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Case 166

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A full-term male infant was born by vaginal delivery. Shortly after birth, the baby presented apnoea and less than 100 bpm heart rate, and then resuscitation manoeuvres were performed in the delivery room. It received positive pressure ventilation with self-inflating bag and endotracheal tube. Apgar scores were 2 and 9 at first and fifth minute, respectively. The newborn was presented to the parents and referred to the neonatal unit of progressive care (NUPC). Clinical examination revealed decreased breath sounds on the left hemithorax, scaphoid-appearing abdomen and barrel-shaped chest. Also, there was a relate of inadequate prenatal care, with only three visits to the health centre and one ultrasound exam carried out, which was done in the first trimester of pregnancy and did not reveal any abnormality. In the NUPC, chest and abdomen bedside radiography was requested.

Given the clinical presentation and image attached, which would be the most appropriate approach?

a) Surgical approach through thoracotomy in emergency

25%

b) Thoracentesis the 2nd left intercostal space in the midclavicular line

25%

c) Inhalation therapy with surfactant and control of acid-base disorders

25%

d) Hemodynamic stabilization with control of acid-base disorders and posterior surgical approach

25%
   

Image Analysis

Image 1: Chest and abdomen radiography showing rounded and hypotransparent formation with air-fluid level in the lower half of the left hemithorax (bordered in red), consistent with gastric bubble. Related to it, there is an opacity in the upper half of the hemithorax and deviation of mediastinal structures to the opposite side. This upper half of the left hemithorax opacity may correspond to atelectasis or pulmonary hypoplasia.

Highlights

- Congenital diaphragmatic hernia (CDH) is a developmental defect in the diaphragm that allows abdominal viscera to herniate into the chest, thereby interfering with normal lung development.

- Lung hypoplasia and pulmonary hypertension are often associated with CDH.

- Diagnosis can be made prenatally with ultrasound examination.

- Acute and severe respiratory distress at birth is the most common clinical presentation.

- Chest radiography associated with the clinical presentation makes the diagnosis.

-Treatment is based on stabilization for posterior surgery.

References

1. Ballén, F.; Arrieta, M.; Hernia diafragmática congénita. Rev. Col. Anest. Mayo - julio 2010. Vol. 38 - No. 2: 241-258

2. MOREIRA, MEL., LOPES, JMA and CARALHO, M., orgs. O recém-nascido de alto risco: teoria e prática do cuidar [online]. Rio de Janeiro: Editora FIOCRUZ, 2004. 564 p. ISBN 85-7541-054-7.

3. Hedrick, H.L.; Adzick, N.S.; Congenital diaphragmatichernia in theneonate. In UpToDate. Disponível em: http://www.uptodate.com/contents/congenital-diaphragmatic-hernia-in-the-neonate. Acessado em 15 de agosto de 2014.

4. Atenção à Saúde do Recém-Nascido - Guia para os Profissionais de Saúde 2011 V.3 – Ministério da saúde

Author

Luanna da Silva Monteiro, 6th year medical student at UFMG.

Email: luannasmonteiro[arroba]gmail.com

Supervisor

Márcia Penido, pediatrician, Professor of the Department of Pediatrics at UFMG School of Medicine.

Email: mgpenido[arroba]gmail.com

Reviewers

Marina Bernardes Leão, Cinthia Barra, Fabio M. Satake, Júlia Petrocchi, André R. Guimarães

Translated by

Ana Júlia Furbino Dias Bicalho, 6th year medical student at UFMG. Email: anajuliabicalho[at]gmail.com

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