Dr Anakha V Ajay Dr Jayasree(Dept of Neonatology) Dr Naveen Vishwanath(Dept of Pediatric surgery) Dr C Jayakumar( Dept of Pediatrics) AIMS Kochi
Eleven day old outborn preterm , born to a forty two year old elderly Gravida 7 ,Abortion 6 mother at 30+5 weeks of gestation as twin one elective LSCS (Indication- DCDA Twins, IUGR).
Mother is a known case of GDM and Hypothyroidism and B a cried immediately . APGAR score 8/9 at 1/5 min.
Due to persistent respiratory distress ba was started on non invasive respiratory support and surfactant was administered via insure which was weaned off day 2 of life.
Ba was observed to have yellow gastric aspirates hence kept nil orally since day 1 of life.
Urine and meconium were passed within 24 hours.
X ray abdomen showed air under diaphragm, hence ba was referred to AIMS for further management.
On examination ba was tachypnoeic. Auxology :
Weight of 950g (3rd centile)
Head circumference of
27cm (25th centile)
Length of 37.5 cm (>10th centile).
No obvious external anomalies noted. Respiratory examination done showed air entry present bilateral. Abdominal examinatiom showed mild distension with bowel sounds present. Anus patent. Other systemic examination was within normal limits.
Ba was transferred to NICU on HFNC with flow of 4L. In view of significant distress with abdominal distention, ba was intubated and put on SIMV mode. X ray chest with abdomen revealed pneumoperitoneum. Ba was kept NPO and started on IV fluids. – Ba was hemodynamically stable without any inotropic support.
Screening ECHO showed PFO Left to right. Peritoneal abscess glove drain was done on day 1 of admission in view of perforated abdomen and taken up for repair and colostomy on day 3 of admission. Babay was extubated on day 5 of admission post-surgery andwas started on feeds which were tolerated well. He has been off respiratory supports since He was loaded on oral caffeine, post extubation and given till day 14 of life. Ba was active, with normal tone. Pre-and post-surgical NSGs were normal. Ba has been enrolled into the early intervention program. In view of presumed sepsis, blood culture was taken and ba was continued on IV Amikacin and IV Meropenem. Sepsis screen was positive and CSF was suggestive of partially treated meningitis. Antibiotics are planned for 21 days total. Prophylactic antifungal in view of central venous line was administered.
Presently ba is on NGT with multivitamin supplementation. Ba is being transferred back to previous hospital at parental request. Parents were explained the risks during transportation and also the need of regular paediatric surgery follow up.
XRAY ABDOMEN SHOWING AIR UNDER DIAPHRAGM
Spontaneous intestinal perforation(SIP) of the newborn is a life-threatening single intestinal perforation typically occurring at the antimesenteric border terminal ileum and that affects very low birth weight infants (birth weight <1500 g). It is associated with high morbidity and mortality. The jejunum and colon are other possible locations for spontaneous intestinal perforation .Even though the exact aetiology of spontaneous intestinal perforation is speculative, prematurity is the significant risk factor for developing this condition. Severe maternal chorioamnionitis with collective evidence of fetalvascular response is reported to be a risk factor for the development of spontaneous intestinal perforation .Early postnatal glucocorticoids have been associated with an increased incidence of spontaneous intestinal perforation. The incidence of spontaneous intestinal perforation is reportedly 1 to 2% for very low birth weight infants (birth weight of less than 1500 g) and 5 to 8% for extremely low birth weight infants (birth weight of less than. 1000 g.)
Diagnosis of spontaneous intestinal perforation is based on the characteristic clinical presentation, which usually presents with acute abdominal distension and bluish-black discoloration of the abdomen can be confirmed the typical radiographic findings of pneumoperitoneum.Necrotising enterocolitis which usually presents will initial signs such as emesis, bloody stools, and abdominal wall edema, crepitus, and induration has to be ruled out.
Supine and lateral decubitus or cross-table lateral views must be obtained. In some cases, an abdominal ultrasound may help detect echogenic free fluid in the peritoneal cavity. Management is initially discontinuation of all enteral feeds and medications, and a nasogastric tube or orogastric tube must be inserted at low intermittent or continuous suctioning to decompress the abdomen. Total parenteral nutrition must be started for nutrition. Intravenous empiric antibiotics should be initiated. Surgical management of spontaneous intestinal perforation includes bedside primary peritoneal drainage and laparotomy. Laparotomy with resection of the affected intestine and creation of a stoma is the traditional surgical approach. Primary peritoneal drainage is frequently considered as temporary management in infants who are unstable to tolerate laparotomy.
Prognosis: The mortality rate is approximately 20 to 40%. Prognosis depends on the severity and extent of the spontaneous intestinal perforation. Concomitant sepsis is associated with a worse prognosis.
Take home message: To maintain high index of suspicion for SIP in newborns with sudden onset of abdominal symptoms and early surgical consultation is crucial for optimal outcomes.