Case 20-2015: A Newborn Girl with Hypotension, Coagulopathy, Anemia, and Hyperbilirubinemia (original) (raw)

2542 T h e ne w e ngl a nd jou r na l o f m e dicine Pr esentation of C a se Dr. Emily B. Rubin (Pediatrics): A newborn girl was transferred to the neonatal intensive care unit (NICU) of this hospital on the first day of life because of hypoten-sion, coagulopathy, anemia, and hyperbilirubinemia. At an affiliated hospital, the infant was born by cesarean section to a 30-year-old primigravida mother at 34 weeks 6 days of gestation, after late-onset oligohy-dramnios and premature labor occurred and a nonreassuring fetal heart-rate pattern developed. The membranes were ruptured at delivery, and the baby emerged vigorous , with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The weight was 2.15 kg (34th percentile for gestational age), the head circumference 31.5 cm (54th percentile), and the length 46 cm (64th percentile). The oxygen saturation was 95% while the baby was breathing ambient air. The initial blood pressure was 40/25 mm Hg (reference range for a premature newborn, 55 to 75 systolic and 35 to 45 diastolic), with a mean arterial pressure of 25 mm Hg; the remainder of the examination revealed features consistent with those of a late preterm infant. The standard dose of vitamin K was administered shortly after birth. The infant was admitted to the special-care nursery. Subsequent blood-pressure recordings reportedly revealed a systolic blood pressure between 30 and 39 mm Hg and a dia-stolic blood pressure between 10 and 19 mm Hg. Laboratory test results are shown in Table 1. Supplemental oxygen through a nasal cannula and boluses of normal saline and dextrose were administered, without improvement. Blood oozed at the site of peripheral punctures, and fresh-frozen plasma was administered. A repeat hematocrit was 29%, and packed red cells were transfused. A chest radiograph reportedly showed diffuse, nonspecific pulmonary haziness. A blood culture was performed, and ampicillin and gentamicin were administered 1 and 2 hours after birth, respectively. Approximately 7.5 hours after birth, the total serum bilirubin level was 6.4 mg per deciliter (109 μmol per liter) and the direct bilirubin level was 1.5 mg per deciliter (26 μmol per liter); phototherapy was begun. A Kleihauer–Betke test (hemoglobin F stain) for fetal–maternal hemorrhage (fetal blood loss across the placenta and into the maternal circulation) was positive