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Another case (for those of you not interested in high affinity hemoglobins) - longFrom: fuf@gulf.netThu Jul 4 14:33:42 1996
A 27 year old g3p0201 is currently on our labor and delivery service at 27 week's with ruptured membranes and complete cervical dilitation. As a 3 year old, she had a right nephrectomy and chemotherapy for Wilm's tumor. She still has hemihypertrophy (L>R) which is associated with Wilms, 8 years ago, she was admitted to the hospital at 34 weeks with advanced cervical dilitation and breech and had a C-section. For her next pregnancy,at 20 week's, she was admitted after 3 hrs of pain. Althought the WBC was elevated, an amniocentesis was negative for infection. The patient rapidly progressed to delivery of a previable infant was delivered. A post partum hemorrhage ensued and laparotomy/hysterotomy was done to achieve hemostasis and remove a retained portion of the placenta. Early this pregnancy (13 wk), my associate and I found the cervix to be short and placed a McDonald Mersilene ribbon cerlclage. At 24 weeks, the patient was admitted with pain, a tense uterus, a WBC of 25,000 and 30 bands. She was afebrile. Cultures and infection studies of her cervix, urine, amniotic fluid, chest were all negative. One day after admission, she tore through the cerlclage and was dilated to 3 cm. The stitch was removed. With the patient infection free by all studies and with the WBC down to 20 bands and 18000, we continued tocolysis (T-pump and indocin) as well as Unasyn and metronidazole and sent her to the floor. The baby always had a perfect score on BPP. At 26 weeks srom occured. Indocin was stopped. Except for a wbc and bandemia which was unchanged, there was no sign of infection. Daily NST's showed no variables and were reactive, with rare contractions on terbutaline by pump. Yesterday I got a call from the radiology sonographer (if you think the rest of this story is strange, then you shoulndt be shocked that the Radiology group has the exclusive right to perform "official" OB ultrasounds at our hospital) that the head appeared to be past the cervix. By (unofficial) perineal scan and speculum exam, the head was in the vagina and past the cervix. I told the patient that we would transfer her to L&D and give her a 2nd round of steroids, then if she was ok and undelivered, let her push for a period of time. If no descent, a Csection would be done. The sono, shows a constriction of the cervix or lower segment at the neck, and may prevent vagina delivery. My associate countered: "what's different now, except that we know the cervix is fully dilated? He says this may have been present for a week and the baby should be allowed more time to grow if it allows us. He is in favor of continuing tocolysis. Her WBC count is 24 K with 25 bands. Again, there are no signs of infection. He would send her back to the floor with daily monitoring if stable. Questions: 1. Can the head of a 27 week fetus sit in the vagina for weeks without deformations or injury occuring? 2. Is this patient who has SROM, oligohydramnios and completely dilated a candidate for continued tocolysis. 3. What is causing her multiple pregnancy problems? The patient and her family are convinced it was the Wilm's tumor or chemotherapy. 4. Have you noticed her white count is above average? any explanation? 5. Recommendations for delivery & timing of delivery? Thanks, Gary Gary E. Kleinman, MD Perinatologist/Geneticist University of FL/Pensacola 5045 Carpenter Creek Drive Pensacola, FL 32503 904 484-9400
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