PERINATAL/NICU PERINATAL/NICU CONFERENCE CONFERENCE Monthly Statistics Report Monthly Statistics Report January 2014 January 2014 Marco Manzano and Clarissa Pangilinan, MD 3 rd Year Resident – Pediatrics Maria Edwardina G. De Leon, MD 3 rd Year Resident – Obstetrics and Gynecology THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the Department of Pediatrics
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PERINATAL/NICU CONFERENCE Monthly Statistics Report January 2014 PERINATAL/NICU CONFERENCE Monthly Statistics Report January 2014 Marco Manzano and Clarissa.
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Neonatal Morbidities, January 2014NUMBER OF NEONATAL MORBIDITIES 36Incidence among total live births 115 per 1000 LBDelivered from Normal Mothers 19Delivered from High Risk Mothers 17
Top 5 Conditions Occurring Among High Risk Mothers, January 2014
Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014
Prematurity = 4Prematurity = 4
Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014
Prematurity = 3LGA = 2SGA = 1
Low birth weight = 1
Prematurity = 3LGA = 2SGA = 1
Low birth weight = 1
Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014
Prematurity = 4LGA = 1
Low birth weight = 1
Prematurity = 4LGA = 1
Low birth weight = 1
Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014
Prematurity = 1LGA = 3
Prematurity = 1LGA = 3
Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014
LGA = 1Poor APGAR = 1
LGA = 1Poor APGAR = 1
CONGENITALANOMALIES
Congenital Anomalies, January 2014
NUMBER OF NEONATES WITH CONGENITAL ANOMALIES 2
Incidence among total live births 15 per 1000 LB
Delivered from normal mothers 1
Delivered from high risk mothers 1
Congenital Anomalies, January 2014
Cleft Palate 1
Imperforate Anus 1
Congenital anomalies: January 2013Antenatal detection and Neonatal outcome
CongenitalAnomalies
N Ultrasound Neonatal outcomeWHCC Done
Detected
Not Detecte
d
Outside Survive
dDied
Cleft Palate 1
Imperforate Anus1
• M. M. P.• 28, G1P0, 39• CC: vaginal bleeding• PNCU: regular,
• BW 3140 g• BL 51 cm• HC 34 cm• CC 34 cm• AC 30 cm
CASE: Cleft Palate
• Maternal History: – UTI- 1st trimester, treated with cefuroxime
• Past Medical History:– (+) asymptomatic MVP
• Family History:– Diabetes, Hypertension, Heart disease, Stroke
• Personal/Social History– Unremarkable
• OB History:– G1 – present pregnancy
• Feeding history– Mixed feeding, expressed breastmilk+milk formula
Physical Findings• Thinly meconium-stained amniotic fluid• Flat fontanels• No molding• Cleft palate• (-) alar flaring• Good air entry, no retractions• HR 150bpm, Good cardiac activity, • Soft abdomen• Grossly female genitalia• Full pulses
Diagnosis
• Live Term Baby Girl• Cleft palate
• NPO• ENT Referral• Therapeutics:
– Obturator fitting c/o pedia dentist– OGT feedings– Feeding plate– Breast feed as tolerated
PLAN
Course in the NICU
Course in the NICU
Cleft Palate Failure of the palatal shelves to fuse Cleft palate: 1 in 2500 (Caucasians) Cleft lip+/- cleft palate: 1 in 750 Cleft palate: Females > Males Cleft lip: Males > Females Syndromes associated w/ Cleft Lip +/- cleft palate : >200 Ethnic factors (Cleft lip +/- cleft palate)
Native Americans (1 in 230 to 1,000) Asians (1 in 400 to 850) African Americans (1 in 1,300 to 5,000)
Incidence of associated congenital malformations and of impairment in development is increased: Cleft palate alone > cleft lip
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Clefting Defects• between the 6th and 9th weeks AOG
– primary palate begins to form at about 35 days– complete lip development by the 6th week– palatal fusion follows
• Cleft lip: interruption or hypoplasia of the mesenchymal layer failure of fusion of the medial nasal process, maxillary process, and lateral nasal process (unilateral or bilateral)
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Cleft Palate
Occurs in the midline and might involve only the uvula or can extend into or through the soft and hard palates to the incisive foramen
When associated with cleft lip: involve midline of the soft palate and extend into the hard palate on one or both sides, exposing one or both of the nasal cavities as a unilateral or bilateral cleft palate
Can also have a submucosal cleft indicated by a bifid uvula, partial separation of muscle with intact mucosa, or palpable notch at the posterior of the palate
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th Edition
Pierre Robin sequence (PRS) micrognathia (small mandible) retropositioned tongue U-shaped cleft palate
• failure of the mandible to grow properly positioning of the tongue in the back of the pharynx blocks the ability of the palatal shelves to fuse properly
• severe respiratory distress: mortality rate as high as 30%• careful monitoring: first 1 to 4 weeks• over time, the lower jaw generally “catches up” in growth vs.
surgical intervention (jaw expansion)• isolated birth defect, but may be part of syndromes such as
trisomy 18 or Stickler syndrome
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Trisomy 18
• Edward’s Syndrome• second most common autosomal trisomy
after trisomy 21• severe psychomotor and growth retardation,
microcephaly, microphthalmia, malformed ears, micrognathia or retrognathia, microstomia, distinctively clenched fingers, and other congenital malformations
Difficulty creating sufficient suction in the mouth to complete a feeding without tiring
Soft artificial (cross-cut) nipples with large openings, a squeezable bottle
Plastic obturator Small, frequent feedings, not
longer than 30mins Burped 2-3x during a feeding:
bottle positioned as upright as possible to avoid air in the nipple, or fed with an angled bottle
Timing of surgical correction is individualized Width of the cleft Adequacy of the existing
palatal segment Morphology of the
surrounding areas Neuromuscular function of
the soft palate and pharyngeal walls
Cleft Palate: Treatment• Cleft lip: “rule of 10s”– 10lbs, 10 weeks old, and hgb of 10.0 g/dL • Goals of surgery:
– Union of the cleft segments– Intelligible and pleasant speech– Reduction of nasal regurgitation– Avoidance of injury to the growing maxilla
• Cleft palate: Usually by 1 year of age (speech development)• Furlow double-opposing Z-plasty (most common)
– may need revisions as they grow older• When delayed beyond 3rd year: a contoured speech bulb can be
attached to the posterior of the maxillary denture• Cleft palate: usually crosses the alveolar ridge and interferes with
teeth formation in the anterior maxillary region– May be displaced, malformed, or missing (replaced by prosthetics)
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th EditionSamanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
Cleft Palate: Treatment
• Postoperative management: gentle aspiration of nasopharynx (minimizes atelectasis or pneumothorax which are common complications)
• Maintenance of clean suture line and avoidance of tension on the sutures
• Bottle-fed with arms restrained and with elbow cuffs• Fluid or semi-fluid diet for 3 wks• Hands, toys, and other foreign bodies are kept away from the
surgical site
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th Edition
Cleft Palate: Sequelae
• Recurrent otitis media and subsequent hearing loss• Displacement of maxillary arches and teeth malposition• Misarticulations and velopharyngeal dysfunction (10-20%
after repair)– Emission of air from the nose– Hypernasal quality – Compensatory misarticulations (glottal stops)
Kliegman et al. 2011. Nelson’s Textbook of Pediatrics. 19th Edition
Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230
• M. B. R.• 33, G2P1 (1001), 38• s/p PCS for arrest of descent• CC: irregular uterine
contractions• PNCU: U/R• Past Medical: s/p Harrington
rod insertion• Personal/Social History: U/R• Family History: (+) DM,
• Maternal History: 3rd Trimester, Cough and Colds, no medications given
• Past Medical History: Scoliosis s/p Spine surgery (1993)
• Family History: Diabetes, Hypertension
• OB History: • G1- 2009- PCS for Arrest of descent- LFT- Male-
TMC- No FMC• G2: Present Pregnancy
• Personal Social: Post-graduate, Works as a market researcher, no vices
Physical Examination: Imperforate Anus
• Had good cry and activity• Clear amniotic fluid• Flat and open fontanelles• Good air entry, no retractions• Regular cardiac rhythm, HR at 150 bpm• Soft Abdomen• Grossly male genitalia• Imperforate Anus• Full pulses
Diagnosis: Imperforate Anus
• Term Baby Boy• t/c Imperforate Anus
PLANS:
• Transfer to Level III care• Maintain on NPO• Referral to Surgery
Course in the NICU: Imperforate Anus
Subjective Objective Assessment Plan
- 5th HOL- On NPO- No vomiting- Active
- T: 36.7, HR 143, RR: 44
- Good air entry, no retractions
- Good cardiac tone
- Soft abdomen
- (+) Imperforate anus
- Term Baby Boy
- t/c Imperforate Anus
- Insert OGT- For
Babygram- Observe for
any fecalith material with UO
- IVF- HGT
monitoring
Course in the NICU: Imperforate Anus
Subjective Objective Assessment Plan
- 7th HOL- On NPO- No vomiting- Active- (+) UO: no
Fecalith matter noted
- T: 36.9, HR 147, RR: 42
- Good air entry, no retractions
- Good cardiac tone
- Soft abdomen
- (+) Imperforate anus
- Babygram: Normal
- Term Baby Boy
- t/c Imperforate Anus
- IVF
Course in the NICU: Imperforate Anus
Subjective Objective Assessment Plan
- 20th HOL- On NPO- No vomiting- Active- (+) UO
- T: 36.7, HR 151, RR: 43
- Good air entry, no retractions
- Good cardiac tone
- Soft abdomen, slightly dilated
- (+) Imperforate anus
- Term Baby Boy
- t/c Imperforate Anus
- For cross table lateral abdominal X-ray in prone position
If the air column is more than 1 cm from the perineum, a colostomy is indicated.
Anoplasty Colostomy
A flat bottom or flat perineum, as evidenced by the lack of a midline gluteal fold and the absence of an anal dimple, indicates that the patient has poor muscles in the perineum.
The presence of meconium at the perineum, a bucket-handle malformation (ie, a prominent skin tag located at the anal dimple, below which an instrument can be passed), and an anal membrane (through which meconium is visible).
greenish amniotic fluid• IE: 4cm, 70%, -3, (-) BO W
• s/p STAT PCS• Male
APGAR 5, 4, 44210 gMT 39 LGA
CASE 3: APGAR 5, 4
Identifying Data
• Live, term, baby boy delivered via STAT caesarian section for nonreassuring fetal heart rate pattern to a 33 year old G1P1 (1001) at 40 weeks age of gestation
• BW= 4210g BL= 452 cm HC= 35 ½ cm CC= 37 cm AC= 32 cm• MT 39 weeks LGA• AS 5, 4, 4
Maternal History• 1st trimester
– Started prenatal check-up (13x for the whole pregnancy)– Ultrasound 5x = normal– Threatened abortion given Isoxilan and bed rest for 2 months
• 2nd trimester– Gestational Diabetes = FBS = 250, referred to endocrinologist
started on insulin 12 ‘u’ BID– FBS repeat after a month = 180, insulin increased to 14 ‘u’ BID
until 26 ‘u’ 2x/day – (+) UTI (pus cells = 50-60) treated with Cefalexin for 7 days,
repeat urinalysis = normal• Upon admission, noted to have variable decelerations with
latest at 70 bpm 3x, with thickly stained amniotic fluid
Past Medical History
• Bronchial asthma since childhood on Symbicort 350mcg 1 puff PRN
• Thyroid nodule 2007 s/p total thyroidectomy, no maintenance medications, last thyroid function test June 2013 (normal results)
• Had thickly stained amniotic fluid, with weak cry, heart rate of 150s, cyanotic, with some flexion and grimace Suctioning and stimulation done
• At 5 minutes: still cyanotic, no cry but with spontaneous respiration, heart rate of 80s positive pressure ventilation done heart rate now 120s, with acrocyanosis, no cry
At 6 minutes, heart rate became 70 positive pressure ventilation done heart rate of 110, still with no cry, and
acrocyanosis
intubated with ET size of 3.5 level 12
Pink, with some flexion, heart rate 160, Good air entry, rales on both lung fields, good cardiac tone, soft abdomen, 2 umbilical
arteries and 1 vein, stained cord, full pulses
• Transferred to Level 3 • Hooked to a mechanical ventilation support • Placed on NPO• Work-up: CBCPC, Blood Culture and Sensitivity, CRP• Chest Xray obtained • VBG done• Antibiotics and Dobutamine drip started at
5mcg/kg/min • IV fluids started• BP and O2 saturations obtained
Complete Blood Count Hgb Hct WBC N L M E band Plt
160 49 23.7 29 63 06 02 172
CRP: 0.49 mg/dl
Chest Xray
Impression: Meconium Aspiration Pneumonia with superimposed pulmonary edema
10th Hour of Life
• Noted to have desaturations to 70’s, with alar flaring and subcostal retractions
• Dopamine started for heart support however held due to tachycardia
• Surfactant 4ml/kg given• Referred to Cardiology for evaluation and
management• 2D Echo done
2D Echo • Situs Solitus• AV & VA concordance• Normal venous connections• Patent foramen ovale 6mm• Intact IV septum• Moderate TR• Mildly dilated RA & RV• Patent ductus areteriosus 3-4mm• Conclusion: Consistent with Persistent
Pulmonary Hypertension
16th hour of life
• O2 saturations at 83-88%• Minimal urine output • Milrinone started at 0.5mcg/kg/min for
pulmonary vasodilation• Dobutamine increased to 10/mcg/kg/min
Day 1-2 of life
S O A P
• Intubated• With
spontaneous respirations, occasional desaturations, no cyanosis
• With episodes of agitation
• Adequate urine output 1.7cc/kg/hr
BP 67/25 CR 154 RR 68 Pre O2sats 94% Post O2 sats 92%Flat fontanellesLight jaundice to abdomen+subcostal retractions, good air entry, rales on both lung fieldsRegular cardiac rhythm, no murmurSoft abdomenFull pulse
Persitent Pulmonary Hypertension
Meconium Aspiration Syndrome
• Mech.Vent.Settings adjusted
• Phototherapy started• IVF adjusted• Dobutamine,
Milrinone Drip continued
• Morphine Drip Started• Antibiotic continued• Fentanyl given as
relaxant as needed• VBG obtained
Day 3 of LifeS O A P
• (+) Fever• Intubated• With
spontaneous respirations
• With ocassional desaturations, no cyanosis
BP 68/27 CR 154 RR 72 O2sats 98% T37.8Flat fontanellesLight jaundice to abdomen+subcostal retractions, good air entry, harsh breath soundsRegular cardiac rhythm, no murmurSoft abdomenFull pulse
Persitent Pulmonary Hypertension
Meconium Aspiration Syndrome
• Feeding with EBM started
• Mech.Vent.Settings adjusted
• Phototherapy continued
• IVF adjusted• Dobutamine,
Milrinone, Morphine Drip continued
• Antibiotic shifted to Ceftazidime and Oxacillin
• CBC, CRP, BCS repeated
• Electrolytes, Bilirubin levels obtained
• Repeat Chest Xray done
Complete Blood Count Hgb Hct WBC N L M E band Plt
142 43 8.5 63 28 04 01 04 148
CRP Mg Na K
0.49 2.51 142 4.2
Total Bilirubin Direct Bilirubin
Indirect Bilirubin
14.85 2.12 12.95 High Risk Zone
Chest Xray
Impression: Interval regression of bilateral infiltrates/edema
Day 4 of LifeS O A P
• No recurrence of Fever
• Intubated• With
spontaneous respirations
• With ocassional desaturations, no cyanosis
BP 74/39 CR 165 RR 61 O2sats 98% Flat fontanellesVery Light jaundice to face+shallow subcostal retractions, good air entry, harsh breath soundsRegular cardiac rhythm, no murmurSoft abdomenFull pulse
Persitent Pulmonary Hypertension
Meconium Aspiration Syndrome
• Midazolam Drip started at 0.5mcg/kg/min
• BCS (Staph. Haemolyticus)
• Transferred to isolation
Day 5 of lifeS O A P
• Intubated• With
spontaneous respirations
• No desaturations, no cyanosis
BP 68/31 CR 167 RR 50 O2sats 94% Flat fontanelsVery Light jaundice to face+subcostal retractions, good air entry, harsh breath soundsRegular cardiac rhythm, no murmurSoft abdomenFull pulse
Persitent Pulmonary Hypertension
Meconium Aspiration Syndrome
• Mech.Vent.Settings adjusted
• Phototherapy discontinued
• Feeding increased and IVF adjusted
• Dobutamine drip discontinued
• Milrinone and Morphine drip decreased
• Midazolam Drip continued
• Lumbar puncture done
Day 6 of life Day 7 of life
• Blood CS: Staph. Haemolyticus • Sensitive to Vancomycin, resistant
to Ceftazidime• Antibiotic shifted to Vancomycin • Milrinone drip discontinued• Mech.Vent. adjusted
• Extubation done• no desaturation, tachypnea, not in distress• Hooked to CPAP then discontinued • Nebulization with Salbutamol for 24hrs• Repeat cbc, crp, blood cs done
Complete Blood Count Hgb Hct WBC N L M E band Plt
176 54 17.2 69 20 08 0 03 114
CRP: 1.4 mg/dl
Day 9 – Day 14 of life
• Good cry and activity• No cyanosis, tachypnea, sign of respiratory
distress • Feeding increased then fed as tolerated• Vancomycin completed for 10days• Referred to Pediatric Ophtalmologist for Retina
screening and Development Pedia for evaluation• Discharged
Final Diagnosis
• Live Term Baby• Meconium Aspiration Syndrome• Persistent Pulmonary Hypertension• Sepsis (Staphylococcus Haemolyticus)• Hyperbilirubinemia Unspecified
MECONIUM ASPIRATION SYNDROME AND PERSISTENT PULMONARY HYPERTENSION
• Meconium passage in utero gasping by the fetus or newly born infant can cause aspiration of meconium-contaminated amniotic fluid can obstruct airways, interfere with gas exchange, and cause severe respiratory distress
• Meconium-stained amniotic fluid: 10-15% births; term and post term
• Meconium aspiration syndrome: 5%, 30% require mechanical ventilation, 3-5% usually die
• May be depressed and require resuscitation at birth• At increased risk of PPHN
• Aspirated meconium vasospasm, hypertrophy of the pulmonary arterial musculature, and pulmonary hypertension that lead to extrapulmonary right-to-left shunting through the ductus arteriosus or the foramen ovale
• results in worsened ventilation-perfusion mismatch, leading to severe arterial hypoxemia persistent pulmonary hypertension of the newborn (PPHN)
• Aspirated meconium also inhibits surfactant function.
Diagnosis
PPHN should be suspected in all term infants who have cyanosis with or without fetal distress, IUGR, moconium stained amniotic fluid, hypoglycemia, and others.
A PaO2 gradient between a preductal (right radial artery) and a postductal (umbilical artery) site of blood sampling >20mmHg sugests right-to-left shnting throughthe ductus arteriosus
94
Diagnosis
Real-time 2D echo combined with doppler flow studies
-demonstrates right to left shunting across a patent foramen ovale and a ductus arteriosus.
Tricuspid or Mitral insufficiency Holosystolic murmur Can be visualized in the 2D echo with poor contractility
when PPHN is associated with myocardial ischemia 95
Response unpredictable, transient, and complicated by the adverse effects of drugs or mechanical ventilation
96
Treatment
Initial management Oxygen Correction of acidosis, hypotension, and
hypercapnia Intubation and mechanical ventilation
- hyperventilation is used to reduce pulmonary vasoconstriction by lowering pCO2 (~25mmHg) and increase the pH (7.5-7.55)
97
Treatment
Inhaled NO Potent and selective pulmonary vasodilator Initial dose 1-20ppm Improves oxygenation Reduces the need for ECMO Initial improvement but not sustained, ECMO is
required If there’s sustained improvement, usually
weaned by the 5th day of therapy.
98
Treatment
Extracorporeal Membrane Oxygenation (ECMO)
When response to 100% oxygen, mechanical ventilation, and drugs is poor
A form of cardiopulmonary bypass that augments systemic perfusion and provides gas exchange
99
Treatment
Extracorporeal Membrane Oxygenation (ECMO)
Venous bypass: Blood is initially pumped through the ECMO circuit at arate ~80% of the estimated cardiac output of 150-200ml/kg/min
Venous return passes through a membrane oxygenator, warmed, and returns to the aortic arch.
100
Treatment
Extracorporeal Membrane Oxygenation (ECMO)
This requires complete heparinization to prevent clotting in the circuit, patients at high risk for IVH are not candidates
Complications: thromboembolism, bleeding, stroke, air embolization, others
101
Prognosis
Survival varies Long term outcome for patients is reated to the
associated HIE and the ability to reduce pulmonary vascualr resistance
Long term prognosis who survive after treatment with hyperventilation is comparable to that infants who have underlying illnesses of equivalent severity Birth asphyxia Hypoglycemia
ECMO: favorable, 85-90% survive, 60-75% of survivors appear normal at 1-3.5 yrs of age 102
• M. I. P.• 34, G2P0 (0010), 29• CC: vaginal bleeding• G1-2012-8 weeks AOG,
• Maternal History: 1st Trimester, Cough and Colds, no medications given
• Past Medical History: Breast cyst, Left, s/p Excision(2012)
• Family History: Hypertension
• OB History: present pregnancy• Personal Social: College graduate, housewife, no vices
Upon Delivery• Good cry and activity, no cyanosis• Clear amniotic fluid• Flat and open fontanelles• Good air entry, no retractions• Irregular cardiac rhythm, HR 140 bpm, no
murmur (skipped beats, 10 -13x per minute)• Soft Abdomen• Grossly normal female genitalia• Full pulses
Initial Impression
• Term Baby Girl• r/o Cardiac Pathology
PLAN:•Transfer to Level 3 of care hook to cardiac monitor•Refer to a pediatric cardiologist
– Hook to cardiac monitor– BP and oxygen saturations on all extremities
Course in the NICUSubjective Objective Assessment Plan- 3rd HOL- Good suck, cry,
and activity- Able to latch
- T: 36.8, HR 146, RR: 44
- No cyanosis, no alar flaring
- Good air entry, no retractions
- Irregular cardiac rhythm, with 1-2 skipped beats/minute
- Full pulses
Live term baby girlr/o cardiac pathology
- Monitor vital signs every hour
- Hook to cardiac monitor
- BP and O2 sats on all extremities
- Watch out for 25-30 skipped beats/minute
• Stable vital signs• BP on all extremities:
• Oxygen saturations on all extremities: 100%
Course in the NICUSubjective Objective Assessment Plan- 10th HOL- Good suck, cry,
and activity- Tolerates 10-
15ml of milk feedings
- T: 37, HR 122, RR: 44
- No cyanosis, no alar flaring
- Good air entry, no retractions
- Irregular cardiac rhythm, with 2-5 skipped beats/minute
- Full pulses
Live term baby girlr/o cardiac patholog
- Bed side 2D-echo
- EG-7
• 2D echo– PFO 4.2mm– Left to right shunt– Trivial mitral regurgitation– PDA 1.8 continuous blow– Normal transitional circulation; no arrhythmia
• Cardiology remarks:– Common incidental finding in newborns– Structural abnormality ruled out– No signs of heart failure noted– Refer for >5 skipped beats per minute
• Sinus pauses from 800 to 1,000 msec may occur in healthy newborns
• Such pauses usually are followed by escape beats from the atria or the atrioventricular (AV) junction
• Pauses of more than 2 seconds are considered abnormal
• Possible causes:– oversedation, (drugs passed through the placenta)– hypothermia– central nervous system abnormalities– increased intracranial pressure– increased vagal tone– obstructive jaundice– hypothyroidism
DISTRIBUTION OF BIRTHS
January 2014
Distribution of Deliveries According to Birthweight
Small for Gestational Age Infants, January 2014
NUMBER OF SGA NEONATES 3 Incidence among total live births 10/1000 LB Delivered from normal mothers 1 Delivered from high risk mothers 2
A. Maternal factors 2
B. Fetal Factors 0
C. Unknown factor 1
Large for Gestational Age Infants, January 2014
NUMBER OF LGA NEONATES 23 Incidence among total livebirths 41 /1000 LB Delivered from normal mothers 15 Delivered from high risk mothers 8
• Bilobed Liver• Dilated hepatic veins• Aorta anterior and left to the spine• IVC to the right of the spine, same level as aorta• Heart is mesocardiac in position pointing to the
left• Poor RV function• Severe Tricuspid Regurgitation