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Washington University Experience | VASCULAR | Cardiac Arrest Encephalopathy | 4A0 Case 4 History
Case 4 History ---- The patient was a 10 day old, 40 week (EGA), 5230 gm female infant born to a 35 year old mother. The pregnancy was complicated by maternal diabetes mellitus and obesity, but the mother had good pre-natal care with a normal ultrasound several days prior to delivery. Three days prior to delivery, the mother noted decreased fetal movements. A non-stress test was performed and was interpreted as normal. Induction of labor was scheduled for 12/21 at an OSH but the mother went into spontaneous labor before induction was begun. Artificial rupture of membranes showed moderate meconium levels. The fetal heart monitor recorded extended fetal bradycardia and multiple late decelerations and a stat C-section was performed after vaginal extraction failed. At the time of delivery, the baby was blue and limp without spontaneous respirations or movement and no detectable heart rate. The patient was intubated and resuscitated with epinephrine and atropine. She developed seizure activity, which resolved with the administration of phenobarbital, and was transferred to SLCH for neurological evaluation. Physical exam at SLCH revealed fixed and dilated pupils without response to pain and no spontaneous respirations or movement. Chest x-ray demonstrated possible cardiomegaly, pleural effusion and patchy pulmonary infiltrates. Neurological evaluation showed severe, bilateral cerebral hemispheric dysfunction with involvement of the midbrain and third cranial nerve. These changes were thought to be secondary to severe hypoxia with subsequent cytotoxic cerebral edema and transtentorial herniation. Serial EEG's (performed 12/22 and 12/26) showed markedly decreased cerebral activity without change over time which were thought to indicate irreversible, profound cerebral damage. Given the patient's poor and irreversible prognosis, the parents agreed to extubation on 12/30 and no further interventional therapy was initiated. The patient became bradycardic with periods of apnea and expired on 12/31, approximately 10 days following her birth. ---- At autopsy the cerebral hemispheres show white matter necrosis with marked reactive astrocytosis, large numbers of foamy macrophages and vascular proliferation with reactive endothelial cells. Focal gray matter necrosis was also noted. The histologic changes were consistent with diffuse, severe cerebral ischemia of approximately 10 days age. Similar changes were also noted in the pons, medulla and in the gray matter of the spinal cord.
