Case 3
A female neonate from the fourth pregnancy complicated by the presence of placenta previa and anemia was delivered via cesarean at 23.5 weeks of gestation because of placental abruption. The neonate, with a birth weight of 820 g, was in severe condition, with the signs of extreme prematurity and progressive respiratory failure. Surfactant (Curosurf, two doses: 200 mg/kg and 100 mg/kg, respectively) was administered on the first day of age, and mechanical ventilation with gradually increased parameters was implemented, along with combined empirical antibiotic therapy with ampicillin and gentamycin. Because of severe hyperglycemia, the neonate received insulin on days 1 to 6. Echocardiography performed at approximately 20 hours of age showed tricuspid regurgitation with velocity up to 3 m/s, mitral regurgitation, reduced myocardial contractility, and a wide DA with right-to-left shunting. The changes found on chest ultrasonography corresponded to the grade 2 RDS. At approximately 21 hours of age, the patient was administered 20% magnesium sulfate (200 mg/kg). Given the lack of improvement, intravenous Milrinone (50 µg/kg for 1 hour, followed by 0.5 µg/kg/min for 2 hours in a continuous infusion, and 0.25 µg/kg/min for another 32 hours) has been implemented starting at approximately 23 hours of age. Furthermore, pressor amines, dobutamine and dopamine, were administered to control hypotension (MBP 20 mmHg) and to improve myocardial contractility. The treatment contributed to the improvement of cardiorespiratory parameters (normalization of oxygen saturation, reduction of oxygen demand, decrease in respiratory effort). The echocardiographic examination demonstrated improvement of myocardial contractility, a decrease in tricuspid regurgitation velocity down to 2.25 m/s, a mild mitral regurgitation and bilateral flow in the DA. Despite these improvements, the patient’s condition remained critical. Echoencephalography carried out on subsequent days showed bilateral hemorrhage, grade 4 (periventricular hemorrhagic infarction, PVHI) according to the modified Papile grading system. Echocardiography revealed hemodynamically relevant left-to-right flow in the DA, which persisted despite an attempt of pharmacological ligation with intravenous paracetamol and furosemide on days 3-5. As the signs of coagulation disorders emerged on days 2 and 3, the patient received vitamin K and fresh frozen plasma. On day 5, the neonate received an additional transfusion of irradiated leukocyte-depleted erythrocyte concentrate because of progressive hypoxemia. Despite intensive therapy, the general condition of the patient continued to deteriorate and was eventually classified as terminal. The neonate died at six days of age due to multiorgan failure associated with extreme prematurity.