Recently, a newborn survived a rare combination of two life-threatening conditions, a severe cardiac rhythm disorder and a devastating intestinal disease, after nearly a month of intensive treatment involving neonatologists, cardiologists and paediatric surgeons.
The baby, born at 35 weeks of gestation at Ankura Hospital in Pune, developed recurrent episodes of supraventricular tachycardia (SVT), a condition in which the heart beats abnormally fast. Days later, he was diagnosed with necrotising enterocolitis (NEC), a serious disease that causes inflammation and death of intestinal tissue and is most commonly seen in premature infants.
Doctors involved in the case believe the repeated episodes of uncontrolled tachycardia may have contributed to reduced blood flow to the intestines, triggering a chain of events that ultimately led to intestinal perforation and emergency surgery.
“Cases where a newborn develops both refractory SVT and surgically managed NEC are exceptionally rare,” said Dr Siddharth Madabhushi, neonatologist and medical director at Ankura Hospital. “Managing either condition alone can be challenging. Managing both simultaneously required constant coordination between multiple specialties.”
According to the medical team, the baby’s troubles began even before birth. During a routine antenatal evaluation at 35 weeks, doctors detected a fetal heart rate exceeding 300 beats per minute, prompting concerns about foetal tachyarrhythmia. Given the risk to the foetus, an emergency caesarean section was performed.
Although the baby cried at birth, he soon developed respiratory distress and was shifted to the neonatal intensive care unit (NICU). Within hours, he began experiencing recurrent episodes of SVT, a condition that can compromise blood circulation if prolonged or uncontrolled.
“Despite standard emergency measures and anti-arrhythmic medications, the episodes continued to recur,” said Dr Ashish Banpurkar, paediatric cardiologist. “The challenge was to maintain cardiac stability while closely monitoring for complications in other organs.”
Over the next few days, doctors noticed signs that something else was going wrong. The infant developed abdominal distension and gastrointestinal bleeding. Investigations confirmed necrotising enterocolitis, a potentially fatal condition that can rapidly progress to intestinal perforation, sepsis and multi-organ failure.
Experts say NEC is most often associated with extreme prematurity, low birth weight and feeding-related complications. However, emerging evidence suggests that compromised blood supply to the intestine can also play a role in certain newborns.
In this case, doctors suspect that repeated episodes of severe tachycardia may have reduced blood flow to the gut, making intestinal tissue vulnerable to injury.
Explaining the physiological link between prolonged SVT, reduced gut perfusion and NEC, Dr Supratim Sen, paediatric cardiologist at Narayana Health, says, "SVT is an abnormally fast heart rhythm where the heart beats at rates above 200-220/minute. If this occurs for a prolonged period, the heart's pumping gets weaker and the baby develops ventricular dysfunction. Both the heart rate and the ventricular dysfunction decrease the blood pressure and blood perfusion to the body. Preterm babies are prone to gut ischemia that is decreased oxygen supply to the gut due to this decreased perfusion, which progresses to necrotising enterocolitis." NEC, he adds, is a common complication in preterm babies and can be potentially life-threatening. "
Dr. Asmita Mahajan, neonatologist and pediatrician, S.L. Raheja Hospital, further adds that as medical professionals specialising in neonatology and paediatrics, it is possible to appreciate the connection between sustained SVT, poor perfusion of the gastrointestinal tract, and NEC from a haemodynamic perspective.
Prolonged SVT, she says, entails that the heart rate increases to an extent such that there is inadequate diastolic filling of the heart chambers. "The consequence of this is a decline in stroke volume and ultimately a reduction in cardiac output, which is compounded by the fact that neonates have low cardiac reserve capacity. The gastrointestinal tract is one of the first body parts affected by perfusion impairment in critical neonates owing to its higher metabolic demand and immature vascular autoregulation. Sustained SVT may lead to mesenteric hypoperfusion, resulting in gut ischemia."
Gut ischemia is a major precipitating factor for the development of NEC. This is because ischemic injury leads to a break in the integrity of the intestinal mucosa, leading to infection, inflammation, and death of the intestinal tissue, say doctors.
"Indeed, not only the presence but also the duration and the haemodynamic effect of SVT determine the risk. Tachyarrhythmia may create a condition like low-output syndrome, resulting in shock. Neonates who suffer from immaturity associated with premature birth are likely to progress along the NEC continuum due to the cascade. Therefore, the timely diagnosis and prompt correction of this issue are crucial for adequate blood supply to the gut and preventing damage," explains Dr Mahajan.
Such cases have been previously documented in medical journals. A case report published in BMJ Case Reports by Dr Jennie Saini and colleagues from The Hospital for Sick Children, Toronto, noted that SVT is the most common arrhythmia seen in newborns, while NEC is a serious intestinal disease most often affecting premature babies. The authors observed that only three previous cases linking neonatal SVT and NEC had been documented in medical literature at the time of publication.
The paper described two late-preterm infants who developed NEC after experiencing recurrent episodes of SVT, even though they did not show signs of major circulatory collapse or haemodynamic instability. Both babies recovered with conservative treatment that included bowel rest and antibiotics.
One of the infants, born at 36 weeks, developed a heart rate exceeding 250 beats per minute shortly after birth. Doctors diagnosed SVT and used multiple doses of adenosine, a medication used to restore normal heart rhythm, before successfully converting the baby back to a normal heartbeat. Although the infant remained clinically stable throughout the episode, blood tests showed elevated lactate levels, suggesting that tissues may have experienced reduced oxygen intake.
The baby later developed recurrent SVT episodes and was started on anti-arrhythmic medication. On the seventh day, doctors noticed bloody stools.
Imaging studies revealed pneumatosis intestinalis, a hallmark sign of NEC in which gas becomes trapped within the intestinal wall. The infant was immediately taken off feeds and treated with intravenous antibiotics.
After a week of bowel rest and treatment, feeds were gradually restarted and the child recovered without requiring surgery.
But the Pune case has been significantly more severe than the Canadian cases described in the BMJ report. Unlike the infants in the Toronto study, who improved with medical management alone, the newborn in Pune progressed to intestinal perforation and required emergency surgery to remove damaged portions of the intestine.
By the eighth day, the baby’s condition worsened. Imaging revealed intestinal perforation, necessitating emergency surgery.
During a nearly two-hour operation, paediatric surgeon Dr Abhijeet Benare identified multiple perforations in the intestine. Two damaged segments had to be removed and reconnected.
“Once perforation occurs, surgery becomes the only definitive option,” Benare said. “The challenge was that the patient was already medically fragile because of the ongoing cardiac condition.”
The weeks that followed required meticulous critical care management. Because the intestine needed complete rest after surgery, the baby could not be fed orally. Instead, he received total parenteral nutrition (TPN), which is intravenous nutrition containing proteins, carbohydrates, fats and micronutrients.
Doctors also had to find alternative ways of administering cardiac medications while ensuring that treatment for one condition did not worsen the other.
The infant required ventilator support, antibiotics, nutritional management and continuous monitoring.
“When the heart and the gut are both critically affected, every intervention becomes interconnected,” said Madabhushi. “The team has to think beyond individual organs and focus on the baby as a whole.”
Feeds were gradually reintroduced once the intestine began healing. By the third week of life, the baby was tolerating milk feeds and showing signs of recovery. He was eventually discharged after 26 days in the NICU.
While the long-term prognosis will depend on continued follow-up, doctors say the infant is currently feeding well and recovering.
The case highlights how advances in neonatal intensive care and multidisciplinary collaboration are improving survival in highly complex newborn emergencies.
