Index of Suspicion in the NurseryCase 1: Preterm Infant With Pleural Effusions and CardiomyopathyCase 2: Pericardial Effusion in the Neonate

Abstract

A 3,220-g male infant is born at 34 weeks’ gestation by urgent cesarean delivery because of concerns for fetal well-being to a 33-year-old gravida 3 para 1 now 2 mother with serologies significant for O positive, rubella nonimmune, hepatitis B surface antigen negative, rapid plasma reagin nonreactive, human immunodeficiency virus negative, Group B streptococcus status unknown. Resuscitation of the infant is significant for the need for positive pressure ventilation, intubation, chest compressions for 1 minute and bilateral thoracentesis with no drainage of fluid. Pregnancy was complicated by previous herpes simplex virus infection with negative bright light examination at time of delivery, previous Cesarean delivery, and new-onset hydrops fetalis. One week before delivery, ultrasound of the fetus was significant for bilateral pleural effusions, cardiac enlargement, increased middle cerebral artery Doppler flow, and polyhydramnios with an amniotic fluid index of 40. Initial assessment reveals a large-for-gestational age infant with generalized edema. He is placed on the high-frequency oscillator on admission. His abdominal examination is significant for the liver edge palpated 3 cm below the right costal margin. An initial chest radiograph reveals bilateral pleural effusions, with right greater than left and hazy lung fields (Fig 1). A cardiology consultation is urgently requested after admission, and the initial echocardiogram reveals a small patent foramen ovale, a small midseptal muscular ventricular septal defect both with left to right flow, right ventricular hypertrophy with normal function, and a tiny pericardial effusion. Figure 1. Initial chest and abdomen radiograph on admission to the NICU displaying a small left pleural effusion and moderate right pleural effusion. Cardiac size is normal for gestational age. ### Initial Evaluation Initial arterial blood gas is pH 7.36 mm Hg, pCO2 45 mm Hg, pO2 132 mm Hg, HCO3 26 mmol/L with base deficit of 0.2 mmol/L. His initial complete blood count reveals white blood cell count …