UN is a two-hour-old male admitted into the Special Care Baby Unit (SCBU) of the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria due to macrosomia, birthweight of 4.6 kg. He was the fourth child of a mother who had one other live child and two miscarriages (para Г mother). He was delivered by normal vertex after a 40-week gestation. The pregnancy was initially supervised in a private clinic from two months until eight months and thereafter in our hospital. She developed glycosuria at six months of gestation; however, the fasting blood sugar was normal (FBS 4.6 mmol/L). The mother was not a known diabetic and had no family history of diabetes. Her first delivery was a male weighing 4.2 kg at birth. There was no gestational diabetes in that pregnancy. There was a positive history of big babies in the mother’s family. Her younger sister delivered a third child who weighed 5.2 kg.
The mother had prolonged first stage of labor (27 hours) as well as prolonged rupture of fetal membrane (>24 hours) in the current pregnancy. The sec ond stage of labor was brief, lasting about 15 minutes.
Figure 1. Longitudinal Ultrasound Scan
Upper film shows an enlarged and echogenic left kidney measuring 85 mm x 44 mm. Thrombus in left renal veins (arrows). Lower scan is a transverse ultrasound scan showing an enlarged and echogenic right kidney. There is thrombus in the right renal veins (single arrows) extending into the inferior vena cava (double arrows).
On delivery, the baby cried immediately with an Apgar score of eight in one minute. He was, however, sent to SCBU for observation due to large size and anticipatory hypoglycemia. Breastfeeding was delayed until about 36 hours of life because the mother was not lactating. Physical examination on admission showed a mildly icteric, jittery and conscious child. There were no renal masses felt, and examinations of other systems were normal. A random blood sugar was 2.0 mmol/L (normal 3.3-5.5mmol/L). He received 10% Dextrose in Vsth normal saline at the rate of 8 mg/kg/minute, and RBS requested to be monitored every 1-2 hourly. The next RBS done one hour later was 5.5 mmol/L. Intravenous Ceftazidine (Fortum, Glaxo Wellcome) at 50 mg/kg/day in two divided doses was started for probable sepsis. Blood culture was sterile. He was also commenced on phototherapy on the second day of life at a total serum bilirubin of 161 mmol/L (normal 5-17 |imol/L) and conjugated of 7 |nmol/L (normal<8.5 цто1/Ь). On the third day of life, bilateral renal masses more on the left lumbar region, firm and non-tender were noticed, with nonpalpable bladder. His blood pressure was normal at 90/50 mmHg. He was passing urine with normal stream. A diagnosis of RVT with a differential diagnosis of polycystic kidney disease, hydronephrosis and bilateral pelvi-ureteric junction obstruction (PUJ) were considered. Serum electrolytes done on the fourth day of life showed sodium of 133 (normal 128-142 mmol/L), potassium 4.1 (3.4-4.8mmol/L), bicarbonate 18 (24-30 mmol/L). Serum urea level was 8.7 (2.4-6.0 mmol/L) and creatinine 60 (60-120 цто1/Ь). Urinalysis showed a specific gravity of 1020, PH 5.0, no blood or protein. Urinary osmolality and fractional excretion of sodium were not done. Urine culture yielded no growth. A full blood count revealed a packed cell volume of 43%, white cell count of 6,400/cmm, neutrophils of 69%, lymphocytes 29% and monocytes of 2%. The erythrocytes sedimentation rate (ESR) was slightly raised (18 mm/hour Westergreen, normal 5-7 mm/hour). Blood film showed presence of band forms. Renal ultrasound showed smooth and markedly enlarged kidneys with marked increase in parenchymal echogenicity, resulting in total loss of pyeloparenchymal differentiation (cortico-medullary differentiation) (Figure 1).
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He received intravenous antibiotics for five days and was discharged home at mother’s request after one week of hospitalization. He has been attending the outpatient clinic. His follow-up laboratory results showed urea 12.7 mmol/L, creatinine 85 цто1/Ь, 137 mmol/L, potassium 3.4 mmol/L, bicarbonate 17 mmol/L and packed cell volume of 24%. There was thrombocytopenia; platelet count was 130 x 109 (150-450 x 109/L), but the rest of his coagulation profile was normal. He is developing normally, although the renal masses have remained the same size.