Infant Suffers Cardiovascular Collapse After Emergency Room Visit

This case takes place in New Hampshire and involves an infant born at forty weeks to a healthy mother. At birth the patient’s APGARs were nine and nine. The amniotic fluid was stained with meconium at birth; however, the infant was not in respiratory distress at this time. A few hours later, the mother noticed the baby to have labored breathing, tachypnea, and noisy breathing. The baby was then taken to the emergency department and found to have moderate respiratory distress, hypoxia, and audible grunting with some intercostal and subcostal retractions. A precordial exam was normal with the exception of a soft 1/6 systolic murmur likely due to a PDA. No cardiology consult was placed and the patient was admitted to the NICU for four days, and then discharged. Three weeks later after the infants PDA closed, she suffered cardiovascular collapse due to coarctation of the aorta. As a result, the patient suffered a hemorrhagic stroke and now has severe neurological deficits.

Question(s) For Expert Witness

1. What is the appropriate pharmacotherapy for coarctation of the aorta?

2. When would a pediatric cardiology consult be pertinent?

3. What is the clinical presentation of a newborn with coarctation of the aorta?

Expert Witness Response E-001331

When a newborn presents with respiratory distress and hypoxia/cyanosis, it must be determined whether or not this is due to respiratory or cardiac disease. If it isn't clearly due to transient lung disease, as evidenced by chest xray/physical exam/etc., then a thorough evaluation (echocardiogram) of possible cardiac origin should be taken. Four-extremity blood pressure, which would suggest coarctation, should be done on all NICU admissions for respiratory disease. A persistent heart murmur should warrant an echo and/or cardiology consult in this situation. If there is any concern in the initial evaluation for a critical coarctation of the aorta, or other ductal dependent cardiac anomaly, then prostaglandins should be initiated until cleared by a cardiologist or negative echo, in order to prevent this sort of unfortunate outcome.