Babies

I may have already mentioned that pregnant ladies terrify me. When obstetrical patients come in to the hospital they are hoping to have the best day of their life, but sometimes it could be the absolute worst--things can turn terrible in an instant. In the ER, it's almost always already the worst day of a patient's life, so as an ER doctor my job is to try to make it a little bit better. I prefer this scenario. In emergency medicine we are not frequently exposed to obstetrical patients once they reach about 20 weeks gestation, and the little experience that we do get is in our intern year, assisting with all the uncomplicated deliveries. And what's even scarier than a pregnant woman? The brand new human she brings into the world--the neonate. Unfortunately, they are NOT just tiny adults. 

Here at KRCH we currently have a late pre-term infant that we are caring for in the ward with hyperbilirubinemia. The patient was born on 12/30 at 35 weeks 3 days of gestation via normal vaginal delivery. This was his mother's second pregnancy, the first of which she also delivered prematurely, but at 29 weeks. That infant did not survive. This current pregnancy was uncomplicated...other than delivering two months early. 

The male infant was born without complication. At 37 hours of life a microbilirubin level was obtained, as is the typical protocol here. The level was 12 which placed the infant just above the intermediate high risk zone. The next day, on January 2, his level climbed to 16.8. At this time we started phototherapy. Since initiating phototherapy we've seen some decline in his MB levels, down to 16 on 1/4, but he's continued to have spikes, peaking at 19.2 yesterday morning. 

The microbilirubin trend over the last week. 

Clinically, he is otherwise doing well. He appears jaundiced, but he is a Thai baby so it is difficult to adequately assess the severity of this. He does not have any obvious yellowing of his eyes. He is breastfeeding well and gaining weight. He is active, with good tone. He does not have labile temperatures. In short, he's doing great other than his elevated bilirubin levels.

Today we sent off labs to assess for G6PD deficiency, which is one of those things in the US that you hear about but rarely diagnose, and certainly never from the emergency room.

And sure enough, this evening the lab came back as positive for G6PD deficiency. 

It turns out that 17% of Thai people have this inherited genetic disorder. It's an x-linked genetic disorder, so it is much more common in males. G6PD is uncommon in the US, but it is the most common enzymatic disorder of RBCs. Basically, without the enzyme G6PD, there is no production of NADPH and RBCs are more prone to oxidative injury ie stress. The disease is more prevalent in areas where malaria has historically been endemic, which has led to the hypothesis that perhaps G6PD deficiency may confer a selective advantage against Plasmodium falciparum.

There's a whole host of types of G6PD deficiency, and ranges of severity.

The treatment is basically to avoid oxidative stress ie certain medications, infections, and fava beans: 

The management of neonatal jaundice due to G6PD deficiency is the same as for neonatal jaundice from other causes. So we'll continue phototherapy here, and hope baby continues to improve!

And speaking of babies....BABY GOATS! There is one other American that lives in our village, Lindsey. She works at the Christian School near the hospital. She is married to a Thai man and has a beautiful baby boy named Benjamin. One of their goats had TRIPLETS just after the new year, and we got to visit them yesterday. FIVE DAY OLD BABY GOAT TRIPLETS. The second picture is Chris feeding one of the babies while the other one is sucking on his finger. 

These kinds of babies don't scare me one bit :)