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Case 1: Preterm Neonate with Hydrops and Lactic Acidosis.

A premature female infant is born to a 29-year-old woman with minimal prenatal care at 34 4/7 weeks of gestation, weighing 1,760 g. The woman had been diagnosed with human immunodeficiency virus (HIV) during her second trimester and treated with emtricitabine, tenofovir, and dolutegravir. The infant is delivered via urgent cesarean section because of ultrasound findings of reversed end-diastolic flow on Doppler with category III fetal heart tracings, growth restriction at the 5th percentile, pericardial effusion, and ascites (Fig). Intrapartum zidovudine prophylaxis is administered, but delivery occurred before 3 hours. Apgar scores are 1, 4, 6, and 7 at 1, 5, 10, and 15 minutes, respectively.



Figure. 
Pericardial effusion (A) and ascites (B) on fetal ultrasonography.



Physical examination demonstrates respiratory distress and generalized edema, notably over the extremities and abdominal wall. She undergoes intubation at delivery and initial laboratory tests show thrombocytopenia, elevated transaminases, and significant lactic acidosis (Table 1). Both the mother and infant have type B, Rhesus factor–positive blood.

View this table:

Table 1. 
Initial Serum Laboratories and Arterial Blood Gas Results



Platelets are transfused, and nevirapine, lamivudine, zidovudine, and total parenteral nutrition are started. She receives ampicillin and gentamicin for 48 hours, with negative blood cultures. Abdominal ultrasonography on day 1 after birth identifies mild ascites, but no hepatomegaly or liver calcifications. Head ultrasonography finds no evidence of intracranial calcifications.

On day 2 after birth, she receives 1 dose of surfactant. Echocardiography is notable for mild …