Clinical case 025: Neonatal Nasty

I decided to post this case because (1) it pushed the limits of my practice as a generalist, (2) I encountered a problem I had not seen before (required some thinking under pressure at 3 AM) and (3) we had a win – not the usual for my Obstetric postings.

We induced a primigravida overnight for post-datism.  She was doing OK, but slow progress – so we did an ARM at 6 cm – and got a gush of bloody amniotic fluid.  This is tricky – intrapartum bleeding is uncommon, but might represent an abruption.  So what to do?  We decided to get her moving with an oxytocin infusion.  So I put in an epidural and put up the synto drip – CTG monitoring showed some decreased variability but nothing sinister.  An hour later she was fully and and hour after that head was on the perineum – so all going as well as can be expected.  The CTG had a few dips, but recovered.  The amniotic fluid had remained blood-tinged throughout.

Then at birth, we got a massive gush of bloody hindwaters containing clots of blood, no meconium – just a lot of blood.  Baby came out flat despite a pretty good FHR in the final stages.  No respiratory effort, cry or tone.  The baby looked pale.

So we did the usual Neonatal Resus maneuvers – stimulation = no response.  Pulse rate dropped off quickly – so I started IPPV via the mask – but could not move the chest.   Hmmmm…. time slows down in these situations.  After another 30 secs of IPPV the penny dropped (probably obvious in retrospect) – this kid needed suctioning, so I sucked out the mouth and nose – no better.  Still unable to move the chest wall.  Next move – intubate and use the Mec trap to suction the trachea…

Bingo – a nasty big, trachea-sized clot came up the tube.  A second round of intubate-suck got up more clot, then the bagging became easy, moving air and spontaneous respiratory effort commenced, pulse rate came up quickly and started squawking – a very happy sound indeed!

By this time my friendly local Paediatrician was on the way – as is typical in these cases, the child looked pretty good, still a bit pale when he arrived.  The placenta looked nasty – lots of clot and not much normal placental tissue.

So I put in an IV and we gave a fluid bolus and the baby pinked up before our eyes.  Still needed a bit of oxygen and the CXR was telling:

Chest XRAY showed some RUL consolidation – consisitent with aspiration

For me this is a matter of pushing the limits of the generalist’s skills and knowledge in several disciplines in the one case.  We do the training and keep up to date, but it is cases like these that test one’s preparation.  Not much time to think, you have to rely on your instinct and training.

Blood aspiration syndrome in neonates is pretty uncommon, and there don’t appear to be guidelines for its management in the specialist literature.  So I guess one should suspect it when there is a lot of blood in the liquor and manage it a bit like meconium aspiration – suction-before-ventilation.  There is a paper by Gordon et al, Royal Children’s Hospital in Melbourne from Journal of Pediatrics 2003.  This is one scenario where the neonatal resuscitation drill was not working.  Without a good suction, I think this child would have become bradycardic and worse pretty quickly and no amount of adrenaline would help.

Have you seen a case of blood aspiration?  Do you routinely suction in the presence of nasty looking liquor?



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