Re: Interesting Case
From: R. Daniel Braun (rd.braun@gmail.com)
Fri May 22 07:56:57 2009
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On Thu, May 21, 2009 at 9:14 PM, <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 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?
>
Maybe
> Do you want to continue the pregnancy?
>
Yes
> Would a good, hard contraction stress test (CST) help you make your
> decision?
>
Definitely
>
> Richard Kaplan
> Greensboro
>
> PS. For extra credit: What is the risk of stillbirth within 48 hours of
> a BPP 10/10?
>
<1% But goes up after 96 hours
> Within 48 hours of a negative CST?
>
Same as BPP but doesn't go up for 7 days
> Does the presence of growth
> restriction or an abnormal cord dopler make these tests less sensitive?
>
No probably more specific.
> What is the risk of neonatal death at 30
> weeks after steroids in a level 3 nursery?
>
Probably 2-3% (WAG) Morbidity even higher
> What is the etiology or pathophysiolgy
> of random decels seen on continuous fetal monitoring in the absence of
> labor?
>
Probably cord compression,
>
> 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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R. Daniel Braun, MD FACOG(L) ABMP CMTh
Professor Emeritus
Dept. of Obstetrics and Gynecology
Indiana U. School of Medicine
R. Daniel Braun
“Science without Religion is LAME; Religion without Science is BLIND"
Einstein 1941
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<br><br><div class="gmail_quote">On Thu, May 21, 2009 at 9:14 PM, <span dir="ltr"><<a href="mailto:rkaplan@triad.rr.com">rkaplan@triad.rr.com</a>></span> wrote:<br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div bgcolor="#ffffff">
<div><font size="2" face="Arial"> 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. </font></div>
<div><font size="2" face="Arial"></font> </div>
<div><font size="2" face="Arial"> 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</font><font size="2" face="Arial"> 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:</font></div>
<div><font size="2" face="Arial"></font> </div>
<div><font size="2" face="Arial"> Do you want a Cesarean (fetus is
in the breech presentation) now?</font></div></div></blockquote><div><br>Maybe<br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div bgcolor="#ffffff">
<div><font size="2" face="Arial"></font></div>
<div><font size="2" face="Arial"> Do you want to continue the
pregnancy?</font></div></div></blockquote><div><br>Yes<br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div bgcolor="#ffffff"><div>
<font size="2" face="Arial"></font></div>
<div><font size="2" face="Arial"> Would a good, hard contraction
stress test (CST) help you make your decision?</font> </div></div></blockquote><div><br>Definitely<br><br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div bgcolor="#ffffff"><div></div>
<div><font size="2" face="Arial"></font> </div>
<div><font size="2" face="Arial">Richard Kaplan</font></div>
<div><font size="2" face="Arial">Greensboro</font></div>
<div><font size="2" face="Arial"></font> </div>
<div><font size="2" face="Arial">PS. For extra credit: What
is the risk of stillbirth within 48 hours of a BPP 10/10? </font></div></div></blockquote><div><br><1% But goes up after 96 hours<br><br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div bgcolor="#ffffff"><div><font size="2" face="Arial"> Within 48 hours
of a negative CST? </font></div></div></blockquote><div><br>Same as BPP but doesn't go up for 7 days<br><br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div bgcolor="#ffffff"><div><font size="2" face="Arial"></font></div>
<div><font size="2" face="Arial">
Does the presence of growth restriction or an abnormal cord dopler make these
tests less sensitive? </font></div></div></blockquote><div><br>No probably more specific.<br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div bgcolor="#ffffff"><div><font size="2" face="Arial"></font></div>
<div><font size="2" face="Arial"> What
is the risk of neonatal death at 30 weeks after steroids in a level 3
nursery?</font></div></div></blockquote><div><br>Probably 2-3% (WAG) Morbidity even higher<br><br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div bgcolor="#ffffff"><div><font size="2" face="Arial"></font></div>
<div><font size="2" face="Arial"> What is
the etiology or pathophysiolgy of random decels seen on continuous fetal
monitoring in the absence of labor?</font></div></div></blockquote><div><br>Probably cord compression,<br> </div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div bgcolor="#ffffff"><div><font size="2" face="Arial"></font></div>
<div><font size="2" face="Arial"></font> </div>
<div><font size="2" face="Arial">PPS. </font><font size="2" face="Arial">I posed
this in the first person because I do <b>not</b> want to hear about
what course of action is least likely to get you
sued.</font></div></div>
</blockquote></div><br>
FACOG(L) ABMP CMTh<br>Professor Emeritus<br>Dept. of Obstetrics and Gynecology<br>Indiana U. School of Medicine<br><br><br>R. Daniel Braun<br><br> “Science without Religion is LAME; Religion without Science is BLIND"<br>
Einstein 1941<br>
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