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THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the

PERINATAL/NICU CONFERENCE Monthly Statistics Report 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

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THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the

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  1. PERINATAL/NICU CONFERENCEMonthly Statistics Report January 2014Marco Manzano and Clarissa Pangilinan, MD3rd Year Resident – PediatricsMaria Edwardina G. De Leon, MD3rd Year Resident – Obstetrics and Gynecology THE MEDICAL CITY Department of Obstetrics and Gynecology: Section of Perinatology and the Department of Pediatrics

  2. TOTAL BIRTHS

  3. Total Births, January 2014

  4. Total Births, January 2014

  5. Total Births, January 2014

  6. Total Births, January 2014

  7. NURSERY ADMISSIONS

  8. December vs January

  9. January 2013 vs January 2014

  10. Deliveries By Levels

  11. NICU Referral (n=9) • Inborn Transfer = 8 • Inborn Readmission = 1

  12. Isolation (n=8) • Inborn Transfer = 2 • Inborn Readmission = 2 • Outborn Admission = 4

  13. NEONATALMORBIDITIES

  14. Neonatal Morbidities, January 2014

  15. Top 5 Conditions Occurring Among High Risk Mothers, January 2014

  16. Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014 Prematurity = 4

  17. Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014 Prematurity = 3 LGA = 2 SGA = 1 Low birth weight = 1

  18. Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014 Prematurity = 4 LGA = 1 Low birth weight = 1

  19. Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014 Prematurity = 1 LGA = 3

  20. Top 5 Maternal Conditions Associated with Neonatal Morbidities, January 2014 LGA = 1 Poor APGAR = 1

  21. CONGENITALANOMALIES

  22. Congenital Anomalies, January 2014

  23. Congenital Anomalies, January 2014

  24. Congenital anomalies: January 2013Antenatal detection and Neonatal outcome

  25. CASE 1: Cleft Palate • Stable Vital Signs • IE: 3cm, 50%, -3, (-)BOW • CTG: Category 1 trace • Intrapartum stay x 10hrs • s/p PCS • Female APGAR 9,9 3140 g MT 38 AGA • M. M. P. • 28, G1P0, 39 • CC: vaginal bleeding • PNCU: regular, unremarkbale • Past Medical/Personal/Social/Family History: U/R

  26. CASE: Cleft Palate • BW 3140 g • BL 51 cm • HC 34 cm • CC 34 cm • AC 30 cm • S.M.P. • Full term via stat cesarean section due to NRFHRP • 28 year old G1P1 (0101) • 39 1/7 weeks AOG, MT 38 AGA • Apgar 9, 9

  27. 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

  28. 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

  29. Diagnosis • Live Term Baby Girl • Cleft palate

  30. PLAN • NPO • ENT Referral • Therapeutics: • Obturator fitting c/o pedia dentist • OGT feedings • Feeding plate • Breast feed as tolerated

  31. Course in the NICU

  32. Course in the NICU

  33. 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

  34. 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) • Cleft palate: palatal shelves fail to fuse • Multifactorial traits: • Genetic: mutations in single genes (TBX22, IRF6, MSX1); Part of chromosomal aneuploidy or deletion syndromes (trisomy 13, velocardiofacial syndrome) • environmental factors: teratogens (anticonvulsants) Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230

  35. 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

  36. 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

  37. 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

  38. Stickler Syndrome • distinctive facial appearance, eye abnormalities, hearing loss, and joint problems • somewhat flattened facial appearance • underdeveloped bones in the middle of the face, including the cheekbones and the bridge of the nose • High myopia, glaucoma, cataracts, retinal detachment • Hearing loss • Loose or hypermobile joints, arthritis, scoliosis, khyphosis, platyspondyly

  39. Velocardiofacial Syndrome • structural or functional palatal abnormalities, cardiac defects, unique facial characteristics, hypernasal speech, hypotonia, and defective thymic development • DiGeorge Syndrome (10%) • at least 2 of the following features: • Conotruncal cardiac anomaly • Hypoparathyroidism, hypocalcemia • Thymic aplasia, immune deficiency

  40. Cleft Palate: Treatment • Immediate problem: Feeding • 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

  41. 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 Edition Samanich, J. Cleft Palate . Pediatrics in Review 2009;30;230

  42. 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

  43. 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

  44. CASE 2: Imperforate Anus • Stable Vital Signs • IE: 1cm, 50% • CTG: category 1 trace • s/p Repeat CS • Male APGAR 9, 9 3350 g MT 38 AGA • 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, Hypertension

  45. Pertinent Data: Imperforate Anus • PBR • Delivered via Scheduled Repeat Cesarean Section • 33 year old G2P2 (2002) • AOG: 38 1/7 weeks • MT: 38 AGA • Apgar Score: 9,9 • Anthropometrics: • BW= 3350 grams • BL= 52 cm • HC= 34 1/2 cm • CC= 34 cm • AC= 29 cm

  46. Pertinent History: Imperforate Anus • 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

  47. 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

  48. Diagnosis: Imperforate Anus • Term Baby Boy • t/c Imperforate Anus

  49. PLANS: • Transfer to Level III care • Maintain on NPO • Referral to Surgery

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