Ibrah III: Other Problems

Multisystem Processes & Disorders


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P22_F1.jpg"}},{"insert":"\n\nYou first met Ibrah, a 33-year-old G4P3A0 stay-at-home mom of an Iraqi migrant family around seven months ago. She was referred to your clinic after antenatal screening showed her to be anemic. You diagnosed her to have iron deficiency anemia, and started treatment.\n\nDuring her subsequent follow up, you found biochemical and ultrasound evidence that her fetus might have an aneuploidy: most likely trisomy 21 (Down syndrome). Ibrah refused invasive diagnostic testing and wished to carry the pregnancy to term.\n\nWhile Ibrah\u0027s previous three children were delivered at home, you strongly recommended that she deliver her new baby at your hospital. She conditionally agreed, promising to come over as soon as her waters broke, or contractions started.\n\nIbrah turned up at your hospital \u2013 but only after she\u0027d had contractions for 6 hours. A timely history and examination revealed that she was in obstructed labor, and you were forced to perform a cesarean section. \n\nYou managed to successfully deliver a baby girl, whose Apgar score was 7\/8 at 1 minute, and 8\/8 from 5 minutes onwards. Her weight was 2300 g, length was 48 cm, and occipitofrontal circumference (OFC) was 39 cm. \n\nIbrah decided to name her daughter \u0022Diana\u0022. Her story continues now...\n"}]}


{"ops":[{"insert":"As the pediatrician on duty, you were present at Diana\u0027s birth, and are already familiar with her antenatal history.\n\nDiana is quiet and alert. Her skin is pink in color \u2013 but you notice that her lips are tinged with blue. You also notice that her face and occiput are flat. She has slanted eyes, with a positive red-eye reflex. Her ears are low-set. Her jaw is small, while her tongue appears unusually large. Her lips and palate appear normal. You also notice hypoplasia of the middle phalanx of the fifth finger, a single palmar crease in both hands, and increased space between the first and second toes in both feet. There is excess skin around her neck. \n\nChest examination reveals normal heart sounds and a systolic ejection murmur over the left sternal border. The abdomen is normal in shape, without visible masses or pulsations. Bowel sounds are normal. Diana hasn\u2019t passed meconium so far. The Ortolani and Barlow maneuvers show no hip abnormalities. Diana\u0027s posture is normal. Her spine appears normal. Diana exhibits spontaneous movements but shows decreased muscle tone. The suck and grasp reflexes are intact. The Moro reflex is poor. \n\nBased on these findings, you realize that Diana has Down syndrome.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P22_F3.jpg"}},{"insert":"\n\nYou kneel down next to Ibrah\u2019s bed and break the bad news. You expect to see despair, shock, or anger. However, your heart warms as Ibrah kisses Diana and tells you that she loves her baby all the same. \n\nYou proceed to explain Down syndrome in detail to Ibrah. After that, you try and answer all of her questions.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P22_F4.jpg"}},{"insert":"\n\nIbrah asks why she\u0027s having trouble breastfeeding Diana. \u0022I never had trouble with my previous three children,\u0022 she states. \n\nYou proceed to explain why children with Down syndrome have trouble breastfeeding. Which of the following will you cite as one reason for this?\n"}]}
1. Hypotonia
2. Macroglossia
3. Laryngomalacia