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Washington University Experience | VASCULAR | Hypoxia-Ischemia, fetal-neonatal | Pontosubicular necrosis | 6A0 Case 6 History
Case 6 History ---- The decedent was born on 12/7 at 29 weeks EGA. His mother received prenatal care and had normal serologies but was GBS positive, for which she received 3 doses of penicillin prior to delivery. Pregnancy was complicated by concern for chorioamnionitis and preterm labor. The mother presented to BJH on 12/6 with brownish vaginal discharge and advanced cervical dilation and she received steroids, penicillin and magnesium. Rupture of membranes with discolored bloody discharge preceded a vaginal delivery. The baby had APGARs of 4, 6, and 7 at 1, 5 and 10 minutes. He was intubated and given surfactant then extubated to CPAP. He received ampicillin and gentamicin. Blood and urine cultures were negative after 48 hours and antibiotics were discontinued on day 3. He received caffeine for occasional apneic spells and bradycardia. He did reasonably well for the one week until the morning of 12/14, when he experienced worsening apnea and bradycardia. Caregivers initiated a sepsis workup and started vancomycin and gentamicin. Blood and urine cultures were positive for E. coli. A lumbar puncture was not performed because it was felt the baby could not tolerate the procedure. A head ultrasound showed a stable grade I subependymal hemorrhage. A new murmur prompted an echocardiogram study, which showed a large patent ductus arteriosus and patent foramen ovale with significant right to left shunting. He was intubated 12/14 and blood gases showed worsening metabolic acidosis. On 12/15 he became increasingly irritable. He required dopamine for hypotension and oliguria and was felt to be in the initial stages of acute tubular necrosis. He began to exhibit writhing movements that progressed to jerking movements. Continuous EEG monitoring showed seizures, which were not suppressed despite phenobarbital, Fosphenytoin, and midazolam. Seizures remained uncontrolled for 48 hours, despite adding levetiracetam therapy. Neurology and neurosurgery were consulted. Antibiotics were switched to cefotaxime and vancomycin for CSF coverage, and on 12/16 cephalosporin was switched to cefepime to broaden coverage. He began to show evidence of disseminated intravascular coagulation, with falling hemoglobin and platelets. He was transfused with packed RBCs, platelets and fresh frozen plasma. On 12/17 MR imaging with contrast showed a large cerebellar hemorrhage, grade 4 intraventricular hemorrhage and infarcts in periventricular white matter. Pupils were fixed and dilated. The family decided to redirect care and the baby passed away. ---- The autopsy exam showed severe hypoxia-ischemia, with pontosubicular necrosis, periventricular infarcts, white matter calcifications, acute E. Coli meningitis, germinal matrix hemorrhages with intraventricular, subarachnoid and subdural hemorrhages.
