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Oleh :
Ledy N Tandiawan
Pembimbing :
Dr dr Rocky Wilar, SpA(K)
dr. Johnny Rompis, SpA(K)
2
Correction
- Tittel :
TERM INFANT APPROPIATE FOR GESTATIONAL AGE, SEPSIS
NEONATORUM, MECONIUM ASPIRATION SYNDROME, AND
DECOMPENTATIO CORDIS EC ATRIAL SEPTAL DEFECT IN A NEONATES
Correction
References:
1. Aakash Pandita, MD; srinivas Mukti, DM; Tejo Pratap Oleti, DM; Baswaraj Tandur, DNB; sai Kiran,
DNB; et all. Effect of Nasal Continous Positive Airway Pressure on Infants With Meconium
Aspiration Syndrome Arandomized Clinical Trial : Original investigation, From the American
Medical Association. JAMA Pediatrics. 2017.3873.
2. Gallacher Dj, Hart K, Kotecha S. Common Respiratory Conditions of The newborn. Department
of Child Health, School of medicine, Cardiff University, Cardiff, UK. Breathe 2016;12:30-42
3. Martin O. Edwards; sarah J. Kotecha; Sailesh Kotecha. Respiratory Distress of The Term
Newborn Infant. Department of child Healt, School of Medicine, Cardiff, UK. Paediatric
Respiratory Reviews 14(2013)29-37
4. Rakesh Amroliwala, Manish Rasania, et all. Study of Congenital Heart Disease in Neonates.
International Journal of Contemporary Pediatrics. 2018 jan;5(1):75-81
5. Jann P Foster, Adam Buckmaster, Lynn Sinclair, Sylvia Lees, Robert Guaran. Nasal Countinous
Positive airway pressure (nCPAP) for term neonates with respiratory distress. The Cochrane
Collaboration 2015, Issue 11. Art. No: CD011962
4
Timeline
Jan 16th 2018 Jan 17th 20178 Jan 29th 2018 Feb 12th 2018
Patient was
admitted to Observation Final
Kandou started observation Reporting
Hospital
5
CASE REPORT
PATIENT’S RECORD
I. IDENTITY
Patient Identity
Patient Name : SP
Sex : Male
Date of birth : january 16th 2018
Place of birth : Permata Bunda
Hospital
Nationality : Indonesia
Ethnic : Minahasan
Religion : Christian
Date of Examination : january 16th 2018
Registration Number : 52.27.XX
6
Parental Identity
FATHER MOTHER
Name : GS Name : FDP
Age : 29 years old Age : 28 years old
Occupation : Goverment Occupation : Housewife
Department Last Education : Bachelor degree
Last Education : Bachelor degree
Family tree 7
1. GS Father M 29 Healthy
2. FDP Mother F 28 Healthy
3. PS Brother M 7 Healthy
4. MS Sister F 6 Healthy
5. SP Patient M 0 patient
8
History of Birth
Mother Patient
Physical examination
General condition : activity (+) decrease , reflex (+) decrease
Heart rate : 180 bpm
Respiratory rate : 90 bpm
Body temperature : 36.8 oC
Sp O2 : 90 %
12
Physical examination
Skin : few veins, lanugo hair was thinning , no jaundice,
Head : oval shape, no caput succadenum, open anterior fontanel (+)
Eye : conjunctiva was not anemic and sclera not icteric, isocor pupil,
Ø 2mm-2mm, light reflex +/+
Mouth : cyanotic lips
Chest : symmetrical respiration movement on the both side hemithorax,
subcostal, intercostal retraction, raised areola 3-4 mm bud
Heart : regular heart rhythm, with murmur
Lung : bronchovesicular breathe sound, retraction (+) subcostal,
intercostal,xyphoid, rales on both sides, no wheezing on both sides
Abdomen: soft and flat, liver and spleen were not palpable, peristaltic
movement was normal, meconium stained umbilical cord
Ekstremities : warm, normal capillary refill time, no deformity.
Genital : male, testes down, good rugae, penis length 2 cm,
phimosis (-)
13
• Downes score :
1. Air entry ( normal ) :o
2. Cyanosis (no with oxygen support) :1
3. Retraction (mild) :1
4. Grunting (audible with no stethoscope) :2
5. Respiration rate ( >80 times per minute) :2
Total :5
14
Laboratory result
Examination 17/01/2018 18/01/2018
Hb (g/dl) 15,9 13,8
Ht (%) 45,6 38,2
Leuco (/L) 18100 11500
Trombo (/L) 263000 227000
Diff.count (%) 0/3/7/45/38/7 1/0/10/45/39/5
ALT (U/L) - 59
AST (U/L) - 8
Ureum (mg/dl) - 93
Creatinin (mg/dl) - 0,3
Clorida (mEq/L) - 99,5
Kalium (mEq/L) - 4,46
Natrium (mEq/L) - 135
Calcium (mg/dl) - 7,54
CRP (mg/L) 6 <6
Total Bilirubin (mg/dl) - 10,27
Direct Bilirubin (mg/dL) 0.25
PT (C) (second) - 17,3 (13,7)
APPT (C) (second) 35,5 (33,2)
15
DIAGNOSIS
Term infant appropriate for gestational age
meconium aspiration syndrome
Suspect neonatal sepsis
Suspect Congenital Heart Defect
16
PROBLEMS
Diagnosis Problems
Blood culture is need long time to see the result
Therapy problems
The theraphy in this patient, use the antibiotics first line in two
days and then up grade with the second line of antibiotics
Follow up problems
Follow up the retraction, body weight, respiratory
17
Planning therapy
Treatment :
- CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m
- IVFD Dextrose 10% 216 ml
Dextrose 40% 11 ml
NaCl 3% 6 ml
KCl 3 ml 10 ml/hour
MgSO4 1,5 ml
Ca gluconas 1,9 ml
Aminosteril 6% 0 ml
Soluvit 0,5 ml
(fluid 80 ml/kgBW/day, protein 0 gr/kgBW/day, GIR 6)
- Ampicillin 2 x 150 mg intravenous injection (1st day)
- Gentamycin 15 mg intravenous injection/ 36 hours (1st day)
- Nothing per oral
- Regular blood glucose measurement / 24 hours
18
Planning treatment
Nutritional Care
good nutritional status based on WHO Z-score chart
body weight per body length for boys 0-6 month, was
on between line +2 to -2 SD.
Planning diagnosis:
Consult to pediatric cardiology department
echocardiography
19
Planning Treatment
Nursing treatment
Vital sign monitoring
Patient hygiene
Nursing care of newborn
Mentally support to the family
FOLLOW UP
20
17January 2018 (Observation day 1st, 1st day hospitalization) 18 January 2018 (Observation day 2, 2nd day hospitalization) 21
S Takipneu(+), short of breathness (+), cyanotic (+) S Takipneu(+), short of breathness (+), cyanotic (-)
General condition : activity (+) decrease, reflex (+) decrease General condition: activity (+) decrease, reflex (+) decrease
Heart rate : 180 beats/minute Sp O2: 90 % Heart rate : 165 beats/minute Sp O2 : 99 %
Respiratory rate : 90 times/minute Respiratory rate : 86 times/minute
Body temperature : 36,8ᴼC Body temperature : 36,7ᴼC
Body weight : 3000 grams Blood glucose : 108 gr/dL Body weight : 2950 grams
Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic Blood glucose : 71 gr/dL
lips HeadHb (g/dl) was not anemic and sclera was
: Conjunctiva 13,8
not icteric, no cyanotic lips
O Chest : Symetrical respiration movement on the both side, retraction (+) O Chest : Symetrical respiration movement on the38,2
Ht (%) both side, retraction (+)
subcostal, intercostal Leuco (/ L)
subcostal, intercostal 11500
Heart : regular heart rhythm, murmur
Consul to cardiology: HeartTrombo (/ L)rhythm, murmur
: regular heart 227000
Lung : bronchovesicular breathe sound, rales on both sides, no wheezing. Lung Diff.count (%) breathe sound, rales
: bronchovesicular 1/0/10/45/39/5
on both sides, no wheezing.
Diagnosa : Decompensatio
Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic ALT Soft
Abdomen: (U/L) and flat, liver and spleen were not59
8
Hb (g/dl)
movement was normal
cordis ec suspect ASD AST (U/L)
palpable, peristaltic movement was normal
15,9
Ekstremities : Warm, normal capillary refill time (<3 seconds) Ekstremities : Warm,
Ureum (mg/dl) normal capillary refill time 93
(<3 seconds)
Ht (%)
Skin : No jaundice Therapy : Captopril 3 x Skin :Creatinin
No jaundice(mg/dl) 0,3
45,6 Clorida (mEq/L) 99,5
- Leuco (/L)
0,9mg oral (do
term infant appropriate for gestational age - term infant
Kalium 4,46
appropriate for gestational age
(mEq/L)
- meconium aspiration syndrome
0,3mg/kgBw/times)
18100 - meconium aspiration syndrome 135
A Trombo (/L) A Natrium (mEq/L)
- neonatal sepsis
Digoxin 263000 - neonatal sepsis
Calcium (mg/dl) 7,54
- Diff.count
Congenital Heart (%)2 x 0,15mg oral (do:
defects - decompensatio
CRP (mg/L) cordis ec suspect ASD <6
0,01mg/kgBw/day) 0/3/7/45/38/7 Total Bilirubin 10,27
CPAP FiO2 IT
40%ratio
CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m
PEEP 7 cmH20 O2 Flow 8 L/m
IVFD (m g/dl) 10% 221 ml
IV0,14
Dextrose
IVFD Dextrose 10%Furosemid 2x3mg (do
CRP (mg/L)
216 ml Direct Bilirubin
Dextrose 40% 26 ml 0.25
Dextrose 40% 11 ml
NaCl 3% 61mg/kgBw/times)
ml
6
10 ml/hour
(fluid 80 ml/kgBW/day)
(mg/d L)
NaCl 3% 6 ml
PTKCl(C) (second)
3 ml 17,3 (13,7)
KCl 3 ml APPT 35,5 (33,2)
MgSO4(C) 1,5 ml
MgSO4 1,5 ml (second)
Ca gluconas 1,9 ml
Ca gluconas 1,9 ml
P P Aminosteril 6% 100 ml
Aminosteril 6% 100 ml
Soluvit 0,5 ml
Soluvit 0,5 ml
Ampicillin 2 x 150 mg intravenous injection (2st day)
Ampicillin 2 x 150 mg intravenous injection (1st day)
Gentamisin 15 mg intravenous injection (2st day)
Gentamicin 15mg intravenous injection (1st day)
Nothing per oral
Nothing per oral
Regular blood glucose measurement / 24 hours
Regular blood glucose measurement / 24 hours
Dobutamin 90mg in NaCl 0,9% 50cc = 5mg/kgBw) = 0,5mcg/kgBw/minutes
Furosemid IV 2x3mg (do 1mg/kgBw/times)
19 January 2018 (Observation day 3, 3rd day hospitalization) 20 January 2018 (Observation day 4, 4th day hospitalization) 22
S Takipneu(+), short of breathness (+), cyanotic (-) S Takipneu(+) decrease, short of breathness (+)decrerase, cyanotic (-)
General condition : activity (+) decrease, reflex (+) decrease General condition : activity (+) decrease, reflex (+) decrease
Heart rate : 160 beats/minute Sp O2 : 99 % Heart rate : 160 beats/minute Sp O2: 99 %
Respiratory rate : 86 times/minute Respiratory rate : 60 times/minute
Body temperature : 36,7ᴼC Body temperature : 36,6ᴼC
Body weight : 2950 grams Body weight : 2940 grams
Blood glucose : 98 gr/dL Blood glucose : 104 gr/dL
Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic lips Head : Conjunctiva was not anemic and sclera was not icteric, no cyanotic
O Chest : Symetrical respiration movement on the both side, retraction (+) O lips
subcostal, intercostal Chest: Symetrical respiration movement on the both side, retraction (-)
Heart : regular heart rhythm, murmur Heart: regular heart rhythm, murmur
Lung : bronchovesicular breathe sound, rales on both sides, no wheezing. Lung : bronchovesicular breathe sound, rales on both sides, no wheezing.
Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic Abdomen : Soft and flat, liver and spleen were not palpable, peristaltic
movement was normal movement was normal
Ekstremities : Warm, normal capillary refill time <3 seconds Ekstremities : Warm, normal capillary refill time (<3 seconds)
Skin : No jaundice Skin : No jaundice
- term infant appropriate for gestational age - term infant appropriate for gestational age
- meconium aspiration syndrome - meconium aspiration syndrome
A A
- neonatal sepsis - neonatal sepsis
- decompensatio cordis ec suspect ASD - decompensatio cordis ec ASD
Medications:
CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m CPAP FiO2 40% PEEP 7 cmH20 O2 Flow 8 L/m
IVFD Dextrose 10% 226 ml IVFD Dextrose 10% 226 ml
Dextrose 40% 21 ml Dextrose 40% 21 ml
NaCl 3% 6 ml NaCl 3% 6 ml
KCl 3 ml KCl 3 ml
MgSO4 1,5 ml MgSO4 1,5 ml
Ca gluconas 1,9 ml Ca gluconas 1,9 ml
P Aminosteril 6% 100 ml P Aminosteril 6% 150 ml
Soluvit 0,5 ml Soluvit 0,5 ml
Ceftazidim 2 x 150 mg intravenous injection (1st day) Ceftazidim 2 x 150 mg intravenous injection 2nd day)
Amikasin 2x 25 mg intravenous injection (1st day) Amikasin 2x 25 mg intravenous injection (2nd day)
Nothing per oral Breast milk 8 x 5ml (needs 15ml/kgBw/day)
Regular blood glucose measurement / 24 hours Regular blood glucose measurement / 24 hours
Dobutamin 90mg in NaCl 0,9% 50cc = 5mg/kgBw) = 0,5mcg/kgBw/minutes Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times)
Furosemid IV 2x3mg (do 1mg/kgBw/times) Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day)
Furosemid IV 2x3mg (do 1mg/kgBw/times)
21-22 January 2018 (Observation day 5-6th, 5-6th day hospitalization) 23 January 2018 (Observation day 7th, 7th day hospitalization) 23
S Takipneu(+) decrease, short of breathness (+)decrerase, cyanotic (-) S Takipneu(+) decrease, short of breathness (+) decrerase, cyanotic (-)
CPAP FiO2 40% PEEP 6 cmH20 O2 Flow 8 L/m CPAP FiO2 21% PEEP 5 cmH20 O2 Flow 8 L/m
IVFD Dextrose 10% 226 ml IVFD Dextrose 10% 226 ml
Dextrose 40% 21 ml Dextrose 40% 21 ml
NaCl 3% 6 ml NaCl 3% 6 ml
KCl 3 ml KCl 3 ml
MgSO4 1,5 ml MgSO4 1,5 ml
Ca gluconas 1,9 ml Ca gluconas 1,9 ml
Aminosteril 6% 150 ml Aminosteril 6% 150 ml
P P
Soluvit 0,5 ml Soluvit 0,5 ml
Ceftazidim 2 x 150 mg intravenous injection 3rd day) Ceftazidim 2 x 150 mg intravenous injection 5th day)
Amikasin 2x 25 mg intravenous injection (3rd day) Amikasin 2x 25 mg intravenous injection (5th day)
Breast Milk 8 x 12ml (needs 30ml/kgBw/day) Breast Milk 8 x 12ml (needs 30ml/kgBw/day)
Regular blood glucose measurement / 24 hours Regular blood glucose measurement / 24 hours
Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times) Captopril 3 x 0,9mg oral (do 0,3mg/kgBw/times)
Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day) Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/day)
Furosemid IV 2x3mg (do 1mg/kgBw/times) Furosemid IV 2x3mg (do 1mg/kgBw/times)
24-25 January 2018 (Observation day 8-9th, 8-9th day 26-28 January 2018 (Observation day 10-12th, 10-12th day24
hospitalization) hospitalization)
Takipneu(+) decrease, short of breathness (+) decrerase, cyanotic
S S Takipneu(-), short of breathness (-), cyanotic (-)
(-)
General condition : activity (+) decrease, reflex (+) decrease
General condition : activity (+), reflex (+)
Heart rate : 152 beats/minute Sp O2 : 96 %
Heart rate : 148 beats/minute Sp O2 : 96 %
Respiratory rate : 48 times/minute
Respiratory rate : 32 times/minute
Body temperature : 36,6ᴼC
Body temperature : 36,6ᴼC
Body weight : 2910 grams
Body weight : 2940 grams
Blood glucose : 110 gr/dL
Head : Conjunctiva was not anemic and sclera was not icteric,
Head : Conjunctiva was not anemic and sclera was not icteric, no
no cyanotic lips
cyanotic lips
Chest : Symetrical respiration movement on the both side,
O Chest : Symetrical respiration movement on the both side, O
retraction (-)
retraction (-)
Heart : regular heart rhythm, murmur
Heart : regular heart rhythm, murmur
Lung : bronchovesicular breathe sound, rales on both sides,
Lung : bronchovesicular breathe sound, rales on both sides, no
no wheezing.
wheezing.
Abdomen : Soft and flat, liver and spleen were not palpable,
Abdomen : Soft and flat, liver and spleen were not palpable,
peristaltic movement was normal
peristaltic movement was normal
Ekstremities : Warm, normal capillary refill time <3 seconds
Ekstremities : Warm, normal capillary refill time (<3 seconds)
Skin : No jaundice
Skin : No jaundice
- term infant appropriate for gestational age - term infant appropriate for gestational age
- meconium aspiration syndrome - meconium aspiration syndrome
A A
- neonatal sepsis - neonatal sepsis
- decompensatio cordis ec suspect ASD - decompensatio cordis ec suspect ASD
Echocardiography:
Result: mild secundum ASD 44mm with L-R shunt
Suggest: echocardiography 1 next later
PROGNOSIS
Ad Vitam : ad bonam
Ad Functionam : dubia ad bonam
Ad Sanationam : dubia ad bonam
26
Disease Course Timeline 27
Observation period
th rd 1th th th th th
jan 17 –23 jan 2018 jan 24 – 25 jan 2018 Jan 26 – 28 2018 Jan 29 2018
tachycardia ↓ tachycardia (-), tachypneu (-), tachycardia (-), tachypneu (-), jaundice (-)
Tachycardia, tachyipneu
tachypneu ↓
term infant appropriate for term infant appropriate for gestational age
Hb (g/dl) 15,9 - term infant appropriate for
gestational age gestational age meconium aspiration syndrome
Ht (%) 45,6
- meconium aspiration syndrome meconium aspiration syndrome neonatal sepsis
Leuco (/L) 18100
- neonatal sepsis Decompentatio cordis ec ASD
Trombo (/L) 263000 neonatal sepsis
0/3/7/45/38/7 - Decompensatio cordis caused by
Diff.count (%) Decompensatio cordis caused by
0,14 suspected ASD
IT ratio suspected ASD
CRP (mg/L) <6
Breast milk on demand
Captopril 3x0,9mg po (do 0,3mg/kgBw/x)
O2 nasal 0,5l/m Digoxin 2 x 0,15mg oral (do:
- term infant appropriate for
Ceftazidim 2 x 150 mg iV Ceftazidim 2 x 150 mg iV
gestational age 0,01mg/kgBw/x)
Amikasin 2x 25 mg IV Amikasin 2x 25 mg IV
- meconium aspiration syndrome Furosemid 2x3mg (do 1mg/kgBw/x)
Milk 8 x30ml (needs 100ml/kgBw/day) Breast milk on demand
- neonatal sepsis
Captopril 3x0,9mg po (do Captopril 3x0,9mg po (do 0,3mg/kgBw/x)
- Congenital Heart Diseases
0,3mg/kgBw/x) Digoxin 2 x 0,15mg oral (do:
Digoxin 2 x 0,15mg oral (do: Echocardiography:
0,01mg/kgBw/x)
0,01mg/kgBw/x)
Furosemid 2x3mg (do 1mg/kgBw/x) Mild secundum ASD
CPAP FiO2 40% PEEP 7cmH2O O2 8l/m Furosemid IV 2x3mg (do 1mg/kgBw/x)
(fluid 150 ml/kgBW/day, protein 3
gr/kgBW/day – milk, GIR 11-12)
Ceftazidim 2 x 150 mg iV
Amikasin 2x 25 mg IV planning :
Breast Milk 8 x 5-12ml (needs Planning: echocardiography echocardiography Discharge
30ml/kgBw/day)
Captopril 3x0,9mg po (do 0,3mg/kgBw/x)
from hospital
Digoxin 2 x 0,15mg oral (do: 0,01mg/kgBw/x)
Furosemid IV 2x3mg (do 1mg/kgBw/x)
28
Male, 0 day
Takipneu after birth
CASE ANALYSIS History of Birth: by sectio caesaria with indication the mother had a history
sectio caesaria before and premature rupture of membranes > 18 hours
Babygram
Supportive Examination
echocardiography
Treatment NCAP
Antibiotic
Decompentatio cordis therapy
Pediatr
Pediatr Indones. 2016.
Indones. Level
2016. of Evidence
Level 2B, rekomendasi
of Evidence B B
2B, rekomendasi
Am J Health
M.o.Edward et all/Paediatric Respiratorybreview
Research. 2015. 14 (2013)
Level of Evidence 29-37
2B, rekomendasi B
JJ.Health
Am Evolution Med. Dent.
Research. 2015.Sci. 2016.
Level Level of Evidence
of Evidence 2B, rekomendasi
2B, rekomendasi B B
Evolution
J. Indian J Med.
Pediatr. 2015
Dent. Sci.Level
2016.ofLevel
Evidence 2B, rekomendasi
of Evidence B
2B, rekomendasi B
Indian J Pediatr. 2015 Level of Evidence 2B, rekomendasi B
29
DISCUSSION
Appropriate for gestational age is defined
as weight between 10th – 90th percentile,
small for gestational age is < 10th percentile
and large for gestational age is > 90th
percentile in Lubchenco curve
Cyanosis may be central, as cause by pulmonary disease and cyanotic heart disease, or
peripheral, as occurs in conditions with impaired cardiac output.
..
Cardiac failure is a clinical syndrome where the heart is unable to provide
the output required to meet metabolic demands on the body
In neonate, the cause of cardiac failure are significantly different and many
cases are due to congenital malformation such as lef to right shunts
Neonate with cardiac failure will show a history hard for drinking, tachypnea
and hard to gain weight and cold sweats
Commonly we could found tachycardia > 150 bpm, tachypnea > 60 bpm,
gallop, hepatomegaly and the chest X-ray we found CTR > 60%.
DISCUSSION 34
There was a systolic ejection murmur from the physical examination and the
echocardiography examination founded there were mild secundum ASD .
DISCUSSION 35
Sepsis is the commonest cause of neonatal mortality and is responsible for 30-
50% of total neonatal deaths each year in developing countries.
• Neonatal sepsis can be divided into two categories, early and late
onset sepsis. Early-onset sepsis (EOS) occuring at ≤ 72 hours in
infants hospitalized in neonatal intensive care unit (NICU) while
late-onset sepsis (LOS) occuring after 72 hours.
• Risk factors for early-onset sepsis include both maternal and infant
factors
EOS
Mayor risk factor Minor risk factors
Bubble NCPAP in comparison with standart care for infants with MAS
reduces the need for mechanical ventilation in the first days of life
Aakash Pandita, MD; srinivas Mukti, DM; Tejo Pratap Oleti, DM; Baswaraj Tandur, DNB; sai Kiran, DNB; et all. Effect
of Nasal Continous Positive Airway Pressure on Infants With Meconium Aspiration Syndrome Arandomized Clinical
Trial : Original investigation, From the American Medical Association. JAMA Pediatrics. 2017.3873.
Martin O. Edwards; sarah J. Kotecha; Sailesh Kotecha. Respiratory Distress of The Term Newborn Infant.
Department of child Healt, School of Medicine, Cardiff, UK. Paediatric Respiratory Reviews 14(2013)29-37
Gallacher Dj, Hart K, Kotecha S. Common Respiratory Conditions of The newborn. Department
of Child Health, School of medicine, Cardiff University, Cardiff, UK. Breathe 2016;12:30-42.
Rakesh Amroliwala, Manish Rasania, et all. Study of Congenital Heart Disease in Neonates. International
Journal of Contemporary Pediatrics. 2018 jan;5(1):75-81
PROGNOSIS
Ad Vitam : bonam
Ad Functionam : dubia ad bonam
Ad Sanationam : dubia ad bonam
44
45