History:

A 25-year-old primigravida gave birth to a 35 week gestational age male infant. The baby had Apgar scores of 4 at 1 minute and 6 at 5 minutes. The baby appeared hydropic, as did the placenta. The baby appeared to be in congestive heart failure. Urine output was poor. Despite resuscitative measures, the baby died 2 days after delivery.

Image 1.1:

The gross appearance of the abdominal cavity is shown here.

There is hepatosplenomegaly. No other features are seen grossly.

Image 1.2:

The high power microscopic appearance of the kidney is shown here.

There are inclusions within enlarged tubular cells consistent with cytomegalovirus.

Questions:

1. Name some causes for hydrops fetalis.

There are numerous causes for hydrops, but hemolytic disease of the newborn (now far less common because of RhoGam therapy), congenital infections, and congenital anomalies (particularly congenital heart disease) are the most common.

2. What was the prognostic value of the Apgar scores?

A poor Apgar score at 5 minutes suggests a poor outcome.

3. What is the etiology in this case?

This is a case of congenital cytomegalovirus infection. Most cases are asymptomatic in the neonatal period. The organs most frequently affected are kidney, liver, and lung. Hepatosplenomegaly usually results from increased extramedullary hematopoiesis. If the fetus is affected early in pregnancy, then the brain may show necrosis, calcification, and microcephaly.

The major congenital infections are:

• Toxoplasmosis
• Other agents (Listeria, syphilis, group B strep, E. Coli)
• Rubella
• Cytomegalovirus
• Herpes simplex, HIV