A 29-year-old G6P0140 individual without prenatal care presented at 22 weeks of gestation with vaginal bleeding and uterine cramping. She recently returned from caring for a family out of state and had not yet established prenatal care for the recent pregnancy. Past medical history was notable for no recent intrauterine device use and Kell alloimmunization (1:8 titer). Her obstetrical history revealed a previous pregnancy that required placement of a McDonald cerclage at 18 3/7 weeks of gestation followed by a revision and removal of the McDonald cerclage and placement of a Shirodkar cerclage at 22 2/7 weeks of gestation. She was subsequently diagnosed with an intrauterine fetal demise at 26 6/7 weeks of gestation during the previous pregnancy (2018).
On current presentation, the patient was afebrile, normotensive, and nontachycardic; moreover, physical examination revealed a visually dilated cervix of 4 cm with a bulging amniotic sac. Transvaginal ultrasound after admission to the hospital demonstrated no measurable cervix, amniotic fluid sludge within the cervical canal, and an estimated fetal weight of 581 g ( Figure 1 , video 1 ). An amniocentesis revealed a glucose level of 12 mg/dL, a Gram stain showing many neutrophils and squamous epithelial cells, yeast suggestive of Candida , and culture-positive Candida albicans. Clindamycin 900 mg intravenously (IV) every 8 hours, ceftriaxone 1 g IV every 12 hours, fluconazole 400 mg IV every 24 hours, and azithromycin 1 g orally every 24 hours were initiated along with corticosteroids for fetal lung maturity. On day 8, a repeat amniocentesis demonstrated persistent culture-positive C albicans infection, a glucose level of 4 mg/dL, and a Gram stain demonstrating many neutrophils, no squamous epithelial cells, and no organism. Intravenous antibiotic therapy was discontinued on day 9, and the patient was delivered vaginally a day later at 23 4/7 weeks of gestation. She delivered a viable male infant weighing 780 g with Apgar scores of 1, 5, and 8 at 1, 5, and 10 minutes, respectively. Placental pathology revealed acute histologic chorioamnionitis, and histologic sections of the umbilical cord demonstrated funisitis ( Figures 2 and 3 ) with fungal yeast and pseudohyphae consistent with C albicans ( Figure 4 ). At 56 days of age, the newborn was still in the neonatal intensive care unit on ventilation with a FiO 2 of 45% and a current weight of 1730 g.
