A 37-year-old woman, gravida 4 para 3, comes to the emergency department due to contractions and vaginal bleeding. She has no leakage of fluid and has had normal fetal movement. The patient did not receive prenatal care, and her last menstrual period was 10 months ago. Her 3 prior pregnancies ended in uncomplicated, term vaginal deliveries. The patient has no chronic medical conditions and takes no medications. Blood pressure is 130/82 mm Hg and pulse is 78/min. The fetal heart rate shows moderate variability, no accelerations, and occasional late decelerations. The tocodynamometer shows contractions every 3 minutes. The cervix is dilated 8 cm and 100% effaced, and the fetal head is at +1 station. The patient is admitted and precipitously delivers a small-for-gestational-age (2.8-kg [6.2-lb]) male infant. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. The infant has green, wrinkled, peeling skin; thin fingers; and long fingernails. Loose skin and prominent skin creases are noted over the thighs and buttocks. The placental membranes are stained green. The remainder of the examination is unremarkable. Which of the following is the most likely cause of this infant's examination findings?

Question

A 37-year-old woman, gravida 4 para 3, comes to the emergency department due to contractions and vaginal bleeding.  She has no leakage of fluid and has had normal fetal movement.  The patient did not receive prenatal care, and her last menstrual period was 10 months ago.  Her 3 prior pregnancies ended in uncomplicated, term vaginal deliveries.  The patient has no chronic medical conditions and takes no medications.  Blood pressure is 130/82 mm Hg and pulse is 78/min.  The fetal heart rate shows moderate variability, no accelerations, and occasional late decelerations.  The tocodynamometer shows contractions every 3 minutes.  The cervix is dilated 8 cm and 100% effaced, and the fetal head is at +1 station.  The patient is admitted and precipitously delivers a small-for-gestational-age (2.8-kg [6.2-lb]) male infant.  Apgar scores are 8 and 9 at 1 and 5 minutes, respectively.  The infant has green, wrinkled, peeling skin; thin fingers; and long fingernails.  Loose skin and prominent skin creases are noted over the thighs and buttocks.  The placental membranes are stained green.  The remainder of the examination is unremarkable.  Which of the following is the most likely cause of this infant's examination findings?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c035_e339_8f63_a58ae9ed72ff_MD0005_00 This infant has signs of fetal postmaturity syndrome, including: wrinkled, peeling skin; long fingernails; thin fingers; and small for gestational age. Other signs include a long, thin body; decreased subcutaneous fat; sparse lanugo hair; and excessive scalp hair. Fetal postmaturity syndrome (also called dysmaturity syndrome) occurs in fetuses who deliver at ≥42 weeks gestation. After 40 weeks gestation, the placental function deteriorates and is no longer able to supply adequate oxygen and nutrition to the fetus, leading to fetal malnutrition and wasting. Placental insufficiency can also cause fetal hypoxia, oligohydramnios, and umbilical cord compression, increasing the risk for fetal heart rate abnormalities (eg, late decelerations) and in utero meconium passage (ie, green-stained membranes). Neonatal complications associated with fetal postmaturity syndrome include meconium aspiration, respiratory distress, hypoglycemia, and seizures. (Choice A) Congenital infection (eg, cytomegalovirus, toxoplasmosis) is associated with fetal growth restriction. However, there are also associated sequelae, including microcephaly, hearing loss, rash, and hepatosplenomegaly, making this diagnosis less likely. (Choice B) Fetal aneuploidy (eg, trisomy 13, 18, or 21) can result in small-for-gestational-age infants who typically have dysmorphic features, including low-set ears, a flattened nasal bridge, transverse palmar creases, and clenched fists with overlapping fingers. This infant has no dysmorphic features. (Choice D) Gestational diabetes mellitus is associated with increased neonatal morbidity (eg, hypoglycemia, respiratory distress) and mortality (eg, stillbirth) due to chronic, increased fetal insulin levels in utero. However, these infants are typically large for gestational age. (Choice E) Intraamniotic infection is a polymicrobial infection of the placenta, amniotic fluid, membranes, or fetus; it presents with fever, maternal and/or fetal tachycardia, and uterine tenderness. Neonatal/fetal complications include in utero meconium passage, Apgar scores <6, and respiratory distress (eg, tachypnea, nasal flaring, grunting). Educational objective: Postmaturity syndrome presents in infants born at ≥42 weeks gestation. Defining features include small for gestational age; wrinkled, peeling skin; long fingernails; decreased subcutaneous fat; and meconium-stained placental membranes. References: Postterm pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/24753906)

A 37-Year-Old Woman, Gravida 4 Para 3, Comes to the Emergency