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.