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Washington University Experience | VASCULAR | Hypoxia-Ischemia, fetal-neonatal | White Matter | 7A0 Case 7 History
Case 7 History ---- The patient was a 17 day old baby girl who was born on 9/20 at 35 weeks EGA to a 30 year old G8P7 mother who presented to the ER with spontaneous rupture of membranes and was found to have umbilical cord prolapse. Fetal heart rate was noted to be in the 30s and she was delivered by emergency C section at which time complete placental abruption was noted. Birth weight was 2.34 kg. She was born apneic and pulseless, requiring CPR for approximately 2 minutes and was intubated. After intubation, her O2 saturations dropped into the 20s, and she underwent needle thoracentesis. Apgar scores were zero at 1 minute, 2 at 5 minutes and 2 at 10 minutes. She was treated with surfactant, transfused, and started on empiric antibiotics and Phenobarbital. She was transferred to the SLCH NICU and treated according to the cooling protocol. Her exam was notable for no eye opening, non-reactive pupils, flaccid hypotonia, and clonus in all extremities. Her EEG on day 1of life showed very low voltage without seizures. ECHO demonstrated low cardiac output, patent foramen ovale, pulmonary hypertension and a large PDA with bidirectional shunting. Head ultrasound demonstrated no evidence of subependymal or intraventricular hemorrhage. Brain MRI on day 2 of life was consistent with global anoxic brain injury. Over the course of her hospitalization, she required dopamine for a brief time to maintain renal perfusion. She also required TPN. The baby was extubated twice when she began to show signs of spontaneous respiration, but required reintubation due to CO2 retention and increased work of breathing. Repeat EEG on day of life 9 demonstrated improved variability but was notably dysmature with no seizure activity. Her neurologic exam did not show any significant improvement. On day of life 17, her mother decided upon DNR/DNI status. The baby was extubated on 10/7 and died later that evening. ---- The weight of the unfixed brain is 310 g (normal=298 + 70 g). Autopsy showed marked hypoxic/ischemic damage with bilateral periventricular leukomalacia, status marmoratus, perinatal telencephalic leukoencephalopathy (diffuse white matter gliosis) and cystic degeneration of the cerebral germinal matrix. The damage appears acute and chronic, suggesting some damage occurred prior to birth.
