The document presents a case study of a late preterm male infant born via cesarean to a mother with no significant medical history, admitted to the NICU due to low birth weight and complications related to prematurity. The infant exhibited normal vital signs and behavior upon examination, receiving necessary immunizations and formula feeding post-birth. The overall assessment concludes the diagnosis of late preterm status with low birth weight.

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CASE PRESENTATION
By Dr Kartik Mehta
UNDER THE GUIDANCE OF
Dr R.A. Langade Ma`am

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Demographic details :
• DOL: 4 ( DOB : 21/09/2024 TOB: 5:27 PM)
• Male
• Belwade ,Kadegaon , Maharashtra
• Hindu
• Mother ( good reliability )
• DOA : 21/09/2024
• DOE : 24/09/2024 ( 04th day of admission )

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Chief complaints :
1) Came with c/o Born before expected period of time an Low
Birth Weight at Birth

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History of presenting illness
• Child was admitted to NICU ivo Prematurity (Late Pre Term) and Low
Birth Weight at birth.
• N/h/o Difficulty in breathing at birth
• N/h/o noisy breathing
• N/h/o vomiting , delayed passage of stools and urine.
• N/h/o lethargy , abnormal movements , high pitched crying or poor
feeding
• N/h/o dark coloured urine
• Stool is yellowish in colour . N/h/o clay coloured stool
• N/h/o trauma during birth

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• N/h/o swelling over the hand
• N/h/o rashes

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Maternal History
• Age : 26 Years
• Non Consanguineous Marriage
• G1 P0 L0 A0
• G1 : Present Pregnancy / Spontaneous Conception
• Mother Blood Group : B+
• Pre pregnancy weight : 38 kg
• Post pregnancy weight : 46 kg
• Weight gain during pregnancy : 8 kg
• Height : 156 cm
• BMI : 18.9 kg/m2
• Occupation : House Wife
• Past History : No h/o hemolytic disease , jaundice , anemia , repeated transfusion or
heart disease

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Paternal History
• Age: 32 Years
• Blood Group : AB+
• Occupation : Bank Employee
• Past History: Not significant

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Antenatal history :
• Age of mother at conception : 26 y
• 1st child, spontaneous conception (G1 P0 L0 A0)
• 10 month since marriage
• Pregnancy was diagnosed at 2M of amenorrhea via UPT.
• 4 Antenatal Visits
• 4 USGs were done
• K/c/o overt GDM
• No h/o hypothyroidism and hypertension during pregnancy
• No h/o TORCH Infection

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• No intake of any drugs
• No h/o consumption of alcohol , tobacco or any other elicit drug
abuse during pregnancy.

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1ST
TRIMESTER :
• No fever with rash or excessive vomiting.
• No h/o intake of any teratogenic drugs
• No h/o exposure to x-rays/irradiation
• Folic acid and Calcium supplements started
2ND
TRIMESTER :
• Tetanus toxoid injection 2 doses taken 4 weeks apart
• Iron supplements taken
3RD
TRIMESTER :
• Fetal movements well perceived
• K/c/o Overt GDM
• No h/o decreased foetal movements
• No h/o PPROM
• No h/o fever, foul smelling discharge or burning micturition
• No PIH/eclampsia/APH

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Birth history :
• Late Pre Term/36 WOG/1.610 KG/
• LSCS/CIAB
• APGAR : 7/10 at 1 Min and 9/10 at 5 min
• Birth Weight:
• BBG : B+
• Born at a Krishna hospital
• No h/o Meconium staining of liquor

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Post Natal History :
• Shifted to NICU ivo Preterm and LBW
• Passed urine and stool within 1 hour of birth
• Started on WSF with Formula Feeding on DOL 1
• U/O : 6-7 times
• S/O : 3-4 times

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Immunization History:
• INJ Vit K given at birth
• BCG and OPV given
• Hep B given

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Family history
• NCM
• Nuclear family.
• No broken family/family disputes
• Birth order : 1
• Detail of other twin : Male child , 2.19 kg , 36 wk , Given OPV ,INJ
BCG & Hep B , Started on EBM on DOL 3
• H/o Twins in family : no
• No similar incidence of LBW and pre term babies in family

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Socioeconomic history
• House made of cement , covered with Tin Roof made . 1 Bedroom and 1
kitchen, own house with 7 members
• Floor covered with cement
• 1 window in Kitchen , 1 in Bedroom and toilet is outside home (Indian style
toilet with sanitary pit present )
• No open air defecation, mother uses LPG and Chulha for cooking, uses
water from Gram Supply for cooking and drinking water from Water Filter .
• Father studied B.com and works as a farmer .
• Mother studied till 12th
Class. Currently is not working and is at home.
• Monthly income : Rs 8000-9000
• Modified Kuppuswamy scale : Lower Middle Class (III)

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FEEDING HISTORY :
• H/o Formula Feeding since DOL 1

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Summary
• A newborn male baby second Twin born via LSCS ivo DCDA Twins
in Labor , cried immediately after birth, admitted to NICU at birth
ivo Preterm and Low Birth Weight . Received formula feeding via
WSF after admission. Hep B , BCG , OPV and Vit K received . This is
probably a case of Preterm and Low birth weight.

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Examination :
• O/E:
• Activity is good
• Tone is normal
• Cry is normal
• Pallor absent
• No cyanosis present
• Icterus absent
• Pulses felt
• Extremities are warm

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VITALS :
• Temp : 98.0 F
• HR : bpm (120-160 bpm)
• RR : / min ( 30-60 / min)
• BP: 62/40 mmHg
• SPO2 – 98 %
• CRT < 3 sec
• u/o : 6-7 Times a day
• S/o : 3-4 Times a day

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ANTHROPOMETRY :
• Birth weight : 1.610 kg
Current Weight : kg
Weight loss:
• Length : 40.5 cm
• Head Circumference: 30.5 cm
• Chest Circumference : 25.5 cm

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HEAD TO TOE EXAMINATION :
Head : Normal
Moulding : Present
Caput Succedaneum and Cephalhematoma : Absent
Anterior Fontanelle : At level
Posterior Fontanelle : Open
No dysmorphic facies
Eyes : Normal
Ears : No renal tags or any sinuses

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Nose : Normal
No cleft palate
Chest : Normal
Back : No hairy tuft , sacral sinus or dimple
Extremities : Polydactyl and syndactyl absent
Umbilicus : Central , No discharge seen
Genital : B/l testis descended . Rugae present
Skin : Icterus absent , No Bruises present , dryness of skin present.

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SYSTEMIC EXAMINATION
• CNS :
• No lethargy
• No hypotonia , high pitched cry , seizures , opisthotonus , fever
Reflex’s
• Moros Reflex : Present
• Rooting : Present
• Sucking : Present
• Asymmetric tonic neck reflex : Present
• Palmar grasp : Present

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• P/A:
Inspection : Abdomen doesn’t look distended
Umbilicus is central
No discharge seen at umbilicus
Umbilicus midway between Xiphisternum and Pubic Symphysis
No dilated veins and scars
Hernial orifices normal
Genitals normal
Palpation :
• Non Tender
• No palpable mass
Auscultation :
• Bowel sounds present on auscultation

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oGenitalia Examination :
B/l descended testis
No swelling of scrotal region
Rugae present
oBack Examination :
Spine is normal
No low hairline
No sinus is present
No hair tuft present

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• CVS : S1 S2 heard, no murmur
Bilateral peripheral pulses felt
• RESPIRATORY SYSTEM :
• Air Entry bilateral equal
• No adventious chest sounds heard
Diagnosis :
• Late pre term with Low Birth Weight

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