Neonate With Necrotic Skin Lesions and Middle Cerebral Artery Stroke in the Context of Fetal Vascular Malperfusion

There are few published reports of neonates born with necrotic skin lesions and stroke. We report the case of a neonate with an identified placental etiology for necrotic skin lesions at birth and multiple arterial thrombi, including a stroke. This neonate was born to a generally healthy mother with gestational hypertension on labetalol in pregnancy. She was born via emergency Caesarean section at 38 + 1 weeks' gestational age due to biophysical profile 2 of 8 and oligohydramnios and was noted to have multiple necrotic skin lesions on the left forearm. She was found to have numerous arterial thrombi, including a left-sided middle cerebral artery stroke. An extensive workup into the etiology of thrombi was done with no hematologic, metabolic, genetic, or infectious cause identified. Her placental pathology examination identified high-grade fetal vascular malperfusion, which encompasses various obstructive fetal vascular lesions, fetal thrombotic vasculopathy, and fetal vascular thrombi. Although fetal vascular malperfusion cannot be detected antenatally at the present time, postnatal identification can bring closure to families and help for subsequent pregnancy planning. Additionally, necrotic skin lesions in neonates present at delivery should prompt clinicians to do imaging to identify thrombi because initiating early postnatal treatment may be of critical clinical importance.