A term newborn develops cyanosis within hours of birth. Respiratory rate is 65/min with no retractions, oxygen saturation does not improve above 80 percent on 100 percent oxygen, and there is a single loud second heart sound with no murmur. Chest radiograph shows a narrow mediastinum with an egg-on-string appearance. What is the immediate priority in management?

• A Administer indomethacin to close the ductus
• B Start a prostaglandin E1 infusion ✓
• C Begin nitric oxide ventilation
• D Perform urgent pericardiocentesis

Explanation

The combination of cyanosis from birth, a single loud S2, refractory hypoxemia and an egg-on-string heart indicates d-transposition of the great arteries. Survival depends on mixing across the ductus and foramen ovale, so an intravenous prostaglandin E1 infusion is started immediately to maintain ductal patency, followed by balloon atrial septostomy if needed. Nitric oxide addresses pulmonary hypertension, not fixed parallel circulation, and indomethacin would worsen mixing by closing the ductus.

Reference: Nelson Textbook of Pediatrics, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.