Index of Suspicion in the Nursery

Abstract

A term female is born to a 19-year-old primigravida woman via vaginal delivery with vacuum assistance. Artificial rupture of membranes occurred 6 hours prior to delivery and revealed clear fluid. The mother is group B Streptococcus -negative and O+, with all serology results negative. She has a history of Chlamydia , treated twice during her pregnancy. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. The birthweight is 3,640 g and the baby's blood type is B+, with a negative direct antibody test result. Prenatal ultrasonography had shown an umbilical cord Wharton jelly cyst. At birth, the umbilical cord is large and contains no bowel. A pediatric surgeon clamps the cord distal to the large swelling. The cord is moist and leaking fluid. No further studies are performed. The rest of her examination results are normal. The infant takes a standard term formula, but develops jaundice at 12 hours after birth. Her white blood cell count is 13.0×103/mcL (13.0×109/L), with 39 segmented neutrophils and 22 bands. Ampicillin and gentamicin are administered and phototherapy is initiated. On examination the following morning, the infant's umbilical cord continues to leak fluid, and her total bilirubin value continues to increase. At 2 days of age, she develops increasing abdominal girth. A kidney-ureter-bladder film shows a lower abdominal midline mass. Abdominal …