Index of Suspicion in the Nursery

Abstract

A term, appropriate for gestational age girl is born at 37 weeks’ gestation to a 19-year-old, gravida 2, para 1 mother. The pregnancy is complicated by maternal preeclampsia that requires delivery via cesarean. Maternal laboratory test results are unremarkable. The prenatal history is unremarkable, except for decreased fetal movements 2 weeks before delivery. The mother tested positive for group B Streptococcus but received adequate antibiotic prophylaxis before delivery. The infant is delivered via cesarean with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. She is admitted to the newborn nursery, where she receives treatment for hypoglycemia initially, but recovers quickly with feeding. The infant is transferred to the neonatal intensive care unit at 23 hours after delivery because of poor feeding, low temperature, and apnea with desaturation and is given ampicillin and gentamicin after blood cultures are performed, but she continues to decline with progressive hypotonia and lethargy. Feeding becomes impossible because of poor suck, and the infant is intubated because of poor respiratory effort and apnea. At 2 days after birth, movements consistent with myoclonic jerks begin. Head computed tomography is performed and the results interpreted as normal. Electroencephalography is performed, which reveals a burst suppression pattern. Blood culture results remain negative. The infant is transitioned to a higher level of care. The results of initial baseline laboratory tests, including a capillary blood …