By Santa J. Bartholomew M.D. FAAP, FCCM
See Corresponding Journal Article: Hypoxic Ischemic Encephalopathy
Ms. Jones is a 26-year-old G2P1 mom who is healthy and had an uncomplicated pregnancy presented to the OB office for a routine visit and it was found that there were decreased fetal heart tones. She was admitted to the hospital and taken for an urgent C-section for non-reassuring fetal status: 23 minutes from arrival to the OB floor to C-section.
Pertinent to her history is that she had been evaluated in the ED the day before for bleeding but was deemed stable and discharged to home.
At C-section, she was found to have complete abruption of the placenta. The infant had occasional gasps at birth, initial HR was 20. Apgars 1-2-5 at 1-5-10 minutes. The infant received positive pressure ventilation to improve heart rate, but gasping respirations continued, and the infant was intubated at 7 minutes of life.
Since the 10-minute Apgar was 5 the infant underwent passive cooling. The infant was transferred to the NICU where the first blood gas had a severe acid build up of -20. She was started on a continuous EEG to monitor for seizures and total body cooling began at 90 minutes of life.
Goals of care for this infant:
-Maintain normal blood gases.
-Maintain MAP between 40-60 mmHg.
-Decrease cardiac output.
-Fluid restriction
-Delay feeds
-Optimize sedation and analgesia.
-Watch for signs of infection or clotting issues.
-Treat seizures
With these strict guidelines this infant had her mild abnormalities in liver and kidney function normalized by day 2 of life, normal sleep-wake cycle by day three of life and was rewarmed on day 4 of life. On day 10 of life she had a brain MRI and was discharged to home.
