CASE PRESENTATION ON LATE PRETERM, HYPERBILIRUBINEMIA, ECLAMPSIA

1. CASE PRESENTATION ON LATE PRETERM,
HYPERBILIRUBINEMIA, RESPIRATORY DISTRESS,
ANTENATAL HISTORY OF ECLAMPSIA
Presented by:
Chandana C
2nd Pharm.D

2. LATE PRETERM
GESTATION PERIOD: fetal development period from time of
conception until birth.
Normal duration of pregnancy: 37- 42 weeks of gestation
Preterm: < 37 weeks of gestation during birth.
• Late preterm: born between 34- 37 weeks of gestation
• Very late preterm: born between 33- 28 weeks of gestation
• Extremely preterm: born at less than 28 weeks of gestation
Post term: 42 weeks completed during birth.
Antenatal/ prenatal period: period before child birth
Postnatal period: period after child birth

3. ETIOLOGY:
The exact cause of preterm birth is not known in many cases.
But it can be due to following cases;
• Multiple pregnancies
• Infections
• Diabetes mellitus
• Hypertension
• Conception by in vitro fertilization
Preterm birth is a worldwide epidemic with global incidence of 15
million cases per year.
It accounts for 47% of all neonatal deaths.

4. ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
• Neonatal ARDS occurring in newborn begins with dyspnea within a
few hours after birth with tachypnea, hypoxia and cyanosis; in severe
cases death may occur within few hours.
• ARDS has a morphological feature of formation of hyaline membrane
in the alveoli hence it is also called as hyaline membrane disease.

5. ETIOLOGY
Many cases of neonatal ARDS remain idiopathic; but following reasons
can lead to ARDS
• Preterm infants
• Infants born to diabetic mothers
• Delivery by caesarean section
• Infants born to mothers with previous premature infants
• Excessive sedation of mother causing depression in respiration of
infant
• Birth asphyxia

6. PATHOGENISIS:
• The basic defect in neonatal ARDS is a deficiency of pulmonary
surfactant, its deficiency leads to increased alveolar surface tension
which causes atelectasis.
• Atelectasis results in hypoventilation, pulmonary hypo perfusion and
ischemic damage to capillary endothelium.
• This results in ischemic necrosis of alveolocapillary wall, exudation of
plasma protein into alveoli and hyaline membrane is formed.

7. HYPERBILIRUBINEMIA
• It is a condition in which there is increased level of bilirubin in blood.
• Bilirubin is a bile pigment, yellowish-orange in color.
• It is product of hemoglobin metabolism.
SYMPTOMS:
• Yellow coloring of baby's skin and eyes.
• Poor feeding

8. ETIOLOGY
• PHYSIOLOGIC JAUNDICE: it is a normal response.
• BREAST MILK JAUNDICE: caused by a substance in breast milk that
increases reabsorption of bilirubin from intestine
• JAUNDICE FRM HEMOLYSIS: excess breakdown of RBC
• JAUNDICE RELATED TO INADEQUATE LIVER FUNCTION
DIAGNOSIS
• BILIRUBIN LEVELS: direct and indirect bilirubin levels are examined

9. EPIDEMIOLOGY
• 80% of premature babies develop hyperbilirubinemia
• 60% of new born develop hyperbilirubinemia
• Neonates of diabetic mothers are more prone to develop it.

10. PATHOGENESIS
• Excess catabolism of hemoglobin leads to hyperbilirubinemia
HEMOGLOBIN
HEME
VERDO HEME
BILIVERDIN BILIRUBIN

11. ECLAMPSIA
• It is a severe complication in pregnancy characterized by
hypertension, proteinuria and seizures.
• It usually follows preeclampsia.
• Eclampsia affects about 1 in every 200 women with preeclampsia
• If the patient doesn’t have a history of seizures also eclampsia will be
developed.

12. SYMPTOMS:
• Seizures
• Elevated BP
• Loss of consciousness
• Agitation
• Swelling in face and limbs
• Excessive weight gain
• Blurred vision
• Difficulty in urinating

13. RISK FACTORS:
• Chronic gestational hypertension
• Being older than 35 years or younger than 20 years
• Pregnancy with twins or triplets
• First time pregnancy
• Diabetes mellitus
• Kidney diseases

14. PATIENT DEMOGRAPHIC DETAILS:
• Name: B/O h….
• Age: NB
• Gender: male
• Weight: 2.9 Kg
• IP no: 18/20004
• Unit: NICU
• DOA: 01/12/18
• DOD: 07/12/18

15. CHIEF COMPLAINTS ON ADMISSION:
Preterm baby of 34+ weeks

16. ANTENATAL HISTORY:
• Eclampsia
• Brief history of mother: primigravida with 34+ weeks of gestation

17. BIRTH HISTORY
• Mode of delivery: LSCS
• APGAR score: 1 min:7 5 min: 8
• Post natal history: no spontaneous breath at birth, baby did not cry
immediately, after doing touch stimulation weak cry.

18. EXAMINATION OF NEW BORN
GENERAL PHYSICAL EXAMINATION VITALS
CVS:
Heart sounds- S1 S2
No murmurs
HR: 160 bpm
RS:
Bilateral air entry
RR: 62 bpm
Per abdomen: shape of abdomen, posture umbilicus
NAD
SPO2: 88% on room air

19. PROVISIONAL DIAGNOSIS
Late preterm with respiratory distress

20. TREATMENT GIVEN
DRUG NAME DOSE FREQUENCY ROA 1 2 3 4 5 6 7
Inj. cefotaxime 145mg BD IV    
Inj. amikacin 22mg BD IV    
Inj. 10% dextrose 60ml/Kg IV       
Inj. Vitamin K 1mg IV       

21. PROGRESS CHART
• DAY 1:
HR: 140 bpm
RR: 46 bpm
CVS: S1 S2 +
Advice: blood culture, serum electrolytes
Nasal prongs oxygen 2 liters- stopped after 6 hrs

22. DAY:2
• Baby color is good.
• Baby cried
• Vitals were normal
• Advice: CST
DAY:3
• GC- stable
• Advice: direct breast feed, CST

23. DAY: 4
• Baby skin color changed to yellow
• Vitals are normal
• Advice: test for bilirubin, TSH, stop antibiotics
DAY:5
• DSPT – double surface photo therapy is advised
• Vitals are normal
• Shifted from NICU to OBG semi-private ward

24. DAY:6
• Single surface photo therapy was advised
• Skin color was good
• Vitals are normal
DAY:7
• Stop photo therapy
• Baby hemodynamically stable
• Prepare for discharge

25. PHARMACEUTICAL CARE PLAN
SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE FINAL DIAGNOSIS
Apnea
Yellow coloration of skin
SPO2: 88%
Bilirubin: total- 11.7 mg/dl
direct- 0.7 mg/dl
indirect- 11.0 mg/dl
Normal value: > 10 mg/dl
Respiratory distress,
hyperbilirubinemia

26. TREATMENT GOAL
• To improve breathing.
• To decrease the bilirubin concentration.
• To decrease the yellowish color of skin and eyes.

27. TREATMENT OPTIONS:
HYPERBILIRUBINEMIA:
• Intravenous immunoglobulin
• Exchange transfusion
RESPIRATORY DISTRESS:
• Extra oxygen.

28. MONITORING PARAMETERS
• Respiratory distress
• Bilirubin levels

29. PATIENT COUNSELLING POINTS
• Warm care of baby should be taken
• Direct breast feed
• Hygienic condition should be maintained
• Immunization as per schedule

30. THANK YOU