You are seeing a 2-week-old in your office for a weight check. The baby was full term, and mom reported a history of hypothyroid, gestational DM and bipolar I disorder. Mom has older children and states she feels like this baby is sleepier than her others were at this age, barely waking to feed. She says she thinks the baby's lips and nails are blue. Vitals include HR 190, RR 55bpm, O2 sat 89%. On the exam, the baby is mildly hypotonic with cyanotic lips and nails. You appreciate a holosystolic murmur at the left lower sternal border and a loud 1st heart sound. You again inquire about the medications mom was on during her pregnancy. The one you are most concerned with is:
Correct!
Wrong!
EXPLANATION
Answer: B: Lithium. The baby described has Ebstein Anomaly. This is found in 1:1000-1:2000 babies who had 1st trimester fetal exposure to lithium. The rate of Ebstein anomaly in the general population is 1:20,000. There are three potential cardiac sounds heard during the exam: a holosystolic murmur at the left lower sternal border during inspiration due to tricuspid regurgitation, a mid-diastolic murmur due to the large volume of blood going across the abnormal valve into the right ventricle during diastole and a loud 1st heart sound, called a "sail sound", from closure of the anterior leaflet.