Case 1: Intramuscular Hematoma in a Neonate in the Nursery

Abstract

A very preterm (29 2/7 weeks) male infant with a birthweight of 998 g is delivered by lower segment cesarean delivery (for transverse presentation with spontaneous leaking). The mother is a 25-year-old gravida 2 woman with no history of consanguinity. There is a history of intrauterine death in a previous pregnancy (at 6 months of gestation) 2 years prior. The neonate does not cry after birth. The Apgar scores are 2 and 5 at 1 and 5 minutes, respectively. The neonate undergoes intubation and is transferred to the nursery for further management in view of ongoing poor respiratory efforts. Clinical evaluation suggests multiple bruises over the left forearm, left leg, and right leg at birth. Early rescue (bovine) surfactant is administered 45 minutes after birth, ventilator settings are gradually lowered, and the neonate undergoes extubation and receives nasal continuous positive airway pressure (CPAP) 24 hours after birth. The neonate is given nothing by mouth for 24 hours, after which orogastric feeding is initiated (20 mL/kg per day) and then increased as per protocol. Treatment with caffeine (intravenous loading followed by oral) and vitamin A (injectable 5,000 IU alternate days, 3 days a week) is initiated. Respiratory distress worsens 72 hours after birth, requiring increased CPAP support. Radiologic evaluation suggests infiltrates in both the lung fields, and treatment with antibiotics (piperacillin and tazobactam with amikacin) is initiated. Respiratory distress gradually improves, antibiotics are stopped after 10 days, and the neonate is weaned to room air on day 12 after birth. The neonate regains his birthweight on day 18 after birth. The neonate is breathing room air with no respiratory distress and receiving full gavage feeds (180 mL/kg per day) till day 21, when he has 4 …