Dr. Hiren Doshi
Director - PICU & NICU
Nanavati Super Speciality
Hospital, Mumbai

Dr. Suresh Birajdar
Joint Director, PICU & NICU
Nanavati Super Speciality
Hospital, Mumbai

Globally, approximately 10% of all pregnancies result in premature delivery even after the best of efforts taken by Obstetricians. The survival of extremely premature babies (those weighing less than 1 kg or born after less than 28 weeks of pregnancy) is even more challenging due to the incomplete development of body organs and functions.

Babies delivered at the gestational age of 23-24 weeks are considered to have borderline survival potential as their organs are extremely immature. Recently, the Neonatal team at Nanavati Super Speciality Hospital was presented with a challenging case of a neonate who was born prematurely after 23 weeks of pregnancy (i.e. less than 6 months of pregnancy). A team of highly dedicated Neonatal specialists and state-of-the-art technology are essential for the nurturing of such delicate lives. The NICU team at Nanavati is used to such challenges, having managed to discharge babies as small as 550 gms (26 weeks of gestation).

It is a herculean measure to manage babies as small as the palm of our hand. There are only a few case reports in our country where babies born before 24 weeks have survived. This unique case of 23- week old gestation baby who was discharged successfully signifies a new milestone and sets the bar even higher for the future.

THE CASE

Mrs. & Mr. Kujur are residents of Tarapur, Palghar in Maharashtra. The mother, Sunita, a 35-year-old woman with premature onset of labour after 23 weeks of pregnancy was referred to Nanavati. This was her second pregnancy with the previous child being 10 years old. She had received a single dose of IV steroid for maturity of the foetal lungs. The baby boy weighing 650 gms was delivered spontaneously in the emergency department. The baby cried after birth, but the breathing was laboured. He was intubated and put on a mechanical ventilator for breathing support wherein he received two doses of surfactant for lung maturity.

THE PROCEDURE

The baby boy responded to an initial management of surfactant therapy, ventilation and intravenous fluids. Total parenteral nutrition was administered through a central catheter. Maintaining metabolic milieu and preventing infections are the biggest challenges in micro-preemies. Early enteral nutrition with exclusive breast milk was administered through a feeding catheter which was gradually increased over the next few weeks. The parenteral nutrition was well tolerated.

Mrs. & Mr. Kujur with Nanavati Hospital team

There is always a very fine balance to be maintained in these babies, because of the high risk of Necrotising Enterocolitis (NEC) that can be precipitated because of enteral feeds. Over the next 30 days, feeds were gradually increased and breastfeeding was started by 35 weeks of gestational age. In addition to two doses of surfactant, the baby boy required a mechanical ventilator for 30 days due to premature lungs. Post ventilator, he required non-invasive CPAP for around 60 days. At the end of 3 months, the baby was breathing on his own with minimal intermittent oxygen requirement administered intra-nasally.

Regular ultrasonographic scans were performed satisfactorily on the baby. A presence of Retinopathy of Prematurity (ROP) was found during regular evaluation of eyes by Paediatric Retina specialist. The infant underwent regular investigations for sepsis and electrolyte levels. He received transfusions of packed red blood cells, iron supplements and erythropoietin for anaemia. For the prevention of Metabolic Bone Disease (MBD) of prematurity, calcium and vitamin D supplements were given to the baby. Inspite of multiple catheters, central lines, prolonged ventilation, the baby did not acquire any major hospitalacquired infection (HAI). This is an important measure of the success of infection prevention protocols, especially when dealing with a micro preemie.

THE RESULT

At the time of discharge, the baby weighed 2.7 kg and was on breastfeed. He maintained adequate oxygen saturation by breathing normal room air.