A newborn boy is evaluated in the delivery room 10 minutes after birth for increasing respiratory distress. He was born at 38 weeks gestation by a forceps-assisted vaginal delivery complicated by a 2-minute shoulder dystocia. The infant's mother did not receive any prenatal care. Temperature is 36.8 C (98.2 F), blood pressure is 70/40 mm Hg, pulse is 168/min, and respirations are 72/min. Oxygen saturation is 82% on room air. Physical examination shows grunting, nasal flaring, and cyanosis of the mucous membranes. Chest x-ray is shown below: Which of the following is the most likely diagnosis in this patient?

Question

A newborn boy is evaluated in the delivery room 10 minutes after birth for increasing respiratory distress.  He was born at 38 weeks gestation by a forceps-assisted vaginal delivery complicated by a 2-minute shoulder dystocia.  The infant's mother did not receive any prenatal care.  Temperature is 36.8 C (98.2 F), blood pressure is 70/40 mm Hg, pulse is 168/min, and respirations are 72/min.  Oxygen saturation is 82% on room air.  Physical examination shows grunting, nasal flaring, and cyanosis of the mucous membranes.  Chest x-ray is shown below:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d71a_61f9_bc81_c564e006c4c9_MD0003_00 Congenital diaphragmatic hernia (CDH) is a defect in the diaphragm that results from incomplete fusion of the pleuroperitoneal folds during fetal development. Protrusion of abdominal contents through this defect (most commonly left-sided) into the thoracic cavity compromises lung development, leading to pulmonary hypoplasia. In utero remodeling of pulmonary vasculature also leads to arterial muscular hyperplasia and persistent pulmonary hypertension. Shortly after birth, patients develop respiratory distress (eg, tachypnea, cyanosis, retractions), often accompanied by absent breath sounds on the side of the hernia. A barrel-shaped chest and scaphoid abdomen (due to displaced abdominal contents) are characteristic findings. Chest x-ray is diagnostic for CDH that is not detected prenatally (eg, lack of prenatal care). Imaging shows intrathoracic bowel loops and a displaced cardiac silhouette, as seen here. Initial management includes intubation with cautious ventilation and gastric decompression. Urgent surgical correction is the definitive treatment. (Choice B) Group B Streptococcus pneumonia presents with respiratory distress shortly after birth, but x-ray shows diffuse alveolar infiltrates and possible pleural effusions. (Choice C) Tension pneumothorax in a newborn can present with acute-onset respiratory distress, asymmetric breath sounds, and deviation of the heart to the contralateral side. However, air in the pleural space is visualized on x-ray. (Choice D) Tetralogy of Fallot with severe right outflow tract obstruction can present shortly after birth with cyanosis and a harsh, systolic ejection murmur. Characteristic chest x-ray findings include a "boot-shaped" heart. "boot-shaped" heart (Choice E) Transient tachypnea of the newborn is due to retained fetal lung fluid and presents in the first few hours of life with tachypnea and increased work of breathing. Hyperinflation and fluid in the fissures are classic chest x-ray findings. Educational objective: Congenital diaphragmatic hernia results in herniation of abdominal contents into the thoracic cavity. Patients have respiratory distress at birth with absent breath sounds on the affected side, a barrel-shaped chest, and a scaphoid abdomen. Chest x-ray shows intrathoracic bowel loops and a displaced cardiac silhouette. References: Abnormal lung development in congenital diaphragmatic hernia. (http://www.ncbi.nlm.nih.gov/pubmed/28641748) A clinical study on congenital diaphragmatic hernia in neonates: our institutional experience. (http://www.ncbi.nlm.nih.gov/pubmed/30050261)

A Newborn Boy Is Evaluated in the Delivery Room 10