- The patient is a 21-day-old male born prematurely at 30 weeks gestation with a birth weight of 1230g. - He has a history of respiratory distress at birth and was treated for late-onset neonatal sepsis on days 5 and 16 of life. - He is now presenting with signs of respiratory distress and sepsis including decreased activity, tachypnea, and desaturation. Laboratory results show thrombocytopenia and elevated inflammatory markers.

1. WELCOME
To
Extended Clinical Meeting
Dr. Shahana Akter
Resident Year 4
Dr. Habibur Rahman Bhuiyan
Resident Year 1
Neonatology, BSMMU

2. Particulars of The Patient
• Name : S/O Sumaiya
• Age : Day 21
• Date of Birth : 14/04/2019
• Sex : Male
• Address : Notun Bazar, Badda, Dhaka
• Date of Admission : 05/05/2019
• Date of examination : 05/05/2019
• Informant : Mother

3. Chief Complaint
•Born before date and low birth weight

4. History of Present Illness
Mother sumaiya 20 years old lady, para 1+0, having blood group
O +ve (Fathers blood group B+ve), was on regular ANC and
properly immunized against Tetanus. She had no history of HTN,
GDM, Cardiac disease, Thyroid disease, or any other chronic
illness. Her pregnancy period was uneventful up to 30 weeks of
gestation, then she developed leaking membrane. So She was
admitted in US BANGLA Hospital & treated with inj ceftriaxone.
Mother got two doses of antenatal corticosteroid (Dexamethasone
12.5mg/ dose 12 Hourly), last dose given 12 hours before delivery.

5. History of Present Illness
After 24 hours of leaking membrane, Emergency LUCS was
done due to severe oligohydramnios (AFI 2.1) and a male baby
was born weighing 1230g. Baby cried immediately after birth.
APGAR score was 7/10 and 8/10 at first and fifth min respectively.
Baby developed respiratory distress Soon after birth and admitted
to NICU of US BANGLA hospital for further management. There
he was managed by O2 supplementation through head box and
nasal cannula and antibiotic inj. Ceftazidim, inj. Amikacin. Baby
was gradually improving upto 5 days of age.

6. But at day 5, baby became lethargic, Antibiotic changed to Inj.
Meropenem and Inj. Vancomycin. Condition of baby was
improving again. From day 7 to Day 10 he got phototherapy for
neonatal jaundice. At day 16 baby got discharge on request and
went home. Next day baby became lethargic again and readmitted
in the same NICU managed by inj. Cefepime and inj. Collistin.
History of Present Illness

7. From day 16 to day 21 baby was gradully improving. But
due to financial constraints referred to NICU BSMMU for
further management. He was transferred by an ambulance
with O2 supplementation 2L/min by nasal catheter in
mothers lap and transportation time was approximately 3
hours.
History of Present Illness

8. Birth history
• Antenatal History: Mother Was on regular antenatal check-up &
Immunized against Tetanus. She had no H/O PIH, GDM, hypothyroi
dism or any other illness. Got two dosed of antenatal corticosteroid
before delivery.
• Natal History : Baby was delivered by LUCS due to oligohydroam
nios followed by PROM, Baby cried immediately after birth. APGA
R score was 7/10 and 8/10 at first and fifth min.
• Post natal history: Baby developed respiratory distress soon after
birth.

9. Birth history
Family history:
He is the 1st issue of non-consanguineous parent.
Socioeconomic history:
The baby belongs to middle socioeconomic background,
father is computer operator & mother is a student.

10. Feeding history
Initially baby was NPO and feeding was started 2nd day of his
life. Baby was in OG feeding during admission (3 ml 2hrly).

11. General Physical Examination
On arrival -
 Pink with O2 supplimenation 2 L/min by Nasal catheter
 Reflex and activity: good
 HR- 134 beats/min
 RR-36 breaths/min
 Temperature- 36.6 C
 CRT- 2 sec
Pulse volume - good
 CBG- 3.2 mmol/L
SpO2- 90-91%

12. General Physical Examination
Heart- 1st and 2nd heart sound normal, no added sound.
Lungs- B/L equal air entry
Swelling: present in the periorbital and scotral region,
Bipedal oedema present.
Skin survey: Normal
Back and spine: Normal.
No apparent congenital anomaly.

13. Anthropometry

14. Weight chart
Weight: 1230 grams
(on 25th to 50th percentile)

15. Length chart
Length: 38 cm
(on 25th to 50th percentile)

16. OFC chart
OFC: 27 cm
(on 25th to 50th percentile)

17.  Chest movement symmetrical
 No Chest in drawing
 RR-36 breath/min
 Bilateral equal air entry
 No added sound
Respiratory System

18.  No visible pulsation
 Apex beat- Left 4th intercostal space, medial to
mid clavicular line
 1st and 2nd heart sound normal
 No murmur
Cardiovascular system

19. Abdomen soft, not distended, BS- present
 Umbilicus : Healthy
 Liver- not palpable
 Spleen: not palpable
 Bowel sound : present.
 Genitalia: male pattern.
 Anus: Normal in position and patent.
Abdomen and Genitalia

20. .
 Baby was conscious,
 Reflexes-
 Moro, rooting, sucking- Good
 Palmar and planter grasp-present
Muscle Tone: Normal
Nervous system

21. Salient Feature
S/O of Sumaiya, outborn, admitted at 21 day of age, 1st issue of
non consanguineous parents hailing from Notun Bazar, Dhaka
got admitted in NICU, BSMMU, with the complaints of Born
before date and low birth weight. Mother sumaiya 20 years old
lady, para 1+0, having blood group O +ve (Fathers blood group
B+ve), was on regular ANC and properly immunized against
Tetanus. She had no history of HTN, GDM, Cardiac disease,
Thyroid disease or any other chronic illness.

22. Salient Feature
Her pregnancy period was uneventful up to 30 weeks of gestation
then she developed leaking membrane for 24 hours of duration &
got 2 dose of antenatal corticosteroid (12.5 mg dexamethasone 12
hrly) 12 hours before delivery. Emergency LUCS was done due to
severe oligohydramnios (AFI 2.1). A male baby was born
weighing 1230gm, cried immediately after birth. APGAR score
was 7/10 and 8/10 at first and fifth min respectively.

23. Salient Feature
Baby develoed respiratory distress Soon after birth and admitted
to NICU of US Bangla hospital for further management & treated
Accordingly. From day 7 to Day10 he got phototherapy for
neonatal jaundice. At day 5 & day 16 he developed LONS in the
form of lethargy & treated accordingly. Then he gradully
improving upto 21 days of age, but reffered to BSMMU, NICU
for financial constraints.

24. Salient Feature
He was transferred by an ambulance with O2 supplementation 2L
/min by nasal catheter in mothers lap. Transportation time was
approximately 3 hours. On arrival, baby was pink with 2 L O2,
vitals are normal. Anthropometrically Appropriate for
gestational age. Systemic examination reveals normal findings.

25. Provisional Diagnosis

26. Provisional Diagnosis
Preterm (30weeks),Very low birth weight (1230g),
Appropriate for gestational age,
Respiratory Distress Syndrome (resolved),
Neonatal jaundice (resolved),
Late onset Neonatal Sepsis.

27. Differential Diagnosis
Congenital pneumonia

28. Points related to RDS
Points In favor-
•Preterm
•Male baby
•LUCS
•Respiratory distress soon
after birth
Points against-
Mother got Two doses
of Antenatal
corticosteroid

29. Points related to congenital pneumonia
In favour-
• H/O PROM for 24 hour
•Respiratory distress soon after birth

30. Management plan on Admission
Counseling
Thermal care
Respiratory support
O2 – 2L/min through Nasal Catheter
Feeding and Nutrition
OG tube feeding – 3ml/2 hourly
Inf. 10% DBS
Protection against infection
inj. Cefepime
inj. Collistin.
Rx and prevention of complications

31. X ray chest on Day 1 (14.4.19)

32. Investigation 14.04.19(day 1)
CBC
Hb 12.7gm/dl
TC 13000/cu mm
Neutrophil 75%
Lymphocyte 20%
Platelet 210000/cu mm
CRP 12.8 mg/dl
Blood C/S No growth

33. Investigation 05.05.19(on admission)
CBC
Hb 13.3 gm/dl
TC 15000/cu mm
Neutrophil 68%
Lymphocyte 28%
Platelet 110000/cu mm
IT ratio 0.27
ANC 10200/cu mm
CRP 117.74

34. Tests 05.05.19
PBF
 RBC – Normocytic & normochromic
 WBC – Mature with normal count and distribution
 Platelet – Reduced
 Comments – Feature suggestive of neonatal septice
mia with thrombocytopenia.
Blood C/S No growth
Investigation

35. S. Electrolyte 05.05.2019
S. creatinine 0.31 mg/dl
Na 144 mmol/l
K 2.8 mmol/l
Cl 114 mmol/l
TCO2 19.7 mmol/l
S. Ca++ 8.2 mg/dl
S. Mg++ 1.5 mg/dl
S. Albumin 20 g/L
Echocardiography A tiny PDA with small
patent foramen ovale
Investigation
Correction
given
To see CVS
morbidity

36. Subjective Objective Assessmen
t / Plan
Intervention
Respiratory
distress
Pink with 0.5L of O2/min
SPo2 88%
Reflex activity – decreased then
previous
CRT – 2 sec with good pulse
volume
Temp – 36.5° C
H/R – 148 /min
R/R- 62 breaths/min
Lung- Poor air entry bilaterally.
Chest retraction mild.
Heart – S1+S2 +0
Abdomen: soft & not distended,
AG- 24cm
Liver 2.5cm enlarged
B/S – present
Edema- absent
UO=110 (3.7ml/kg/hour)
Bowel: not moved
CBG: 5.1mmol/L
LONS/
pneumonia
•Oxygen 2L/m
•Antibiotic changed to inj
Piperacillin +Tazobactam
and inj. Linezolid
INV:
septic work up
Chest xray
S.Electrolyte
S.Cr
S.Calcium
S.Mg
F/U on 08/05/2019, PNA 24days HS D4

37. Chest x ray on 08.05.19

38. Investigation 08.05.19
CBC
Hb 15 gm/dl
TC 25,000/cu mm
Neutrophil 75%
Lymphocyte 18%
Platelet 50,000/cu mm
IT ratio 0.21
ANC 18750/cu mm
CRP 137.05

39. Tests 08.05.19
PBF
 RBC – Normocytic & normochromic
 WBC – Mature with normal count and distribution.
 Platelet – Reduced
 Comments – Feature suggestive of neonatal septicemia with
thrombocytopenia.
Blood C/S 8.05.19 Acinatobacter positive sensitive to
netilmycin, collistin
(report available 3 days later,
though patient improving so antibiotics
not changed)
Investigation

40. S. electrolyte 08.05.2019
Na 135 mmol/l
K 4.6 mmol/l
Cl 105 mmol/l
TCO2
S.Cr
20 mmol/l
0.35mg/dl
Investigation

41. Subjective Objective Assessme
nt / Plan
Intervention
Vomiting for 2
episodes (8ml+3
ml) – yellowish
in color
Desaturation
upto 74% in
room air
• Pink with 0.5 L of O2/min
 SPO2 96%
 Reflex activity - good
 CRT – 2 sec with good pulse vo
lume
 Temp – 97.8° f
 H/R – 119 /min
 R/R- 52 breaths/min
 Lung- equal air entry bilaterally
Heart – S1+S2 +0
 Abdomen: soft & distended
 AG- 24.5cm(increased 1.5cm)
 Hepatomegaly- 2.5cm
 OG aspirat: Nill
 B/S – present
 UO=3.9 ml/kg/hour
 Bowel: 4 times
 CBG: 3.4 mmol/L
New onset
of sepsis
Hold feed
Plan:
Septic work up
Xray abdomen
Antibiotics not
changed because
patient
improving with
supportive care, and
no further vomiting.
F/U on 11/05/2019, PNA 27days HS D7

42. Investigation 11.05.19
CBC
Hb 15.6 gm/dl
TC 15000/cu mm
Neutrophil 80% (10% band cell)
Lymphocyte 15%
Platelet 30000/cu mm
IT ratio 0.12
ANC 12000/cu mm
CRP 94.3mg/dl

43. Tests 11.05.2019
PBF
 RBC – Anisochromia and anisocytosis
 WBC – Mature with normal in total count
 Platelet – Reduced
Blood C/S 11.05.19 Klebsiella positive sensitive
to collistin
(report available 3 days later,
though patient improving so
antibiotics
not changed)
Investigation

44. S. electrolyte 11.05.2019
Na 136 mmol/l
K 5.1 mmol/l
Cl 111 mmol/l
TCO2 17 mmol/l
S. Ca++ 8.3 mg/dl
S. creatinine 0.35 mg/dl
Investigation

45. Subjective Objective Assessment /
Plan
Intervention
Desaturation
Upto 80%
with
trachypnoea
Unusal
weight gain
70g
• Pink with 0.5l/min O2
• SPo2 80%%
 Reflex activity – less then
before
 CRT – 2 sec with good pulse
volume
 Temp – 36.8° C
 H/R – 130 /min
 R/R- 68 breaths/min
 Lung- equal air entry bilaterally.
 Heart – S1+S2 +0
 Abdomen: Soft. Distended,
Bowel sound present.
 Hepatomegaly 2.5cm
 Edema- present
 UO=4ml/kg/hour
 Bowel: 6 times
 CBG: 3.7 mmol/L
New onset sep
sis
•Oxygen 2 L/m
•Fluid restriction
•Antibiotic changed
to inj Netilmycin
and inj. Collistin
(according to previous
blood C/S reports)
Plan:
•septic work up
•S. Albumin
•S. Electrolytes
•S.Cr
•S.Ca
•S.Mg
•Chest xray
F/U on 15/05/2019 ,PNA 31 days HS 11 days

46. x ray on 15.05.19

47. Investigation 15.05.19
CBC
Hb 11.6 gm/dl
TC 17000/cu mm
Neutrophil 69%
Lymphocyte 25%
Platelet 10,000/cu mm
IT ratio 0.07
ANC 11730/cu mm
CRP 38 mg/dl

48. Tests 15.05.2019
PBF
 RBC – Normochromic and normocytic
 WBC – Mature with increased total count with neutrophilia
 Platelet – Grossly Reduced
Comments – Neutrophilic leukocytosis with thrombocytopenia.
Blood C/S 15.05.19 Klebsiella positive sensitive to
collistin and chloramphenicle
(report available 3 days later,
though patient improving so antibiotic
not changed)
Investigation

49. S. electrolyte 15.05.2019
Na 129 mmol/l
K 3.5 mmol/l
Cl 105 mmol/l
TCO2 17 mmol/l
S. Albumin 12 g/dl
S. Creatinine 0.38 mg/dl
Investigation
Rx:
•Fluid Restriction
•Albumin
Transfusion

50. S. electrolyte 17.05.2019
Na 136 mmol/l
K 4.9 mmol/l
Cl 106 mmol/l
TCO2 21.8 mmol/l
Investigation

51. 18.05.2019 at 10.am
• Baby had single episode of mild nasal bleeding
• Patient was clinically stable so according to round decision
we sent only CBC which shows Hb% 13.9, WBC 20,000
RBC 4.8*10^12 platelet 20000. hematocrit 35.7 %
• No further bleeding occur, so no intervention taken and LP
was post ponded.

52. •From 19.05.19 – 22.5.19
• Baby was relatively stable, patient getting antibiotic inj.
Netilmycin, inj. Collistin Day 7, we reducd O2 gradually and
feeding advancement ensured. Baby is getting KMC.
• PLAN to do LP and take decision regarding antibiotic
duration.

53. Subjective Objective Assessment / Pla
n
Intervention
•Decrease
activity
•abdominal
distension
• Pink in room air
• SPo2 96%
 Reflex activity – poor
 CRT – 2 sec with good pulse
volume
 Temp – 36.8° C
 H/R – 112 /min
 R/R- 48 breaths/min
 Lung- equal air entry
bilaterally.
 Heart – S1+S2 +0
 Abdomen: distended, loopy A
G- 25 cm (1cm increased)
 Gastric aspirate 2cc
undigested milk
 B/S – present
 UO=4ml/kg/hour
 Bowel: 2 times
 CBG: 7.4 mmol/L
New onset sepsis/
NEC
Antibiotic
changed
netilmycin to
Ciprofloxacin
Septic work up
S. Creatinine
S. electrolytes
Abdominal xray
ABG
PH: 7.38
PCO2:29 mmH
g
HCO3:16.8 mm
ol/L
PO2: 86 mmHg
BE- -7.4
F/U on 23/05/2019 ,PNA 38 days HS 18 days

54. x ray on 23.05.19

55. Investigation 23.05.19
CBC
Hb 10.7 gm/dl
TC 30,000/cu mm
Neutrophil 90% (30%band form)
Lymphocyte 06%
Platelet 50,000/cu mm
IT ratio 0.33
ANC 27000/cu mm
CRP 154.17 mg/dl

56. Tests 23.05.2019
PBF
 RBC – normocytic and normochromic
 WBC – Mature with increased total count wit
h neutrophilia
 Platelet – Reduced
Comments – feature suggestive of septicemia
Blood C/S Pending
Investigation

57. S. electrolyte 23.05.2019
Na 124 mmol/l
K 3.9 mmol/l
Cl 97 mmol/l
TCO2 14.1 mmol/l
S. Ca++ 8.9mg/dl
S. Mg++ 1.8mg/dl
S. Creatinine 0.25 mg/dl
Investigation
Fluid
restriction

58. S. electrolyte 24.05.2019
Na 120 mmol/l
K 3.2 mmol/l
Cl 95 mmol/l
TCO2 14.8 mmol/l
Investigation
Sodium
Correction
given

59. S. electrolyte 25.05.2019
Na 137 mmol/l
K 3.1 mmol/l
Cl 110 mmol/l
TCO2 14 mmol/l
Investigation

60. Antibiotic chart
• Ceftazidim + Amikacin - D1 - D5 = 5 days
• Meropenem + Vancomycin - D6-D16= 11 Day
• Cefepime + Colistin - D 17- D 25 = 8 days
• Piperacillin and Tazobactum + Linezolid - D26 – D29 = 3 days
• Collistin + Netilmycin - D30- D 37 = 7 days
• Collistin + Ciprofloxacin- D 38- Continue

61. Final Diagnosis
Preterm (30weeks), Very low birth weight (1230g),
Appropriate for gestational age, Respiratory Distress
Syndrome (resolved), Neonatal jaundice (resolved),
CHD (tiny PDA), Late onset Neonatal Sepsis
(culture positive –Acinatobacter, klebsiella),
Hypokalemia(corrected)Hypomagnesemia (corrected)
Hyponatremia(corrected)Hypoalbuminaemia(corrected)
Necrotizing enterocolitis.

62. NEXT
EXTENDED PART

63. INTRODUCTION
Our patient S/O Sumaiya, presented with
Respiratory distress soon after birth. So possibilities
are-
• Respiratory Distress Syndrome
• Congenital Pneumonia
•Perinatal Asphyxia
•Congenital Anomalies
Provisional Dx: RDS

64. Respiratory distress syndrome

65. Definition of RDS
Incidence and risk factors
Pathogenesis
Presentation
Diagnosis
Management
Complications
Prevention
Prognosis & Outcome
Outline

66. What is RDS ?
Also known as Hyaline Membrane Disease
Major cause of respiratory distress in preterm infants
It is caused by surfactant deficiency
It is characterized by-
Tachypnea (R/R ≥6O/min)
Chest retraction
Expiratory grunting
Presenting within 4 hrs of birth.

67. Incidence
RDS typically affects infants <35 weeks gestational age
Incidence of RDS is inversely proportional to
gestational age & birth weight.

68. Gestational age Incidence
23-25 weeks 91%
26-27 weeks 88%
28-29 weeks 74%
30-31 weeks 52%
INCIDENCE

69. Risk factors
Increased Risk
 Prematurity
 Male sex
 Familial predisposition
 Cesarean section
without labor
 Perinatal asphyxia
 Maternal diabetes
Decreased Risk
• Female sex
• Vaginal delivery
• Antenatal Corticosteroid
• Maternal use of narcotics
/cocaine
• Thyroid hormone
• Tocolytic agents
In our patient- Risk factors are Prematurity, male sex & LUCS

70. Pathophysiology

71. Natural History of RDS
Present within the first 4 hours of life.
Worsen in the next 24-36 hrs.
Followed by increased endogenous surfactant
production.
A static period for about another 48 hrs.
A steady improvement by following 60-72 hrs.
Our patient’s
Respiratory status
improved by
5days of age

72. Clinical Manifestations
•Respiratory distress begins at birth or soon after birth
•Signs include
•Tachypnea: RR > 60 breaths/min
•Expiratory grunting
•Chest retractions
•Nasal flaring
•Cyanosis in room air
•Other signs include, hypothermia, Hypotonia and
hypoactivity.
Our patient presented with-
Respiratory distress soon after birth
Tachypnea
Chest retractions

73. Investigations
Chest x ray
Blood tests:
Blood gas analysis
Septic work up
Blood Glucose
Serum Electrolytes
Serum calcium
Echocardiography

74. Radiological grading
Grade I:
Fine reticulogranular mottling
Grade II:
Mottling with air bronchogram
Grade III:
Diffuse mottling
Heart borders just discernible
Prominent air bronchogram
Grade IV:
Bilateral confluent opacification (white out)

75. Chest X Ray

76. In our Patient CXR

77. In our patient
•Echocardiography
A tiny PDA with small patent foramen ovale.

78. Management of RDS
A) Supportive:
 Thermal care
 Fluid and nutrition
 Circulation- N/S, Dopamine
 Infection- Broad spectrum antibiotic

79. Management of RDS
B) Respiratory support:
 Oxygen supplimentation- to maintain SPO2 88% -92%
 CPAP-
 Prevent atelectasis
 Decrease lung injury
 Preserve surfactant
 Decrease need for O2
Our patient
got O2
therapy

80. Management of RDS
When to initiate CPAP?
•Early CPAP- all preterm infants (<35 weeks’) with any
sign of respiratory distress should be started
immediately on CPAP
•CPAP helps mainly by preventing the alveolar collapse
in infants with surfactant deficiency. Once atelectasis
and collapse have occurred, CPAP might not help
much. AIIMS- NICU protocols 2008

81. Management of RDS
Respiratory support:
 Mechanical ventilation-
 Indication-
 Respiratory acidosis, PCO2 >55 mm of Hg
 PaO2 <50 mm of Hg
 Apnea

82. Surfactant
Function of the Surfactant:-
Decrease the surface tension
To promote lung expansion during inspiration
To prevent alveolar collapse and loss of lung
volume at the end of expiration

83. Development of surfactant
Week 20: start of surfactant production and
storage. Does not reach lung surface until later
Week 28-32: maximal production of surfactant and
appears in amniotic fluid
Week 34-35: mature levels of surfactant in lungs

84. Surfactant Therapy
Prophylactic - within 15 minutes of delivery if <26 wks
of gestation or pre term infants who require delivery
room intubation for stabilization
Rescue - Pre term babies with an evidence of RDS
Early: within 2hours
Late: 2-12hours

85. Surfactant therapy
European Consensus Guidelines on the Management
of RDS – 2016 Update-
Prophylactic - in the delivery room in extremely preterm
infants who require intubation for stabilization
Early rescue- babies <26 weeks’ gestation when FiO2
requirements >0.30 and babies >26 weeks when FiO2
requirements >0.40
A second, and sometimes a third, dose of surfactant should be
administered if there is evidence of ongoing RDS such as
persistent oxygen requirement and need for MV
Neonatology 2017;111:107–125

86. Review article
Korean J Pediatr 2017;60(9):273-281
Update of minimally invasive surfactant therapy
• MIST is a method of surfactant administration without intubation in
spontaneously breathing preterm infants with RDS. There are four
different MIST methods, i.e., surfactant administration by
intrapharyngeal instillation, aerosolization, laryngeal mask, and
tracheal catheterization. Several clinical studies showed an advantage
of MIST via tracheal catheterization over either CPAP alone or
surfactant application via INSURE technique; moreover, MIST via
catheter application seems gentle, safe, feasible, and effective in
preterm infants with RDS. Intrapharyngeal surfactant instillation and
surfactant nebulization are less invasive, but there are few data to
recommend these methods. Further studies are needed to resolve
uncertainties of the MIST method, including appropriate infant
selection, optimal surfactant dosage and administration method, and
need for sedation

87. Management of infant with RDS
Infant with RDS
FiO2 < 40%
Watch for apnea, severity of distress and CXR
CPAP 7 cm of H2O
FiO2 as needed
Few or no apneic episodes
Or Downe score 4-7
Or Hazy lung
Assisted ventilation
+
Surfactant
Surfactant
Continue CPAP
FiO2 >40%
Many apneic episodes
Or Downe score >7
Or White-out lung
Continue CPAP

88. Complication
acute
Apnea
Air leak
infection
ICH
PDA & foramen
ovale
End-organ hypoxic
injury
chronic
ROP
PPH & BPD
Neurodevelopmental
impairment

89. Prevention of RDS
Assessment of gestational age by USG
Prevent preterm labour
Assessment of fetal lung maturity
Antenatal corticosteroids

90. Assessment of fetal lung maturity
Lecithin/Sphingomyelin (L:S) ratio :
≥ 2 indicates low risk for RDS.
Lamellar body count :
Values of > 50,000/µl indicates lung maturity.

91. Shake Test:
Also called foam test.
Serial dilution of ethanol is added to a fixed amount
of amniotic fluid to remove non surfactant foam.
The sample is then shaken to permit formation of
stable foam layer.
Presence of bubble that persist on the surface for 15
min consider +ve test implying low risk for RDS.
Assessment of fetal lung maturity

92. Antenatal corticosteroids
Benefits of ACS
Reduction of incidence & mortality of RDS
Reduce the need for & duration of ventilatory
support & admission to NICU
Reduction of incidence of IVH
Necrotizing enterocolitis
Early onset sepsis

93. Antenatal corticosteroids
Types of ACS Used-
Betamethasone- 12mg IM q 24hrs X 2 doses
OR
Dexamethasone- 6mg IM q 12hrs X 4 doses
Glucocorticoids should be given at least 24 hrs and no
more than 7 day before preterm delivery
Our patient got
ANC Dexamethasone
12.5 mg 12 hrly

94. Antenatal corticosteroid
European Consensus Guidelines on the Management of
RDS – 2016 Update-
A single course of prenatal corticosteroids to all women at risk
of preterm delivery before 34 completed weeks’ gestation
A single repeat course of antenatal steroids may be appropriate
if the first course was administered more than 1–2 weeks
previously and the duration of pregnancy is <32–34 weeks’
 Antenatal steroids can also be considered for CS not in labour
up to 39 weeks
In late preterm pregnancy at risk of early birth, a course of
antenatal steroids may also be considered provided there is no
evidence of chorio-amnionitis
Neonatology 2017;111:107–125

95. Prognosis & Outcome
• The survival of infants with RDS has improved greatly, by
using ANC, Surfactant & CPAP therapy.
• The survival with or without respiratory & neurologic
sequelae is highly dependent on birth weight and gestational
age.
• RDS in infants born at ≥ 32 wks gestational age having no
long term pulmonary sequelae. Major morbidity –BPD, NEC,
severe IVH & poor postnatal growth remain high for the
smallest infants.
In our patient
having guarded
prognosis