Index of Suspicion in the Nursery

Abstract

A 39-5/7 weeks’ gestation infant boy weighing 3.670 kg is born by emergency caesarian section for significant fetal distress. The mother is a 37-year-old primigravida whose pregnancy is uneventful except for oligohydramnios due to “leaky” membranes. Liquor is scanty, meconium stained and has an offensive smell. The infant is born in poor condition, needs resuscitation, and moves to the neonatal unit ventilated and passively cooled. Apgar scores are 1, 4, and 6 at 1, 5, and 10 minutes, respectively. Cord blood pH is 6.8, and base excess is −18 mmol/L. On admission, temperature is 38.3°C, and the infant, covered with thick meconium, is hypertonic, tachycardiac, breathing with difficulty, not synchronizing with ventilator, and having a bilaterally distended chest, diminished air entry to both lung fields, muffled heart sounds, and a pre- and postductal O2 saturation difference of 10% to 15%. After two boluses of normal saline, and initiating active whole-body cooling, sedation, muscle relaxation, intravenous antibiotics, maintenance fluids, inhaled nitric oxide, and cerebral function monitoring, umbilical lines are placed. Blood tests confirm both sepsis and severe hypoxic-ischemic injury. Chest radiograph reveals abnormal bell-shaped chest, small lung volume, and bilateral pneumothoraces, more on the right hemithorax, necessitating chest drain insertion. A urinary catheter is placed. Urine output (UOP), noticed to be low during the first 36 hours, starts to recover. He is rewarmed after 72 hours of cooling, the urinary catheter is pulled out, and antibiotics are stopped by day 5. Ventilation remains difficult to wean, and pneumothoraces keep reaccumulating. Ultimately, he is extubated to air, and chest drains are removed, by day 14. Once the urinary catheter is removed, the infant’s UOP significantly drops, which is thought to be related to urinary bladder atony complicating the hypoxic-ischemic injury. Another urinary catheter is placed, and UOP starts to normalize between …