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Washington University Experience | VASCULAR | Hypoxia-Ischemia, fetal-neonatal | Pontosubicular necrosis | 8A0 Case 8 History
Case 8 History ---- The patient was a 10-day-old female infant born to a G4P4 mother at 39 weeks EGA. The pregnancy was complicated by no prenatal care, no Rhogam, daily tobacco use, and methamphetamine use. The delivery was uncomplicated with APGARs of 8 and 9. At 1 hour of life was found to be hypoxic and jaundiced. Initial arterial blood gas showed a pH of 6.7 from a severe metabolic acidosis. Bilirubin was 10, reticulocyte count was 23%, with hemoglobin of 8. She was intubated and placed on HFOV with iNO. Antibiotics and vasopressors were started. Prior to arrival at SLCH, she received several boluses of calcium gluconate for persistent hypocalcemia, NS bolus x3, FFP x2 for coagulopathy, pRBCs x5, and platelets x1. During initial resuscitation and transportation, worsening abdominal distention was noted. The OSH identifies the mother as O negative, and infant A positive with DAT positive for Anti-D and Anti-C. She arrived in distributive and cardiogenic shock secondary to hydrops fetalis from anti-D and anti-C hemolytic disease of the newborn. Due to decreasing mean arterial pressure (despite maximal pressor support and stress hydrocortisone), VA ECMO was initiated on day of arrival. Pressors were discontinued for a time, but she required maximal flows to maintain MAPS in goal range. A pigtail catheter was placed into intraperitoneal space by pediatric general surgery at bedside and was immediately productive for 120 mL of blood. Catheter output slowed over following days and became progressively more serous. Shortly after arrival, EEG demonstrated seizure activity. Phenobarbital was increased until cessation of seizures. She completed 48 hours of broad spectrum antibiotics with negative cultures upon arrival. She was started on tandem CRRT and plasmapheresis on 2/8 for fluid overload and hyperkalemia. Hyperkalemia resolved and some improvement in fluid overload was seen; however, she continued to have profound anasarca. Right MCA stroke was also noticed on head ultrasound 2/10 without evidence of new seizures. A right chest U/S to evaluate pleural effusion demonstrated hypoechoic lesions throughout the liver consistent with areas of necrosis which worsened. Given transaminitis, she was started on acyclovir and screened for HSV. On 2/13, E. Coli sepsis (blood and abdominal fluid) developed after worsening metabolic acidosis, decrease in mean arterial pressure, and low platelets on 2/13. She was treated with meropenem. In the setting of severe Gram negative septic shock, irreversible liver necrosis, and kidney failure, the parents elected to redirect care and she passed away on 2/15. ---- Autopsy showed acute to subacute infarction in the right MCA/PCA territories, diffuse white matter hypoxic ischemic injury and pontosubicular necrosis.
