Case 1: A 31-week Fetus with Intestinal Atresia and Sudden Fetal Hemorrhage

Presentation

A 34-year-old gravida 1, para 0 woman is pregnant with a fetus with known duodenal atresia and polyhydramnios. This pregnancy is the result of in vitro fertilization. Prenatal ultrasonography and fetal echocardiography findings are otherwise normal. Cell-free DNA testing is negative for trisomy and the parents decline amniocentesis. Family history is unremarkable at this time. Preterm premature rupture of membranes (PPROM) occurs at 31 weeks and 4 days of gestation, and the mother is admitted to the obstetrics department for continuous fetal monitoring. Latency antibiotics and betamethasone are administered.

Recurrent late decelerations are noted 46 hours after PPROM. Emergency cesarean delivery is performed under general anesthesia and the amniotic fluid is grossly bloody. The 2,115-g large-for-gestational age female infant emerges pale, apneic, and hypotonic. The initial heart rate is 40 beats/min. Large amounts of bloody secretions are suctioned from the mouth and airway. Bradycardia persists despite positive pressure ventilation with good chest movement. Chest compressions are performed, and the infant undergoes intubation. The infant continues to be bradycardic and hypoxic with weak pulses and poor perfusion. A low-lying umbilical venous catheter (UVC) is inserted, and normal saline and epinephrine are administered. The heart rate improves slowly as does the hypoxia. The infant’s Apgar scores are 0, 2, 3, and 4 at 1, 5, 10, and 15 minutes after birth. Arterial cord blood gas values are as follows: pH 7.10, partial pressure of carbon dioxide (Pco₂) 65 mm Hg (8.6 kPa), bicarbonate 22 mEq/L (22 mmol/L), base deficit 19; venous cord blood gas values are as follows: pH 7.15, Pco₂ 58 mm Hg (7.7 kPa), bicarbonate 22 mEq/L (22 mmol/L), base deficit 9.7. The umbilical cord is noted to be grossly abnormal with short, curved vessels visible outside the Wharton jelly (Fig 1).