Title: Maternity
Original airdate12/7/2004
Synopsis: An epidemic strikes the maternity ward at PPTH. Several babies become seriously ill, and the team has little time to determine the cause.
Patient: Maxine Hartig, Baby Boy Chen-Lupino, Baby Boy Howsam, Baby Girl Perry, and two others.
Initial symptoms: high fever, seizure

*****Spoilers below*****

Differential diagnosis:

The Hartigs are holding their newborn daughter, trying to decide on a name, when she spits up. The parents become alarmed and call the obstetrician in to look at her. He notes that she is lethargic and feels hot. The baby begins to seize, and the OB calls for the crash cart and Ativan.

House is loafing in the OB/GYN lounge when he hears the obstetrician talking about the case with another OB. Baby Girl Hartig has been diagnosed with a bowel obstruction and is under observation. House is intrigued, and investigates. He finds Baby Boy Howsam in the NICU. This child has a fever of unknown origin, 101 and rising.

House believes an infection is spreading through the maternity ward. He notes that the two babies shared a delivery room, and their rooms were next to each other, making transmission possible. Wilson points out that the Hartig baby has a bowel obstruction, but House says the baby's x-ray has a normal gas pattern, showing air in the colon, eliminating the possibility of a blockage.

House demands that the maternity ward be shut down, but Cuddy refuses, on the grounds that two sick babies does not qualify as an "epidemic," and that House is just seeing what he wants to see because the alternative is uninteresting.  House rounds up the Doclings to search for more sick babies. They find none on the second floor, but Baby Boy Chen-Lupino on the third floor has developed a sudden fever. A fourth baby, Baby Girl Perry,  is also showing early symptoms. Cuddy sets a team of med students to swab the maternity ward while House and his team begin the differential diagnosis.

The babies all have fevers and low blood pressure. They rule out parasites, as the infection is speading too quicky. A viral infection is considered, but Cameron thinks the babies are too sick, and notes the blood tests showed no 
lymphocytosis. Foreman agrees because they're not responding to the antivirals, acyclovir and ribavirin, and if it is a virus that doesn't normally respond to those medications, they don't have time to find it.

They decide the children must have a resistant bacterial infection, since broad-spectrum antibiotics are having no effect.  Foreman suggests MRSA and H Flu as possibilities, Cameron thinks it could be Pseudomonas, and Chase suggests VRE. House orders vancomycin for MRSA and aztreonam for the others, and MRIs to look for 
abscesses or occult infections.

The Hartig and Chen-Lupino babies develop kidney failure, which they attribute to the antibiotics as the urine tests show no casts. Since both drugs can cause kidney failure and they don't know which infection the babies have, House wants to take one baby off vancomycin and the other off aztreonam.

The Doclings, Cuddy, and the hospital lawyer view this as an unethical experiment, though Cuddy allows it, since the alternative is to allow the babies to die of the infection, and two more babies are now ill. Foreman explains to the Hartigs that they think the baby has MRSA, and they are taking her off the aztreonam. Cameron tells Judy and Kim the baby probably has Pseudomonas, so they are taking him off vancomycin.

Shortly after, the Chen-Lupino baby's blood pressure drops precipitously. The baby is given Levophed and pressors, but his BP continues to drop, and he develops v-fib. Chase delivers several shocks, but the child dies. House concludes that the aztreonam is ineffective, and orders vancomycin for the remaining babies He tells Cameron to tell the Chen-Lupinos that their baby probably saved five lives.

The ethical dilemma is rendered moot when Chase informs House that the Hartig baby is continuing to decline. The vancomycin isn't working, either, so they're back at square one.

Foreman suggests theya re dealing with a superbug. Chase thinks the Howsam baby's skin rash could be scalded-skin syndrome, which would indicate VRSA,
though Cuddy says there has only ever been two cases in the United States. House launches into a rant about the practice of overprescibing antibiotics, but changes his line of thinking when he remebers how low the baby's blood pressure was before his death, even with three pressors. Wilson speculates the baby had heart damage. House sends the team home, as there is nothing more they can do, and performs an autopsy on Baby Boy Chen-Lupino.

The autopsy revealed fibrosis and lymphocytic infiltrates in the boy's myocardium, though there was no sign in earlier blood tests. They conclude that the infection must be viral. The process of finding the virus is daunting as there are thousands of possibilities and limited time. Chase also points out that if they take vials of blood from the babies, rather than stick-tests, they can only take five or six without exsanguinating the infants.

House divides the white board into yes/no columns, and separate the possibilities based on the symptoms and effects of the medications they've tried. Herpes viruses 1 and 2, adenovirus, toxoplasmosis, rubella, TORCH syndromeparamyxoviridae, and a number of others are added to the "no" column.

The "yes" column consists of CMVEcho 11, influenza A, Coxsackie, rotavirus, Epstein-Barr, Parvovirus B19, and RSV. The Doclings draw the blood, though Chase feels that eight vials is "pushing it." Wilson heads off to research which antivirals are effective against the eight viruses, and Cuddy draws blood from the last remaining baby at the hospital who was unaffected by the infection.

All the sick babies tested positive for echovirus 11, CMV, and parvovirus B19.  The healthy baby tests positive for echovirus 11 and CMV also, which Foreman thinks is odd. House realizes that the babies have their mothers' antibodies, so if the mothers had had any of these infections in the past, her antibodies would be passed to the newborns, rendering them immune as well.

Testing of the mothers' blood reveals the culprit to be echovirus 11. Cameron tells the Hartigs that while the virus can cause flu-like symptoms and diarrhea in adults, but can be deadly for newborns, and that the virus is damaging her heart. The team acquires an experimental antiviral from a company in Pennsylvania which has shown promise in laboratory tests. After a tense period of waiting, the babies recover.

When the maternity ward reopens, House continues to to seek the source of the infection. Wilson urges him to wait for the results of testing on stool samples that Cuddy got from the entire staff, but House is adamant. He says the manner of transmission of enteroviruses is fecal-oral or respiratory secretions, and the shedder must have been showing symtpoms that Cuddy would have noticed.  Wilson thinks House's determination is "weird," but just after Wilson walks off, House hears coughing.

An elderly hospital volunteer walks by pushing a trolley and wiping her nose on her hand. The trolley contains a basket of teddy bears, which she handed out to all the babies. House has found the one person all the babies had in common.

House agrees to deliver the baby of Jill, a clinic patient, so he can continue to loaf in the OB/GYN lounge for five more months.


Diagnosis: Echovirus 11 infection


Incidental terms:
Physician's Desk Reference
azithromycin
Levaquin
penicillin
smallpox

Myoviridae
Orthomyxovirus
Bymovirus

Lassa
Ippy
varicella
Equine
papovavirus
rhabdovirus
Hordeivirus



Soap Opera:
Medical ethics: when the babies' kidneys fail

Cameron is unable to give bad news to the babies' parents, even in response to direct questions, to the point where Foreman, Wilson, and House question her professionalism. When the decision is made to discontinue one of the antibiotics, Foreman tells the Hartigs that the baby is gravely ill, and they don't know of she will survive. He does so gently and with tact. Cameron, however, does not give the Chen-Lupinos the full truth about how sick their baby is.  When Wilson calls her out for it, she claims the poor women will not care what she said today if their baby dies tomorrow, and it is better to give them hope.

When the Chen-Lupino boy dies, House tells Cameron to inform the parents. She tries to get out of it, but House insists. She appraoches the parents, but freezes, saying nothing. Wilson delivers the news for her.

Comments
:


Cameron needed a good, hard slap. She soft-pedaled the baby's condition, leaving the mothers unprepared for his death.  When she clammed up in front of the parents, Wilson did her no favor by delivering the bad news for her. They most certainly will remember what their doctor said to them before their baby's death.

House performs the autopsy on the baby with surprising tenderness, but you'd think a pathologist would be doing that.
Cameron consistently pronounces vancomycin as "vanco-mya-cin." It's nitpicky, but I'm saying.  

Oops: Either House's office has moved itself to the second floor, or the set dresser forgot to change the sign by the elevator. In the scene where Jill drags Charlie to the hospital, the directory by the elevators is wrong.
Oops: When House tells the OB he's delivering a baby in late March, the OB replies, "That's five months from now." House gives the date as December 2. Jill is four months along, so she will be giving birth in five months, but it won't be March.

I wonder if they told the teddy bear lady what happened. If she knew her sniffles caused a baby's death, she would probably feel like absolute crap for the rest of her life.
Clinic Patients:

Jill



Everybody Lies:

PPTH People: 

Karen Hartig
Ethan Hartig
Kim
Judy
Tie Clip
Blonde NICU nurse
Brunette NICU nurse
Baby Boy Limpert
Security 12
Dr. Kent
Dr. Leland
Dr. Lee

Other People
:

Charlie


Cast:
cast

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