Indian Journal of Neonatal Medicine & Research

A Case of Neonatal Hypertension with Chronic Kidney Disease Presenting as Anasarca, Hypoalbuminemia and Pulmonary Bleed

Srijan Singh

Incidence of hypertension is reported to be around 0.2% in healthy term newborns and up to 3% in the infants in Neonatal Intensive Care Units (NICUs). Neonatal Chronic Kidney Disease (CKD) is defined as a decrease in kidney function which manifests in the neonatal period. Neonatal CKD has an estimated incidence of 1 in 10,000 live births. The diagnosis of CKD in the neonatal period is typically made after a renal ultrasonogram, first performed in the prenatal period and repeated soon after birth. This case report is about a 22-days-old male neonate that presented with abdominal distension, generalised pitting oedema and hypertension. On day 33 of life, the baby developed pulmonary haemorrhage. A diagnosis of CKD was made, based on renal ultrasonogram along with urine microscopy and urine protein creatinine findings. Renal Doppler was not suggestive of renal artery stenosis or renal vein thrombosis. A 2D echo was not suggestive of coarctation of aorta or interrupted aortic arch. Ultrasonography of abdomen did not reveal any mass. Plasma renin levels were normal. Hypertension finally normalised on oral amlodipine. Baby has been normotensive on oral amlodipine during follow-up over the last six months. This is a rare case of hypertension with CKD presenting in the neonatal period.

A Prospective Study to Assess the Predictors of Neonatal Mortality among very Low Birth Weight Neonates in Neonatal Intensive Care Unit at Teaching Hospital of Raipur, Chhattisgarh, India

Nagendra Bagri, Ram Kumar Panika, Vikas Gupta, Inder K Nathani

Introduction: Around 4-7% of the live births are Very Low Birth Weight (VLBW) neonates and their mortality is very high (50%). The survival of this population of infants is closely related to various factors which include maternal factors (significant obstetric problems, use of antenatal steroids etc.), gestational age, Apgar Scores and Respiratory Distress Syndrome (RDS). With identification of predictors, it is possible to prevent, particularly aiming the improvement of newborn children care. Aim: To determine the predictors of neonatal mortality among VLBW neonates in Neonatal Intensive Care Unit (NICU) at teaching hospital of Raipur, Chhattisgarh. Materials and Methods: This was a hospital-based prospective study carried out among all premature newborns weighing less than 1,500 grams and more than 26 weeks admitted to NICU with a sample size of 129. The data was prospectively recorded on a standard proforma and their outcome was monitored post birth till 28 days. If the neonate was discharged prior to 28 days, telephonic follow-up was done weekly to monitor the newborn outcomes at home. A bivariate analysis using the Chi-square test or Fisher-exact test, where appropriate, was performed to evaluate differences between groups for categorised variables. All tests were performed at a 5% level of significance; thus, an association was significant if the p-value was less than 0.05. Multivariate logistic regression analysis was used to calculate adjusted Odds Ratio with 95% CI (association between mortality and qualitative variables) to eliminate confounders. Results: The binominal multivariate logistic regression analysis of predictors of neonatal mortality and adjusted odds ratio with 95% CI was obtained and most of birth and maternal variables such as birth weight, gestational age, foetal distress and non use of antenatal steroids were statistically significant except sex, required assisted ventilation, initiation of enteral feeding, maternal fever and premature rupture of membrane. Conclusion: The present study identifies the risk factors associated with mortality in VLBW neonates and helps in prioritising them so that health care workers can intervene and prevent mortality in these neonates. There is therefore a need of such infants requiring care at centers, which have adequately trained staff with appropriately developed support infrastructure.

Comparative Study of Cord Blood Nucleated Red Blood Cell Count in Asphyxiated and Non Asphyxiated Babies at Birth in a Tertiary Health Centre

Sambedna, Amit Kumar, Rita chakore

Introduction: Perinatal asphyxia is a major cause of neurological morbidity and mortality among survivors and is a complication that occurs between 5-10% of deliveries. The term asphyxia should be exclusively used to indicate those babies who have metabolic acidosis and hypoxia at birth. Aim: To analyse whether the increase in Nucleated Red Blood Cell Count (NRBC) in asphyxia is significant or not as compared to the non asphyxiated group. Material and Methods: This was a prospective study in Department of Obstetrics and Gynaecology in tertiary care health centre. Cord blood samples were collected from 100 newborns with asphyxia at birth and equal number of normal appropriately matched control to study NRBC per 100 WBC in Cord blood sample. The study was done during the period of December 2013 to November 2015 over 200 newborns. The statistical analysis was done using SPSS software version 16 and Chi-square test. Results: The mean count of NRBC/100 WBC in the study was 25.59±7.19 (SD). Mean count in the control group was 12.69±5.29 (SD). The difference was statistically significant (p<0.001). Conclusion: NRBC count can be useful for the evaluation of perinatal asphyxia, where facilities for pH sampling are not available and can serve as a liable, inexpensive and easily available marker of perinatal asphyxia.

Sonographic Assessment of Fetal Cephalic Index among the Population of Western UP: A Prospective Observational Studymorphometry

Nandkishor Gupta, Neeshu Bala, Nitya Nand Srivastava, Kailash Mittal

Introduction: Cephalic Index (CI) also called as cranial index is the ratio of the maximum breadth to maximum length of head. Aim: To assess the shape of skull according to the CI and to identify factors affecting the CI estimation like gestational age, weight of fetus, maximum breadth of fetal heads and maximum length of fetal heads in the Etawah Region (UP) in India. Materials and Methods: The present prospective observational study was performed on the pregnant ladies. These ladies were enrolled for the study when they visited the Radio-diagnosis Department of Uttar Pradesh Medical University Hospital, Saifai, Etawah for Ultrasound (USG). A total number of 550 ultrasound images were collected for study. The measurement of Maximum Breadth of Fetal Heads (BPD i.e., Biparietal Diameter) and Maximum Length of Fetal Heads (APD i.e., Antero-Posterior Diameter) were taken on USG machine, recorded for analysis. When associating the measures of precision for different subgroups, one-way ANOVA analysis of variance was used for the modest and efficient errors. Multivariate logistic regression analysis was used to identify factors affecting the CI estimation like gestational age, weight of fetus, maximum breadth of fetal heads and maximum length of fetal heads. Results: Out of 550 studied fetus, majority 222 (40.4%) of the fetus were belonging to the gestational age group 30-35 weeks. Weight of fetus, maximum breadth of fetal heads, and maximum length of fetal heads in different gestational age were statistically significant; but CI was statistically insignificant. Pearson correlation between the gestational age, weight of fetus, maximum breadth of fetal heads, maximum length of fetal heads and CI was determined and correlation was statistically significant with each other’s; but statistically insignificant correlation was observed between maximum length of fetal heads and CI. Conclusion: Mesocephaly is the dominant head shape among the western part of UP (India) particularly in Etawah and Mainpuri region which was of CI range from 75 to 79.9.

Renal Functions in Relation to Severity of Perinatal Asphyxia in Term Neonates

Introduction: Kidney is one of the most important organs commonly involved in the multiple organ dysfunction caused by perinatal asphyxia. Monitoring the serum urea, creatinine and urine output helps in early assessment of severity of perinatal asphyxia and, thus improving the outcome. Aim: To study renal functions in perinatal asphyxia and various stages of Hypoxic-Ischemic Encephalopathy (HIE) in term neonates. Materials and Methods:This observational study included 118 full-term perinatally asphyxiated neonates admitted in Neonatal Intensive Care Unit (NICU) of Uttar Pradesh University of Medical Sciences, Saifai, Etawah. Serum urea, creatinine and urine output were assessed on 1st, 3rd and 10th day of admission. A total of 48 newborns with normal Renal Function Test (RFT) and urine output were kept in Group A, while 70 newborn with abnormal RFT and urine output were kept in Group B. To compare RFT in various HIE stages of perinatal asphyxia, neonates were graded by the Levene staging system and divided in mild HIE (stage I), moderate HIE (stage II) and severe HIE (stage III). A total of 52 neonates who did not fulfill criteria of any stage of Levene were diagnosed as asphyxia without HIE and were excluded from comparison. Results: Significant differences (p-value <0.05) in serum urea, creatinine and urine output were found between Group A and B on postnatal day 1, 3 and 10. Total 66 neonates were diagnosed to have HIE with various grades (Stage I-15, Stage II-32 and Stage III-19). Rest 52 neonates were suffering from perinatal asphyxia but did not come in any category of HIE. On day 1, there was an increasing trend in concentration of both serum urea and serum creatinine as HIE staging progressed from HIE I to HIE III. On Day 3, serum urea and creatinine were found to be significantly higher in HIE III compare to HIE II. On day 10, serum urea and creatinine were significantly higher in HIE III as compared to HIE I and II. In all three days, urine output decreased as HIE stages progressed to I to III. Conclusion: Renal dysfunction correlates well with increasing severity of asphyxia in terms of HIE staging and it can be used as a marker to assess the severity of perinatal asphyxia.

An Audit of Antibiotic Usage among Neonates in a Neonatal Intensive Care Unit: A Prospective Observational Study

Saikiran Deshabhotla, Rajshekar Sigilipelli, Baswaraj Tandur

Introduction: Antibiotics are used frequently in the Neonatal Intensive Care Unit (NICU). Evaluating the antibiotic usage pattern at institutional or unit level would help in preventing antibiotic overuse and antibiotic resistance. Aim: To assess antimicrobial usage among neonates admitted to the NICU. Materials and Methods: The study was a prospective observational study done in the level III NICU at Hyderabad, India. All the antibiotics used among infants admitted to the NICU from January 2019 to December 2019 were monitored. Data collected were entered in Microsoft Office Excel 2016 and analysed using OpenEpi Version 3. Student t-test for continuous variables and chi-square test for dichotomous variables was used. Results: A total of 986 infants were admitted to the NICU during the study period. Antimicrobials were prescribed in 322 (32%) infants. Antibiotics were most frequently prescribed in symptomatic infants (48%) for suspected sepsis. Amikacin was prescribed most frequently in 74% of infants. Cephalosporin was prescribed only in 8.9% cases. Blood culture positivity rate was 28%. Antibiotics were stopped only in 40% of the infants after the receipt of a negative blood culture report. Conclusion: In this study, 68% of the infants were managed without any exposure to antibiotics. Half of the antibiotic usage was in suspected infection cases and antibiotics were continued in majority of cases with negative blood culture report. These clinical scenarios are amenable to antibiotic stewardship strategies in reducing antibiotic usage. Cephalosporin usage can be minimised with proper antibiotic usage guidelines.

Perinatal Factors Associated with Spontaneous Regression of Retinopathy of Prematurity– One Year Experience from a Tertiary Care Hospital

Introduction: Spontaneous regression of Retinopathy of Prematurity (ROP) usually happens without serious residual sequelae in most neonates, while in some, blindness or serious visual impairment results from severe ROP. Aim: The aim of the study was to estimate the incidences of ROP that spontaneously regress and ROP that requires intervention and to identify the perinatal factors that are associated with spontaneous regression of ROP. Materials and Methods: This is a one year prospective descriptive study done in the Special Newborn Care Unit of a tertiary care hospital. All neonates diagnosed to have ROP of any stage on screening were included in the study. All these neonates were followed-up weekly for progression or regression of ROP. Data collected from case records included demographic, perinatal and neonatal profile of the study participants. The study group was divided into two groups – those neonates with spontaneous regression of ROP (Group 1) and those neonates who had severe ROP requiring intervention (Group 2). Results: The incidence of ROP was 22.89%. The incidences of ROP spontaneously regressing and ROP requiring intervention were 93.5% and 6.5%, respectively. The univariate analysis of the factors showed a positive Odds Ratio (OR) for spontaneous regression for male gender, multiparity, lower segment caesarian section delivery and increasing gestational age. The OR was negative for factors like maternal anaemia, neonatal Respiratory Distress Syndrome (RDS), neonatal sepsis, phototherapy usage, neonatal blood transfusion, neonatal Intraventricular Hemorrhage (IVH) and increasing oxygen days. The Chi-square test revealed a significant p-value (<0.05) for the factors including IVH (p=0.002), gestational age (p=0.01), birth weight (p=0.01) and oxygen days (p=0.003). Conclusion: The present study reiterates the need to develop a statistical model or a scoring system to predict the need for intervention in neonates with ROP by doing a larger multi-centric study.

Comparison of Transcutaneous Bilirubin with Serum Bilirubin in a Tertiary Care Newborn Unit- A Cross-Sectional Study

Maruthi Prasad Upputuri, Satnam Kaur, Sugandha Arya, Harish Chellani

Introduction: Transcutaneous Bilirubin (TcB) is a non invasive, point of care test for assessing bilirubin level. There has been renewed interest in use of this method with availability of newer generation transcutaneous bilirubinometer (Bilichek and JM-103). Indian studies evaluating TcB with newer generation bilirubinometer have limitations of small sample size, inclusion of mainly term neonates and focusing only on correlation between the two methods (ignoring agreement between the two). Aim: To compare TcB measurement with Total Serum Bilirubin (TSB) in neonates (term as well preterm) with clinically significant jaundice. Materials and Methods: This cross-sectional study enrolled 400 healthy neonates (<34 weeks-50, 34-37 weeks-152, >37 weeks-198) who were judged to have clinically significant jaundice and required TSB estimation. TcB was measured at forehead using TcB meter (DRAGER, JM-103) within 30 minutes of obtaining sample for TSB. TcB -TSB difference was computed. Pearson’s correlation coefficient and Bland Altman analysis were used to assess the strength of association and agreement, respectively between the two values. Results: Mean (±SD) TcB-TSB difference was 0.68±2.12 mg/dL (range -5.6 to 6.9 mg/dL). Corresponding difference in preterm and term babies was 1.20±1.92 mg/dL (range -4.1 to 5) and 0.15±2.19 mg/dL (range -5.6 to 6.9 mg/dL) respectively. Correlation between TcB and TSB was good across various gestational ages (r value 0.75 overall and 0.71, 0.74 and 0.74 in 30-34 weeks, 34-37 weeks and >37 weeks gestational age, respectively) and between TSB values of 10-18 mg/dL (r-value 0.79). However, correlation was poor when TSB was less than 10 mg/dL and moderate at TSB level above 18 mg/dL (r value 0.36 and 0.65, respectively). Clinically relevant discrepancy of ≥±3 mg/dL between TcB and TSB was present in 17% of study subjects. The 95% limits of agreement between TcB-TSB and mean of TcB and TSB by Bland Altman analysis were estimated to be -3.48 to 4.84 suggesting poor agreement between two methods. Conclusion: TcB correlates well with TSB in TSB range of 10-18 mg/dL but agreement between two methods is not good and underestimation by TcB at higher values of TSB is a concern. So, TcB is not a substitute for TSB and should never be used in isolation.

Gastroschisis Repair Technique using Autologous Umbilical Cord Flap in a Resource Limited Setup: Case Series

Dileep Garg, Vinay Mathur, Umesh Bahadur Singh, Jitendra Grover

The commonly used surgical methods of gastroschisis repair are operative fascial closure (primary closure), silo application (staged closure), or sutureless closure technique, adapted accordingly to different scenario. This case series presents an initial experience of gastroschisis repair method with an under-reported surgical technique that can be adapted for the repair of gastroschisis in a resource limited setup. The umbilical flap cover is a reasonable method, seems to have favourable results that can render an autograft like covering to exposed visceral organs. This method does not increase the intra-abdominal pressure and also providing a better compliant environment for the growth of the abdominal space. Eight cases have been managed with this technique during the last 4 to 5 years, out of which seven are under follow-up, with age ranging from two months to four years. Umbilical flap harvested from the native umbilical cord is a readily available autologous tissue with an abundance of Wharton’s jelly and stem cells.