Case 2: Acute Respiratory Distress, Hypoxia, and Pulmonary Hypertension in the Nursery

Abstract

A female infant is born at 39 weeks’ gestation to a 28-year-old, gravida 3, para 2 woman who received regular prenatal care. Her history is significant for blood type O negativity (for which she received Rho(D) immunoglobulin at 28 weeks), hypothyroidism (treated with levothyroxine), polycystic ovarian syndrome (treated with metformin), and anxiety. The neonate is born via repeat cesarean section with vacuum assistance. The infant’s Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. In the well-child nursery, the infant is hypoxic and has an oxygen saturation of 40%, requiring nasal continuous positive airway pressure of 5 cm H2O and fraction of inspired oxygen (FiO2) of 50%; she is transferred to the NICU. In the NICU, she was noted to have increased work of breathing, and required nasal intermittent mandatory ventilation and FiO2 of 50%. Chest radiography suggested respiratory distress syndrome versus pneumonia. Blood and urine samples were obtained for culture, and she was started on empirical antibiotic treatment for clinical pneumonia in the setting of presumed sepsis. Pediatric cardiology was consulted because of the clinical suggestion of pulmonary hypertension. Hyperoxia test, electrocardiography, and echocardiography showed no evidence of congenital heart disease. An incidental finding of ductus arteriosus thrombus extending to the main pulmonary artery and left pulmonary artery was uncovered on echocardiography (Figs 1 and 2). Figure 1. Echocardiographic parasternal short-axis view shows a cross-sectional image of the heart. Here the thrombus is protruding from the patent ductus arteriosus into the main pulmonary artery (MPA) and left pulmonary artery (LPA). Figure 2. Echocardiographic images captured along the suprasternal notch view demonstrate the aortic arch. Here the patent ductus …