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Case 3: Premature Infant with Bilateral Choanal Atresia and Esophageal Atresia/Tracheoesophageal Fistula.

A 26 6/7-week preterm male infant is born to a 24-year-old gravida 2, para 0-0-1-0 woman via urgent cesarean section for preterm labor in breech position. The pregnancy had been uncomplicated, with the exception of preterm labor. All serologic test results are unremarkable. Before delivery, the mother received 1 dose of intramuscular betamethasone 3 hours before delivery. The infant is pale, apneic, and limp on delivery and is taken to the warmer. He is placed in a bowel bag and dried, and positive pressure ventilation is provided immediately, with minimal chest rise. The initial heart rate is less than 100 beats/min. Resuscitation is remarkable for difficulty placing the bag on the infant because of increased secretions and large obstructive tongue. After repeated attempts, the infant undergoes intubation with a 2.5-mm uncuffed endotracheal tube; his heart rate improves to more than 100 beats/min and oxygen saturations were adequate. No epinephrine or chest compression are required. Apgar scores are 2, 4, 5, and 9 at 1, 5, 10 and 15 minutes after birth, respectively. The infant is transferred to the NICU 30 minutes after birth in an intubated and stable condition. Physical examination at birth demonstrates a preterm infant with a relatively large tongue and small size for gestational age.

On arrival at the NICU, the infant was advanced to mechanical ventilation and he was given surfactant. Umbilical arterial catheter and umbilical venous catheter were placed. Initial arterial blood gas measurement was reassuring. A large …