Case 1: Late-Onset Hypoglycemia in an Extremely Low-Birthweight Infant

Abstract

An 800-g extremely low-birthweight female (25 5/7 weeks) twin A of a dichorionic-diamniotic gestation is born via primary low transverse cesarean delivery to a 37-year-old gravida 5, para 0-4-0-0 woman. The mother of the child is group B Streptococcus positive, and received 1 dose of penicillin less than 4 hours before delivery. Results of other antenatal testing had been reassuring. Preterm delivery is indicated for prolonged rupture of membranes of twin B, and the mother had received 2 doses of betamethasone 24 hours apart at the estimated 24th week of gestation. The neonate has Apgar scores of 3 and 8 at 1 and 5 minutes, respectively. She is stabilized on continuous positive airway pressure and transferred to the NICU by 5 minutes after birth. In the NICU, she requires intubation and fraction of inspired oxygen greater than 60% to maintain oxygenation. An umbilical artery catheter and umbilical venous catheter are established and she is treated with ampicillin and gentamicin. She initially has hypotension requiring a 10-mL/kg bolus of normal saline without improvement, necessitating institution of a dopamine drip titrated from 2 to 5 μg/kg per minute to maintain mean arterial pressures above 25 mm Hg. She is started on intravenous fluids of 100 mL/kg per day with a glucose infusion rate (GIR) of 5 mg/kg per minute, which is reduced to 3.1 mg/kg per minute by 1 day after birth because of worsening hyperglycemia. Despite serial reduction of GIR, she persistently demonstrates capillary blood …