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Re: Interesting Case From: rkaplan@triad.rr.com Sun May 24 13:38:37 2009 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: art fougner, md: "Re: Interesting Case" Previous message: Charlie Chambers: "Re: Interesting Case" In reply to: art fougner, md: "Re: Interesting Case" Next in thread: art fougner, md: "Re: Interesting Case" Reply: art fougner, md: "Re: Interesting Case" Reply: JD Stewart,MD: "Re: Interesting Case" Your replies have been very insightful. Personally, I would not have gone to section if this were my baby. I am very worried about all the minor and major complications that can occur in the NICU with a 30 week neonate and would have hated to put my child through all that when the NST and BPP were normal. This patient was indeed sectioned by my partner with the approval of our perinatologist at 30-31 weeks. The baby weighed 970 gms. and was not acidotic at birth. The placenta weighed 132 gm. and other than "a small pale yellow sub chorionic thrombus" the path report was normal. The cord appeared normal and was paracentrically inserted. The baby is still in NICU seven weeks after her birth. He had only mild RDS and her main problem was slow bowel function. I just looked up his record on the hospital computer and he has had 30 radiologic procedures. He has no cardiac anomalies and his chromosomes are normal. The literature that I could find on absent end diastolic flow (AEDF) is indeed quite scary with a perinatal mortality of close to 10% in some studies. My problem in reading the articles was that in some, reversed flow and absent flow were grouped together and some literature suggest that the prognosis is quite different between the two (reversed flow being much more worrisome). My other problem was that it was not clear how many stillbirths occurred when the BPP and NST were normal in the setting of AEDF. Art, please reference your statement about spontaneous variable decels since I was unaware of this, and it was for this reason that this baby was delivered. I suggested a CST to see if these decels were due to cord compression or tenuous placental function but this was not done. In general I will not put a baby in intensive care unless ante partum testing is abnormal. As Dan pointed out the risk of neonatal death at 30 weeks is about 10 fold higher than the risk of intraparum death after a normal BPP. In the former case, however, we as obstetricians feel less responsible. > ----- Original Message ----- From: "art fougner, md" <evsono@pipeline.com> To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net> Sent: Saturday, May 23, 2009 5:39 PM Subject: Re: Interesting Case > 0.6 per thousand is the corrected stillbirth rate within a week of a > reassuring biophysical profile. > > Also, the presence of spontaneous variable decelerations are associated > with an increased perinatal mortality rate, irrespective of the > biophysical. > > Art > > At Sat, 23 May 2009, art fougner, md wrote: >> >>I'd look at fetal middle cerebral artery and ductus venosus. Abnormal >>arterial doppler correlates with hypoxemia while abnormal venous doppler >>correlates with acidemia. >> >>Art >> >>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. >> >>-- >>art fougner, md >>"May The Wings of Liberty Never Lose a Feather." - Jack Burton >> > > -- > art fougner, md > "May The Wings of Liberty Never Lose a Feather." - Jack Burton -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -- -------------------------------------------------------------------------------- No virus found in this incoming message. Checked by AVG - http://www.avg.com Version: 8.5.339 / Virus Database: 270.12.37/2130 - Release Date: 05/23/09 07:00:00 Next message: art fougner, md: "Re: Interesting Case" Previous message: Charlie Chambers: "Re: Interesting Case" In reply to: art fougner, md: "Re: Interesting Case" Next in thread: art fougner, md: "Re: Interesting Case" Reply: art fougner, md: "Re: Interesting Case" Reply: JD Stewart,MD: "Re: Interesting Case"

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