What is your diagnosis?

Abstract

A 25-year-old primigravida, was admitted to the antenatal ward at 32 weeks gestation with decreased fetal movements. The patient lived in a remote hilly region and did not go for antenatal checkups because of the non-availability of transport due to the lockdown imposed during the coronavirus pandemic. The patient did not undergo an anomaly scan in the first or second trimester. The present pregnancy was conceived spontaneously, without any history of ovulation induction. There was no history of consanguineous marriage. There was no history of teratogenic drug exposure in the antenatal period. The patient did not have any risk factors for gestational diabetes, body mass index was 22.6 kg/m 2 , and family history was not significant. Blood sugar profile was normal after admission, and during the intrapartum and postpartum periods while hemoglobinA1c was normal at 5.8%. On examination, the fundal height corresponded to 26 weeks, and fetal parts were palpable superficially, suggesting decreased liquor and fetal growth restriction (FGR). The ultrasound showed a single live fetus in breech presentation, corresponding to gestational age 32 weeks with severe FGR, abdominal circumference less than the third centile, biparietal diameter and head circumference at the fifth centile and femur length at the tenth centile with placenta praevia and almost absent liquor. Due to grossly decreased liquor, the radiologist could not comment on fetal anatomy at this gestation. A Doppler study of the umbilical arteries suggested reversed end-diastolic flow with brain sparing effect. Cardiotocography was suggestive of prolonged late decelerations. After discussion with the parents, the patient was taken for lower segment caesarean section because of primigravida with placenta praevia, breech presentation and Stage 4 FGR with high suspicion of fetal acidosis (1).