Index of Suspicion in the Nursery

Abstract

A 3.3-kg male term infant is born via vacuum-assisted vaginal delivery to a 26-year-old G2P1001, now P2002, woman whose serology results were within normal parameters. Membranes ruptured 4 hours before delivery, and Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. A hematocrit obtained shortly after birth is 46% (0.5). At 14 hours after birth, the infant has swelling around the posterior scalp that increases in size over the next 6 hours. The swelling is fluctuant and shifts with movement of the infant's head and body. The infant appears pale, and a complete blood count is obtained. The infant's hematocrit 22 hours after birth is 12% (0.12). Skull radiographs appear normal. The infant is transfused with packed red blood cells. Coagulation studies reveal a prothrombin time of 15.8 sec, International Normalized Ratio of 1.3, and partial thromboplastin time of 60 sec. The infant is transferred to a tertiary care hospital neonatology unit for further management. A previously well 11-day-old infant is brought to the emergency department for evaluation of fever and eye discharge. The maximum temperature measured at home was 39.2°C. The mother mentions that the baby is sleepier and has had reduced oral intake of formula as well as redness in one eye over the past 24 hours. The baby was born at term via spontaneous vaginal delivery and had uncomplicated prenatal and perinatal periods. Physical examination in the emergency department reveals a well-appearing febrile infant whose rectal temperature is 39.5°C, heart rate is 176 beats/min, respiratory rate is 32 beats/min, and oxygen saturation is 100%. He does not appear to be in any distress and is alert and easily consolable. The rest of the physical examination findings are within normal limits, except for right eye …