Re: Interesting Case
From: JD Stewart,MD (jdstewartmfmob@hotmail.com)
Fri May 22 11:55:15 2009
Agree a DV doppler would be helpful IF it pushes towards delivery. If
the problem is an unsupported furcate cord insertion that intermittently
twists and and may occlude, then the DV (and one would expect the Umb AA
doppler ) to read as abnormal while the event is happening. Doesn't
explain away why the repeated lousy AEDF cord dopplers.
This could be easily missed unless you are looking for it, and even if
you suspect it , you are left with a guessing game as to when and how
badly it will twist. A CST may or may not catch this....
The studies showing a significant fetal /prenatal mortality rate with
AEDF included ALL comers, including the unexplained babies who got "A's"
on all the rest of their report cards. This is what gets my attention.
Don't think Amnio/FISH - waiting for results helps...as this will not
change managment. Will you watch a Downs syndrome baby heart rates
crash without delivering? Is there any syndrome you can think of for
this described baby that benefits from early delivery just because
he/she has syndrome XYZ and they always do better at 30 weeks instead of
term?
This is a mystery best figured out in the NICU...the baby is firing
warning shots all over the place...
Anyone in favor of a preterm breech with decels and AEDF induction
protocol???
Prefer to defer to Drs Bard and Parker.....heal with steel.
At Fri, 22 May 2009, Dr. Bülent Potur wrote:
>
>Is there cord around the neck or wrapped around an extremity of the
>fetus?
>Are there any genetic study results?
>Is there a detailed report of fetal heart examined by an expert fetal
>cardiologist?
>What is the result of DV (ductus venosus) doppler study?(1)
>If NST is reactive and DV doppler results are good I would opt for
>waiting and follow up. Personally I am against CST in this situation,
>at this particular moment. If you have decided to go on with C/S it
>will merely provide you a written record to support your decision.
>
>Bulent Potur MD Obgyn
>Kirikkale Turkey
>
>1) 1: Ultrasound Obstet Gynecol. 2004 Feb;23(2):111-8.
>Doppler application in the delivery timing of the preterm
>growth-restricted fetus: another step in the right direction.Baschat AA.
>
>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 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.
--
JD Stewart, MD
MFM up all night, every night
10 years later..
