LifeLines OnLine
2002 Summer Faculty Workshop
The Case: Multiple Births - Multiple Problems

A young couple, Martha and Mike have one child. They both decided it was time for their little boy to have a sister or brother.  Martha had some previous problems with uterine infections and was under antibiotic therapy.   This seemed to affect her uterus and the ovary physiology some how. But they still want to have a baby!!  Fertility hormones were prescribed for Martha by an endocrinologist, who assured them that she will have no chance of multiple births.

Luckily, Martha became  pregnant and has had a very normal pregnancy for the the first four months. Mike was very eager to know more about this pregnancy and convinced his wife to have a sonogram.  The good shocking news was that she is pregnant with triplets.  Martha  was given all the medical advice and precautions about the possible complications of this type of pregnancy.

On the 23rd week of the gestation, Martha started to  dilate and  knew she was in the early stage of labor. She was rushed to the Emergency Room and was put under some medications to delay the labor, but two days later she began the second stage of labor.   Soon after the first baby was delivered.  Her medications were increased, but two days later the second baby was delivered.   A  day after the third baby was delivered.

Each of the babies weighed approximately 500 grams and had to be rushed to the Neonate Intensive Care Unit.   The babies  were  given oxygen and food through  naso-tracheal and naso-gastric tubes respectively.

The first child,  a boy, died suddenly during the first week. No clear symptoms of any infection could be detected.

The second child,  a girl, had the following complications described by the attending neonatologist:

a- Chronic lung disability and has to depend on Oxygen supplement
b- Interventricular Hemorrhage which later cause bulging of the fontanel and increasing the  head circumference.
c- Sepsis
d- Patent Ductus Arteriosis.
e- Cardiac vegetation.

The third child,  a boy,  had the following complications:

a- Respiratory distress of  prematurity.
b- Brochopulmonary dysplasia and has to depend on oxygen supplement.
c- Patent Ductus arteriosis.
d- Cardiac vegetation.
e- Sepsis.

The most serious complications that the children exhibited were: 

a- Lung Congestion, which led to low oxygen saturation.
b- Kidney malfunction, which resulted in very low urine volume.
c- Ventricular enlargement.
d- Anemia and  Transient Thrombocytopenia which  required  a series of blood and platlets transfusion.

Case Author: Mahmoud Bishr
Labette Community College

Case Analysis

The differences  in circulation between the  premature and  the full term baby .

The difference in the development of the brain,  lungs and kidneys of both fetus and adult and how that affects their physiological functions.  

What physiological changes occur in both of these organs after delivery.

How the blood culture results relate to the complications observed in the newborns.

What do you know? What do you need to know?

Learning Goals


What do you think are the most important skills, attitudes or knowledge your students will obtain by working on this case and its associated investigations?
  • Apply information about the Circulatory, Nervous and Urinary system with respect to the Anatomy and Physiology.
  • As a result of group discussion and collaboration, students will teach each other.
  • Critical thinking  skills are practiced by solving the case questions.


Investigations and Activities

Day 1

  • The class will be split in 3 groups based on the student's course of study.
  • The first group, the premed students- write a  short analysis  of the newborns conditions  from a doctors perspective.
  • The second group, Nursing student- write a  short analysis  from a nurse perspective.
  • The third group, non majors, write a  short explanation of what is happening to the newborns,  in the form of letters to the relative of the family.

Day 2

  • Each group presents a five minutes summary of their  findings.

Day 3

  • Each student needs to write a summary  explaining  the reason (s) for all these complications. They should include why both of the surviving  children have lung and kidney malfunctions.

Day 4

Each student needs to  answer the following questions:

  1. What is meant by Patent ductus arteriosis?
  2. What is (are) the long-term effect of this condition if not corrected?
  3. What is the function of the Ductus arteriosis and what is the fate of this ductus arteriosis in complete development of the newborn full term baby.

Day 6 and 7

Each student  should answer these questions:

  1. Define hydrocephalus and explain why those children had Hydrocephalus.
  2. What is ( are) the long term effect of the Hydrocephalus?
  3. Why do you think  these children have low oxygen saturation in their blood?
  4. What is (are) the most probable cause (s) of the first baby 's death? Explain.
  • Write down a protocol to  isolate and identify  the blood culture isolates.
  • Identify here the kinds of scientific investigations that you consider relevant to this question.
  • Describe at least one specific laboratory or field exercise, simulation, or investigative activity that would be useful for your students to do, that also relates to their case question and supports your learning objectives.


Harvard University - Vascular Anatomy

Harvard University - The Whole Brain Atlas

The Franklin Institute Online - The Preview of the Heart

What is Hydrocephalus?

Human Anatomy and Physiology textbook

Lab experience- Brain and heart dissection.  Microscopic examination of blood cells.


Special Data Items

Lab Results  of the newborns:
Very Low WBC, RBC and platelets count.
  Blood culture showed :

  Gram-positive oval and ovoid cells.

  Gram positive cocci  catalase positive .

 Gram positive cocci  catalase negative.

Students Products 

- Group Summary Report on their analysis of the newborns.

- Group presentation of finding.

-Individual summary and answers  to questions.

-Individual protocol to isolate and identify the blood culture  isolates.

Assessment and Evaluation Plan

The students will assessed as follow:-

Group presentation - 20%

Peer review of group presentation - 10%

Individual Summary - 20%

Answers to the questions  and protocol development - 50%



Identify the specifics for using the cases in your classes.

Course name:
Anatomy and Physiology
Likely sequence in syllabus:
After finish talking about the Nervous and Cardiovascular systems. 
Time during term:
 The fourth week ( Summer term ) and the eighth week ( fall and Spring term )
One week ( summer ) 2 weeks ( fall and spring) 
Laboratory periods.
Students in course:
Nursing, premed and non majors.
Collaborative elements:
Work  both  individually and  in groups.  Share access to resources. Likely to discuss cases outside of class. Do dissection  in pairs.
Additional notes:
Any Anatomy and Physiology Text.




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