Re: Interesting Case
From: Charlie Chambers (ricechaz@me.com)
Thu May 21 23:52:30 2009
Agree
Amnio and FISH. If normal, consider cesarean versus daily BPP.
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Charlie Chambers
Hood River, OR
--
cchamber@alumni.rice.edu
"Almost anything you do will seem insignificant but it is very important
that you do it....You must be the change you wish to see in the world"
-- Mahatma Ghandi.
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On May 21, 2009, at 9:30 PM, Joanne Bulley, MD wrote:
> Ditto.
>
> JEB
>
> At Thu, 21 May 2009, Garry E. Siegel, M.D. wrote:
>>
>> Something is not right. Chromosomes normal or done yet?
>>
>> I would section. The CST won't help me decide this.
>>
>> Garry
>>
>> A stab at extra credit:
>>
>> 1/1000 risk of stillbirth within 48 hours of those tests if due to
>> UPI.
>>
>> Risk of death of a 30 weeker is quite low, but this is not a normal
>> 30
>> weeker.
>>
>> At Thu, 21 May 2009, rkaplan@triad.rr.com wrote:
>>>
>>> You (or your wife) are now 30 weeks pregnant. Ultrasound at 20
>>> weeks showed normal fetal anatomy but growth was 2 weeks behind
>>> date proposed by ultrasound at 7 weeks. Work up for early FGR
>>> (TORCH studies) were all negative. At 29 weeks there is another
>>> week lag from the scan at 20 weeks and umbilical cord study shows
>>> no end diastolic flow. The fetus is symmetric (head circumference
>>> = abdominal circumference), amniotic fluid index is normal and
>>> fetal Biophysical Profile (BPP) is 10/10. You (or your wife) are
>>> admitted, given steroids for fetal lung maturation, and placed on
>>> continuous fetal monitoring. Repeat ultrasound in the hospital by
>>> the perinatologist confirms no end diastolic flow, symmetric FGR,
>>> and normal BPP. While on continuous monitoring, your fetus has U
>>> shaped decels which dropped from 120 to 70 bpm and last from 1-2
>>> minutes (would meet the criteria of severe variable decels if you
>>> were in labor). These decels occur sometimes 30 minutes apart and
>>> s!
> ometimes 2 or more hours apart. At all other times the FHT shows
> excellent variability and spontaneous accels. You feel good fetal
> movement and do not feel any contractions nor are any contractions
> seen on the tracing. You have 2 more ultrasounds in the hospital
> which confirm the absence of end diastolic flow but normal BPP.
>>> Your perinatologist knows that you are an experienced Ob care
>>> provider. She knows that you understand the risks of neonatal
>>> complications that can occur in the 30 week newborn. She also
>>> feels very uncomfortable with these random decels in a growth
>>> restricted 30 week fetus with absent end diastolic flow, even
>>> though the fetus is growing symmetrically and the BPP is 10/10.
>>> She asks you:
>>>
>>> Do you want a Cesarean (fetus is in the breech presentation) now?
>>> Do you want to continue the pregnancy?
>>> Would a good, hard contraction stress test (CST) help you make
>>> your decision?
>>>
>>> Richard Kaplan
>>> Greensboro
>>>
>>> PS. For extra credit: What is the risk of stillbirth within 48
>>> hours of a BPP 10/10? Within 48 hours of a negative CST?
>>> Does the presence of growth
>>> restriction or an abnormal cord dopler make these tests less
>>> sensitive?
>>> What is the risk of neonatal
>>> death at 30 weeks after steroids in a level 3 nursery?
>>> What is the etiology or
>>> pathophysiolgy of random decels seen on continuous fetal
>>> monitoring in the absence of labor?
>>>
>>> PPS. I posed this in the first person because I do not want to
>>> hear about what course of action is least likely to get you sued.
>>
>> --
>> Garry E. Siegel, M.D.
>> Private Practice
>> Roswell, GA
>>
>
> --
> Joanne Bulley, MD
> solo gyn
> Keene, NH
