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• W2118380986 abstract "An 18-year-old gravida 1 woman delivers a 600-g male infant at 28 weeks estimated gestational age by emergency cesarean section. The pregnancy was complicated by oligohydramnios, pregnancy-induced hypertension, and intrauterine growth restriction. Labor was induced due to worsening hypertension, and an emergency cesarean section was performed due to abruption. The baby's Apgar scores are 3 at 1 minute and 7 at 5 minutes.The infant is resuscitated initially with infant ventilation in the delivery room. However, the development of marked respiratory distress, deep retractions, and poor air entry bilaterally prompts endotracheal intubation and placement of the infant on mechanical ventilation. Ventilator settings are: positive inspiratory pressure of 17 mm Hg, positive end-expiratory pressure of 5 mm Hg, Fio2 of 0.4, and intermittent mandatory ventilation of 35 breaths/min. Surfactant is administered because of continued respiratory distress, and dopamine administration is initiated for persistent low blood pressure. Serum is obtained for hematology laboratory evaluation and blood culture, abdominal and chest radiographs are taken to evaluate respiratory status, and empiric antibiotic therapy with intravenous ampicillin and gentamicin is initiated.The initial complete blood cell count reveals a white cell count of 8.29×103/mcL (8.29×109/L), hemoglobin of 11 g/dL (110 g/L), hematocrit of 32% (0.32), and platelet count of 84 ×103/mL (84×109/L). Electrolytes are reported as: sodium, 138 mEq/L (138 mmol/L); potassium, 4.8 mEq/L (4.8 mmol/L); chloride, 108 mEq/L (108 mmol/L); bicarbonate, 23 mEq/L (23 mmol/L); blood urea nitrogen, 12 mg/dL (4.3 mmol/L); and creatinine, 0.8 mg/dL (70.7 mcmol/L). Blood cultures are negative.Chest radiography reveals an elevated diaphragm with a prominent stomach bubble (Fig. 1). A size 8 French Replogle tube is inserted and connected to low-wall intermittent suction. At 18 hours of age, the patient demonstrates increasing abdominal distention (Fig. 2). Left lateral decubitus abdominal radiograph shows free air in the abdomen and grossly dilated intestinal loops; the abdominal radiograph shows an abundant amount of free air. Another imaging study reveals the diagnosis.Abdominal computed tomography (CT) scan revealed a defect in the left hemidiaphragm (Fig. 3). The herniation of fluid filling the peritoneum through the defect in the left hemidiaphragm gave the false impression of diaphragmatic eventration on plain chest radiography. CT scan documented gastric perforation in association with diaphragmatic hernia.Neonatal gastric perforation can occur spontaneously through overdistention or as a result of underlying diseases such as duodenal atresia, pyloric atresia, tracheoesophageal fistula, malrotation, diaphragmatic eventration, and diaphragmatic hernia. Due to the few case reports of gastric perforation in association with diaphragmatic hernia, the pathogenesis is poorly understood, but the condition is believed to be due to overdistension of the stomach wall or acute gastric volvulus. Most perforations occur in the greater curvature of the stomach. Extreme prematurity, low birthweight, and delay in diagnosis are associated with a poor prognosis. Early diagnosis and correction of hemodynamic and metabolic status leads to improved outcome.An exploratory laparotomy was performed at the bedside for this infant. A large collection of clear fluid was found in the left upper portion of the abdomen, with a massive perforation noted in the posterior wall of the stomach. The rest of the abdominal contents, including the small and large intestines, liver, and spleen, appeared normal. The perforation was closed, leaving a tube through a hole in the anterior stomach wall connected to suction.Gastric perforation can present with any combination of abdominal distention, feeding intolerance, respiratory distress, or poor activity. The most common radiographic finding in gastric perforation is pneumoperitoneum. In this case, abdominal CT scan was employed for its sensitivity in differentiating between diaphragmatic hernia and eventration. Early diagnosis of gastric perforation, with correction of hemodynamic and metabolic status, leads to improved outcome and reduced morbidity. (Venkatakrishna Kakkilaya, MD, Guillermo Sangster, MD, Dalibor Kurepa, MD, Sameh Hussein, MD, Hassan Ibrahim, MD, Louisiana State University Health Science Center, Shreveport, La.)" @default.
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• W2118380986 date "2009-04-01" @default.
• W2118380986 modified "2023-09-27" @default.
• W2118380986 title "Index of Suspicion in the Nursery" @default.
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• W2118380986 doi "https://doi.org/10.1542/neo.10-4-e198" @default.
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