Pulmonary hypertension in preterm newborn with refractory hypoxemia undergoing ECMO

Background: Among the most common autonomic signs visible in preterm neonates, apnea can represent the first sign of several neurologic and non-neurologic disorders, and seizure is a relatively infrequent cause. Herein authors present a case of Pulmonary hypertension in a preterm newborn with asphyxia due to placental abruption, with refractory hypoxemia undergoing ECMO.

Case report: Fatema is a late-preterm newborn female (EG 36 + 5 wks) Weight 2900 g, of Asian breed, born from urgent CT due to placental abruption, with cardio-respiratory depression at birth which required intubation with tracheal aspiration of abundant blood fluid and external heart massage. Considering the risk of hypoxic-ischemic encephalopathy, she underwent hypothermic treatment. The respiratory failure  progressively worsened with the onset of refractory hypoxemia (Oxygenation Index 30) to the therapies in place (Ventilatory assistance in PC / AC with FiO2 100%, INO 40 ppm, inotropic therapy). The management of the newborn was complicated by severe hemodynamic instability which was managed pharmacologically to maintain balance between pulmonary hypertension and systemic hypotension.At about 80 hours of life, the ECMO team started an extracorporeal arteriovenous circulation in the ward and then proceeded with the transfer.  Despite brain CT showed "brain tissue damage on an ischemic level in the superficial and deep area of the right middle brain with millimeter areas of hemorrhagic infarction and laminar necrosis", the patient showed a good neurological outcome, assessed with  Nicu Network Neurobehavioral Scale (NNNS).

Conclusions: Fatema was discharged in clinical equilibrium at 3 months and 8 days of life, with a regular follow-up program at our center and neuromotor therapy 3 times a week at an Affiliated Center with the NHS. Despite the refractory hypoxemia in the acute phase, ECMO and the results of the cerebral instrumental investigations, the follow-up carried out in the first years of life at our center highlighted neurological and behavioral outcomes above expectations.

The authors are highly specialized neonatologists from the intensive care unit of the Betania Evangelical Hospital in Naples, who treated the newborn in question. The authors/neonatologists have extensive expertise in resuscitation, ultrasound, and neonatal intensive care.