Re: Interesting Case
From: art fougner, md (evsono@pipeline.com)
Sun May 24 13:54:11 2009
Eden et al comment on the significance of variable decelerations as a
reason NOT to abandon the NST as part of the biophysical profile.
Obstet Gynecol 1988 71: 365-9.
Art
At Sun, 24 May 2009, rkaplan@triad.rr.com wrote:
>
> 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
>
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--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
