Index of Suspicion in the Nursery

Abstract

A 36-week estimated gestational age male infant is born via spontaneous vaginal delivery to a 26-year-old G2P2 woman following a pregnancy complicated by late oligohydramnios. He cries spontaneously and receives routine resuscitation (Apgar scores of 8 and 9 at 1 and 5 minutes, respectively). The infant is symmetrically small for gestational age but has otherwise normal findings on physical examination. He is transferred to the newborn nursery for normal transition. Shortly after birth, he develops profound hypoglycemia with a glucose value of 5.0 mg/dL (0.28 mmol/L) and is transferred to the neonatal intensive care unit for further management. The hypoglycemia resolves with administration of intravenous dextrose-containing fluids, but on the second postnatal day, he develops direct hyperbilirubinemia. Liver transaminase values are normal despite the elevation of direct bilirubin. Over the next several days, the infant continues to have direct hyperbilirubinemia (peak bilirubin, 15.8 mg/dL [270.2 mcmol/L]), hypoalbuminemia (albumin, 1.5 g/dL [15 g/L]), and increasing blood urea nitrogen/creatinine values as well as the onset of oliguria, hypotension, and increasing diffuse edema. Hepatic and renal ultrasonography is interpreted as normal. Echocardiography shows a small patent ductus arteriosus but appears otherwise normal. Dopamine administration is initiated, and the infant responds well. A TORCH evaluation is initiated to look for the presence of congenital infection and later is found to be negative. The patient begins to have spontaneous bleeding from his umbilical artery catheter site and is found to have a coagulopathy, with a prothrombin time of 114.5 seconds and a partial thromboplastin time of more than 150 seconds in conjunction with thrombocytopenia. Due to his severe coagulopathy, hypotension, and oliguric renal failure, the patient is transferred to a tertiary care facility. On his second hospital day, he is intubated because of a spontaneous pulmonary hemorrhage that resolves. He continues to have persistent coagulopathy, …