Case 2
A male neonate from the fifth pregnancy (third labor) complicated with
anemia and hypothyroidism was delivered at 41 weeks of gestation with a
birth weight of 4120 g. The neonate presented with meconium aspiration
syndrome (MAS) and the signs of congenital infection. Moreover, the
signs of progressive respiratory failure and an evident increase in the
levels of inflammatory markers have been observed beginning at birth. A
combined empirical antibiotic therapy with ampicillin and gentamycin was
started, and at approximately 4 hours of age, the neonate was intubated
and administered surfactant (Curosurf). Despite this, the patient’s
condition remained severe, and laboratory evidence of hypoxemia emerged
(oxygen saturation 80-85% despite 100% fiO2). Given
the suspicion of progressive PPHN, an infusion of 20% magnesium sulfate
was started, but without a satisfactory therapeutic effect.
Echocardiography showed left-to-right flow through the F.o.,
right-to-left shunting in the DA and mild tricuspid regurgitation.
Administration of milrinone at approximately 10 hours of age (loading
dose of 50 µg/kg, followed by 0.5 µg/kg/min) contributed to a rapid
increase in oxygen saturation so that the ventilation parameters could
be reduced. Echocardiography demonstrated predominantly left-to-right
flow in the DA and F.o. Milrinone was withdrawn after achieving a
satisfactory therapeutic effect at approximately 27 hours of the
treatment. However, the patient’s condition has deteriorated rapidly
approximately three hours later, requiring modification of the pressor
amine doses, re-introduction of milrinone at continuous infusion (0.75
µg/kg/min), administration of 20% magnesium sulfate (200 mg/kg in
bolus) and transfer to another center where iNO therapy was available.
Following the transfer, the neonate remained under mechanical
ventilation, received 20% MgSO4 and pressor amines,
along with vancomycin and cefuroxime as MRCNS strain of S.
epidermidis was isolated from the lower respiratory tract. The
treatment contributed to a gradual improvement of the patient’s
condition. At approximately ten days of age, the neonate could be
extubated, and oxygen therapy was no longer needed starting on day 12.
No abnormalities were found on control echoencephalography carried out
before the discharge.