Case 14 A serious feeding problem
Tanya is born at 18.30, at 41 weeks gestation following a normal pregnancy. She has Apgar scores of 8 at 1 minute and 9 at 5 minutes and weighs 3.12 kg. Tanya’s mother received an epidural for pain relief, and labour lasted for 15 hours. Tanya looks well, and is put to the breast in the labour ward.
During the evening, Tanya’s mother feels hot and shivery and is reviewed by the Obstetric ST3, who thinks that the cause might be a urinary tract infection, sends a maternal urine sample to the laboratory, and prescribes amoxicillin.
What are the implications of this finding for the baby?
The following morning at 06.10, it is noted that Tanya has stopped latching onto the breast. She requires supplementary feeding using expressed breast milk by nasogastric tube, and is put to the breast every 3 hours. At 14.30, the midwife notices that Tanya is grunting and tachypnoeic, and calls the neonatal ST2 to examine her. The ST2 reviews Tanya at 14.45, and observes that she is grunting and pale, with a respiratory rate of 90/min, and a heart rate of 180/min. Her CRT is 2 secs. She is admitted to NICU immediately.
What information do you need?
On admission to NICU, Tanya’s temperature is 36°C, her pulse 185/min, and her blood pressure 88/50 mmHg. Her respiratory rate is 100/min with recession and expiratory grunting. Her oxygen saturation is 82% in air, rising to 93% in 50% oxygen. Her capillary blood gas shows a pH 7.15 (normal 7.35–7.45), PCO2 8.4 kPa (4.7–6.4 kPa) and lactate 6.0 mmol/L (<2mmol/L).
What further tests should you do?
An iv line is sited, and blood cultures are taken. A FBC is sent, and a CXR is requested. The blood glucose is 8.4 mmol/L (2.8–4.5 mmol/L). Intravenous benzylpenicillin and gentamicin are administered at 15.05. Shortly afterwards, the FBC is reported: Hb 17.4 g/dL (14–22 g/dL), WBC 6.2 × 109/L (9–30 × 109/L), neutrophils 0.5 × 109/L (4–24 × 109/L), platelets 65 × 109/L (150–400 × 109/L). Tanya’s CXR shows widespread patchy consolidation, with a small pleural effusion at the left base. Shortly after the CXR, Tanya starts to have profound apnoeas and requires intermittent positive pressure ventilation.
What is your working diagnosis?
At 17.00 the microbiology laboratory reports that the mother’s urine has a heavy growth of a Gram positive coccus. Tanya continues to deteriorate, becomes oliguric and hypotensive, and requires inotropic support with dopamine and noradrenaline infusions for 2 days. She is ventilated for 6 days, and receives iv benzylenicillin and gentamicin for 10 days. A lumbar puncture is done and the CSF is sterile, but her blood cultures produce a heavy growth of Group B beta haemolytic streptococcus. At follow-up, she is developmentally delayed with acquired microcephaly.
Tanya’s mother makes a complaint stating that her daughter’s developmental delay resulted from delayed treatment of her septicaemia.
Expert opinion
Early-onset Group B Streptococcal (GBS) Septicaemia has a fulminant presentation. Although the labour went well, and this appeared to be a low risk delivery, the mother’s symptoms immediately postnatally suggest that she is likely to have had a Group B streptococcal urinary tract infection in labour that was undiagnosed. A maternal GBS urinary tract infection is a marker of heavy maternal colonization, and increases the risk of neonatal infection approximately 10-fold.
If the maternal infection had been recognized antenatally, the mother would have beenoffered intrapartum penicillin prophylaxis, to reduce the risk of vertical transmission of the infection. In the UK, there is currently (2011) no national screening programme for GBS in pregnancy, although GBS screening in late pregnancy is routine in the USA, because the prevalence of maternal GBS carriage is significantly higher there than in the UK.
Postnatal antibiotic prophylaxis for the infant of a GBS colonized mother has been shown to be ineffective, but vigilance for symptoms and early treatment of the symptomatic baby is essential.
In this case, there was no postnatal communication between the obstetric and neonatal teams. The mother was managed independently, and the implications of her infection for Tanya were not considered.
Failure of a term baby to feed requires active investigation – any term baby who needs a nasogastric tube requires a formal diagnosis. In this case, it is highly likely that the feeding difficulties were due to the combination of tachypnoea and floppiness, resulting from bacterial sepsis.
It is thus clear that there was at least an eight-hour delay in initiating treatment, and that if more intensive observation of the baby had been instituted when her mother had a rigor, it is distinctly possible that Tanya may have been treated earlier and that the neurological sequelae could have been avoided.
The microcephaly that was subsequently identified was a consequence of injury to the white matter of the brain as a result of the septic shock.
Legal comment
Tanya’s mother has complained to the hospital about the treatment of her newborn baby. If she seeks compensation, then this could be a £1,000,000+ claim at full valuation, depending on the severity of the developmental delay and its future implications for Tanya’s life. The extent of the claim will depend on the answers to such questions as: will Tanya be able to find employment and will she need a carer when she reaches maturity?
We say ‘full valuation’, because there could be significant question marks concerning causation. Treatment should probably have been started earlier, but initially, Tanya is likely to have just been observed. The real question is: when would a reasonable doctor have started intensive antibiotic treatment? It is likely that the opinions of the instructed experts will differ. Clearly the hypothetical time when Tanya ‘should’ have received treatment may make a difference to whether her microcephaly and developmental delay could have been avoided.
It is, therefore, likely that any claim will be settled at a discount.
The main error here appears to be a systems failure: the mother’s postnatal infection was not communicated to the paediatric team. The Obstetric and Paediatric Departments need to talk to each other!
