premature infant with problems

Hi, my sister just had her baby at 28 weeks gestation.  She had several problems during her pregnancy and delivery.  She had placenta abruption right before the emergency C section.  The baby was not breathing and it took 4 minutes of CPR to get him breathing.  He also only had 35 percent of his blood volume.  He weighed 2 lbs. 8 ounces and was 14 inches long.  His blood pressure was not good and they started him on blood pressure medicine.  He also had a transfusion to replace some of the blood loss from the abruption.  He also had very high blood sugar and was given 2 insulin injections.  He is now one week 5 days old and three days ago he was still struggling with blood pressure and they detected a heart murmur.  They said he has PDA and they start medicine to close the hole.  It worked and the hole is only slightly detectable with Echo.  But,  last evening he declined so they called my neice and husband in to tell them that he is very agitated and that his blood pressure is very low as well as his heart rate.  They added another blood pressure medicine, 3 now, as well as started him on 3 antibiotics.  They also put him into a drug induced coma to quiet down the agitation.  They do not know why he is doing this and his blood pressure is so low.  They did blood work and said that there was not an infection but are treating him in case he is sepsis and it is not showing yet.  They are just monitoring him.  My sister is very concerned.  Any thoughts of what might cause this that you might know of?  The doctors said it is unusual for his blood pressure to drop and his heart rate to drop too as usually the heart rate goes up, so they are stumped.  I was wondering if the lack of oxygen at and before birth could have resulted in this?  Does your brain regulate your blood pressure and if the baby is without oxygen for more than 5 minutes could his brain be damaged?  Thanks for any comments you might have.  

[Yao Sun, MD, PhD]

I am sorry to hear that your sister's baby is so sick.  Many of the problems he is having are common to extremely premature infants, such as low blood pressure, the PDA (patent ductus arteriosus), and high blood sugars.  Premature infants are also at very high risk for infections, so it is very common to obtain tests for infection and to treat with antibiotics.  Because the tests for infection are not 100% accurate, we sometimes continue to treat with antibiotics for a "full course" of medication even if the tests are negative, because the infant can be infected and the tests results could be false.

As you pointed out, the baby could be having additional problems because of blood loss from the abruption.  This can cause injury to any/all parts of the body because the blood loss leads to lack of oxygen and nutrient delivery.  In severe cases, the various organs of the body can be severely injured, including the brain.

Low blood pressure and low heart rate can sometimes be associated with brain injury, but can also just be from severe illness.  

Your sister and her husband may want to have an honest discussion with the neonatologists about their expectations for their baby, and get the neonatologist's opinion about possible outcomes including possible long-term problems from this acute illness.  This type of discussion can help both the parents and the doctors decide the type of management that is in the best interest of the baby.

My thoughts are with you, your sister, and your family during this difficult time.