Case 2: Conjugated Hyperbilirubinemia in a Late Preterm Neonate

A 1,770-g male neonate is born at 35 weeks and 2 days of gestation to a 31-year-old gravida 1, para 0 woman who was found to have prolonged premature rupture of membranes (PPROM), with an amniotic fluid index (AFI) of 2.4. Ultrasonography performed 1 month prior showed a normal AFI of 12.6 and a fetus with multiple anomalies: small chest, hyperechogenic bowel, bilateral clubbed feet, and intrauterine growth restriction. Prenatal maternal laboratory screening was unremarkable, except for a high rubella titer. The mother reports having a flulike syndrome during her pregnancy but does not recollect the presence of a rash. Group B Streptococcus (GBS) status is unknown. The infant is born via spontaneous vaginal delivery. Apgar scores are 2 and 8 at 1 and 5 minutes, respectively. At birth, the infant is vigorous and cries immediately; however, his respiratory effort decreases, and he becomes limp, apneic, and cyanotic. Positive pressure ventilation is administered in the delivery room followed by continuous positive airway pressure (CPAP) for respiratory distress upon admission to the community hospital NICU. The infant is weaned from CPAP and is breathing room air by 2 weeks after birth. An umbilical venous catheter is placed, a blood culture specimen is obtained, and treatment with ampicillin and gentamicin is initiated for PPROM and unknown GBS status. Physical examination findings are significant for a small-appearing infant (birthweight <10th percentile, length <10th percentile, head circumference 10th percentile), bilateral undescended testes, and bilateral clubfeet. Because of the growth restriction and other anomalies, a workup is initiated in the NICU. Cranial ultrasonography performed on the day of birth is normal for age. Echocardiography on day 2 after birth shows a small patent ductus arteriosus and small patent foramen ovale. Complete abdominal ultrasonography performed to follow up on the prenatal ultrasonography shows normal liver texture …