Morning Report Well Baby Nursery

1/28/2013 Jim Gottlieb, MD

Case Presentation
Term AGA male born to a 23 y/o G4P2103 at 38 5/7 weeks via NSVD on 12/19 12/20 (@ ~31 hours of life) nursing staff reports that pre and post-ductal saturations are 86-87%

History
Pre-pregnancy maternal history/Pregnancy complications: Obesity (no DM/GDM), Hx DVT during previous pregnancy - on anti-coagulation during pregnancy. Tobacco use during this pregnancy and previous narcotic use though reportedly has not used in over 8 years. Maternal serologies: Rubella: immune. RPR: non-reactive. Maternal blood type: A, positive, Coombs negative. GBS Status: positive. HBsAg: negative. Chlamydia: negative. Gonorrhea: negative. HIV: negative. Family history: No history of congenital heart disease, no hip dysplasia, no jaundice requiring phototherapy. No metabolic, genetic, or seizure disorders or any other pediatric illness or congenital disease. Social history: Parents married. Has 3 older sibs who live with MGM. Father has just been laid off. They have been working on Medicaid coverage for baby. Dad has expressed financial concerns and stated several times that his family situation is "not good" but did not divulge other details.

Labor/Delivery
Rupture of membranes: SROM 2 hours prior to delivery Fluid color: clear

Delivery Resuscitation: There were late concerns for shoulder dystocia though infant delivered without assistance. Peds called after baby delivered. Resuscitation included warm/dry/stim. APGAR 9/9. Infant stable and left with mother in delivery room.

Events leading up to presentation

Noted to bottle feed poorly. Per mother only taking 5mL via bottle per feed before spitting up. Brought into nursery to assess feeding and able to take about 30mL.

Glucose initially low (32) but improved with feeds (no IV fluids needed). 1230 on 12/20 (@ 30 hours of life) nursing staff reports that pre and post-ductal saturations are 86-87%

Physical Exam
VS since birth: T 36.3-37.3 HR 128 RR 30-52 BW 3945g Daily Wt: 3895g (95% BW) HC 35.5 cm Length 49cm General: Well appearing, laying in crib in no distress. Head: Normal Shape, Anterior Fontanel Soft and Flat. Eyes: Pupils equal and reactive, Red reflex present. Ears: Normal shape. Nose: Patent. Mouth: Palate intact. Neck: No masses, Normal clavicles. Respiratory: Clear to auscultation. Normal rate. No retractions/nasal flaring. Cardiac: Capillary refill < 3 seconds, Regular rate and rhythm, 1/6 SEM best at LUSB, Brachial and femoral pulses palpable and equal. Abdomen: Bowel tones present, Soft, full, non tender. Liver at the RCM. External genitalia: Normal female. Anus: Patent. Extremities/Hips: Warm and well perfused. Normal digits, No hip clicks or clunks. Neurological: Normal newborn reflexes, Strong cry, Good tone. Skin: No rashes, lesions, birthmarks, cyanosis.

Differential Diagnosis
Hypoxia in the newborn term infant

Mechanisms of Hypoxia
Alveolar Hypoventilation Ventilation Perfusion Mismatch R->L Shunt: Intracardiac, level of the great vessels, intrapulmonary Diffusion Limitation Reduced Inspired Oxygen Tension Impaired O2 Transport

Differential Diagnosis
Respiratory Depression/Hypoventilation RDS Pneumothorax Pulmonary arterio-venous malformations Pneumonia Sepsis Hemolytic anemia or hemoglobinopathy Persistent pulmonary hypertension Congenital heart disease: 5Ts, intracardiac shunting Meconium aspiration Transient tachypnea of the newborn

Work-Up: Pulmonary vs. Cardiac Cause

Careful Physical Examination 4 Extremity Blood Pressures
SBP with gradient >10 in UE versus LE is specific but not sensitive for coarctation

Hyperoxia Test: To evaluate for fixed intracardiac R->L shunt

-PaO2 via blood gas at pre and post-ductal sites, compare room air versus 100% O2

Work-up: Lungs vs. Heart

CXR: Lungs, pneumothorax, pulmonary vasculature, heart size and morphology
90% of infants with R arch have CHD

Echo

Back to our patient

Checked equipment - Consistently 86-87% 4 pt: RUE: 69/44 LUE: 68/39 RLE: 70/45 LLE: 64/38 Hyperoxia" test with BBO2, with increase to 92-94% for both pre and post-ductal

CXR
Cardiomegaly and apparent right-sided aortic arch.

Urgent Echocardiogram
TTE: Tricuspid atresia, ASD, VSD, RV hypoplasia, transposition, arch hypoplasia with coarctation.