Case 3: Emesis in a Term Infant with Dysmorphic Features.

Abstract

A female infant is born at 38 weeks’ estimated gestational age to a 23-year-old, gravida 2, para 2 woman. Maternal history is significant for poorly controlled chronic hypertension and limited prenatal care. The woman reports she was returning home from vacation when she experienced painful, frequent contractions, prompting presentation to the nearest emergency department. Her initial blood pressure is 152/102 mm Hg. She has spontaneous rupture of membranes and undergoes repeat cesarean section 3 hours after arrival at the academic medical center. In the delivery room, Apgar scores are 7 at 1 minute (0 for skin color, and 1 for respiratory effort) and 9 at 5 minutes (1 for skin color). Growth parameters are consistent with a small-for–gestational age infant; the newborn’s head circumference, weight, and length are all less than the 1st percentile for gestational age. Initial physical examination is remarkable for upper limb abnormalities, including oligodactyly with the presence of only 2 formed digits on the left upper extremity, a single palpable forearm bone in the left upper extremity, a sacral dimple, significant hirsutism, and abnormal facial features, including synophrys and highly arched eyebrows. She is admitted to the NICU for further care. In the NICU, she is initiated on feeds of expressed breast milk and colostrum. She passes meconium on the first day after birth. The neonate initially tolerates small volumes of feeds, but by day 2, she experiences nonbilious emesis 15 to 30 minutes after each feed. Intravenous fluids are initiated and a Replogle tube is placed. An abdominal radiograph is obtained on the second day after …