Sunday, November 25, 2012

Interesting Case Gallery : Smallest one ever delivered

This is a picture of one of the Quadruplets preserved as Embryo intrauterine . Mother was induced with Clomiphene Citrate for Subfertility .
During the Delivery, after 3 babies of  all less than a kilogram weight each, this beautiful piece was discovered by the Obstetrician. It was like the one I had seen in Embryology book. Never seen something in Real like this before.

Wednesday, November 21, 2012

Breast engorgement in Newborns : Galactorrhea or Witch's Milk

Concerned parents appear in the Out patient Department, with a newborn who has bilateral breast engorged and obviously secreting milk. Parents had tried to squeeze the milk out but instead the breast got further engorged.
Few months before a neonate was admitted for Intravenous antibiotics for similar problem , after parents tried to squeeze out the milk, it led to formation of an abscess that needed incision and drainage.

What is Witch's milk?
Medical Dictionaries have defined Witch's milk as "Milk resembling colostrum sometimes secreted from the breasts of newborns of either sex three to four days after birth and lasting no longer than two weeks, due to endocrine stimulation from the mother before birth."
The term “witch’s milk” comes from ancient folklore that milk from a newborn’s nipple was a source of nourishment for witches.

Why Does it occur?
Galactorrhea is the result of the influence of the mother’s hormones on the baby before delivery. It is caused by a combination of the effects of maternal hormones before birth, prolactin and growth hormone passed through breast feeding and the postnatal pituitary and thyroid hormone surge in the infant. Blood from the nipples is nearly always benign and associated with the normal growth of the ducts, rather than mastitis. In extremely rare cases mastitis may develop. Removing the milk from the breasts can prolong milk production and is customary in some cultures but considered harmful by medical professionals.
Witch's milk is more likely to be secreted by infants born at full term, than by prematurely-born infants.

While breastfeeding may also contribute to prolonged milk production and breast enlargement, temporary or permanent weaning is not recommended.

Incidence-  5% of newborns and can persist for two months though palpable breast buds can persist into childhood. Infants with galactorrhea have significantly larger breast nodules than infants without galactorrhea.

No treatment necessary unless the area becomes red or tender.
Avoid massage or manipulation of the breast tissue

Mastitis when squeezed
Breast Abscess

Mastitis Neonatorum

Compilation By Dr Sujit K Shrestha, Pediatric Resident, TUTH

Thursday, November 15, 2012

Exchange Transfusion for Rh Incompatibility : NICU

Case Of a baby with Hyperbilirubinemia due to Rh incompatibility - hemolysis"
A baby was delivered via Emergency Cesarean section at 36 weeks of gestation for Rh isoimmunization. A 2.6 kg Male baby was born with Apgar score 7/10, 8/10  to a 26 years Gravida 2 mother of "O Negative" blood group. She had delivered a child of Rh Positive blood group 6 years back in another hospital settings and had missed a Rhogam " Anti-D Antibody" injection during the pregnancy. Thus in the settings of Rh isoimmunization and history of previous Rh positive baby, baby was transferred to Neonatal Intensive care Unit ( NICU ).
As per the protocol, the Cord blood was sent for Investigations:
1 Hemoglobin, PCV,Plateletes
2. Retics
3. Peripheral smear
4. Direct Coomb Test in Baby's blood
5. Blood Grouping and Rh Typing.

Arrangement for fresh "O negative " Donor was made.
Transcutaneous bilirubnometer ( TcB) showed reading of 6 mg/dl in 4 hours so, Photo therapy was started immediately and Serum total bilirubin (TSB )level was sent.  TSB readings were 8 mg/dl at 6 hrs. Extensive phototherapy was continued while the all the reports had arrived.
Blood group : A positive
Hb: 14 g/dl, PCV- 45g, plateletes- 214,000
Cord blood TSB- 3.8mg/dl
DCT- Negative
Retics- 8%
Peripheral smear showed no features of hemolysis

Mother received Anti-D antibody injection.
The phototherapy was continued as there was no immediate need for Exchange transfusion.

Repeat Hb and TSB was sent after 4 hours
Report showed- Hb - 10.2g/dl and TSB= 10mg/dl
There was a significant drop in hemoglobin, with rising serum bilirubin despite phototherapy. Baby looked Pale clinically with no organomegaly appreciable
Exchanged Tranfusion was required to save the baby. Parents were counselled about the procedure in details and Settings were Setup in NICU for the procedure.
Strict sterile precautions were needed and were followed.
Exchanged transfusion Set was prepared.
Baby was placed under Radiant warmer with phototherapy on till the actual procedure was started.
All the doctors and nurses involved in the procedure were as aseptic as possible with cap, mask , sterile gowns, gloves.

It was my first exchange transfusion experience.
In the next Article, i will be discussing the Indications and Procedure : exchange transfusion along with hazards and long term outcomes.
Keep reading

Monday, November 5, 2012

Interesting Pediatric Cases Photo gallery I

A Neonate with Staphylococcal Scalded Skin Syndrome

A girl with Hodgkin Lymphoma- Cervical Lymphadenopathy

An Infant with Fetal Hydantoin Syndrome.
Mother was on Phenytoin during pregnancy.