Index of Suspicion in the Nursery

Abstract

A woman is admitted for induction of labor at 40-3/7 weeks' gestation. Prenatal care was initiated at 21 weeks' gestation. Ultrasonographic examinations at 23 and 34 weeks' gestation revealed a slightly enlarged right kidney and polyhydramnios, with amniotic fluid indices of 18.6 and 26.7, respectively. An emergency cesarean section is performed for fetal distress. Meconium-stained fluid is noted at delivery. A female infant weighing 3,140 g (10th to 25th percentile for weight) is delivered and assigned Apgar scores of 2, 5, and 9 at 1, 5, and 10 minutes, respectively. At delivery, she is flaccid and apneic but responds quickly to nasal and oral suctioning, stimulation, and bag-mask ventilation. She requires endotracheal intubation for worsening respiratory distress and desaturations. Her initial chest radiograph shows an enlarged cardiac silhouette and diffusely hazy lung fields (Fig. 1). An additional study is performed, which helps to explain the infant's presentation. Figure 1. Chest radiograph shows an enlarged cardiac silhouette and bilateral streaky opacities. Physical examination reveals a grade II/VI systolic ejection murmur along the left sternal border without radiation. Peripheral pulses are diminished in all extremities. She is having moderate respiratory distress on mechanical ventilation support. Her abdomen is soft but distended, and the liver edge is palpable 4 cm below the right costal margin and extends across the midline. No splenomegaly is noted. A palpable mass in the right flank is also detected. A three-vessel cord is present, with a prominent umbilical vein. An abdominal radiograph demonstrates a paucity of bowel gas consistent with ascites and hepatomegaly (Fig. 2). Laboratory results include a white blood cell count of 8.0×103/μL (8.0×109/L) with a normal differential count, a hematocrit of 24% (0.24), and a platelet count of 71×103/μL (71×109/L). Bacterial and viral cultures are negative. Figure 2. Abdominal radiograph of …