Case 9 History ---- The patient was a 2 week-old male twin born in October 2009 by Cesarean section at a gestational age of 29 weeks 4/7 days to a 28 year-old G1P0 (now P2) mother with type O+ blood, Coombs negative, antibody screen negative, rubella immune, RPR nonreactive and unknown GBS status. He was the smaller twin in a monochorionic, diamniotic twin gestation, with known twin-twin transfusion syndrome as determined by prenatal ultrasound. His mother was admitted to an outside hospital for preeclampsia at 27 6/7 weeks gestation which was treated with Procardia and labetalol, and then subsequently IV magnesium at delivery. The neonate’s birth weight was 1030g and his birth length was 34.5 cm. His Apgar scores at birth and at 5 min were 6 and 7. He immediately received CPAP for oxygen saturations in the 80s and taking only occasional spontaneous breaths that subsequently required intubation. He was extubated shortly after receiving surfactant. He remained on CPAP, but required reintubation due to increasing work of breathing and respiratory acidosis. A head sonogram showed bilateral intraventricular hemorrhage with slight increase in the ventricular size. He also developed hypernatremia and hyperbilirubinemia that required IV fluids and phototherapy. A week after he was extubated, he developed necrotizing enterocolitis and required exploratory laparotomy with resection of 65 cm of his small intestine. Postoperatively, he developed acidosis with difficulty ventilating requiring reintubation, fluid boluses, antibiotics, steroids and dopamine for sepsis (Proteus mirabilis and Enterobacter aerogenes). He subsequently developed anuria with worsening metabolic acidosis and hyperkalemia. He then showed signs of hemodynamic encephalopathy including decreased heart rate and episodes of ventricular fibrillation requiring epinephrine to keep his heart rate up. Due to his poor prognosis, his family decided to withdraw care, and he expired.
