Sudden unexpected postnatal collapse (SUPC) in apparently well term babies, in the first week of life, is rare

Summary of BAPM SUPC observations and recommendations

• Increased likelihood of congenital anomaly or metabolic disease
• Need comprehensive investigation to determine underlying cause
• Involve interdisciplinary liaison to maximise diagnostic yield 
• Senior doctor to obtain detailed family history and situational events 
• Notify coroner of all babies who die from such collapse
• For all babies who die, post-mortem to be performed by a perinatal pathologist
• If collapse happened after baby left hospital, safeguarding issues must be considered 
• Detailed multiprofessional case review should follow investigation of unexpected baby death 

Information after the event

Collect the following as soon as possible after presentation 

Parental medical history

• Full parental drug, alcohol and nicotine history
• 3-generation family tree (where available) noting egg donation, sperm donation (where relevant) 

Obstetric history (from consultant obstetrician or senior trainee)

• Infection
• Fetal growth
• Suspected fetal anomalies
• Fetal movements 
• Liquor volume 

Labour and birth (from consultant obstetrician or senior trainee)

• Maternal medication 
• Markers of fetal wellbeing
  • scalp pH
  • cord pH
  • electronic fetal monitoring
  • passage of meconium
  • requirement for resuscitation 

Health of baby until collapse

• Growth and feeding

Other information

• Circumstances surrounding collapse
  • who was present?
  • was baby feeding?
  • position of baby (from staff and family present at time of collapse)
• It is also important to collect information from other agencies who may have been involved with the family e.g. primary care, social care and police
• Full resuscitation details

Maternal investigations

• Placenta: as soon as possible after birth, send both fixed and fresh samples of placenta and cord (where available) for pathology and microbiology
• Maternal blood: Kleihauer, viral titres (serum to be frozen for acute phase titres), toxicology
• Maternal high and low vaginal swabs

Investigations whilst baby alive

• Carry out a full examination
• Liaison with local and regional laboratories is mandatory to ensure optimal collection and timing of samples. Use your judgment about which tests to prioritise to ensure optimal diagnostic yield with least intervention
• If baby sufficiently stable, consider transfer to a specialist unit for imaging

• If there is suspicion that the event may have been due to unrecognised hypoventilation/apnoea, send DNA sample for PHOX2B gene abnormalities (commonly implicated in congenital central hypoventilation syndrome) 
• Consider testing for mutations and copy number variation in MECP2 gene. This may present as newborn encephalopathy and/or apnoeas and respiratory collapse
• Array-based comparative genomic hybridisation is a useful investigation (will replace conventional karyotyping for detecting causative chromosomal deletions and duplications)

Investigations before post-mortem

• If it has not been possible to take samples during life, take samples (where feasible) while awaiting post-mortem to prevent degradation of material and loss of important diagnostic information. Where possible, discuss and agree baseline samples with a pathologist and, where indicated, a biochemist
  • if difficulty obtaining necessary kit for investigations, most labour wards have a ‘stillbirth kit’ which will contain much, if not all, of what is needed. Discuss with laboratory before beginning procedure if a full kit cannot be collected
• Throat and nose swabs for bacterial and viral culture 
• Blood culture 
• Blood and urine for metabolic studies
  • glucose, acylcarnitine, organic and amino acids including orotic acid and sulphocysteine, freeze urine for storage 
• Blood for DNA, chromosomes and dried bloodspots on several cards 
• CSF obtained by lumbar puncture or ventricular tap – biochemistry
  • glucose
  • culture
  • virology
  • lactate
  • amino acids including glycine, freeze and store
• Skin biopsy (if possible locally) for culture and storage of fibroblasts: 3 x 2 mm full thickness using aseptic technique into culture or viral transport medium or gauze soaked in sodium chloride 0.9%. Send promptly to cytogenetics laboratory (see Skin biopsy guideline)
• Muscle biopsy (if possible locally) for electron microscopy, histopathology and enzymology. Wrap in aluminium foil, snap freeze and store at −70°C. Contact metabolic physician or pathologist before sample collection 

Safeguarding issues

• Must be considered in all cases of out of hospital collapse
• The process of investigation for unexpected child deaths sometimes needs following even if baby survives 
• Involves the rapid response team from the district who need to undertake a home visit to gather additional information regarding the critical event

For documentation and investigation check list for SUPC, use appendices from full BAPM guidelines

http://www.bapm.org/resources/19-guidelines-investigation-of-newborn-infants-who-suffer-a-sudden-unexpected-postnatal-collapse