This is a case of 25-year-old G4P1021 diagnosed with an in utero fetal stroke at 26 weeks gestation. She had ultrasounds at 19 weeks and 23 weeks, which showed no anatomic abnormalities (see Figures 1(a) and 1(b)). She presented to labor and delivery at 26 weeks complaining of vaginal spotting. Labor and rupture of membranes were ruled out; however she had a Category II tracing with minimal to absent variability. Ultrasound exam revealed severe ventriculomegaly, a left-sided frontal porencephalic cyst, enlarged 4th ventricle, mild abdominal ascites, open hands, and echogenic bowel (see Figures 1(c) and 1(d)). A thrombophilia panel, antiphospholipid panel, cytomegalovirus and toxoplasmosis antibodies, and neonatal alloimmune thrombocytopenia panel were ordered and were negative. She went into spontaneous preterm labor at 26 weeks 4 days' gestation and delivered a female infant, weighing 895g with APGARS of 1, 1, and 1, at 1, 5, and 10 minutes of life. Heart rate was in the 60s and abnormal rigid tone was noted. Intubation did not improve saturations (never over 60% despite correct placement confirmed), and chest x-ray showed bilateral whited out lungs. Compressions and chest tube placement did not yield improvement. Umbilical vein catheterization was unsuccessful and surfactant and epinephrine were given via the endotracheal tube. Despite extensive resuscitative efforts, there was no improvement in the clinical status, and the mother opted to switch to comfort care. Vesicular lesions were noted on the infant, which were positive for HSV2 by PCR (see Figure 2). A postmortum ventricular tap was performed and cerebral spinal fluid was also positive for HSV 2.
Her first clinically documented HSV outbreak was immediately prior to pregnancy and she was treated with acyclovir. She became pregnant approximately 5 weeks later. A 6-week ultrasound confirmed those dates. She was seen for her initial prenatal exam at 11 weeks, which confirmed a positive HSV-2 IgG. She had no further outbreaks during pregnancy, and her pregnancy was otherwise uncomplicated. She was not on suppression during her pregnancy, though it was planned for 36 weeks.