MUERTE FETAL EN MADRE DE 30 AÑOS

Presentation of Case

A 30-year-old primigravida was admitted to the hospital in active spontaneous labor at 39.7 weeks’ gestation.

The patient had received prenatal care at this hospital since 11.1 weeks’ gestation. She had been well. She had had varicella and had received bacille Calmette–Guérin (BCG) vaccine as a child. Four years earlier, a tuberculin skin test had been positive, and a chest radiograph had been negative; she had received antituberculosis medication for 6 months. There was no history of sexually transmitted diseases, and she did not smoke cigarettes, drink alcohol, or use intravenous drugs. She was born and raised in West Africa and had immigrated to the United States 7 years earlier. She had returned to Africa twice in the previous 3 years, most recently 2 months before the first prenatal visit, and had not received pretravel vaccinations or malaria prophylaxis. Her father had type 2 diabetes mellitus.

Physical examination at the first prenatal visit revealed a blood pressure of 116/70 mm Hg. Ultrasonographic examination of the pelvis showed a single intrauterine gestational sac containing a normal-appearing fetus with a normal heart rate. The placenta was posterior, and the nuchal translucency was normal (<3 mm). Urinalysis showed 3 to 5 white cells per high-power field, with few squamous cells, and urine culture grew moderate mixed bacteria and rare (100 to <1000) group B streptococci.

At 14.6 weeks’ gestation, the pelvic examination was normal, and a Papanicolaou smear revealed yeast. Screening tests for Neisseria gonorrhoeae and chlamydia were negative. Terconazole was prescribed. The white-cell count was 15,200 per cubic millimeter; the remainder of the complete blood count was normal. The blood type was B Rh-positive, and an antibody screen was negative; antibodies against rubella were present. Tests for antibodies against human immunodeficiency virus, rapid plasma reagin, and hepatitis B surface antigen were negative. Ultrasonographic examination at 18.1 weeks’ gestation showed an active fetus with normal fetal and placental anatomy; biometric assessment was consistent with a gestation of 19.0 weeks.

At 23.6 weeks’ gestation, the patient reported pelvic cramping and pain with ambulation. Routine culture of the urine showed rare mixed bacteria (100 to <1000 colony-forming units per milliliter) that included one potential pathogen. The internal laboratory record described the potential pathogen as forming gray, nonhemolytic colonies on sheep-blood agar but did not further identify it because the quantity was less than 1000 colony-forming units per milliliter and it was mixed with several types of regional flora. According to the current laboratory procedure at this hospital, potential group B streptococcus would be fully identified and reported if present in any quantity in a patient known to be pregnant. Her symptoms resolved without treatment.

At 25.9 weeks’ gestation, pain developed over the right rib cage; it was worse with coughing, laughing, and moving. A diagnosis of costochondritis was made, and acetaminophen was prescribed. Fetal activity was noted at 27.1 weeks’ gestation. At that time, the results of a glucose-tolerance test were normal. The white-cell count was 12,800 per cubic millimeter, platelet count 370,000 per cubic millimeter, hematocrit 34.8%, hemoglobin 11.7 g per deciliter, hemoglobin A 97.2%, and hemoglobin A2 2.7%.

Between 30.1 and 36.1 weeks’ gestation, fetal growth and activity were appropriate for gestational dates. Approximately 6 weeks before admission, a red, oval-shaped rash with central clearing developed on the left inner thigh. It resolved within 10 days; a second, similar lesion that developed on her right arm shortly thereafter also resolved spontaneously. She had no fever or arthralgias.

At weekly visits between 36.1 and 39.1 weeks’ gestation, fetal movement was present. There was no vaginal bleeding, rupture of membranes, or cervical tenderness. On the last visit, the blood pressure was 130/80 mm Hg. She had gained 8.62 kg in weight during the pregnancy, and the fundal height was normal at 37 weeks’ gestation, with a cephalad presentation. The estimated fetal weight was 3400 g (45th percentile). Ultrasonographic examination of the uterus revealed a single active fetus in vertex presentation, with a posterior placenta. The fetal heart rate and amniotic-fluid volume appeared to be normal, and no structural abnormalities of the fetus were detected.

On the day of admission, the fetal movements ceased in midmorning. Spontaneous, regular contractions began approximately 4 hours later, and the patient was admitted to the labor and delivery department of this hospital 2.5 hours after the onset of contractions.

There was no recent abdominal trauma, and the patient had no symptoms of bleeding, fever, chills, diarrhea, cough, shortness of breath, or headache. She had no recent exposure to cats or other animals. She had traveled to Cape Cod, Massachusetts, during the late spring (5 months before admission).

Physical examination showed normal vital signs and a fully dilated cervix. Sterile vaginal examination showed an intact and bulging amniotic sac. The remainder of the examination was normal. An external fetal monitor did not detect a fetal heartbeat. Fetal death was confirmed by means of ultrasonographic examination.

Thirty minutes after arrival in the labor and delivery department of this hospital, the membranes were ruptured, and 4 minutes later, spontaneous vertex vaginal delivery of a stillborn male infant occurred. The weight was 3093 g, the head was soft, and the skin was macerated. The amniotic fluid was clear and did not have a foul odor. There was no nuchal cord.

An autopsy was performed.

PARA LEER EL ARTICULO ORIGINAL ACCESE A ESTA DIRECCION

http://content.nejm.org/cgi/content/full/357/9/918

 

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