Pediatric Examination and Board Review (205 page)

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UGGESTED
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EADING

Gleason PF, Eddleman KA, Stone JL. Gastrointestinal disorders of the fetus.
Clin Perinatol.
2000;27;901-920.

Maisels MJ. Neonatal jaundice.
Pediatr Rev
. 2006;27(12):443-453.

Nold JL, Geogieff MK. Infants of diabetic mothers.
Pediatr Clin North Am.
2000;51(3):619-637.

Semel-Concepcion J. Neonatal brachial plexus palsies. Emedicine Web site.
http://emedicine.medscape.com/article/317057-overview
. Accessed July 20, 2009.

CASE 115: A NEONATE WITH A HISTORY OF MATERNAL GROUP B STREPTOCOCCAL COLONIZATION AND A REACTIVE RAPID PLASMA REAGIN TEST FOR SYPHILIS

A 3230-g infant was born to a 25-year-old G1P1 woman who had prenatal care starting in the third trimester. She had syphilis 2 years before that, according to her, had been treated with “shots.” Her screening test for syphilis (rapid plasma reagin [RPR]) was positive at a titer of 1:4 during this pregnancy. She has a history of cocaine abuse as well as a seizure disorder for which she takes phenytoin. She was found to be a vaginal carrier of group B beta-hemolytic streptococcus. On admission, she was in active labor and delivered the baby before receiving prophylactic intrapartum penicillin. The Apgar scores were 8 and 9 at 1 and 5 minutes of life, respectively.

SELECT THE ONE BEST ANSWER

1.
Which is the best way to assess active syphilis in the mother?

(A) repeat RPR test

(B) VDRL (Venereal Disease Research laboratory) test

(C) culture of vaginal secretions

(D) FTA-ABS (fluorescent treponemal antibody absorption)

(E) A or B

2.
Which statement is most accurate regarding a neonate with congenital syphilis?

(A) congenitally infected neonates asymptomatic at birth will most likely remain asymptomatic

(B) a neonatal RPR titer 4 times higher than the mother is indicative of congenital syphilis

(C) a twofold decrease in maternal RPR titer after treatment for syphilia is indicative of successful therapy

(D) Jarisch-Herxheimer reactions are common in neonates after treatment for congenitally acquired syphilis

(E) IV ceftriaxone is the treatment of choice in congenital syphilis

3.
Which of these is least likely to be a manifestation of congenitally acquired syphilis?

(A) hemolytic anemia

(B) pseudoparalysis of Parrot

(C) snuffles

(D) patent ductus arteriosus

(E) periostitis and osteochondritis

4.
Maternal cocaine use during pregnancy has been associated with which of the following?

(A) gastroschisis

(B) LGA (large for gestational age) babies

(C) increased incidence of Wilms tumor in children

(D) neural tube defects

(E) Ebstein anomaly

5.
A medical student following this baby with you asks if the baby is at risk for neonatal abstinence syndrome. Which drug is most commonly associated with neonatal abstinence syndrome?

(A) heroin

(B) marijuana

(C) phencyclidine (PCP)

(D) cocaine

(E) tobacco

6.
Anticonvulsant embryopathy has many features in common with fetal alcohol syndrome. Both have the following in common except

(A) hypertelorism

(B) atrial septal defect

(C) fingernail defects

(D) broad nasal bridge

(E) small for gestational age (SGA) at delivery

7.
Infants born to women taking anticonvulsants are most likely at risk for complications due to decreased stores/function of which vitamin?

(A) C

(B) A

(C) K

(D) E

(E) D

8.
What is the drug of choice for intrapartum antibiotic prophylaxis against group B streptococcus (GBS) if the mother is known to react to penicillin with anaphylaxis?

(A) vancomycin

(B) cefazolin

(C) clindamycin

(D) ceftriaxone

(E) levofloxacin

9.
Which is a true statement regarding intrapartum antibiotic prophylaxis to prevent GBS disease?

(A) since the implementation of consensus guidelines for intrapartum antibiotic prophylaxis, there has been a significant decrease in the incidence of late-onset GBS disease

(B) asymptomatic babies born at greater than 35 weeks of gestation to mothers who have received 4 or more hours of intrapartum penicillin or ampicillin need no further evaluation or therapy for GBS sepsis if the baby appears to be clinically well

(C) asymptomatic babies born at greater than 35 weeks of gestation to mothers who have received 4 or more hours of intrapartum antibiotic prophylaxis need only limited further evaluation for GBS sepsis consisting of a CBC and blood culture

(D) ampicillin is not an appropriate first-line antibiotic for intrapartum anti-GBS prophylaxis

(E) since the implementation of consensus guidelines for intrapartum antibiotic prophylaxis, there has been a significant decrease in the incidence of neonatal sepsis due to other organisms

10.
Late-onset GBS infection in neonates would most likely present as

(A) hepatitis

(B) NEC

(C) urinary tract infection

(D) conjunctivitis

(E) meningitis

11.
Does a positive FTA-ABS on the cord blood diagnose congenital syphilis?

(A) yes

(B) no

12.
Would a negative RPR titer on the cord blood rule out congenital syphilis?

(A) yes

(B) no

13.
In the case in the vignette, can you rule out the possibility that the mother has been reinfected with syphilis since her treatment 2 years ago?

(A) yes

(B) no

14.
What would be the most conservative approach to the management of this newborn?

(A) follow the baby’s RPR titers over the next 6 months

(B) treat the baby with one intramuscular (IM) benzathine penicillin injection

(C) treat the baby with 10 days of IM aqueous procaine penicillin or IV aqueous penicillin

(D) follow the RPR over the next 12 months, but no treatment

(E) do a lumbar puncture (LP) to obtain cerebrospinal fluid (CSF) for analysis and serologic testing

15.
If the mother had received adequate intrapartum penicillin prophylaxis for GBS, would that eliminate the concern over the possibility of congenital syphilis in the newborn?

(A) yes

(B) no

16.
Of the following choices, what should be done with a term newborn whose mother did not receive intrapartum penicillin prophylaxis for her known group B streptococcal colonization?

(A) admit the infant to the NICU and observe

(B) draw a blood culture and leukocyte count and admit the infant to the well-baby nursery and observe

(C) begin the baby on oral penicillin

(D) begin the baby on ampicillin and gentamicin after a leukocyte count and a blood culture

(E) give the baby a 50 mg/kg IM of ceftriaxone, one time

17.
If the blood culture is positive, how long will it likely take to be recognized as such by the microbiology laboratory staff?

(A) within 24-36 hours

(B) 48-72 hours

(C) more than 72 hours

(D) there is patient-to-patient variation

(E) this information is not known

18.
If the baby develops symptomatic early-onset GBS disease, this will most likely present at

(A) less than 24 hours of age

(B) after 24-48 hours of age

19.
How long should the baby in question 15 remain in the hospital for observation for GBS disease, assuming she or he is asymptomatic?

(A) 24 hours