Index of Suspicion in the Nursery

Abstract

A newborn boy is admitted to the neonatal intensive care unit (NICU) because of pallor and respiratory distress. His mother is a 32-year-old primigravida, who has type 2 diabetes mellitus and whose pre-pregnancy treatment with metformin was changed to insulin early in the pregnancy. In the first trimester, the mother had a throat infection that was treated with clarithromycin. Results of routine antenatal serologic screening, ultrasonography, and fetal echocardiography were normal. The mother presented to hospital with decreased fetal movements at 36 weeks and 3 days of gestation. Electronic fetal heart rate monitoring (EFM) was performed (Fig. 1) and she returned home. Several hours later, after review of the EFM record, she was recalled but could not be reached until the next morning, when EFM was repeated (Fig. 2). Figure 1. Initial electronic fetal heart rate monitoring strip. Figure 2. Second electronic fetal heart monitoring strip. A pale and nonvigorous male baby, who had a heart rate of 80 beats/min, was delivered by urgent cesarean section. He was resuscitated with bag-and-mask ventilation for 60 seconds followed by 100% free-flow oxygen; oxygen saturation was 75% at 3 minutes. His birthweight was 2.6 kg, his Apgar scores were 5 at 1 minute and 6 at 5 minutes, and his umbilical venous pH was 7.20. On admission to the NICU, the infant's physical examination shows extreme pallor, tachypnea, mild-to-moderate subcostal retractions, nasal flaring, and intermittent grunting. His oxygen saturation is 92% on nasal continuous positive airway pressure of 5 cm H2O and Fio2 of 0.35. Pulmonary and cardiac auscultation yield normal results. His pulse is weak and capillary refill time is 4 seconds. His heart rate is 200 beats/min and oscillometric blood pressure cannot be obtained. His liver and spleen are not palpably enlarged. Neurologically, he is alert but irritable, he has …