Index of Suspicion in the Nursery

Abstract

A male infant is born at 38 weeks’ gestation via emergency repeat cesarean delivery after the mother presented in labor with thick meconium-stained amniotic fluid present. Apgar scores are 2, 7, and 8 at 1, 5, and 10 minutes, respectively. After initial resuscitation in the delivery room that required intubation and suctioning of meconium, the infant is transferred to the neonatal intensive care unit. Respiratory support is weaned to high-flow nasal cannula. Hypoglycemia and neutropenia are found on initial blood work. A blood culture is performed, and ampicillin and cefotaxime are administered for high clinical suspicion of neonatal infection. Maternal blood work includes blood type O, Rh positive, and negative antibody screen result. The mother tests negative for hepatitis B, human immunodeficiency virus, group B Streptococcus, and syphilis. She is immune to rubella. She did not have prolonged rupture of placental membranes or fever. There is no maternal history of hypertension or preeclampsia. On physical examination, the infant weighs 3.2 kg, and vital signs are as follows: pulse oxygen saturation, 96% to 100% on 4-L/min high-flow nasal cannula with a fraction of inspired oxygen of 0.40; respiratory rate, 46 to 83 breaths per minute; heart rate, 110 to 160 beats per minute; blood pressure, 89/52 mm Hg; and afebrile. The infant is alert, and newborn reflexes are intact. There is no pallor, petechiae, ecchymosis, or jaundice. Peripheral perfusion is normal. Findings of the remainder of the physical examination are unremarkable. Laboratory studies on admission reveal the following: hemoglobin, 12.2 g/dL (122 g/L); hematocrit, 34.5% (0.35); platelet count, 149 × 103/μL (149 × 109/L); …