Transcript
CLINICAL MEETING
PRESENTED BYDR. MAIMUNA SAYEED
Particulars of the PatientsName: D/O TaslimaAge: Day 4OutbornAddress: PabnaDate of admission: 21.07.16Date of examination: 21.07.16
Presenting Complaints Born before date Twin attached at head since birth
History of Present Illness Mother Taslima, 32 years old, Para 2+1
(abortion), having blood group O+ve and the father’s blood group is O+ve. She received 5 regular antenatal checkup and got 2 doses of tetanus toxoid. She has no h/o PIH, GDM, hypothyroidism, PROM or any other chronic illness. She had no h/o taking ovulation inducing drug and no family h/o twin. At 28 weeks of gestation USG revealed single viable pregnancy with mild hydrocephalus and BPD is 9cm which corresponds to 36 weeks.
History of Present Illness (Contd.)So mother was advised to take neurology consultation about the outcome of baby. After consultation from neurologist, as she heard about the poor outcome of the baby, she planned for elective LUCS. At 35 weeks of gestation, elective LUCS was done in a local clinic and a twin female babies were born with their head attached together. Both babies cried immediately after birth, APGAR score was 6/10 & 7/10 at 1st & 5th min respectively but birth weight was not documented.
History of Present Illness (Contd.) Then the babies were kept with mother
and was on EBF. Both of them passed urine and meconium within first 12 hours of life. Later the babies were referred to BSMMU for further evaluation & management. At day 4 of post-natal age, the babies were transferred to BSMMU by an ambulance in mother’s lap with proper wrapping and transportation time was about 7 hours without any difficulties.
Birth History Antenatal: Mother received 5 ANC and the
period was uneventful.
Natal: Conjoint twins were delivered by LUCS at 35 weeks of gestation.
Postnatal: Both of the babies cried immediately after birth, APGAR score was 6/10 & 7/10 at 1st & 5th min respectively, and both of them passed urine and meconium within first 12 fours of life.
Family History They are the 2nd issue of non-
consanguineous parents. Other sib is 5-year-old and healthy.
There is no family h/o twins.
Socioeconomic History Parents are from middle socio-
economic background. Both parents are private school
teacher.
General ExaminationFirst twin: Pink in room air Icteric up to leg Reflexes and activities: good CRT: <3 sec Anterior fontanel: open, not bulged Skin survey: Normal
General Examination (Contd.) Umbilicus: Healthy (2 arteries, 1 vein) Genitalia: female pattern Anus: Patent CBG: 5.6 mmol/L
Vital signs: HR – 138 b/min RR – 42 br/min Temp - 98˚F
General Examination (Contd.)Second twin: Pink in room air Icteric up to leg Reflexes and activities: good CRT: <3 sec Anterior fontanel: open, not bulged Skin survey: Normal
General Examination (Contd.) Umbilicus: Healthy (2 arteries, 1 vein) Genitalia: female pattern Anus: Patent CBG: 5.6 mmol/L
Vital signs: HR – 142 b/min RR – 46 br/min Temp - 98˚F
General Examination (Contd.) Head
examination:Both babies were attached together over a part of both parietal and occipital region of head.
General Examination (Contd.)Anthropometry: Weight – 2780gms (combined)First Twin: Length – 47 cm (50th - 75th centile) OFC – 31 cm (25th centile)Second Twin: Length – 47 cm (50th - 75th centile) OFC – 30 cm (10th centile)
Resp. System ExaminationFirst Twin: RR – 42 br/min Chest in-drawing: absent No grunting Bilateral good air entry in both lungs
with no added sound
Resp. System Examination (Contd.)Second Twin: RR – 46 br/min Chest in-drawing: absent No grunting Bilateral good air entry in both lungs
with no added sound
CVS ExaminationBoth twins Apex beat: left 4th intercostal space
on the mid-clavicular line. Heart Sound: first and second heart
sounds are audible in all four areas. No murmur was present.
GIT ExaminationBoth twins Abdomen: soft, not distended No organomegaly Bowel sound present
Urinary System ExaminationBoth twins Kidney: not ballotable Urinary bladder: not palpable
Other systemic examination reveals no abnormal findings.
Salient Features D/O Taslima, outborn, 2nd issue of non-
consanguineous parents, hailing from Pabna was admitted on their 4th post-natal age due to prematurity and fused head with each other from birth. Mother Taslima, 32 years old, Para 2+1 (abortion), having blood group O+ve was on regular antenatal checkup and was immunized against tetanus. She has no h/o PIH, GDM, hypothyroidism, PROM or any other chronic illness. No h/o taking ovulation inducing agents.
Salient Features (Contd.) At 28 weeks of gestation antenatal USG revealed
a single viable pregnancy with mild hydrocephalus. At 35 weeks of gestation, due to risk of poor outcome of baby, elective LUCS was done in a local clinic and a twin female babies were born who were fused together at head. They cried immediately after birth, APGAR score was 6/10 & 7/10 at 1st & 5th min respectively of both twin, birth weight was not documented. They passed urine and meconium within first 12 hours of life. At day 4 of post natal age babies were referred to BSMMU for further evaluation & management.
Salient Features (Contd.) On examination, babies were pink in air,
icteric up to leg, reflex activities were good, normothermic, well perfused, euglycemic, vitals within normal range, both head were fused with each other over part of both parietal and part of occipital region, anthropometry of each baby were in centile chart, combined weight was 2780 gm, systemic examinations revealed nothing abnormality.
Provisional Diagnosis
?Preterm (35wks), 2780gm, Conjoint twin
(craniopagus), Neonatal Jaundice
Treatment on admission Thermal care Cup feeding with EBM Inf. 10% dextrose in 0.225% NaCl
Investigations after admission(21.7.16)
Investigations
Findings
Twin 1 Twin 2
CBC HbWBC-TCDC
Platelet
19.4 gm/dl12x109/LN 53%, L 40%,M 05%, E 02%350x109/L
18.8 gm/dl12x109/LN 50%, L 44%, M 05%, E 02%350x109/L
PBF Non-specific morphology
Non-specific morphology
S. Total Bilirubin
19.9 mg/dl[Phototherapy level 17mg/dl, Exchange level 22 mg/dl]
20.5 mg/dl[Phototherapy level 17mg/dl, Exchange level 22 mg/dl]
Investigations after admission(Contd.)
Investigations
Findings
Twin 1 Twin 2
S. ElectrolytesSodiumPotassiumChlorideT-CO2
134 mmol/L6.3 mmol/L103 mmol/L15.5 mmol/L
142 mmol/L5.0 mmol/L110 mmol/L17.1 mmol/L
S. Calcium 1.7 mmol/L 2.2 mmol/L
S. Creatinine 0.2 mg/dl 0.2 mg/dl
PT 32.0 sec 32.0 sec
APTT 12.0 sec 12.0 sec
Investigations after admission(Contd.)
X-ray skull
Investigations after admission(Contd.)
X-ray chest A/P view
Consultation: Paediatric Surgery
Advice: Thermal care Nutritional support Proper & careful nursing Only baseline investigations including x-
ray skull Plan for OT after neonatal period Keep the patient in cabin
Follow up on 5th PNA (22.7.16)
Twin 1Subjective
Objective Assessment/Plan
Intervention
Low urine output
Good reflex activity HR: 138 b/minRR: 42 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 4.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyU. Bladder: not palpableInput IV+BF 60+30 ml/dayUrine output 0.7 ml/kg/hr (25 ml/day)Stool passed 1 timeWt: 2610 gm(6.1% wt loss)
Oliguria Full IVF started Single surface
phototherapy
Follow up on 5th PNA (22.7.16)
Twin 2Subjective
Objective Assessment/Plan
Intervention
No new events
Good reflex activity HR: 134 b/minRR: 38 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.6 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput IV + BF 203 ml/dayUrine output 3.8 ml/kg/hr (150 ml/day)Stool passed 2 time
Static Continue previous treatment
Bilirubin Trend Twin 1
day 4 day 4 (6hrs later)
day 5 day6 day 7
17 17 17 17 17
22 22 22 22 2219.9
18.516.4
14.215.7
Photolevel exchange TSB
Bilirubin Trend Twin 2
day 4 day 4 (6hrs later)
day 5 day6 day 7
17 17 17 17 17
22 22 22 22 2220.5
18.7
15.8
13.214.9
Photolevel exchange TSB
Follow up on 13th PNA (30.7.16)
Twin 1Subjective
Objective Assessment/Plan
Intervention
Low urine output
Reflex activity: reduced than previous day HR: 136 b/minRR: 52 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyU. Bladder: not palpableInput Demand BFUrine output 0.3 ml/kg/hr + 1 time (10 ml + 1 time)Stool passed 3 timesWt: 2950 gm (2.4% wt gain)
Oliguria Correction of electrolyte imbalance
S. ElectrolytesNa+ 123 mmol/LK+ 6.3 mmol/LCl- 92 mmol/LTCO2 17.8 mmol/LS. Creatinine0.99 mg/dl
Follow up on 13th PNA (30.7.16)
Twin 2Subjective
Objective Assessment/Plan
Intervention
No new events
Good reflex activity HR: 140 b/minRR: 32 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.8 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput Demand BFUrine output 4.2 ml/kg/hr + 5 times (150ml + 5 times)Stool passed 2 time
Static Continue previous treatment
S. ElectrolytesNa+ 132 mmol/LK+ 6.1 mmol/LCl- 92 mmol/LTCO2 17 mmol/LS. Creatinine0.53 mg/dl
Follow up on 14th PNA (31.7.16)
Twin 1Subjective
Objective Assessment/Plan
Intervention
Low urine output
Good reflex activity HR: 136 b/minRR: 30 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyU. Bladder: not palpableInput 360 ml/dayUrine output 0.8 ml/kg/hr + 1 time (30 gm + 1 time)Stool passed 1 timeWt: 2980 gm(1.01% wt gain)
Persistent oliguria
Correction of electrolyte imbalance
Ca++ gluconate added
Nephrology consultation
Treatment: NaHCO3 Inj. Furosemide Nebulization
by salbutamol 20% curtail IVF
S. ElectrolytesNa+ 124 mmol/LK+ 7.4 mmol/LCl- 93 mmol/LTCO2 12.2 mmol/LS. Creatinine0.78 mg/dl
Follow up on 14th PNA (31.7.16)
Twin 2Subjective
Objective Assessment/Plan
Intervention
No new complaints
Good reflex activity HR: 140 b/minRR: 40 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.8 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput 360 ml/dayUrine output 8 timesStool passed 2 times
Static Correction of electrolyte (Na+) imbalance
Continue previous treatment
S. ElectrolytesNa+ 129 mmol/LK+ 6.2 mmol/LCl- 95 mmol/LTCO2 14.9 mmol/LS. Creatinine0.65 mg/dl
Consultation: Paediatric Nephrology (01.08.16)
Investigations to evaluate: Urine pH, urinary Na+
Urine R/M/E S. Creatinine S. Electrolytes RBS USG of the whole abdomen with special
attention to the adrenal glands
Follow up on 16th PNA (02.08.16)
Twin 1Subjective
Objective Assessment/Plan
Intervention
No urine output in last 10 hrs
Good reflex activity HR: 142 b/minRR: 38 br/minCRT <3 secPulse volume: goodAF: at levelDehydration: absentEdema: absentCBG: 3.4 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distendedU. bladder: not palpableWeight: 3080gm (static)Input IV+BF 161+144 ml/dayUrine output 0.2 ml/kg/hr (20 ml/day)Stool passed nil
Persistent oliguria
N/S bolus 10 ml/kg
Inj. Lasix 1 mg/kg
N/S bolus repeat
20% fluid curtailS. ElectrolytesNa+ 130 mmol/LK+ 5.8 mmol/LCl- 99 mmol/LTCO2 17.8 mmol/LS. Creatinine0.54 mg/dl
Follow up on 16th PNA (02.08.16)
Twin 2Subjective
Objective Assessment/Plan
Intervention
No new complaints
Good reflex activity HR: 152 b/minRR: 36 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 4.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput IV+BF 221+172 ml/dayUrine output 3.8 ml/kg/hr (210 ml/day)Stool passed 3 times
Static Continue previous treatment
Follow up on 17th PNA (03.08.16)
Twin 1Subjective
Objective Assessment/Plan
Intervention
No urine output in last 24 hrs
Good reflex activity HR: 136 b/minRR: 42 br/minCRT <3 secPulse volume: goodAF: at levelDehydration: absentEdema: absentCBG: 3.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distendedU. bladder: not palpableWeight: staticInput IV+BF 135+101 ml/dayUrine output nilStool passed 1 time
Anuria N/S bolus 10 ml/kg
Inj. Lasix 1 mg/kg
Nephrology consultation
Advice: Observe the
twins No more Lasix
if anuria
S. ElectrolytesNa+ 131 mmol/LK+ 4.7 mmol/LCl- 98 mmol/LTCO2 20.9 mmol/LS. Creatinine0.44 mg/dl
Follow up on 17th PNA (03.08.16)
Twin 2Subjective
Objective Assessment/Plan
Intervention
No new complaints
Good reflex activity HR: 152 b/minRR: 36 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 4.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput IV+BF 132+156 ml/dayUrine output 0.6 ml/kg/hr + 7 times (20 gm + 7 times)Stool passed 3 times
Static Continue previous treatment
InvestigationInvestigations
Findings(04.08.16)
Twin 1 Twin 2
S. ElectrolytesSodiumPotassiumChlorideT-CO2
133 mmol/L6.4 mmol/L97 mmol/L20 mmol/L
137 mmol/L5.2 mmol/L98 mmol/L23 mmol/L
S. Creatinine 0.53 mg/dl 0.63 mg/dl
Investigation (Contd.) USG Brain:
Both Twinsi. Single 3rd ventricle.ii. Single set lateral ventricle.iii. 4th ventricle could not visualized.iv. Brain parenchyma echotexture
normal.v. No evidence of hemorrhage.
Investigation (Contd.) USG of whole abdomen:
Twin 1 Twin 2
Urinary bladder not visualized
Left sided mild hydronephrosis
On 19th PNA the babies were discharged on request due to financial constrain and advised to follow up after 15 days.
Final DiagnosisPreterm (35wks), 2780gm, Conjoint Twin
(craniopagus) with Neonatal Jaundice (resolved), Electrolyte imbalance
(hyponatremia, hyperkalemia -corrected)
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