessive transepidermal water loss.
Phototherapy and radiant warmers aggravate this loss.
Pathophysiology
What is G6PD?
• G6PD enzyme glucose-6-phosphate dehydrogenase is one of many
enzymes that help the body process carbohydrates and turn them
into energy. G6PD also protects red blood cells from potentially
harmful byproducts that can accumulate when a person takes
certain medications or when the body is fighting an infection.

• G6PD deficiency is an inherited condition in which the body doesn't


have enough of the G6PD, which helps red blood cells (RBCs)
function normally. This deficiency can cause hemolytic anemia,
usually after exposure to certain medications, foods, or even
infections.
What is Jaundice?
• Bilirubin is a normal pigment made when red blood cells
break down in the body. It is usually processed by the
liver, recycled and eliminated in the baby’s stool.

• Jaundice is very common in newborn babies. The baby’s


skin and whites of the eyes turn a yellow colour. When a
baby has jaundice, it means either his body is making
too much bilirubin or the liver is not eliminating.
Medical Management
Parameters

Normal Neonatal Vital Signs

Temperature: Rectal : 35.6 C to 37.5 C


Axillary: 36.4C to 37.2C

Heart Rate: 110 to 160 beats / min

Blood pressure:
•Systolic: 60 to 80 mmHg
•Diastolic: 40 to 50 mmHg

Respiration: 30 to 50 breaths / min


Blood Investigations
Immunohaematogical
Mother Blood Group O+

Antibody Negative

Baby Blood Group B+

Antibody Negative
Full Blood Count
Date 1st day 2nd day

WBC (9.0 – 30.0) 23.52 X 10 (9) / L 19.5 X 10 (9) / L

Hb (14.0 – 24.0) 15.6 G/DL 12.5 G/DL

PLT (140 – 440) 421 X 10 (9) /L 441 X 10 (9) / L

Reticulocytes (2.5 – 14.6 % 3.0%


6.5)
Urea Electrolytes
Date 19/01/08 21/01/08

Urea (2.8 – 7.1) 11.1 mmol 11.0

Sodium (131 -144) 142 152

Potassium (4.5 – 6.8) 6.6 5.2

Chloride (102 – 112) 107 120

Bicarbonate (17.0 – 26.0) 18.9 16.1

Creatintine (35 – 88) 98 114


Cerebrospinal Fluid
CSF Latex Agglutination Negative For:

• Haemophilus Influenzae type B

• Streptococcus Pneumonia

• Streptococcus group B

• Neisseria Menigitidis ACY W 135

• Neisseria Menigitidis B

• Escherichia coli
Culture & Aspiration Result
Blood Culture No bacterial growth @ 48
hours

Ear Culture Swab No bacterial growth @ 48


hours

Gastric Aspiration Escherichia coli


Phototherapy
Phototherapy is the treatment modality of choice for
Jaundice in neonates ,it’s the application of UV light
between 420-490nm
Photo therapy
Phototherapy (light treatment) is the process of using light to eliminate
bilirubin in the blood. The neonate's skin and blood absorb these light
waves. These light waves are absorbed by your baby's skin and blood and
change bilirubin into products, which can pass through their system.
Side effects

Babies under any type of phototherapy


treatment will have frequent and loose bowel
movements that are sometimes greenish in
color. This is normal since this is the way the
body removes the bilirubin.
Diet
Date

21/11/2018 Breast Milk or Full Strength (Premature Formula)


@ 4 ml, 3 hourly X 8 per day

22/11/2018 Breast Milk or Full Strength (Premature Formula)


@ 4 ml, 3 hourly X 8 per day

23/11/2018 Breast Milk or Full Strength (Premature Formula)


@ 5ml, 3 hourly X 8 per day
References
• Engle, W.A., Trautman, M.S., & Applengate, K.E. (2005). Nonsurgical causes of
respiratory distress. in Hertz, D.E.(ED.). Care of the newborn: A handbook
for primary care. Philadelphia: Lippincott Williams & Wilkins.

• Greenough, A., & Roberton, N.R.C. (1999). Acute respiratory distress in the newborn.
In Rennie, J.M., & Roberton, N.R.C. (ED.). Textbook of neonatology (3rd ed.).
Edinburgh: Churchill Livingstone.

• Harold, C.E., & Priff, N. (ED). (2008). Springhouse nurse’s drug guide 2008 (9th ed.).
Philadelphia: Lippincott Williams & Wilkins.

• Kelnar, C.J., Harvey, D., & Simpson, C. (1995). The sick newborn baby(3rd ed.).
London: Bailliere Tindall.

• Kenner, C., Amlung, S.R., & Flandermeyer, A.A. (1998). Protocols in neonatal
nursing. Philadelphia: W.B. Saunders.
References
• Kenner, C., Lott, J.W., & Flandermeyer, A.A. (1998). Comprehensive neonatal
nursing: A physiologic perspective (2nd ed.). Philadelphia: W.B.Saunders.

• Merenstein, G.B., & Gardner, S.L. (2006). Handbook of neonatal intensive care (6th
ed.). St. Louis: Mosby Elsevier.

• Vargo, L.E., Trotter, C.W. & Freda, M.C. ( n.d.). The premature infant: Nursing
assessment and management (2nd ed.) [On-line slides]. Available:
http://72.14.235.104/search?q=cache:3xiYF8fn3JsJ:www.marchofdimes.com/n
ursing/modnemedia/othermedia/premature_infant_blue.ppt+treatment+of+RDS
+in+preterm+infants&hl=en&ct=clnk&cd=73 (2008, 01,18)..

• Yeo, H. (1998). Nursing the neonate. London: Blackwell science.