Index of Suspicion in the NurseryCase 1: Persistent Severe Metabolic Acidosis in a NewbornCase 2: Late Preterm Infant With a Difficult Intubation

Case 1 Presentation

A female preterm infant was born at 28-weeks’ gestation to a G3P2A1 mother (third degree consanguineous marriage) by emergency cesarean delivery due to severe fetal growth restriction, oligohydramnios, and increasing liver transaminase levels in the mother. First conception was miscarriage at 12-weeks’ gestation. The second conception was intrauterine fetal demise at 30-weeks’ gestation; the pregnancy was complicated with acute fatty liver of pregnancy (AFLP) and acute kidney injury. Placenta showed massive perivillous fibrin deposition. Present pregnancy was spontaneously conceived. Pre-pregnancy, mother was diagnosed as hypothyroid and was started on thyroxine. She had also been started on aspirin since the last pregnancy and had received a complete course of antenatal steroids at 27-weeks’ gestation. Blood pressure of the mother at the time of admission was 140/90 mm Hg. This pregnancy was also complicated with AFLP, with serum glutamic-pyruvic transaminase levels of 586 U/L and lactate dehydrogenase levels of 863 U/L. The infant at birth weighed 960 g, required resuscitation with bag and mask for 30 seconds, and had Apgar scores of 5 and 7 at 1 minute and 5 minutes, respectively. Immediately after resuscitation, the infant was noted to have respiratory distress (Silverman-Andersen score of 8 of 10). In view of this distress, the infant was shifted to the NICU on a T-piece resuscitator and was started on continuous positive airway pressure at 15 minutes of age with a positive end-expiratory pressure of 5 cm and fraction of inspired oxygen of 0.50. Chest radiograph revealed surfactant deficiency. Surfactant (INSURE [intubation, surfactant administration, and extubation]) was given at 2 and 6 hours after birth in view of persistent respiratory distress and increased fraction of inspired oxygen requirement, respectively. She also had poor circulation, was off-color, and had increased capillary perfusion starting from 2 hours after birth. This shock was initially managed with a …