Index of Suspicion in the Nursery

Abstract

A female infant is delivered by spontaneous vaginal delivery at 29 weeks of gestation. Her Apgar scores are 8 at 1 minute and 9 at 5 minutes. Her weight is 1,300 g, length is 38 cm, and head circumference is 27 cm. The mother is a 20-year-old primiparous African American female who had one previous live term pregnancy and one abortion. Her past medical and surgical histories are otherwise unremarkable. She had adequate prenatal care, and her prenatal laboratory test results were normal, including a negative screen for group B Streptococcus and normal findings on prenatal ultrasonography. She experienced premature contractions at 27 weeks, at which time a dose of betamethasone was administered. At 29 weeks of gestation, she went into labor. Clear amniotic fluid was drained after artificial rupture of membranes just prior to delivery. At the time of delivery, the mother did not have fever or tachycardia, although she had a white blood cell count of 16.9×103/mcL (16.9×109/L), with 58% neutrophils, 12% bands, 15% lymphocytes, and 12% monocytes by manual differential count. The mother did not receive antibiotics during the intrapartum period. The baby is admitted to the neonatal intensive care unit (NICU) due to prematurity and is treated with intravenous ampicillin and gentamicin for 48 hours until cultures are negative and the baby remains clinically stable. She begins oral feedings with expressed human milk (EBM) on the second day after birth. Small amounts of residue are present periodically after feedings. She otherwise remains clinically stable, breathing comfortably in room air. On day 13 after birth, she develops abdominal distention and vomits once. Greenish material is aspirated via the orogastric tube. Feedings are discontinued, and further evaluation is undertaken. A 41-day-old term boy presents with fussiness and a rectal temperature to 101.2°F (38.5°C). He …