Case Report 1

TERM INFANT APPROPIATE FOR GESTATIONAL AGE, SEPSIS

NEONATORUM, MECONIUM ASPIRATION SYNDROME, AND
DECOMPENTATIO CORDIS EC ATRIAL SEPTAL DEFECT IN A
NEONATES

Oleh :
Ledy N Tandiawan

Pembimbing :
Dr dr Rocky Wilar, SpA(K)
dr. Johnny Rompis, SpA(K)
 2

Correction
- Tittel :
TERM INFANT APPROPIATE FOR GESTATIONAL AGE, SEPSIS
NEONATORUM, MECONIUM ASPIRATION SYNDROME, AND
DECOMPENTATIO CORDIS EC ATRIAL SEPTAL DEFECT IN A NEONATES

- Nutrition : breast feeding, breast milk on demand

- The result of Echocardiography : mild secundum ASD
44mm with L-R shunt
 3

Correction
References:
1. Aakash Pandita, MD; srinivas Mukti, DM; Tejo Pratap Oleti, DM; Baswaraj Tandur, DNB; sai Kiran,
DNB; et all. Effect of Nasal Continous Positive Airway Pressure on Infants With Meconium
Aspiration Syndrome Arandomized Clinical Trial : Original investigation, From the American
Medical Association. JAMA Pediatrics. 2017.3873.
2. Gallacher Dj, Hart K, Kotecha S. Common Respiratory Conditions of The newborn. Department
of Child Health, School of medicine, Cardiff University, Cardiff, UK. Breathe 2016;12:30-42
3. Martin O. Edwards; sarah J. Kotecha; Sailesh Kotecha. Respiratory Distress of The Term
Newborn Infant. Department of child Healt, School of Medicine, Cardiff, UK. Paediatric
Respiratory Reviews 14(2013)29-37
4. Rakesh Amroliwala, Manish Rasania, et all. Study of Congenital Heart Disease in Neonates.
International Journal of Contemporary Pediatrics. 2018 jan;5(1):75-81
5. Jann P Foster, Adam Buckmaster, Lynn Sinclair, Sylvia Lees, Robert Guaran. Nasal Countinous
Positive airway pressure (nCPAP) for term neonates with respiratory distress. The Cochrane
Collaboration 2015, Issue 11. Art. No: CD011962
 4

Timeline

Jan 16th 2018 Jan 17th 20178 Jan 29th 2018 Feb 12th 2018

Patient was
admitted to Observation Final
Kandou started observation Reporting
Hospital
 5

CASE REPORT
PATIENT’S RECORD

I. IDENTITY
Patient Identity
Patient Name : SP
Sex : Male
Date of birth : january 16th 2018
Place of birth : Permata Bunda
Hospital
Nationality : Indonesia
Ethnic : Minahasan
Religion : Christian
Date of Examination : january 16th 2018
Registration Number : 52.27.XX
 6

Parental Identity
FATHER MOTHER
Name : GS Name : FDP
Age : 29 years old Age : 28 years old
Occupation : Goverment Occupation : Housewife
Department Last Education : Bachelor degree
Last Education : Bachelor degree
 Family tree 7

No Name Relation with patient Gender Age (years old) Information

1. GS Father M 29 Healthy
2. FDP Mother F 28 Healthy
3. PS Brother M 7 Healthy
4. MS Sister F 6 Healthy
5. SP Patient M 0 patient
 8

January 16st, 2018

January 17st, January 29st,

January 16st, 2018 2018
2018

The baby was 17.00 wita

born at 11 : 00 Echocardiography:
AM, Result: mild secundum
Chief Complaint: Observation started
birth weight short of breath ASD 44mm with L-R shunt
3000 gr, body
length 49 cm Additional
and Apgar score Complaint:
retraction
7-9.
Discharge from hospital
 9

History of Birth
Mother Patient

The baby was born from a 28

ANC 5x by a specialist years old mother, G3P2A0 with
obstetric gynecology aterm pregnancy.
TT Immunisation 2x birth weight 3000 gr, body
length 49 cm and Apgar score
7-9
 10
History of social-economics and family

Father  Goverment department

BPJS grade II
mother  housewife

They live in a permanent house consisted of 3

bedrooms, occupied by 4 persons (2 adults).
There wereGood hygiene
2 bathroom inside&the
good
house, public
electricity, well water and public waste disposal
sanitation
 Antopometri Status 11

• Body weight : 3.000 grams

• Body lenght : 49 cm
TERM INFANT APPROPIATE FOR
• Head circumference: 35 cm (normal)
GESTATIONAL AGE

Physical examination
General condition : activity (+) decrease , reflex (+) decrease
Heart rate : 180 bpm
Respiratory rate : 90 bpm
Body temperature : 36.8 oC
Sp O2 : 90 %
 12

Physical examination
Skin : few veins, lanugo hair was thinning , no jaundice,
Head : oval shape, no caput succadenum, open anterior fontanel (+)
Eye : conjunctiva was not anemic and sclera not icteric, isocor pupil,
Ø 2mm-2mm, light reflex +/+
Mouth : cyanotic lips
Chest : symmetrical respiration movement on the both side hemithorax,
subcostal, intercostal retraction, raised areola 3-4 mm bud
Heart : regular heart rhythm, with murmur
Lung : bronchovesicular breathe sound, retraction (+) subcostal,
intercostal,xyphoid, rales on both sides, no wheezing on both sides
Abdomen: soft and flat, liver and spleen were not palpable, peristaltic
movement was normal, meconium stained umbilical cord
Ekstremities : warm, normal capillary refill time, no deformity.
Genital : male, testes down, good rugae, penis length 2 cm,
phimosis (-)
 13

• Downes score :
1. Air entry ( normal ) :o
2. Cyanosis (no with oxygen support) :1
3. Retraction (mild) :1
4. Grunting (audible with no stethoscope) :2
5. Respiration rate ( >80 times per minute) :2
Total :5
 14

Laboratory result
Examination 17/01/2018 18/01/2018
Hb (g/dl) 15,9 13,8
Ht (%) 45,6 38,2
Leuco (/L) 18100 11500
Trombo (/L) 263000 227000
Diff.count (%) 0/3/7/45/38/7 1/0/10/45/39/5
ALT (U/L) - 59
AST (U/L) - 8
Ureum (mg/dl) - 93
Creatinin (mg/dl) - 0,3
Clorida (mEq/L) - 99,5
Kalium (mEq/L) - 4,46
Natrium (mEq/L) - 135
Calcium (mg/dl) - 7,54
CRP (mg/L) 6 <6
Total Bilirubin (mg/dl) - 10,27
Direct Bilirubin (mg/dL) 0.25
PT (C) (second) - 17,3 (13,7)
APPT (C) (second) 35,5 (33,2)
 15

DIAGNOSIS
Term infant appropriate for gestational age
meconium aspiration syndrome
Suspect neonatal sepsis
Suspect Congenital Heart Defect
 16

PROBLEMS
Diagnosis Problems
Blood culture is need long time to see the result

Therapy problems
The theraphy in this patient, use the antibiotics first line in two
days and then up grade with the second line of antibiotics

Follow up problems
Follow up the retraction, body weight, respiratory
 17
Planning therapy
Treatment :
- CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m
- IVFD Dextrose 10% 216 ml
Dextrose 40% 11 ml
NaCl 3% 6 ml
KCl 3 ml 10 ml/hour
MgSO4 1,5 ml
Ca gluconas 1,9 ml
Aminosteril 6% 0 ml
Soluvit 0,5 ml
(fluid 80 ml/kgBW/day, protein 0 gr/kgBW/day, GIR 6)
- Ampicillin 2 x 150 mg intravenous injection (1st day)
- Gentamycin 15 mg intravenous injection/ 36 hours (1st day)
- Nothing per oral
- Regular blood glucose measurement / 24 hours
 18
Planning treatment
Nutritional Care
good nutritional status based on WHO Z-score chart
body weight per body length for boys 0-6 month, was
on between line +2 to -2 SD.

Fluid/food : Dextrose, Ca gluconas, sodium,

potassium, amino acids 6%, soluvit, breast milk

Planning diagnosis:
Consult to pediatric cardiology department 
echocardiography
 19
Planning Treatment
Nursing treatment
Vital sign monitoring
Patient hygiene
Nursing care of newborn
Mentally support to the family
FOLLOW UP

20
 17January 2018 (Observation day 1st, 1st day hospitalization) 18 January 2018 (Observation day 2, 2nd day hospitalization) 21
S Takipneu(+), short of breathness (+), cyanotic (+) S Takipneu(+), short of breathness (+), cyanotic (-)

General condition : activity (+) decrease, reflex (+) decrease General condition: activity (+) decrease, reflex (+) decrease
Heart rate : 180 beats/minute Sp O2: 90 % Heart rate : 165 beats/minute Sp O2 : 99 %
Respiratory rate : 90 times/minute Respiratory rate : 86 times/minute
Body temperature : 36,8ᴼC Body temperature : 36,7ᴼC
Body weight : 3000 grams Blood glucose : 108 gr/dL Body weight : 2950 grams
Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic Blood glucose : 71 gr/dL
lips HeadHb (g/dl) was not anemic and sclera was
: Conjunctiva 13,8
not icteric, no cyanotic lips
O Chest : Symetrical respiration movement on the both side, retraction (+) O Chest : Symetrical respiration movement on the38,2
Ht (%) both side, retraction (+)
subcostal, intercostal Leuco (/  L)
subcostal, intercostal 11500
Heart : regular heart rhythm, murmur
Consul to cardiology: HeartTrombo (/ L)rhythm, murmur
: regular heart 227000
Lung : bronchovesicular breathe sound, rales on both sides, no wheezing. Lung Diff.count (%) breathe sound, rales
: bronchovesicular 1/0/10/45/39/5
on both sides, no wheezing.
Diagnosa : Decompensatio
Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic ALT Soft
Abdomen: (U/L) and flat, liver and spleen were not59
8
Hb (g/dl)
movement was normal
cordis ec suspect ASD AST (U/L)
palpable, peristaltic movement was normal
15,9
Ekstremities : Warm, normal capillary refill time (<3 seconds) Ekstremities : Warm,
Ureum (mg/dl) normal capillary refill time 93
(<3 seconds)
Ht (%)
Skin : No jaundice Therapy : Captopril 3 x Skin :Creatinin
No jaundice(mg/dl) 0,3
45,6 Clorida (mEq/L) 99,5
- Leuco (/L)
0,9mg oral (do
term infant appropriate for gestational age - term infant
Kalium 4,46
appropriate for gestational age
(mEq/L)
- meconium aspiration syndrome
0,3mg/kgBw/times)
18100 - meconium aspiration syndrome 135
A Trombo (/L) A Natrium (mEq/L)
- neonatal sepsis
Digoxin 263000 - neonatal sepsis
Calcium (mg/dl) 7,54
- Diff.count
Congenital Heart (%)2 x 0,15mg oral (do:
defects - decompensatio
CRP (mg/L) cordis ec suspect ASD <6
0,01mg/kgBw/day) 0/3/7/45/38/7 Total Bilirubin 10,27
CPAP FiO2 IT
40%ratio
CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m
PEEP 7 cmH20 O2 Flow 8 L/m
IVFD (m g/dl) 10% 221 ml
IV0,14
Dextrose
IVFD Dextrose 10%Furosemid 2x3mg (do
CRP (mg/L)
216 ml Direct Bilirubin
Dextrose 40% 26 ml 0.25
Dextrose 40% 11 ml
NaCl 3% 61mg/kgBw/times)
ml
6
10 ml/hour
(fluid 80 ml/kgBW/day)
(mg/d L)
NaCl 3% 6 ml
PTKCl(C) (second)
3 ml 17,3 (13,7)
KCl 3 ml APPT 35,5 (33,2)
MgSO4(C) 1,5 ml
MgSO4 1,5 ml (second)
Ca gluconas 1,9 ml
Ca gluconas 1,9 ml
P P Aminosteril 6% 100 ml
Aminosteril 6% 100 ml
Soluvit 0,5 ml
Soluvit 0,5 ml
Ampicillin 2 x 150 mg intravenous injection (2st day)
Ampicillin 2 x 150 mg intravenous injection (1st day)
Gentamisin 15 mg intravenous injection (2st day)
Gentamicin 15mg intravenous injection (1st day)
Nothing per oral
Nothing per oral
Regular blood glucose measurement / 24 hours
Regular blood glucose measurement / 24 hours
Dobutamin 90mg in NaCl 0,9% 50cc = 5mg/kgBw) = 0,5mcg/kgBw/minutes
Furosemid IV 2x3mg (do 1mg/kgBw/times)
 19 January 2018 (Observation day 3, 3rd day hospitalization) 20 January 2018 (Observation day 4, 4th day hospitalization) 22
S Takipneu(+), short of breathness (+), cyanotic (-) S Takipneu(+) decrease, short of breathness (+)decrerase, cyanotic (-)

General condition : activity (+) decrease, reflex (+) decrease General condition : activity (+) decrease, reflex (+) decrease
Heart rate : 160 beats/minute Sp O2 : 99 % Heart rate : 160 beats/minute Sp O2: 99 %
Respiratory rate : 86 times/minute Respiratory rate : 60 times/minute
Body temperature : 36,7ᴼC Body temperature : 36,6ᴼC
Body weight : 2950 grams Body weight : 2940 grams
Blood glucose : 98 gr/dL Blood glucose : 104 gr/dL
Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic lips Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic
O Chest : Symetrical respiration movement on the both side, retraction (+) O lips
subcostal, intercostal Chest: Symetrical respiration movement on the both side, retraction (-)
Heart : regular heart rhythm, murmur Heart: regular heart rhythm, murmur
Lung : bronchovesicular breathe sound, rales on both sides, no wheezing. Lung : bronchovesicular breathe sound, rales on both sides, no wheezing.
Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic
movement was normal movement was normal
Ekstremities : Warm, normal capillary refill time <3 seconds Ekstremities : Warm, normal capillary refill time (<3 seconds)
Skin : No jaundice Skin : No jaundice
- term infant appropriate for gestational age - term infant appropriate for gestational age
- meconium aspiration syndrome - meconium aspiration syndrome
A A
- neonatal sepsis - neonatal sepsis
- decompensatio cordis ec suspect ASD - decompensatio cordis ec ASD
Medications:
CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m
IVFD Dextrose 10% 226 ml IVFD Dextrose 10% 226 ml
Dextrose 40% 21 ml Dextrose 40% 21 ml
NaCl 3% 6 ml NaCl 3% 6 ml
KCl 3 ml KCl 3 ml
MgSO4 1,5 ml MgSO4 1,5 ml
Ca gluconas 1,9 ml Ca gluconas 1,9 ml
P Aminosteril 6% 100 ml P Aminosteril 6% 150 ml
Soluvit 0,5 ml Soluvit 0,5 ml
Ceftazidim 2 x 150 mg intravenous injection (1st day) Ceftazidim 2 x 150 mg intravenous injection 2nd day)
Amikasin 2x 25 mg intravenous injection (1st day) Amikasin 2x 25 mg intravenous injection (2nd day)
Nothing per oral Breast milk 8 x 5ml (needs 15ml/kgBw/day)
Regular blood glucose measurement / 24 hours Regular blood glucose measurement / 24 hours
Dobutamin 90mg in NaCl 0,9% 50cc = 5mg/kgBw) = 0,5mcg/kgBw/minutes Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times)
Furosemid IV 2x3mg (do 1mg/kgBw/times) Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day)
Furosemid IV 2x3mg (do 1mg/kgBw/times)
 21-22 January 2018 (Observation day 5-6th, 5-6th day hospitalization) 23 January 2018 (Observation day 7th, 7th day hospitalization) 23
S Takipneu(+) decrease, short of breathness (+)decrerase, cyanotic (-) S Takipneu(+) decrease, short of breathness (+) decrerase, cyanotic (-)

General condition : activity (+) decrease, reflex (+) decrease

General condition : activity (+) decrease, reflex (+) decrease
Heart rate : 156 beats/minute Sp O2 : 96 %
Heart rate : 158 beats/minute Sp O2 : 98 %
Respiratory rate : 50 times/minute
Respiratory rate : 58 times/minute
Body temperature : 36,6ᴼC
Body temperature : 36,6ᴼC
Body weight : 2900 grams
Body weight : 2900 grams
Blood glucose : 110 gr/dL
Blood glucose : 110 gr/dL
Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic
Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic lips
O O lips
Chest : Symetrical respiration movement on the both side, retraction (-)
Chest : Symetrical respiration movement on the both side, retraction (-)
Heart : regular heart rhythm, murmur
Heart : regular heart rhythm, murmur
Lung : bronchovesicular breathe sound, rales on both sides, no wheezing.
Lung : bronchovesicular breathe sound, rales on both sides, no wheezing.
Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic
Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic
movement was normal
movement was normal
Ekstremities : Warm, normal capillary refill time (<3 seconds)
Ekstremities : Warm, normal capillary refill time (<3 seconds)
Skin : No jaundice
Skin : No jaundice
- term infant appropriate for gestational age - term infant appropriate for gestational age
- meconium aspiration syndrome - meconium aspiration syndrome
A A
- neonatal sepsis - neonatal sepsis
- decompensatio cordis ec ASD - decompensatio cordis ec suspect ASD

CPAP FiO2 40% PEEP 6 cmH20 O2 Flow 8 L/m CPAP FiO2 21% PEEP 5 cmH20 O2 Flow 8 L/m
IVFD Dextrose 10% 226 ml IVFD Dextrose 10% 226 ml
Dextrose 40% 21 ml Dextrose 40% 21 ml
NaCl 3% 6 ml NaCl 3% 6 ml
KCl 3 ml KCl 3 ml
MgSO4 1,5 ml MgSO4 1,5 ml
Ca gluconas 1,9 ml Ca gluconas 1,9 ml
Aminosteril 6% 150 ml Aminosteril 6% 150 ml
P P
Soluvit 0,5 ml Soluvit 0,5 ml
Ceftazidim 2 x 150 mg intravenous injection 3rd day) Ceftazidim 2 x 150 mg intravenous injection 5th day)
Amikasin 2x 25 mg intravenous injection (3rd day) Amikasin 2x 25 mg intravenous injection (5th day)
Breast Milk 8 x 12ml (needs 30ml/kgBw/day) Breast Milk 8 x 12ml (needs 30ml/kgBw/day)
Regular blood glucose measurement / 24 hours Regular blood glucose measurement / 24 hours
Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times) Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times)
Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day) Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day)
Furosemid IV 2x3mg (do 1mg/kgBw/times) Furosemid IV 2x3mg (do 1mg/kgBw/times)
 24-25 January 2018 (Observation day 8-9th, 8-9th day 26-28 January 2018 (Observation day 10-12th, 10-12th day24
hospitalization) hospitalization)
Takipneu(+) decrease, short of breathness (+) decrerase, cyanotic
S S Takipneu(-), short of breathness (-), cyanotic (-)
(-)
General condition : activity (+) decrease, reflex (+) decrease
General condition : activity (+), reflex (+)
Heart rate : 152 beats/minute Sp O2 : 96 %
Heart rate : 148 beats/minute Sp O2 : 96 %
Respiratory rate : 48 times/minute
Respiratory rate : 32 times/minute
Body temperature : 36,6ᴼC
Body temperature : 36,6ᴼC
Body weight : 2910 grams
Body weight : 2940 grams
Blood glucose : 110 gr/dL
Head : Conjunctiva was not anemic and sclera was not icteric,
Head : Conjunctiva was not anemic and sclera was not icteric, no
no cyanotic lips
cyanotic lips
Chest : Symetrical respiration movement on the both side,
O Chest : Symetrical respiration movement on the both side, O
retraction (-)
retraction (-)
Heart : regular heart rhythm, murmur
Heart : regular heart rhythm, murmur
Lung : bronchovesicular breathe sound, rales on both sides,
Lung : bronchovesicular breathe sound, rales on both sides, no
no wheezing.
wheezing.
Abdomen : Soft and flat, liver and spleen were not palpable,
Abdomen : Soft and flat, liver and spleen were not palpable,
peristaltic movement was normal
peristaltic movement was normal
Ekstremities : Warm, normal capillary refill time <3 seconds
Ekstremities : Warm, normal capillary refill time (<3 seconds)
Skin : No jaundice
Skin : No jaundice
- term infant appropriate for gestational age - term infant appropriate for gestational age
- meconium aspiration syndrome - meconium aspiration syndrome
A A
- neonatal sepsis - neonatal sepsis
- decompensatio cordis ec suspect ASD - decompensatio cordis ec suspect ASD

O2 nasal 0,5 l/m

Ceftazidim 2 x 150 mg intravenous injection (6th day)
Amikasin 2x 25 mg intravenous injection (6th day)
P Breast Milk 8 x 30ml (needs 100ml/kgBw/day)
P
Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times)
Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day)
Furosemid IV 2x3mg (do 1mg/kgBw/times)
Ceftazidim 2 x 150 mg intravenous injection (8th day)
Amikasin 2x 25 mg intravenous injection (8th day)
Breast feeding on demand
Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times)
Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day)
Furosemid 2x3mg (do 1mg/kgBw/times)
 29 January 2018 (Observation day 13, 13th day hospitalization)
25

S Takipneu(-) , short of breathness (-), cyanotic (-)

General condition : activity (+), reflex (+)

Heart rate : 138 beats/minute
Respiratory rate : 40 times/minute
Body temperature : 36,6ᴼC
Body weight : 2950 grams
Sp O2 : 96 %
Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic lips
Chest : Symetrical respiration movement on the both side, retraction (-)
Heart : regular heart rhythm, murmur
O
Lung : bronchovesicular breathe sound, rales on both sides, no wheezing.
Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic movement was normal
Ekstremities : Warm, normal capillary refill time (<3 seconds)
Skin : No jaundice

Echocardiography:
Result: mild secundum ASD 44mm with L-R shunt
Suggest: echocardiography 1 next later

- term infant appropriate for gestational age

- meconium aspiration syndrome
A
- neonatal sepsis
- decompensatio cordis ec mild secundum ASD

Breast milk on demand

Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times)
P Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day)
Furosemid IV 2x3mg (do 1mg/kgBw/times)
Discharge from hospital
 26

PROGNOSIS
Ad Vitam : ad bonam
Ad Functionam : dubia ad bonam
Ad Sanationam : dubia ad bonam

26
 Disease Course Timeline 27
Observation period

th rd 1th th th th th
jan 17 –23 jan 2018 jan 24 – 25 jan 2018 Jan 26 – 28 2018 Jan 29 2018

tachycardia ↓ tachycardia (-), tachypneu (-), tachycardia (-), tachypneu (-), jaundice (-)
Tachycardia, tachyipneu
tachypneu ↓

GC: activity (+) , reflex (+)

GC: activity (+) ↓, reflex (+) ↓ GC: activity (+) , reflex (+)
GC: activity (+) ↓, reflex (+) ↓ HR 140 x/m
HR 180 x/m HR 148 x/m
HR 152 x/m RR: 32 x/m
temp: 36,7ᴼC temp: 36,5ᴼC
temp: 36,7ᴼC temp: 36,5ᴼC
Sp O2: 90 % Sp O2: 96 %
Sp O2: 98 % Sp O2: 98 %
RR 90 x/m RR: 32 x/m
RR: 48 x/m

term infant appropriate for term infant appropriate for gestational age
Hb (g/dl) 15,9 - term infant appropriate for
gestational age gestational age meconium aspiration syndrome
Ht (%) 45,6
- meconium aspiration syndrome meconium aspiration syndrome neonatal sepsis
Leuco (/L) 18100
- neonatal sepsis Decompentatio cordis ec ASD
Trombo (/L) 263000 neonatal sepsis
0/3/7/45/38/7 - Decompensatio cordis caused by
Diff.count (%) Decompensatio cordis caused by
0,14 suspected ASD
IT ratio suspected ASD
CRP (mg/L) <6
Breast milk on demand
Captopril 3x0,9mg po (do 0,3mg/kgBw/x)
O2 nasal 0,5l/m Digoxin 2 x 0,15mg oral (do:
- term infant appropriate for
Ceftazidim 2 x 150 mg iV Ceftazidim 2 x 150 mg iV
gestational age 0,01mg/kgBw/x)
Amikasin 2x 25 mg IV Amikasin 2x 25 mg IV
- meconium aspiration syndrome Furosemid 2x3mg (do 1mg/kgBw/x)
Milk 8 x30ml (needs 100ml/kgBw/day) Breast milk on demand
- neonatal sepsis
Captopril 3x0,9mg po (do Captopril 3x0,9mg po (do 0,3mg/kgBw/x)
- Congenital Heart Diseases
0,3mg/kgBw/x) Digoxin 2 x 0,15mg oral (do:
Digoxin 2 x 0,15mg oral (do: Echocardiography:
0,01mg/kgBw/x)
0,01mg/kgBw/x)
Furosemid 2x3mg (do 1mg/kgBw/x) Mild secundum ASD
CPAP FiO2 40% PEEP 7cmH2O O2 8l/m Furosemid IV 2x3mg (do 1mg/kgBw/x)
(fluid 150 ml/kgBW/day, protein 3
gr/kgBW/day – milk, GIR 11-12)
Ceftazidim 2 x 150 mg iV
Amikasin 2x 25 mg IV planning :
Breast Milk 8 x 5-12ml (needs Planning: echocardiography echocardiography Discharge
30ml/kgBw/day)
Captopril 3x0,9mg po (do 0,3mg/kgBw/x)
from hospital
Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/x)
Furosemid IV 2x3mg (do 1mg/kgBw/x)
 28
Male, 0 day
 Takipneu after birth
CASE ANALYSIS  History of Birth: by sectio caesaria with indication the mother had a history
sectio caesaria before and premature rupture of membranes > 18 hours

Problem Tachypneu and tachicardia

Clinical signs & Physical  RR > 60 x/m

examination  HR > 180 x/m
 Murmur
 Umbilical cord

Babygram
Supportive Examination
echocardiography

- term infant appropriate for gestational age

- meconium aspiration syndrome
Diagnosis - neonatal sepsis
- decompentatio cordis ec ASD

Treatment  NCAP
 Antibiotic
 Decompentatio cordis therapy

Response to treatment Ad vitam : ad bonam

Prognosis
Laboratory evaluation Ad functionam : dubia ad bonam
Complication Ad sanationam : dubia ad bonam

 Pediatr
Pediatr Indones. 2016.
Indones. Level
2016. of Evidence
Level 2B, rekomendasi
of Evidence B B
2B, rekomendasi
 Am J Health
M.o.Edward et all/Paediatric Respiratorybreview
Research. 2015. 14 (2013)
Level of Evidence 29-37
2B, rekomendasi B
 JJ.Health
Am Evolution Med. Dent.
Research. 2015.Sci. 2016.
Level Level of Evidence
of Evidence 2B, rekomendasi
2B, rekomendasi B B
 Evolution
J. Indian J Med.
Pediatr. 2015
Dent. Sci.Level
2016.ofLevel
Evidence 2B, rekomendasi
of Evidence B
2B, rekomendasi B
Indian J Pediatr. 2015 Level of Evidence 2B, rekomendasi B
 29

DISCUSSION
Appropriate for gestational age is defined
as weight between 10th – 90th percentile,
small for gestational age is < 10th percentile
and large for gestational age is > 90th
percentile in Lubchenco curve

• In this baby From physical examination we

founded that birth weight was 3000 gram, birth
length was 49 cm. The Ballard score for this
patient was 39 weeks. By Lubchenco curve it
was defined as aterm (between 10th – 90th
percentile) with appropiate for gestational age.
 30
One of the major signs of respiratory difficulty (e.g., cyanosis, tachypnea, grunting,
retraction and nasal flaring) are usually present in neonates both with pulmonary and
non pulmonary causes of respiratory distress.

Cyanosis may be central, as cause by pulmonary disease and cyanotic heart disease, or
peripheral, as occurs in conditions with impaired cardiac output.

Tachypnea typically manifest infants with decreased lung compliance.

Grunting is produced by and adduction of vocal cords during expirations. Grunting is

more typical of infants with decreased functional residual capacity.

Examination of cardiovascular system and assessment of peripheral perfusion yield

many close toward a diagnosis. Poor cardiac output, pathologic murmurs, decreased
femoral pulses suggest a primary cardiac cause for the respiratory distress.
 DISCUSSION 31
..

Meconium aspiration syndrome

one of respiratory distress that often occurs

in newborns

Meconium is a greenish-colored viscous liquid

that mixes with gastrointestinal secretions,
bile, mucus, blood, and lanugo is, which mark
with the presence of meconium-staining

Babies born with meconium can develop

into hypoxia
 DISCUSSION 32

In this patient, after birth , there are dyspnea with subcostal

and intercostal retraction and meconium staining. From
mucus suction thick greenish-colored with foul-smelled
meconium was obtained, so we can diagnose this patient with
meconium aspiration syndrome.

During treatment found symptoms of decreased activity,

groaning, shortness of breath, with thick greenish-
colored with foul-smelled meconium and meconium
staining. Radiology finding shown hyperinflation with
patchy opacities on both sides of lungs, those strengthen
the diagnose of meconium aspiration syndrome.
 DISCUSSION 33

..
Cardiac failure is a clinical syndrome where the heart is unable to provide
the output required to meet metabolic demands on the body

Neonatal cardiac failure is characterized by many unique anatomic and

physiologic features

In neonate, the cause of cardiac failure are significantly different and many
cases are due to congenital malformation such as lef to right shunts

Neonate with cardiac failure will show a history hard for drinking, tachypnea
and hard to gain weight and cold sweats

Commonly we could found tachycardia > 150 bpm, tachypnea > 60 bpm,
gallop, hepatomegaly and the chest X-ray we found CTR > 60%.
 DISCUSSION 34

Congenital heart defects (CHD) is the most common birth

defects. Current estimates are that 8 of every 1.000 infants
born each year in United State have some form of CHD.
Patent Ductus Arteriosus (PDA) and Atrial Septal Deffect
(ASD) are the type of congenital heart defects

In this patient we found tachycardia (180 bpm), tachypnea (90

bpm), and murmur, so we could diagnosed this patient with
decompensatio cordis

There was a systolic ejection murmur from the physical examination and the
echocardiography examination founded there were mild secundum ASD .
 DISCUSSION 35

Neonatal sepsis is defined as a clinical syndrome caused by the invasion of

microorganisms into the bloodstream in the first months of life

Sepsis is the commonest cause of neonatal mortality and is responsible for 30-
50% of total neonatal deaths each year in developing countries.

Incidence of neonatal sepsis in the hospital showed a much higher rate,

especially in reference hospital
 36

• Neonatal sepsis can be divided into two categories, early and late
onset sepsis. Early-onset sepsis (EOS) occuring at ≤ 72 hours in
infants hospitalized in neonatal intensive care unit (NICU) while
late-onset sepsis (LOS) occuring after 72 hours.

• Risk factors for early-onset sepsis include both maternal and infant
factors
 EOS
Mayor risk factor
• consist of rupture of membranes
>18 hours,
• maternal fever with temperature
>38°C,
• chorioamnionitis,
• fetal heart rate >160 bpm
• smelling membranes.
Minor risk factors
• such as rupture of membranes >12 hours,
• maternal fever >37.5oC
• low APGAR score (1 minute <5, 5 minute
<7)
• very low birth weight infants (<1500 g),
• age of gestation <37 weeks
• vaginal discharge in women who are not
treated
• multiple pregnancy
• women with suspected UTI or UTI is not
treated
 38

• In this patient, the sepsis is early onset sepsis because it is

happen < 72 hours. There is a 1 mayor is premature rupture
of membranes > 18 hours, and 2 minor factor is untreated
urinary tract infection and untreated flour albous.

• In this patient, the clinical manifestations of neonatal sepsis

include respiratory, metabolic, and neurological system.
 39

• On septic marker investigation, it was found that patient

leucocyte 15900/m3, CRP <6 mg/dL and IT ratio was
0.13. the blood culture has result as a steril, so in this
patient, accompanied by clinical symptoms involving 2
systems can be diagnosed as neonatal sepsis
40
 41

Bubble NCPAP in comparison with standart care for infants with MAS
reduces the need for mechanical ventilation in the first days of life

Aakash Pandita, MD; srinivas Mukti, DM; Tejo Pratap Oleti, DM; Baswaraj Tandur, DNB; sai Kiran, DNB; et all. Effect
of Nasal Continous Positive Airway Pressure on Infants With Meconium Aspiration Syndrome Arandomized Clinical
Trial : Original investigation, From the American Medical Association. JAMA Pediatrics. 2017.3873.

(level of evidence 2B, rekomendasi B).

The early recognition and initiation of appropiate management is

important to ensure the optimal outcome for all infant presenting
with respiratory distress

Martin O. Edwards; sarah J. Kotecha; Sailesh Kotecha. Respiratory Distress of The Term Newborn Infant.
Department of child Healt, School of Medicine, Cardiff, UK. Paediatric Respiratory Reviews 14(2013)29-37

(Level of evidence 2b, rekomendasi B).

 42

Prompt recognition of the more serious underlying conditions is

important to improve outcomes

Gallacher Dj, Hart K, Kotecha S. Common Respiratory Conditions of The newborn. Department
of Child Health, School of medicine, Cardiff University, Cardiff, UK. Breathe 2016;12:30-42.

(Level of evidence 2B, rekomendasi B)

MAS is a major cause of mortality in developing countries, studies

focusing on prevention and early treatment should be continued tu
reduce mortality and morbidity
Kamala Swarnam et al. Advances in the managenent of meconium aspiration syndrome.
International Journal of Pediatrics, vol 2012,article ID 359571,7

(Level of evidence 2B, rekomendasi B)

 43

Early recognition of congenital heart disease during neonatal life is

important as its appropiate and timely management can result in good
outcome

Rakesh Amroliwala, Manish Rasania, et all. Study of Congenital Heart Disease in Neonates. International
Journal of Contemporary Pediatrics. 2018 jan;5(1):75-81

(Level of evidence 2B, rekomendasi B)

 44

PROGNOSIS
Ad Vitam : bonam
Ad Functionam : dubia ad bonam
Ad Sanationam : dubia ad bonam

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