A 3-day-old boy is in the neonatal intensive care unit for management of prematurity. For the past hour, the patient has had decreased spontaneous movements and tone. He has also had one episode of bradycardia and apnea. The patient was delivered vaginally at 28 weeks and 5 days gestation by a multiparous woman with cervical insufficiency. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Birth weight was 1.04 kg (2 lb 5 oz). Prenatal laboratory studies and ultrasounds were normal. Rupture of membranes occurred 3 hours prior to birth. The amniotic fluid was clear, and there was no maternal fever. Temperature is 37.1 C (98.8 F). Head circumference is 28.5 cm, an increase of 3 cm from yesterday. Examination shows a lethargic neonate with a weak cry, tense fontanelle, and generalized hypotonia. The patient then develops a generalized seizure. Which of the following is the most likely cause of this patient's condition?

Question

A 3-day-old boy is in the neonatal intensive care unit for management of prematurity.  For the past hour, the patient has had decreased spontaneous movements and tone.  He has also had one episode of bradycardia and apnea.  The patient was delivered vaginally at 28 weeks and 5 days gestation by a multiparous woman with cervical insufficiency.  Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.  Birth weight was 1.04 kg (2 lb 5 oz).  Prenatal laboratory studies and ultrasounds were normal.  Rupture of membranes occurred 3 hours prior to birth.  The amniotic fluid was clear, and there was no maternal fever.  Temperature is 37.1 C (98.8 F).  Head circumference is 28.5 cm, an increase of 3 cm from yesterday.  Examination shows a lethargic neonate with a weak cry, tense fontanelle, and generalized hypotonia.  The patient then develops a generalized seizure.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d6f4_ff6d_bc81_8b9a690bc06a_MD0003_00 This premature neonate with acute neurologic abnormalities and rapid increase in head circumference most likely has an intraventricular hemorrhage (IVH). IVH is typically due to the rupture of germinal matrix vessels and can extend into the lateral ventricles. Premature (specifically <32 weeks gestation) and very low birth-weight (<1500 g) newborns are at increased risk because their vasculature is fragile and more susceptible to changes in cerebral perfusion (eg, hypotension, hypoxia, hypo- or hyperventilation). IVH typically occurs in the first few days of life and is often asymptomatic. Symptomatic patients, such as this newborn, can have acute neurologic changes (eg, lethargy, hypotonia, seizures). Hemorrhage may also cause anemia, a bulging fontanelle, a rapidly increasing head circumference, bradycardia (eg, Cushing reflex), and apnea. Cranial ultrasound is used to diagnose and grade IVH. Coagulated intraventricular blood has increased echogenicity compared with cerebrospinal fluid filling a normal ventricle. Repeated scans are typically required to monitor progression of the bleed. (Choices A and B) Hypocalcemia and hypoglycemia can cause lethargy, hypotonia, and seizure, but not a rapidly increasing head circumference. (Choice C) Hypoxic ischemic encephalopathy (HIE) is a global, anoxic cortical brain injury that occurs after severe perinatal asphyxia and acidosis. This patient had normal Apgar scores and acute onset of neurologic abnormalities on day 3 of life, making HIE unlikely. (Choice D) Inborn errors of metabolism (eg, maple syrup urine disease) are a rare cause of neonatal seizure, and a rapidly enlarging head circumference makes IVH more likely. (Choice F) Neonatal meningitis can present with nonspecific symptoms (eg, cardiopulmonary instability, neurologic decline). However, this patient's normal temperature and lack of infectious risk factors (eg, maternal fever, prolonged rupture of membranes) make IVH more likely. Educational objective: Intraventricular hemorrhage is a common complication of prematurity and can present with acute neurologic changes (eg, seizure, apnea), a bulging fontanelle, and a rapidly increasing head circumference. References: Intraventricular hemorrhage and neurodevelopmental outcomes in extreme preterm infants. (http://www.ncbi.nlm.nih.gov/pubmed/24379238) Preterm neuroimaging and neurodevelopmental outcome: a focus on intraventricular hemorrhage, post-hemorrhagic hydrocephalus, and associated brain injury. (http://www.ncbi.nlm.nih.gov/pubmed/30166622)

A 3-Day-Old Boy Is in the Neonatal Intensive Care Unit