A 1-hour-old boy is evaluated in the newborn nursery. The patient was born at 38 weeks gestation via spontaneous vaginal delivery to a 24-year-old woman, gravida 3 para 2. The mother had asymptomatic group B Streptococcus bacteriuria in the first trimester and was told that she would receive antibiotics prior to delivery. All other prenatal laboratory results were normal. The mother had spontaneous rupture of membranes at home, came immediately to the hospital, and received one dose of intravenous ampicillin. She delivered approximately 2 hours later. The patient's Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. He received ophthalmic erythromycin and intramuscular vitamin K. Temperature is 37.1 C (98.8 F). All other vital signs are normal for age. Examination shows a quiet, awake neonate with normal tone and posture. What is the most appropriate next step in management of the patient?

Question

A 1-hour-old boy is evaluated in the newborn nursery.  The patient was born at 38 weeks gestation via spontaneous vaginal delivery to a 24-year-old woman, gravida 3 para 2.  The mother had asymptomatic group B Streptococcus bacteriuria in the first trimester and was told that she would receive antibiotics prior to delivery.  All other prenatal laboratory results were normal.  The mother had spontaneous rupture of membranes at home, came immediately to the hospital, and received one dose of intravenous ampicillin.  She delivered approximately 2 hours later.  The patient's Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.  He received ophthalmic erythromycin and intramuscular vitamin K.  Temperature is 37.1 C (98.8 F).  All other vital signs are normal for age.  Examination shows a quiet, awake neonate with normal tone and posture.  What is the most appropriate next step in management of the patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c02f_2c6e_8f63_0367c1c883e3_MD0005_00 Group B Streptococcus (GBS) is the most common cause of early-onset (age <7 days) neonatal sepsis and is transmitted via ascending colonization of the maternal genital tract. Intrapartum antibiotic prophylaxis can prevent transmission of GBS to the neonate and minimize this risk. Indications for prophylaxis include maternal GBS bacteriuria, a positive maternal rectovaginal culture for GBS (obtained at 36-38 weeks gestation), or a sibling with invasive GBS disease; an unknown GBS status with certain risk factors (eg, rupture of membranes >18 hr) warrants prophylaxis as well. Prophylaxis is considered adequate if ampicillin, penicillin, or cefazolin is administered ≥4 hours before delivery. Administration of vancomycin, clindamycin, or other antibiotics is considered inadequate due to bacterial resistance and slower distribution across the placenta and into the amniotic fluid. This patient is full-term patient and well-appearing. The mother is afebrile; however, ampicillin prophylaxis, which was indicated for GBS bacteriuria, was inadequate because it was given only 2 hours before delivery. Neonates of gestational age ≥35 weeks who are well appearing with inadequate intrapartum GBS prophylaxis warrant observation alone due to a lower risk of infection than those who appear ill or are premature. Observation involves serial examinations and vital sign monitoring over 36-48 hours; during this time, almost all neonates with early-onset GBS sepsis will develop symptoms. Well-appearing infants whose mothers are well and received adequate prophylaxis only require routine newborn monitoring due to a very low risk of infection. (Choices A, B, C, and D) Due to a high risk of infection, neonatal blood cultures with or without intravenous antibiotics are indicated regardless of prophylaxis in the following circumstances : Clinical signs of neonatal infection (eg, temperature instability, lethargy) Maternal fever during labor and delivery Gestational age <35 weeks with delivery prompted by signs of possible infection (eg, preterm labor) Ill-appearing infants also typically undergo lumbar puncture for evaluation of meningitis. Unless the patient is hemodynamically unstable, antibiotics should be administered after cultures are obtained. Educational objective: Well-appearing neonates of gestational age ≥35 weeks born to mothers who received inadequate (eg, not administered ≥4 hr before delivery) but indicated prophylaxis against group B Streptococcus should be observed for signs of sepsis over 36-48 hours. Blood culture and antibiotics are indicated for clinical signs of neonatal infection, intrapartum maternal fever, or preterm delivery prompted by potential infection. References: Management of infants at risk for group B streptococcal disease. (http://www.ncbi.nlm.nih.gov/pubmed/31285392)

A 1-Hour-Old Boy Is Evaluated in the Newborn Nursery