Indian Journal of Neonatal Medicine & Research

Floyd Type II Congenital Tracheal Agenesis in a Preterm Neonate: A Rare Case Report

Shikha Khandelwal, Priya Singh, Rama Anand, Ajay Dudeja, Varinder Singh

Tracheal agenesis is a rare and life-threatening airway malformation, and currently, there is no curative treatment available. The described case involves a preterm male newborn at 30 weeks of gestational age who could not be intubated during resuscitation, despite multiple attempts. However, the baby could be ventilated after oesophageal intubation. Tracheal stenosis/atresia was suspected, and airway evaluation was performed using a thin, flexible fiberoptic bronchoscope. No tracheal opening could be identified, and upon introducing the bronchoscope into the oesophagus, a triluminal opening was found, through which the scope could not be further navigated. To further delineate the anatomy, a Contrast-enhanced Computed Tomography (CECT) thorax was performed, revealing the absence of a tracheal lumen and the communication of both bronchi at the carina with the oesophagus. Unfortunately, the baby succumbed to the illness after three days. Tracheal agenesis is an anatomical malformation that typically presents as respiratory distress and the absence of an audible cry at birth. Attempts to establish a definite airway are unsuccessful, which may result in early neonatal death. Oesophageal intubation may temporarily establish ventilation until palliative surgery is performed.

Effect of Low-volume Exchange Transfusion on Neonatal Hyperbilirubinaemia: A Retrospective Cohort Study

Manu Rajan Idicula, Krishna Kumar Diwakar, Leela Sudhakaran Kamath

Introduction: A double volume exchange transfusion for hyperbilirubinaemia often requires more than one pack of compatible blood to fulfil the calculated volume. This is often unavailable, necessitating exchange transfusion using less than the calculated double-volume. During practice, the authors found that many patients had a positive therapeutic response even when the exchange blood volume was reduced. Aim: To study the effect of the reduced volume of blood used for exchange transfusion in neonates with hyperbilirubinaemia. Materials and Methods: A retrospective cohort study was conducted in the Neonatal Intensive Care Unit (NICU), Malankara Orthodox Syrian Church Medical College (tertiary level), Kerala, India, between January 2015 and December 2020. Total 116 patients who underwent exchange transfusion for hyperbilirubinaemia, regardless of gestational age, were included. Pre- and postexchange details, blood chemistry and haemogram were collected from the records and analysed. The patients were grouped into group 1 (80-≤120 mL/kg) and group 2 (>120-≤160 mL/kg) based on the volume of blood used for exchange transfusion. The correlation of exchange blood volume with the percentage drop in bilirubin, rebound rise of bilirubin at six hours, duration of phototherapy, and duration of admission was studied using Pearson’s/Spearman’s correlation. Data were statistically analysed using Independent samples t-test, Paired sample t-test, and Chi-square test to determine, if there was a significant difference between the groups. Results: Out of 116 patients, group 1 had 67 (57.78%) patients, and group 2 had 49 (42.24%) patients. The mean±Standard Deviation (SD) gestational age was 37.6±1.57 weeks, and 59 (50.86%) were males. The mean±SD postexchange bilirubin was 13.12±3.85 mg/dL in group 1 and 10.26±2.78 mg/dL in group 2, resulting in a bilirubin reduction of 40.74±12.81% and 53.81±11.67%, respectively. The rebound bilirubin at six hours (13.15±4.32 mg/dL vs 11.23±2.30 mg/dL) made no clinical difference in the management of the patient. The median duration of phototherapy was 48 hours, and the median duration of admission was five days in both groups. Conclusion: Exchange transfusion with a lower volume of blood, followed by phototherapy, can lead to a clinically acceptable reduction in serum bilirubin. Non availability of the exact 160 mL/kg of blood for exchange is not an adequate reason to delay exchange transfusion.

Risk Factors for Deranged Renal Function in Term Asphyxiated Newborn Babies: A Cross-sectional Study

Piyusha Raju Thite, Leena Ajay Dhande

Introduction: Perinatal asphyxia is a significant cause of morbidity and mortality in the Neonatal Intensive Care Unit (NICU). As the kidneys are very sensitive to hypoxia, renal insufficiency can occur within 24 hours of a hypoxic insult and may lead to irreversible injury. Aim: To evaluate risk factors for impaired renal function in term asphyxiated newborn babies in a tertiary care hospital located in Central India. Materials and Methods: A cross-sectional observational study was conducted in the Neonatal Intensive Care Unit (NICU), IGGMC and Mayo Hospital, Nagpur, Maharashtra, Central India, from October 2020 to September 2022. A total of 95 term neonates with perinatal asphyxia were enrolled. Risk factors were noted, urine output was recorded, and neonates were classified according to the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Network (AKIN) criteria. Data were tabulated and statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 21.0 to determine the significance of each risk factor for AKI. Continuous variables were compared using the unpaired t-test or Mann-Whitney U Test (when datasets were not normally distributed). Categorical variables were compared using the Chi-square test or Fisher’s-exact test. Results: Out of 95 neonates, comprising 53 males and 42 females with a mean gestational age of 38.6 weeks in the AKI group and 34 weeks in the non AKI group, 58 (61.1%) had AKI; 15 (25.86%) were AKI stage 1, 28 (48.27%) were AKI stage 2, and 15 (25.86%) were AKI stage 3. Among the risk factors, significant perinatal risk factors included Meconium-Stained Liquor (MSL) (p-value=0.0252), oligohydramnios (p-value=0.0246), prolonged labour (p-value=0.0276), and endotracheal tube (ETT) intubation as a mode of resuscitation (p-value=0.0008). Maternal risk factors such as Gestational Diabetes Mellitus (GDM) (p-value=0.0488) and Pregnancy-induced Hypertension (PIH) (p-value=0.0392) were significant. Neonatal shock (p-value=0.001) and Hypoxic-ischaemic Encephalopathy (HIE) (p-value=0.0049) were significant risk factors for AKI in this study. Conclusion: Perinatal asphyxia is one of the common causes of neonatal mortality, with AKI being the earliest and most common complication as seen in the current study, where 61.1% of neonates with perinatal asphyxia had AKI. By early detection and prevention of risk factors causing AKI in perinatal asphyxia, neonatal mortality can be reduced significantly.

Role of Autopsy and Genetic Testing in the Diagnosis of Perinatal Deaths due to Congenital Anomalies: A Cross-sectional Study

Introduction: Foetal autopsy is one of the primary modalities for establishing the underlying causative aetiology in congenitally anomalous foetuses. Genetic aetiology is the cause in at least half of the foetuses. A correlative approach including dysmorphological evaluation, histopathology, imaging studies, and genetic testing plays a significant role in establishing the final diagnosis and management of such cases. Aim: To investigate the cause of perinatal death through a correlative approach involving Ultrasonography (USG), cytogenetic analysis, and autopsy in congenitally malformed neonates. Materials and Methods: This cross-sectional study was conducted in the Department of Pathology and Obstetrics and Gynaecology at SCB Medical College, Cuttack, Odisha, India, from June 2018 to June 2020. The study included 19 congenitally malformed foetuses/aborted foetuses/neonates not compatible with life, born in the labour room. Written informed consent was obtained, and cord/cardiac blood/soft tissue samples from congenitally anomalous foetuses were collected in a heparinised vial/sterile container during delivery and sent for cytogenetic testing. The deceased foetuses were weighed, external abnormalities and anthropometry were recorded, and then they were preserved in 10% formalin. Autopsies were performed using Virchow’s method. All internal abnormalities were recorded, and sections were sent for Histopathological (HP) study. All the data was analysed using the Statistical Package for Social Sciences (SPSS) software version 20.0. Results: The study included a total of 19 cases, including 11 (57.8%) cases of Intrauterine Deaths (IUD). The majority were males 8 (42%), in the gestational age group of 20-25 weeks (36.7%). Maternal age ranged from 21 to 30 years, with the majority being nine cases (47.3%), and 13 cases (68.3%) without antenatal check-ups. The study comprised 6 cases (31.57%) of genetic syndromes, including Trisomy 21, 13, 18, and Monosomy X, 5 cases (26.3%) of musculoskeletal defects such as Meckel Gruber syndrome, Heterotaxy syndrome, and Thanatophoric dysplasia, and 5 cases (26.3%) of neural tube defects. Conclusion: Autopsy determined the cause of death in 90% of the cases and, when combined with genetic analysis, established the syndromic diagnosis. Autopsy findings can complement or modify the ultrasonographic findings. Therefore, perinatal autopsy should always be included in the management of deaths due to congenital anomalies.

Evaluation of Cerebral and Spinal Abnormalities on Magnetic Resonance Imaging in Infants with Myelomeningocele: A Retrospective Observational Study

Sweta Swaika

Introduction: Spinal dysraphism includes a diverse collection of congenital spinal abnormalities that occur due to flawed closure of the neural tube and can be classified as open or closed types. The most common form of open spinal dysraphism is Myelomeningocele (MMC), which is characterised by a bony spinal defect and a sac in the back region containing dysplastic neural tissue and cerebrospinal fluid. MMC is associated with various intracranial and spinal anomalies that can lead to neurological, intellectual, and cognitive impairments. Imaging is necessary for the diagnosis of these anomalies and for surgical management planning and follow-up. Aim: To evaluate the associated intracranial and spinal anomalies in infants with MMC who presented with low back swelling since birth. Materials and Methods: The retrospective observational study was conducted in the Department of Radiology at Gajara Raja Medical College, Gwalior, Madhya Pradesh, India, from January 2020 to December 2022. A total of 117 subjects under one year of age, clinically diagnosed with MMC, were included in the study. Brain Magnetic Resonance Imaging (MRI) images were available for 84 patients, and spine MRI images were available for 113 patients. The MRI images were evaluated for bony and spinal anomalies. Data analysis was performed using IBM’s Statistical Package for Social Sciences (SPSS) version 20.0. Results: The mean age of the study participants was 1.7±2.9 months, with 70 males and 47 females (M:F=1.5:1). The most common location of spina bifida was lumbosacral 36 (31.9%), followed by lumbar 31 (27.4%), dorsolumbar 30 (26.5%), and sacral 16 (14.2%). A low-level spinal defect was observed in 39 cases (34.5%), and a high-level spinal defect was observed in 74 cases (65.5%). The spinal anomalies detected on MRI included syringomyelia 80 (70.8%), low-lying cord 59 (52.2%), bony abnormalities 26 (23.01%), diastematomyelia 16 (14.2%), and fatty filum terminale 3 (2.7%). Among the intracranial anomalies, the most common was dilated lateral ventricles 62 (73.8%). The most common infratentorial anomaly was Chiari II malformation 58 (69.1%). Corpus Callosum (CC) abnormalities were found in 40 cases (47.6%), with complete agenesis seen in three cases (3.6%), cerebellar hypoplasia in 20 cases (23.8%), absent septum in 15 cases (17.9%), and colpocephaly in 10 cases (11.9%). Conclusion: Spinal dysraphism, such as MMC, and cerebral anomalies often co-exist and can have an impact on neurological, intellectual, and cognitive functions. Chiari II malformation, corpus callosal anomalies, ventriculomegaly, and syringomyelia are frequently associated with MMC. Therefore, imaging evaluation of both the spine and brain is necessary for surgical treatment planning and long-term follow-up in MMC.

Mortality Risk Assessment by SNAP-II and SNAPPE-II among Very Low Birth Weight Newborns- An Observational Study

Somenath Ganguly, Uttam Kumar Sarkar, Sankar Das, Goutam Das, Akash Rai

Introduction: Very Low Birth Weight (VLBW) babies are those with a birth weight of less than 1500 gm and require special care, attention, and resources. However, despite all efforts, their mortality rate remains high. Proper assessment of these neonates is crucial to identify high-risk cases and take early steps to reduce mortality. In addition to technical advances in neonatal care, severity scores have been developed to predict neonatal mortality. Richardson developed the Score for Neonatal Acute Physiology (SNAP-II) and SNAP with Perinatal Extension (SNAPPE-II) as scoring systems for predicting mortality in the Neonatal Intensive Care Unit (NICU). Aim: To assess the usefulness of SNAP-II and SNAPPE-II as predictors of mortality in VLBW neonates. Materials and Methods: This was an observational cross-sectional study involving 145 VLBW neonates admitted to the NICU of North Bengal Medical College and Hospital (NBMCH) from May 2019 to April 2020. Relevant data were collected to assess the mortality risk scores SNAP-II and SNAPPE-II. The outcome of discharge or death was recorded. Data entry was performed using MS excel and analysed using Statistical Package for Social Sciences (SPSS) version 20.0. The relationship between newborn survival and SNAP-II or SNAPPE-II final scores was determined using the Mann-Whitney U test, and the relationship between survival and various SNAP-II and SNAPPE-II score categories was determined using Fisher’s-Exact Test. A p-value of less than 0.05 was considered statistically significant. An ROC curve was generated to determine the best cutoff score for predicting mortality. Results: The mean scores of SNAP-II and SNAPPE-II were higher in babies who expired compared to those who survived. The mean (±SD) SNAP-II scores were 8.96 (±13.865) for survived newborns and 41.08 (±23.174) for expired newborns. The mean (±SD) SNAPPE-II scores were 20.01 (±14.54) for survived newborns and 48.85 (±25.02) for expired newborns. The optimal cutoff values for SNAP-II and SNAPPE-II in predicting mortality were 31.5 and 36, respectively. The sensitivity and specificity of SNAP-II were 83.0% and 89.1%, while for SNAPPE-II they were 69.8% and 89.1%, respectively. Conclusion: The mean SNAP-II and SNAPPE-II scores were higher among expired VLBW neonates compared to those who survived. A SNAP-II score of 31.5 and SNAPPE-II score of 36 were associated with higher mortality, indicating that both scores are effective predictors of mortality regardless of Gestational Ages (GA) and birth weight.

Cord Blood Vitamin D Status and Its Anthropometric Correlation in Term, Appropriate-for-Gestational-Age Newborns: A Cross-sectional Study

Ved Pratap Tiwari, Kedar Pramod Kulkarni, Anvita Jain

Introduction: Hypovitaminosis D is highly prevalent worldwide, including in India. Vitamin D deficiency during pregnancy can also lead to deficiency in the foetus. This deficiency can have a negative impact on foetal growth, as vitamin D is essential for calcium and bone homeostasis, as well as skeletal growth. Aim: To determine the cord blood vitamin D status and evaluate the correlation between cord blood vitamin D levels and neonatal anthropometric measurements in term, appropriate-for-gestational-age newborns at birth. Materials and Methods: A cross-sectional study was conducted at a tertiary care centre. Two hundred term, appropriate-for-gestational-age newborns were included in the study. Cord blood 25(OH)D levels and anthropometric measurements were taken at birth. The data were analysed statistically, and significance was determined using the Analysis of Variance (ANOVA) test. Results: Vitamin D levels were deficient (<12 ng/dL) in 80 (40%) samples, insufficient (<20 ng/dL) in 93 (46.5%) samples, and sufficient in 27 (13.5%) samples of cord blood. No significant relationship was found between cord blood vitamin D concentrations and neonatal weight, length, and head circumference at birth (p>0.05). Conclusion: A very high level of vitamin D deficiency or insufficiency was observed in cord blood samples. There was no association between maternal vitamin D concentrations and neonatal anthropometric measurements in the infants.

Factors Influencing Maternal Stress during Infant’s NICU Stay in a Tertiary Care Center, South Kerala, India: A Cross-sectional Study

Chris Placid, Jacob Abraham

Introduction: Recent advances in neonatal medicine have helped sick babies survive. However, the birth of a baby needing Neonatal Intensive Care Unit (NICU) stay may be a significant source of stress for mothers. Aim: To assess the maternal stress level perceived due to an infant’s NICU stay and the factors influencing this stress. Materials and Methods: The present cross-sectional study was conducted in the NICU of Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India, between March 2021 and September 2021. The study included 74 mothers of infants requiring at least five days of NICU stay. The stress levels were recorded using the Parental Stressor Scale: NICU (PSS:NICU) questionnaire, which included 27 items under three stressor domains: Sights and Sounds (SS), Parental Role Alteration (PRA), and looks and behaviour of the baby. Data were statistically analysed using the Mann-Whitney U test and Kruskal-Wallis tests. Results: In the study group, 33 (45%) mothers experienced moderate stress, 18 (24%) experienced a high level, and the remaining 23 (31%) experienced only low-level stress. The overall maternal stress perceived in the study group was found to be at a moderate level with a mean of 3.36±0.67. Factors causing stress in mothers included prematurity, low birth weight, low 1st-minute Appearance, Pulse, Grimace, Activity and Respiration (Apgar) score, expressed breastfeeding, and previous experience with abortion. Conclusion: The present study found that mothers experienced moderate stress when their babies were admitted to the NICU. Significant stress was experienced by mothers when they were unable to perform their maternal duties.