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Washington University Experience | VASCULAR | Hemorrhage - Neonatal | 22A0 Case 22 History
Case 22 History ---- The patient was a 5 week old infant, born on 8/16 at 24 weeks EGA. His mother is a 19 year old G2P0 woman with limited prenatal care and a positive drug screen for marijuana. She presented with preterm labor and preterm rupture of membranes. She delivered by urgent Cesarean section ~1 hr after rupture of membranes. The amniotic fluid was described as bloody and she had a clinical diagnosis of placental abruption. Birth weight was 690 g. Apgar's were 2 at 1 min, 4 at 5 min, 3 at 10, and 5 at 15 min. His initial course was remarkable for resuscitation including intubation, epinephrine and chest compressions (30-45 minutes). He was transferred to SLCH where he received surfactant and high frequency oscillator ventilation until 9/9 with right and left pneumothoracies. His initial head ultrasound on day of life 0 showed possible periventricular leukomalacia. A repeat ultrasound on day of life 1 showed bilateral grade 2 intraventricular hemorrhages with blood in the third and fourth ventricles. A repeat ultrasound on 8/28 showed progressive hydrocephalus involving all four ventricles. The ductus had closed as evaluated by echocardiogram on 8/21; however, on 9/11 an echocardiogram again showed a large PDA with a right to left shunt but was not a candidate for medical or surgical treatment of the PDA. On 8/23, a renal ultrasound showed a large right perinephric and subcapsular hematoma distorting the right kidney with right pyelocaliectasis which spontaneously liquefied without change in size. His anuria was unresponsive to fluid boluses, diuretics and dopamine. His edema worsened as did his hyponatremia and hyperkalemia. He received phototherapy on day of life 0-10 as he was initially very bruised and had a high risk for hyper-bilirubinemia. He had intermittent episodes of thrombocytopenia but no DIC requiring multiple platelet transfusions. Notably, the platelet count was normal at the time of development of the hematomas. On 9/23 an episode of bradycardia with a heart rate in the 30s did not respond to epinephrine and he expired. ---- At autopsy the brain weighed 130 g (normal=154 + 26 g) but was macerated. There was clear dilation of the lateral ventricles and blood within the lateral ventricles. The full spectrum of hypoxic-ischemic injury was evident, most prominently in the periventricular regions. Areas of frank white matter infarction were seen. The ependymal lining was discontinuous, broken up by hemorrhage and with developing granular ependymitis. Macrophages and hemosiderin were prominent, consistent with the clinical history of long-standing hemorrhage.
