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Endgames Picture Quiz

A congenital anomaly in a preterm newborn

BMJ 2010; 340 doi: (Published 14 January 2010) Cite this as: BMJ 2010;340:b5241
  1. Marijn J Schuurman, paediatric resident1,
  2. Simon G Robben, paediatric radiologist2,
  3. Jasper V Been, paediatric resident1
  1. 1Department of Paediatrics, Maastricht University Medical Centre, 6202 AZ Maastricht, Netherlands
  2. 2Department of Radiology, Maastricht University Medical Centre, 6202 AZ Maastricht, Netherlands
  1. Correspondence to: JV Been jasper.been{at}

    A boy was born by spontaneous preterm delivery at 33 weeks’ gestation (birth weight 1340 g). The pregnancy had been uneventful and no abnormalities had been noticed during regular obstetric checkups, including ultrasonographic evaluation.

    On delivery, the infant had no respiratory drive and a pulse of around 80 beats a minute. After proper positioning to open the airway, his breathing was briefly supported by bag and mask. A heart rate above 100 beats/min was maintained throughout resuscitation. The one minute and five minute Apgar scores were 5 and 8, respectively.

    The newborn was transferred from the delivery suite to the neonatal intensive care unit. Shortly after admission, an umbilical catheter was inserted for administration of parenteral nutrition. A nasogastric tube was passed to start enteral feeding. A chest and abdomen radiograph, obtained to verify proper position of the umbilical catheter, revealed an unanticipated congenital anomaly (fig 1).

    Fig 1 Chest and abdominal radiograph


    • 1 The Apgar score is composed of five items. What are they?

    • 2 Which congenital anomaly of the internal organs is seen on the chest and abdomen radiograph?

    • 3 What are the immediate and subsequent management priorities?

    • 4 Which sequence of malformations is most frequently associated with this anomaly?

    • 5 Given the appearance of the radiograph, is the intravascular catheter inserted in the umbilical vein or in an umbilical artery?


    Short answers

    • 1 The Apgar score consists of the following items, each of which can be scored 0, 1, or 2 points: heart rate; respiratory effort; muscle tone; reflex irritability; and colour.

    • 2 Oesophageal atresia can be seen on the chest radiograph (fig 2). The radio-opaque nasogastric tube is curled up in a blind, dilated upper oesophageal pouch.

    Fig 2 Annotated chest and abdominal radiograph. (A) Nasogastric tube curled up in a blind, dilated upper oesophageal …

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