Re: Interesting Case
From: Joe (forcep@intercom.net)
Fri May 22 06:55:18 2009
Since you directed to "me or my wife" our decision would be to ask
you to leave us alone and let whoever we believe in take care of our
problem. I have been down this road in my practice and there is no good
outcome - something is seriously wrong with this infant and nature is a
much better provider of care. Joe C
> 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 sometimes 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.
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