Case of the Year

Lyn CallaghanAdvanced Neonatal Nurse Practitioner

Wishaw General Hospital

Background

• Baby boy born by SVD at 40+2 weeks

• Spontaneous onset of labour

• No Infection risks• Crash Call at delivery due

to Shoulder Dystocia• Baby born in good

condition• Apgars 9/1 9/5

• Mum’s second baby• Healthy pregnancy• Blood Group 0 Negative• Anti D during pregnancy

Newborn Examination

• Baby now 15 hours of age– Breast feeding well– Passed urine and

meconium

• Mother – no concerns• Midwife – feels baby

intermittently tachypnoeic

• On examination– Pale– No respiratory distress– Normal tone– Normal examination– Note baby becomes

tachypnoeic on handling– Heart rate +/- 150 when

settled

• Do you think anything is wrong with the baby?

• What do you think it could be?

• What do you do next?

What happened next?• Chased Cord bloods

• Repeated FBC and bilirubin

• Informed mum of rationale

• At Birth– Hb 15.5 HCT 0.56, WCC

19.0, Plat 204, Retics 5.5%– Bili 24. – Blood Group O pos– DCT Negative

• At 15 hrs of age– Hb 8.2 HCT 0.23, WCC

20.1, Plat 143, Retics 7.1%.– Bili 28

Treatment threshold graph for babies with neonatal jaundiceBaby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group >=38 weeks gestation

Phototherapy

Exchange transfusion

0

50

100

150

200

250

300

350

400

450

500

550

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Tota

l ser

um b

iliru

bin

(mic

rom

ol/l

itre)

Days from birth

MultipleSingle

• Admit to NNU

• Repeat FBC, Partial sepsis screen, DCT, Coagulation

• Chest x-ray – normal• Echo – normal

structure

• Baby examines well– Pale– Tachypnoeic– Tachycardia– Mean BP normal

• At 17 hrs of age– Hb 5.1, HCT 0.19, WCC

22, Plat 98. Retics 8.2%– Bili 29– CRP <6– Coag mildly deranged– Blood Group O pos– DCT Neg

Stabalisation

• TUT• Platlet transfusion• FFP• CRUSS• Abdominal X-ray• Abdominal Scan

Progress

• By 21hrs of age baby developed abdominal tenderness and guarding

• Differential diagnosis– Haemorrhage– ? Bowel– ?Liver

• Transferred to Surgical Centre

• MRI Confirmed Diagnosis

Haemangioma of Liver

Can cause• Heart failure• Anaemia• Thrombocytopenia

Treatment• Corticosteroids• Embolization• Hepatic Artery Ligation• Liver Resection

Congenital Hepatic Haemangioma• Hepatic tumours account for 1-5% of all

Paediatric tumours• Hepatic Haemangioma is the third most

commonest tumour of childhood• Occasionally diagnosed on antenatal scan• Often never detected

– Rarely present as large abdominal mass– Cardiac failure due to massive atreriovenous shunting– Jaundice from compression of bile ducts– GI Bleeding– Fever/illness resembling systemic inflammatory

process

What is a haemangioma?

• A vascular birthmark caused by abnormal blood vessels in or under the skin

• Most common benign tumour of the vascular endothelium in infancy

• Can occur anywhere outside and inside of the body

• What are the common types found on the newborn examination?

• What do we tell the parents?

Salmon Patch

• Stork Bite/Mark• Angels Kiss

Salmon Patch

• Pink maculae• Dilated superficial

capillaries• Commonly seen at nape

of the neck, mid forehead and upper eyelids

• Most common vascular malformation

• Usually fades within a year

Strawberry Haemangioma

• Bright red and sharply demarcated

Strawberry Haemangioma• Bright red vascular

tumour• Dilated mass of capillaries• Usually protrudes above

the skin• Can appear anywhere on

the body• Can start as a flat red

superficial lesion• Can increase in size over

next year

Strawberry Haemangioma• Usually, growth is complete

and involution has commenced by twelve months.

• Half of all infantile haemangioma have completed involution by age five.

• 70% by age seven, and most of the remainder by age twelve

• In more severe cases haemangioma may leave residual tissue damage.

Strawberry Haemangioma Complications

• Psychological• Haemangioma near the

eyes, nose, mouth, or on throat may interfere with vital functions and therefore require removal

• Some may – break down and ulcerate– Bleed

• Rarely can cause heart failure if large and blood being diverted into the excess blood vessels

• Lesions next to bone can also cause erosion of the bone

Strawberry Haemangioma Treatment

• Oral corticosteriods– Smaller lesions

sometimes injected• Propranalol• Timolol gel• Interferon• Vincristine• Surgical removal• Pulsed dye laser

– For very early flat lesions

Port Wine Stain

• Nevus Flammeus• Usually present at birth

and on face, but can occur anywhere

• Permanent capillary angioma

• Does not blanch with pressure

Port Wine Stain

• Grows in proportion to general growth

• Early stains are usually flat and pink – as child matures colour can deepen to a dark red or purple colour

• In adulthood can become bumpy and raised

Port Wine StainComplications

• If over forehead and upper lip Sturge Weber Syndrome must be excluded

• Spine abnormalities• Varicose veins

• Psychological• Eye problems is on

eyelid or next to eye

Port Wine StainTreatment

• Some may improve over time

• Laser treatment– variable results

depending on skin colour

– Works best in young children

– Works best on smaller stains

• Skin camouflage still common treatment – Some provided free on

NHS

• Support Groups– Birthmark Support

Group– British Association of

Skin Camouflage– Changing Faces

Mongolian Blue Spot• Congenital Dermal

Melanocytosis• Benign , flat birthmark• Irregular borders and shape• Commonest colour is blue,

but can also be blue-grey, blue-black or deep brown

• Normally disappears by 3 - 5 yrs of age

• Almost certainly by puberty• Important to document on

record

• Prevalent among– Mongolians– Asians– Malay– Polynesians– East African– Latin Americans– Turkish

Questions/Discussion