Clinical case
Hypertrophic pyloric stenosis in a preterm infant: a case report
Estenosis hipertrófica de píloro en un prematuro: a propósito de un caso
L.P. Islas-Domíngueza,d,
, J.R. Jiménez-Jiménezb,d, J. Cruz-Díazc,d, K. Castellanos Reyesc,d
Corresponding author
luneonatos@hotmail.com
Corresponding author at: Hospital General de México Dr. Eduardo Liceaga, Dr. Balmis 148, Colonia Doctores, Delegación Cuauhtémoc, C.P. 06720 Mexico City, Mexico.
Corresponding author at: Hospital General de México Dr. Eduardo Liceaga, Dr. Balmis 148, Colonia Doctores, Delegación Cuauhtémoc, C.P. 06720 Mexico City, Mexico.
a Head of Paediatrics Department, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
b Neonatologist, Neonatal Intensive Care, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
c Registered Nurse, Hospital General de México, “Dr. Eduardo Liceaga”, Mexico City, Mexico
d Neonatologist, Instituto Mexicano del Seguro Social, Centro Médico Nacional la Raza, Mexico City, Mexico
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Note increased length and thickness of muscle wall.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertrophic pyloric stenosis (HPS) is a disease which occurs in the second week of life, of unknown origin, which consists of the narrowing of the pylorus due to concentric muscular hypertrophy, causing gastric outlet obstruction with progressive vomiting that leads to malnutrition, dehydration and serious metabolic disorders.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Prompt diagnosis prevents complications, reduces the morbidity rate and enables surgical treatment with an excellent prognosis.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The origin is unknown, but the most accepted hypotheses suggest the use of concentrated baby formulas, lack or reduction of pyloric muscle innervation, elevation of gastrin and gastric somatostatin and even allergy.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Repeated vomiting favours oedema of the pyloric mucous membrane, which exacerbates the symptoms, leading to loss of fluids, hydrogen ions and chlorine, all of which leads to hypochloraemic alkalosis. The lack of actual ingestion leads to malnutrition and greater sensitivity to metabolic, haemodynamic and infectious complications.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2,5,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Some patients present jaundice derived from elevated indirect bilirubin, from a not completely understood mechanism that reduces glucuronyl transferase and increases enterohepatic bilirubin circulation; this is corrected when the patient undergoes surgery.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The symptoms do not usually appear before the second or third week of life, and earlier onset is exceptional.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8–11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0035" class="elsevierStylePara elsevierViewall">A male newborn (NB), from the second pregnancy of a 27-year-old mother. She denies drug addiction. Three normal obstetric ultrasounds. Discharge of clear transvaginal fluid for 30<span class="elsevierStyleHsp" style=""></span>h. Baby born vaginally with Apgar 8-9, Capurro “B” 35 weeks, gestation, weight 2550<span class="elsevierStyleHsp" style=""></span>g, height 48<span class="elsevierStyleHsp" style=""></span>cm.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Management starts with fasting, oxygen therapy, ampicillin and amikacin for seven days due to premature membrane rupture. Insidious respiratory and infectious evolution. Sudden onset of postprandial non-biliary vomiting and increase of indirect bilirubin. Given the possibility of nosocomial infection, he is started on cefepime plus dicloxacillin. X-ray of chest and abdomen shows gastromegaly (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Oral ingestion is resumed, with enteral stimulation, but vomiting persists so he continues to fast, a central line is installed and parenteral nutrition is started. Gastric hyperperistalsis and palpation of pyloric mass. Blood gas shows normochloraemic metabolic alkalosis. Ultrasound shows pylorus 18.8<span class="elsevierStyleHsp" style=""></span>mm long, with slices showing muscle wall thickness of up to 4.3<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), confirming the diagnosis of HPS.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Surgical finding: 2<span class="elsevierStyleHsp" style=""></span>cm pylorus with pearly appearance. Oral intake resumed 24<span class="elsevierStyleHsp" style=""></span>h after surgery, well tolerated and accepting milk increments. Antibiotics suspended as there is no evidence of infection. Discharged home with follow-up as outpatient.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Hypertrophic pyloric stenosis is a very rare condition in preterm infants. The literature describes an incidence rate of 1 to 2.9 cases per 1000 pre-term births.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10,13,14</span></a> It is a very common cause of surgery in the first month of life. Despite the radical change of this condition's presentation in the last 10 years,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a> the rarity of its presentation in preterm infants is still emphasised.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In full-term newborns it appears from the second to the seventh week after birth, and its incidence rate is much higher than in pre-terms.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> This year, Stark et al. reported a series of 2466 newborns with HPS, 208 (8.43%) of whom were premature, compared with 2258 (91.57%) full-term babies with the problem, showing how rare this condition is in babies with less than 37 weeks of gestation (wog).<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The literature describes factors associated to preterm newborns with HPS: mothers with multiple pregnancies, exposure to macrolides and male gender<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a>; however, the greater the prematurity, from 28 to 31 wog, a ratio of 1:1 F–M is reported. This ratio increases to 2:1 F–M from 32 to 36 wog, and for full-term NBs, the F–M ratio is 5:1.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a> Our patient was of the gender primarily reported in the literature.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Predominance of the male gender has a genetic component, as the greater risk of gastrointestinal malformations in that gender is well documented, as is the risk of rotavirus infections in childhood. This suggests considerable differences in the development, maturity and function of the gastrointestinal tract between men and women.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">15–19</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Mutations in chromosomes 2q, 3p, 5q, 7p, 11q, 16p and even in chromosome x play an important role in the development of HPS.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">14,17–21</span></a> However, despite a large variety of studies, it has not been possible to document a Mendelian inheritance pattern, not even when present in monozygotic twins, which supports the theory that environmental factors are fundamental in its presentation.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Other risk factors associated to HPS are: caesarian birth and mothers smoking during pregnancy.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">12,13</span></a> However, caesarian birth as a risk factor is not fully clear, as in some series the birth method is consistent with maternal infection. Vaginal birth has also been described as beneficial, as it prevents hormonal cascades and stress factors in newborns. Our patient was born vaginally and therefore not affected by such a risk factor.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The association with smoking has also been attributed to tobacco substances that cause pyloric spasm and muscular hypertrophy.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">12,13</span></a> The mother of the NB in question denied any toxic habits.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Mothers under 20 years of age, diabetic and with a low education level have also been associated to a greater risk of HPS, as are women exposed to pesticides, as they act as endocrine disruptors.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">20,23</span></a> None of these factors were present in this case.</p><p id="par0090" class="elsevierStylePara elsevierViewall">On the other hand, prostaglandin infusion at standard doses has also been reported as a cause of the condition, due to direct pharmacological effects on the pyloric muscle.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a> This drug was not administered to our patient, as he did not present a ductus arteriosus-dependent cardiopathy, but it is important to consider this undesirable effect in patients who do.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The clinical presentation often consists of vomiting that could initially be mistaken for reflux, yet episodes often lead to metabolic alkalosis due to loss of hydrogen ions and chlorine. This is consistent with our patient's symptoms. This presentation in pre-term newborns is often diagnosed and treated as gastroesophageal reflux, as premature babies have multiple risk factors such as the use of methyl-xanthines and immaturity of the upper oesophageal sphincter. This makes it difficult to consider HPS as the primary origin of vomiting.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Our patient was initially treated with anti-reflux measures, using widely recommended drugs at standard doses.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">25–27</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The patient was examined, palpating a pyloric mass, a pathognomic sign of the condition.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">28</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Abdominal ultrasound is considered to be a highly sensitive (91%) and specific (100%) test, which also makes it possible to distinguish duodenal membranes or other malformations as differential diagnoses.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">28,29</span></a> In our patient, the ultrasound showed the findings described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, which are consistent with the literature.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">28,29</span></a> Three factors have been suggested for the condition's diagnosis: the presence of delayed gastric output by ultrasound, pyloric sphincter muscle thickness of ≥2.5<span class="elsevierStyleHsp" style=""></span>mm and muscle length ≥14<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Other diagnostic tests mentioned in the literature are a gastroduodenal oesophageal series and endoscopy, which can also have therapeutic purposes.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">28,30–32</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Laparoscopic, or minimally invasive, surgery is increasingly recommended in the literature, but requires appropriate medical instruments and equipment to tackle the physiology of pre-term infants and their reduced surgical fields,<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">30–33</span></a> with small incisions through the umbilical scar and excellent results, starting food intake the following day. However, our hospital does not yet have the equipment required for this procedure in pre-term infants. Even so, the results were excellent in our patient, operated on with a conventional technique, enabling him to feed after 24<span class="elsevierStyleHsp" style=""></span>h, with no complications and outpatient follow-up.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The objective of presenting this case report is to consider HPS as a possible diagnosis in pre-term NB patients with food intolerance symptoms,<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10–13,25,29</span></a> even when gestational age and days of onset are not commonly reported in the literature, as presentation has radically changed in the last 10 years and even male predominance is not common in such patients. This could prevent said diagnosis, delaying treatment, increasing the duration of hospitalisation and inherent complications.</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is therefore important to broaden our diagnostic approach and consider this condition in our patients, as the tendency towards preterm birth in intensive or intermediate care units, mothers aged 20 years or less, with low educational levels, smoking, and the use of macrolides and prostaglandins for commonly associated conditions are increasingly common in our hospital population.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1086609" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1030752" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1086610" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1030751" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-16" "fechaAceptado" => "2017-02-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1030752" "palabras" => array:3 [ 0 => "Preterm infant" 1 => "Pyloric hypertrophy" 2 => "Vomiting" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1030751" "palabras" => array:3 [ 0 => "Recién nacido prematuro" 1 => "Hipertrofia de píloro" 2 => "vómito" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We report the case of a preterm infant of 35 weeks gestation, who presents vomiting towards the end of the first week of life. Suspected diagnosis of hypertrophic pyloric stenosis by exclusion. The ultrasound confirms the diagnosis. Pyloromyotomy is performed with excellent evolution. We describe this case due to time of onset of the disease associated to a preterm infant.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se presenta el caso de un recién nacido prematuro de 35 semanas de gestación, quien presenta vómitos de contenido gástrico hacia el final de la primera semana de vida. Se sospecha diagnóstico de estenosis hipertrófica de píloro por exclusión. El ultrasonido corrobora el diagnóstico. Se realiza piloromiotomía con excelente evolución. Se describe este caso por el tiempo de presentación del padecimiento asociado a un recién nacido prematuro.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1818 "Ancho" => 1625 "Tamanyo" => 71918 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">X-ray of abdomen and chest. Note the presence of gastromegaly.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1739 "Ancho" => 1625 "Tamanyo" => 147313 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pyloric ultrasound. Note increased length and thickness of muscle wall.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">a) Pyloric diameter from 15 to 18<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">b) Muscle thickness from 3 to 4<span class="elsevierStyleHsp" style=""></span>mm and length more than 17<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">c) Narrow intestinal span with characteristic “double track” appearance \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1856397.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pathognomic findings in abdominal ultrasound.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infantile hypertrophic pyloric stenosis: genes and environment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 80 | 25 | 105 |
| 2024 September | 153 | 60 | 213 |
| 2024 August | 139 | 69 | 208 |
| 2024 July | 120 | 44 | 164 |
| 2024 June | 126 | 31 | 157 |
| 2024 May | 151 | 35 | 186 |
| 2024 April | 193 | 49 | 242 |
| 2024 March | 228 | 42 | 270 |
| 2024 February | 173 | 22 | 195 |
| 2024 January | 252 | 29 | 281 |
| 2023 December | 207 | 31 | 238 |
| 2023 November | 235 | 22 | 257 |
| 2023 October | 269 | 42 | 311 |
| 2023 September | 183 | 37 | 220 |
| 2023 August | 162 | 13 | 175 |
| 2023 July | 167 | 30 | 197 |
| 2023 June | 223 | 19 | 242 |
| 2023 May | 295 | 27 | 322 |
| 2023 April | 278 | 19 | 297 |
| 2023 March | 207 | 18 | 225 |
| 2023 February | 132 | 14 | 146 |
| 2023 January | 187 | 22 | 209 |
| 2022 December | 130 | 21 | 151 |
| 2022 November | 164 | 26 | 190 |
| 2022 October | 159 | 21 | 180 |
| 2022 September | 142 | 16 | 158 |
| 2022 August | 152 | 26 | 178 |
| 2022 July | 127 | 30 | 157 |
| 2022 June | 136 | 35 | 171 |
| 2022 May | 149 | 43 | 192 |
| 2022 April | 197 | 35 | 232 |
| 2022 March | 210 | 37 | 247 |
| 2022 February | 269 | 44 | 313 |
| 2022 January | 214 | 56 | 270 |
| 2021 December | 168 | 58 | 226 |
| 2021 November | 198 | 39 | 237 |
| 2021 October | 211 | 63 | 274 |
| 2021 September | 197 | 64 | 261 |
| 2021 August | 216 | 49 | 265 |
| 2021 July | 159 | 26 | 185 |
| 2021 June | 148 | 34 | 182 |
| 2021 May | 268 | 42 | 310 |
| 2021 April | 610 | 58 | 668 |
| 2021 March | 386 | 50 | 436 |
| 2021 February | 195 | 38 | 233 |
| 2021 January | 210 | 21 | 231 |
| 2020 December | 225 | 44 | 269 |
| 2020 November | 231 | 24 | 255 |
| 2020 October | 188 | 30 | 218 |
| 2020 September | 118 | 37 | 155 |
| 2020 August | 144 | 51 | 195 |
| 2020 July | 88 | 29 | 117 |
| 2020 June | 163 | 25 | 188 |
| 2020 May | 127 | 19 | 146 |
| 2020 April | 173 | 17 | 190 |
| 2020 March | 217 | 28 | 245 |
| 2020 February | 156 | 23 | 179 |
| 2020 January | 150 | 26 | 176 |
| 2019 December | 116 | 27 | 143 |
| 2019 November | 107 | 18 | 125 |
| 2019 October | 125 | 24 | 149 |
| 2019 September | 136 | 36 | 172 |
| 2019 August | 94 | 14 | 108 |
| 2019 July | 128 | 20 | 148 |
| 2019 June | 130 | 43 | 173 |
| 2019 May | 199 | 70 | 269 |
| 2019 April | 219 | 21 | 240 |
| 2019 March | 78 | 15 | 93 |
| 2019 February | 63 | 15 | 78 |
| 2019 January | 37 | 5 | 42 |
| 2018 December | 42 | 2 | 44 |
| 2018 November | 54 | 1 | 55 |
| 2018 October | 62 | 5 | 67 |
| 2018 September | 15 | 8 | 23 |
| 2018 August | 0 | 9 | 9 |
| 2018 July | 1 | 4 | 5 |
| 2018 June | 0 | 6 | 6 |
| 2018 May | 4 | 12 | 16 |
| 2018 April | 1 | 2 | 3 |
| 2018 March | 1 | 4 | 5 |
| 2018 February | 6 | 4 | 10 |
| 2018 January | 8 | 3 | 11 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 12 | 2 | 14 |
| 2017 October | 2 | 1 | 3 |
| 2017 September | 1 | 0 | 1 |
| 2017 August | 2 | 4 | 6 |
Show all