Admission Round: Respiratory Distress in Newborn (Case Study with Differential Diagnoses)

2. • ทารกแรกเกิดชายไทย
• Date of Birth – 9 พ.ค. 2557, 3.39 น.
• Age - 39 minutes after birth (4.15 น.)
• ภูมิลาเนา จ.เชียงราย

3. • Mother was 32 y/o
• G2P1A1L1
• Monthly ANC 7 times at
another hospital
– 1st ANC was GA 9+5,
12th Nov 2013
• Anti-HIV: NR; HBsAg:
Neg; VDRL: NR
• Blood type= O Rh +
• No fever
• No intrapartum
conditions, illnesses, or
underlying diseases
during pregnancy
• No history of smoking,
alcohol, illicit drugs or
any medication

4. • Preterm (35 weeks)
• C/S due to primibreech
• PPROM of 4 hours
• BW=2,200 gms (AGA)
• APGAR=9,10,10
• No resuscitation

5. • รับใหม่จาก LR มาด้วย shallow and rapid breathing
at 70/min, irregular, with nasal flaring and
mild retraction
• suction เสมหะขาวขุ่นมีจานวนมาก O2 Sat=98%
• No cyanosis, asphyxia, thick meconium, or
fever noted
• Admitted at 39 minutes old (4:15 AM)

6. • No known heredofamilial diseases
• No exposure to smoking in the family

7. • T=37.2°C
• PR=137/min,
regular
• RR=
• SpO2 94%
• BP=63/39
mmHg
• BW=2,200
gms
• Lt=46 cm
• HC=33 cm
• CC=28 cm
• Active
• No
dysmorphic
feature

8. • No pallor, no
jaundice, no
cyanosis, no
plethora
• No purpura
• Fontanelles not
depressed or
bulging
• No mass or
swollen scalp
• No cleft lip/palate
• No ear or nasal
secretion
• Symmetrical, no
lesions,
, no
lags
• Equal breath
sounds
• No stridor, no
crepitation, no
wheezes/rhonchi

9. • No visible
hyperactive
precordium
• Normal rate,
regular rhythm
• Normal S1 S2
• No murmur
• No distant heart
sounds
• No thrills
• Globular, no
distention, no
lesions
• Normoactive
bowel sounds
• Soft, no
tenderness, no
spleen or liver
enlargement
• Normal male
genitalia

10. • Patent • Warm pink
• No gross
deformities
• No clubbing
• No edema
• No collapsing
pulses
• Alert
• No stiff neck
• Normal grasping
reflex
• Babinski positive

11. • PPROM of 4 hrs
• Preterm (35 weeks)
• Respiratory Distress soon after birth
– Dyspnea
– Tachypnea (70/min)
– Nasal flaring
– Mild retraction

12. • TTN (Wet lung
syndrome)
• RDS/HMD
• Congenital Pneumonia
• Pneumothorax
• Meconium aspiration
syndrome
• Sepsis
• Hypoglycemia
• Congenital Anomalies
• Polycythemia/Anemia
• Perinatal asphyxia
• Cardiac Conditions
• Cold stress / hypothermia

13. MAS: no history of
mconium stained
Pneumothorax: no history of fetal
distress, resuscitation, difficult
delivery, aspiration of meconium,
blood, or mucus; in PE findings: (-)
cyanosis, symmetrical chest wall
on expansion, equal breath
sounds, liver not palpable, and no
distant heart sounds
Perinatal asphyxia:
APGAR 9,10,10 with no
history of fetal distress,
resuscitation, or
meconium stained
Cardiac conditions
(heart failure or PDA):
no murmur, collapsing
pulses, cyanosis, or
hepatomegaly
Cold stress or
hypothermia: no history
of low or unstable temp
recorded within 39
minutes of life

14. Differential
diagnosis
PROS CONS Investigation
Transient
Tachypnea
of Newborn
• Preterm
• C/S
• RD soon
after birth
- CXR
Respiratory
Distress
Syndrome /
Hyaline
Membrane
Disease
• Preterm
• RD soon
after birth
• Active
• No cyanosis
• No edema
CXR
Congenital
Pneumonia
• Preterm
• PROM
• RD soon
after birth
• No maternal/NB fever
• No records of predisposing
factors: (no chorioamnionitis,
no offensive liquor at birth)
• PROM < 18 hours
CBC
Hemoculture
CXR

15. Differential
diagnosis
PROS CONS Investigation
Sepsis • RD
• Preterm
• PROM
• Active with APGAR
9,10,10
• PROM <18 hrs
• no maternal/NB fever
• Other SIRS criteria not
met
• CBC
• H/C
• UA
• CRP
Hypoglycemia • RD
• Preterm
• Active
• No maternal DM
DTX
Congenital
Anomalies
RD • No pertinent PE
findings
CXR
Polycythemia /
Anemia
RD • No plethora / pallor
• Active
CBC

16. • CBC
– Corrected WBC=12,210uL;
Neutrophils 43%,
Lymphocytes 53%,
Eosinophils 4%
– Hb=14.5 g/dL; Hct=43.4%
– Platelet count = 398,000 uL
• CXR = infiltrate, air
bronchogram, haziness,
mediastinal shift,
cardiomegaly or anomalies
• DTX=81 mg%
• CRP < 5.0 mg/L
• H/C = No growth

17. CBC:
• Congenital
Pneumonia
(confirmed
again with
CXR)
• Sepsis (other 3
criteria of SIRS
are not met:
Temp, HR,
WBC;
confirmed
again with CRP
and H/C)
• Polycythemia
• Anemia
CXR:
• RDS
• Congenital
Pneumonia
(agreed with
CBC)
• Congenital
Anomalies
• MAS
• Pneumothorax
• Heart Failure
DTX:
• Hypoglycemia
CRP & H/C
• agreed with
CBC for
Sepsis

19. • NPO (due to RD to
prevent aspiration)
• Start IV fluid
– 10% D/W 500ml IV 5.9
cc/hr
• On O2 box 5LPM
• Keep O2 sat ≥92%
• Vitamin K 1mg IM
• Supportive care
• Antibiotics 5 days
– Ampicillin 220 mg IV q 12 hr
– Gentamicin 8.5 mg IV OD
– Couldn’t rule out Early Onset
Sepsis on admission, hence
give Ampicillin (100 mkdose) +
Gentamicin (4 mkdose)
• Routine newborn care,
record V/S q 4 hours (SBP,
Temp, RR, HR, SaO2),
record BW OD, record Lt &
HC once a week

20. clinical signs gradually
improved after birth
and disappeared by
24 hours