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Washington University Experience | VASCULAR | Hypoxia-Ischemia, fetal-neonatal | Pontosubicular necrosis | 7A0 Case 7 History
Case 7 History ---- The baby, weighing 2630 grams, was born at EGA 34-35 weeks gestation to a 29 year-old gravida 1, para 0-1 woman with unrecognized pregnancy due to irregular periods. She presented to an OSH 3-4 days prior to admission with increasing crampy and back pain, pregnant and dilated to 7 cm with marked hypertension (BP ~200/120 mmHg). Fetal heart rate was approximately 145 bpm. The baby was delivered vaginally in the emergency department and had APGAR scores of 0,0 at 1& 5 minutes. Bag mask ventilation and chest compressions were begun immediately and the baby received endotracheal epinephrine. At 21 minutes of life the baby had a heart rate of 136 bpm and chest compressions were discontinued. At that time glucose was 32 mg/dL and she received D10W. Capillary blood gas at 51 minutes of life showed acidosis and elevated pCO2 (pH=6.9, PCO2=49 mmHg). The baby was also placed on conventional mechanical ventilation with PEEP. Venous blood gas analysis, performed en route from the OSH to SLCH, also showed acidosis (pH=6.9) and an elevated pCO2 (50 mmHg). In the SLCH NICU he was comatose, had no spontaneous respirations or movements, and flaccid to absent tone without suck, Moro, or grasp reflexes. His pupils were reactive to light and he did have a variable heart rate. EEG was markedly low voltage, invariant, and showed no evidence of reactivity. Head sonography showed diffuse echogenicity concerning for hypoxic/ischemic encephalopathy. MRI of the brain showed diffuse restricted diffusion in the cerebral hemispheres (cortex>white matter), the brain stem, and the right cerebellar hemisphere. Numerous hemorrhagic foci in bilateral cerebral hemispheres and cerebellum were also identified with MR spectroscopy showing a large lactate peak in the left basal ganglia. The radiological impression was of severe diffuse hypoxic injury. Seizure-like activity developed and was treated medically. The family was consulted and indicated their desire to redirect his support. He was subsequently extubated to room air and died. ---- Autopsy showed an immature neonatal brain with edema (430g vs nl ~257g), severe global hypoxic-ischemic injury and parenchymal microhemorrhages involving all gray matter with ‘watershed’ areas exhibiting relatively greater injury. Neuronal apoptosis in the subiculum and basis pontis and necrosis of the deep periventricular white matter (periventricular leukomalacia [PVL]) represent a neonatal pattern.
