Index of Suspicion in the Nursery

Abstract

A woman presents with decreased fetal movement, and ultrasonography reveals hydrops fetalis. Specific findings include massive ascites and a small pericardial effusion that was not present on ultrasonography 1 week ago. A 37 weeks' gestation boy is delivered via emergent cesarean section. Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. The baby is intubated endotracheally 10 minutes after delivery because of increased work of breathing from his markedly distended abdomen and transported to the neonatal intensive care unit (NICU). Physical examination findings are normal, except for increased work of breathing and a tight, distended abdomen with visibly dilated veins. Initial laboratory results include a white blood cell count of 18.3×103/mcL (18.3×109/L), hemoglobin of 9.7 g/dL (97 g/L), and platelet count of 331×103/mcL (331×109/L). Chemistry results are within normal limits. Blood is sent for cultures, and empiric therapy with ampicillin and gentamicin is initiated. The baby also receives a 15-mL/kg packed red blood cell transfusion. A Replogle tube is placed to low intermittent suction. The infant is made NPO and started on intravenous fluids. Paracentesis is performed to relieve the pressure on his diaphragm and improve breathing, and 755 mL of green/brown fluid with particulate matter that has the appearance of meconium is aspirated. Umbilical lines are placed and pediatric surgery is consulted. Abdominal radiography shows intra-abdominal calcifications. An 11-day-old term girl whose mother had a positive cervical culture for human papillomavirus (HPV) is referred for admission because of a rectal temperature of 38.6°C and a history of “gasping for air.” Four days after birth, the baby became fussy, especially with feedings, and developed an intermittent cough and hoarse cry. Over several days, she became sleepier, only waking every 4 to 5 hours to breastfeed. On the pediatric ward, the baby …