A preemie’s travailsOctober 8, 2019
Gayatri was in her 31st week of pregnancy when her blood pressure started rising and she was taken to the Apollo Children’s Hospitals, Chennai. She had to undergo an emergency C-section to deliver a pre-term baby boy who weighed only 1.2 kgs. At 31 weeks, babies are still far from being ready to live independently, and baby Nethran, as he was named, was no different. He was placed in the incubator and given external ventilator support for his immature lungs under the care of Dr Latha Kanchi Parthasarathy, a consultant neonatologist. Normally, pre-term babies may need ventilator support for a few days.However, Nethran was unable to come out of support for several weeks as his lungs kept collapsing repeatedly.
By 6 weeks, he became lethargic and was not taking his feed properly. Blood culture tests came back positive for Staphylococcus aureus and he was immediately started with antibiotics. A routine abdominal ultrasound done showed a liver mass. Such liver abscesses are commonly associated with S. aureus infections and require treatment for 4-6 weeks for complete remission. A repeat ultrasound after one week showed positive results with the abscess shrinking by more than 50%. However, a repeat ultrasound done at 6 weeks showed that the liver mass had significantly increased, instead of decreasing. It was now under debate as to whether the mass was infection related or something else. A CT scan and new investigative blood tests were carried out. The CT scan revealed that the mass was likely to be a tumour, either malignant or benign. Blood tests came back positive for alpha-fetoprotein (AFP), a tumour marker. A biopsy then confirmed that the mass was a hepatoblastoma, a rare cancerous tumour.
Since the tumour mass was quite large, chemotherapy was started in an attempt to shrink the tumour before surgical excision. Drugs were carefully selected keeping Nethran’s condition in mind and he underwent a successful first cycle of chemotherapy. The second cycle was in progress when matters took another turn. Nethran had one more problem. He had a hole in his heart — a septal defect — something that had been detected during a prenatal ultrasound scan at 5 months of pregnancy. Such septal defects tend to close on their own and do not cause any serious problems normally. Unfortunately for Nethran, the hole in the heart was now creating more complications. Because of its size, excessive blood flowing through the hole started exerting increased pressure on the lungs. After consulting the haemato-oncology team and the cardiology team, it was decided that Nethran should undergo an immediate open-heart surgery. The chemotherapy cycles had to be interrupted.
Open-heart surgery was carried out on the 1.5 kg baby. While the surgery went well, even post-surgery, Nethran’s lungs were still weak and kept collapsing. To make matters worse, he now developed a second bout of sepsis, which put him in a life-threatening situation. It took him 3 weeks to recover.
On the tumour front, the liver mass continued to grow fast, and there was new urgency to operate on the liver. About 1 month after the heart surgery, and at about 5 months of age, Nethran underwent a second surgery, this time to excise the liver mass. This was a very delicate surgery as the mass was vascular and close to the major blood vessels of the heart. Nethran had massive blood loss and was unstable during this surgery. However, the little boy fought on. “The first ten days post-surgery were very critical. Fluid accumulated in the pleural space and abdomen, and chest drainage had to be performed,” recalls Dr Latha.
Four weeks after the liver surgery, chemotherapy was recommenced. Initially, 4 cycles were planned. However, by the 3rd cycle, a new issue surfaced. Nethran’s skull bone started fusing prematurely. This put pressure on the brain and the head started growing in a cone shape. The neurosurgical team now stepped in to perform a cranial surgery. With this final surgery, Nethran was finally on the path to recovery. He got to complete the fourth and last chemotherapy cycle and was discharged from the hospital after spending the first 9 months of his life in the care of a myriad of doctors and nurses.
His parents have been advised to bring him in every 4 weeks for follow-ups. The plan is to monitor him carefully and to carry out blood tests at each visit and abdominal scans every 3 months.
Dr Latha says: “As a neonatologist, I routinely encounter pre-term cases where the small tiny, babies have to fight and struggle to breathe independently. But Nethran’s case was emotionally very stressful, with back-to-back battles. We are thankful that the parents were very positive and trusted us completely. Immense teamwork came into play as multiple medical teams — including paediatricians, cardiologists, haemato-oncologists, radiologists and neurosurgeons — came together to treat Nethran. But the true hero was Nethran, who continued to fight throughout and didn’t give up!”