CASE REPORT

LOW BIRTH WEIGHT BABIES (P07.1) +

MODERATE NEONATAL ASPHYXIA (P21.1)
+ NEONATAL HYPOGLICEMIA (P70.4) +
NEONATAL VAGINAL HAEMORRHAGE
(P54.6)

Ibnu Rahman
I11108065

LECTURE :
dr. Hilmi Kurniawan Riskawa, Sp.A, M. Kes

Department of Pediatric
Kartika Husada Hospital
Faculty of Medicine Tanjungpura
University
1

September 26, 2016 December 3,

IDENTITY

Mrs. Ds baby, 2 days old girl, Medical Record

number 105443, was hospitalized at Perinatal
Room Kartika Husada Hospital for 7 days from
October 4th, 2016 until October 11th, 2016

2
CHIEF COMPLAINT

Baby had delayed cry after born.

3
PRESENT ILLNESS HISTORY
The patient had delayed cry after born, with blue
skin and not spontaneus breathing stimulate
weak cry after 1 minute
APGAR Score was 4/7/8
Delivered by C-Section because of impending
eclampsia, aterm pregnancy, 39 weeks.
This is second pregnancy
Mother had no history of taking medicine, animals
contact, or abdominal trauma during pregnant
Parents have no history of diabetes mellitus or
hypertention
PHYSICAL EXAMINATION
(DECEMBER 29, 2015)

General appearance : inactive, weak cry

Anthropometric
Weight : 1690 gr
Lenght : 50 cm
Head circumstance : 31 cm
Chest circumstance : 26 cm
Belly circumstance : 23 cm
Vital Sign:
Heart Rate : 148 x/min, regular, strong in palpable
Respiration Rate : 64 x/min, abdominothoracal
Temperature : 36,3C

5
 Head : Normocephal, slight black colored hair
Eyes : Clean, symetric, conjuctiva not anemic, sclera not
icteric
Ear : Clean, symetric
Nose : Good shape
Mouth : Good shape
Lung
Inspection : Symmetric shape and motion, retraction (-)
Palpation : Same tactile fremitus of right and left lung
Percution : Sonor in both lung fields
Auscultation : Vesicular breath sound, there is no ronkhi and
wheezing
Heart : Heart sound S1 and S2 single, regular, there is no
murmur and gallop
6
 Abdomen
Inspection : Flat, no mass
Auscultation : Bowel sound normal
Percution : Timpani in all field of abdomen
Palpation : Liver and spleen not palpable, there is no
mass
Anus and genitalia : Anus is clean, normal shape. Female
genitalia, the labia mayora is larger but not covering labia
minora, there is no abnormality
Extremities : Cold, Capillary Refill Time (CRT) less than
3 second, there is no cyanosis
Skin : Redness, slihgtly hair
7
 Down Score = 3

RDS Score 0 1 2
Cyanosis None Cyanotic in air Cyanotic in 40% O2
Retractions None Mild Severe
Grunting None Audible with Audible without
stethoscope stethoscope
Air entry-make baby cry Clear Delayed or Barely audible
and listen to breath decreased
sounds while baby cries
Respiratory rate 60 60 to 80 80 or apneic episodes
8
 Ballard Score = 36

Recor
d
-1 0 1 2 3 4 5
Score
:
superfi parch
cracki leathe
sticky, gelati cial ment,
smoot ng, ry,
friable nous, peelin deep
h pink, pale cracke
Skin , red, g &/or cracki
visible areas, d,
transp transl rash, ng, no
veins rare wrinkl
arent ucent few vessel
veins ed
veins s
Lanug Abund Thinni Bald Mostly
None Sparse Sparse
o ant ng areas bald 9
 Ballard Score = 36

Recor
d
-1 0 1 2 3 4 5
Score
:
Heel-
Anteri Creas
toe Creas
Planta >50m or es
40 Faint es
r m transv over
50m red over
surfac no erse anteri
m: -1 marks entire
e crease crease or 2/3
<40m sole
only of sole
m: -2
Stippl
Raised Full
Flat ed
Imper Barely areola areola 10
areola areola
Breast ceptibl percep 3 5
no 1
e tible 4mm 10m
 Ballard Score = 36

Recor
d
-1 0 1 2 3 4 5
Score
:
Well-
Lids Lids Sl.
curved Forme Thick
fused open curved
Eye pinna d& cartila
Loosel pinna pinna
and soft firm ge
y: -1 flat soft;
Ear but instant ear
Tightly stays slow
ready recoil stif
: -2 folded recoil
recoil
Promin Promin Majora
ent ent & Majora
Clitoris Majora
Genita clitoris clitoris minor cover 11
promi large,
ls & & a clitoris
nent & minor
(Femal small enlargi equall &
LABORATORY EXAMINATION
(DECEMBER 29, 2015)
Haematologi Value Normal Value
Leucocyte 12.900 / mm3 9.000-30.000 /mm3
Erytrocyte 4.22 million/mm3 3,90-5,50 million/mm3
Haemoglobin 12,9 g/dl 13,5-22,0 g/dl
Haematocrite 49,3% 42.0-60.0%
Trombocyte 370.000/mm3 150.000-350.000 /mm3
Glucose 49 mg/dl 45-125 mg/dl

12
DIAGNOSIS

WORKING DIAGNOSIS
Actual problems
Low weight born babies + Asphyxia neonatorum
Cumulative problems
Term Infant (TI) + Appropriate Gestasional Age (AGA) +
Head presentation + Green amniotic fluid + C-section
delivery because Impending Eclampsia

13
TREATMENT

Care for in incubator

O2 3 liters perminutes (lpm) via canule nasal
IVFD D10% 10 drops perminutes.
Random blood sugar test 1 hour after IVFD start.
Termoregulation
Umbilical cord caring
Vit K 1 mg intramuscular (IM) injection
Cefotaxime 2x80 mg IM injection
Eye ointment administration
Fasting for 6 hours, then give mother milk or formula milk 8x30 cc
Vital sign observation

14
FOLLOW UP

05- 09/10/16 10/10/16 11/10/16

08/10/16
S - Loosen the - Loosen the - Loosen the - Loosen the
U bowel (+) bowel (+) bowel (+) bowel (+)
- Urinating (+) - Urinating (+) - Urinating (+) - Urinating (+)
B - Drink Formula - Drink Formula - Drink Formula - Drink Formula
J milk 15-30 cc milk 20 cc milk 20 cc milk 20 cc
E - Nausea (-) - Nausea (-) - Nausea (-) - Nausea (-)
C - Vomiting (-) - Vomiting (-) - Vomiting (-) - Vomiting (-)
T - Bleeding from - Bleeding from - Bleeding from
I vagina vagina (+) vagina (+)
V
E
 PHYSICAL EXAMINATION
Vital 05/10/1 06/10/1 07/10/ 08/10/ 09/10/ 10/10/1 11/10/16
Sign 6 6 16 16 16 6
HR 148 x/m 120 x/m 140 x/m 132 x/m 128 x/m 136 x/m 116 x/m
RR 65 x/m 63 x/m 62 x/m 60 x/m 40 x/m 42 x/m 40 x/m
T 36,6C 36,5C 36,0C 36,6C 36,5C 36,5C 36,5C
BB 1690 gr 1870 gr 1900 gr 1890 gr 2040 gr 2040 gr 2080 gr
SpO2 99 %
05/10/1 06/10/16 07/10/1 08/10/1 09/10/1 10/10/1 11/10/16
6 6 6 6 6
O
B
J
E
Conjunctiva not anemic, no bleeding sign, extremities warm,
C
T CRT less than 2 second
I
V
E
 LABORATORY EXAMINATION
Date of Examination

05/10/16 06/10/16

06.0 09.0 12.0 15.0 18.00 21.0 24.0 03.0 06.0 09.0 12.0
0 0 0 0 0 0 0 0 0 0
Random
Blood
30 65 52 56 58 71 71 64 71 76 96
Glucose
(mg/dl)

17
LABORATORY EXAMINATION

Haematology, 08/10/2016
Leucocyte : 6.500/mm3
Erytrocyte : 5.50 million/mm3
Haemoglobin : 20.4 g/dl
Trombocyte : 169.000/mm3
Haematocrite : 55.35%
Billirubin Direct : 0.83 mg/dl
Billirubin Indirect : 0.2 mg/dl
Blood :A

18
PROGNOSIS

Ad Vitam : ad Bonam
Ad Functionam: ad Bonam
Ad Sanactionam : ad Bonam

19
FINAL DIAGNOSIS

Low weight born babies + moderate neonatal

asphyxia + neonatal hypoglicemia + neonatal
vaginal hemorrhage

HOME THERAPY
San-B Plex 2x0,2 cc per oral

20
PROBLEM OF CASE

Diagnose
Treatment
Prognose
DIAGNOSE
Low birth weight babies
Patient sign and
If birth weight <2500 symptom:
Asphyxia Delayed cry
APGAR score at first APGAR score 4/7/8
minutes :4
moderate Birth weight <2500
Not only diagnose use gr
APGAR score Tacypneu
Hypoglicemia
Random blood glucose Vaginal bleeding
<30 mg/dl
Vaginal hemorrhage
Inspection
Laboratory finding:
Hypoglicemia
 TREATMENT
Medication Function

O2 percanul nasal Support O2 inhalation

IVFD D10% 10 cc/hour Glucose intake via intravein

Vitamine K 1 mg IM Cardiotonic

Eye ointment Prevention of eye infection after birth

Cefotaxime 2x80 mg IM Prevention nosocomial infection

San B Plex 2x0,2 cc PO Multivitamine

PROGNOSE

Quo ad vitam : dubia ad bonam

Patient condition is life threatening if not treat
carefully
Quo ad functionam : dubia ad bonam
Functional vital organ can be compromise
because of asphyxia
Quo ad sanactionam : ad bonam
Recurrent incident of asphyxia, hypoglicemia,
and vaginal hemorrhage are non to small