A 1-day-old girl is in the neonatal intensive care unit due to low birth weight. She was born at 36 weeks gestation to a 25-year-old woman via a precipitous spontaneous vaginal delivery. The patient required minimal manual stimulation after delivery and had a subsequent strong cry. Apgar scores were 5 and 8 at 1 and 5 minutes, respectively. Weight, length, and head circumference are

Question

A 1-day-old girl is in the neonatal intensive care unit due to low birth weight.  She was born at 36 weeks gestation to a 25-year-old woman via a precipitous spontaneous vaginal delivery.  The patient required minimal manual stimulation after delivery and had a subsequent strong cry.  Apgar scores were 5 and 8 at 1 and 5 minutes, respectively.  Weight, length, and head circumference are <3rd percentile.  The red reflex is absent bilaterally, and both pupils appear cloudy.  A continuous, harsh murmur is best heard over the left upper sternal border.  The abdomen is nondistended and nontender.  The liver and spleen are enlarged.  Tone is normal, and Moro reflex and palmar grasp reflex are intact.  Which of the following maternal factors is most commonly associated with this patient's presentation?

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11ec25c8_d6cf_eb00_bc81_25a79053b966_MD0003_00 This patient has symmetric growth restriction and hepatosplenomegaly, nonspecific findings of congenital infection. The continuous, harsh murmur is consistent with a patent ductus arteriosus (PDA), and cloudy pupils with absent red reflexes are suggestive of cataracts; these features raise suspicion for congenital rubella syndrome (CRS). Sensorineural hearing loss is another characteristic feature typically identified on routine newborn hearing screen before hospital discharge. Rubella is transmitted transplacentally, and the risk for developing significant fetal defects is highest during the first trimester. Although prenatal maternal infection may present with a self-limited illness (eg, fever, joint pain, rash), many adults are asymptomatic, which was likely the case in this mother. Because most mothers in the United States received the measles, mumps, and rubella vaccine series during childhood, rubella is uncommon. Lack of childhood vaccinations and resulting lack of maternal immunity increase the possibility for an unvaccinated mother to give birth to a neonate with CRS. The live attenuated rubella vaccine should be given to all nonpregnant, nonimmune women of childbearing age prior to conception because live attenuated vaccines carry the potential risk for viral transmission to the fetus if given during pregnancy. (Choice A) Avoiding cat litter, which can harbor Toxoplasmosis gondii from feces of infected cats, during pregnancy can prevent congenital toxoplasmosis. Symptoms include growth restriction and hepatosplenomegaly, but chorioretinitis and jaundice would also be expected. Cataracts and PDA are not classic findings. (Choice B) Fetal alcohol syndrome, caused by prenatal alcohol consumption, presents with growth restriction, CNS anomalies, and facial dysmorphisms. Heart defects can occur, but hepatosplenomegaly and cataracts are not seen. facial dysmorphisms (Choice C) Prenatal or perinatal transmission of sexually transmitted infections causes various findings, such as vesicular skin lesions (neonatal herpes simplex) or hepatomegaly and jaundice (congenital syphilis). This patient's PDA and cataracts are classic for CRS. (Choice D) Prenatal ingestion of unpasteurized products increases risk for Listeria monocytogenes infection, which can present as neonatal sepsis or meningoencephalitis, not cardiac and ophthalmic abnormalities. (Choice F) Infants born to mothers with poorly controlled pregestational diabetes mellitus are at increased risk for congenital heart disease (most commonly transposition of the great vessels). However, cataracts and hepatosplenomegaly would not be seen. Educational objective: Congenital rubella syndrome classically presents with cataracts, patent ductus arteriosus, and sensorineural hearing loss; symmetric growth restriction and hepatosplenomegaly are nonspecific findings. Prevention is with maternal vaccination before conception. References: Congenital rubella. (http://www.ncbi.nlm.nih.gov/pubmed/29939656)

A 1-Day-Old Girl Is in the Neonatal Intensive Care Unit