What do you think of this case?

[goooooober]

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A 37 y.o. G2P1 hispanic female, Hx of cholelithiasis, cholecystitis, and choledocholelithiasis one year ago s/p cholecystectomy, ERCP and biliary stenting with subsequent removal of stent with no other history, presented to her OB/GYN specialist with CC of discharge and weight loss at 35 weeks of gestation. Her discharge was characterized as clear to white. She also complained of feeling hot and cold at times, but no major fevers at home. She had suffered from a nasty cold for a few weeks with coughs prior to this visit, but most of her symptoms were resolving. Good fetal movement per mother. Previous ultrasound done at 24 weeks was normals. Previous pregnancy not complicated. Has only been taking prenatal vitamins. Socially, she is married for 7 years, no smoking, no drinking, excellent prenatal care from early pregnancy. Her exam is not significant, with normal vitals and fetal heart tones in the 140s, otherwise normals exam. She did have UA run that showed no UTI.

She was given Monistat for discharge and told it is probably yeast infection. She was also advised to drink more.

She was seen again for the following two weeks. Her weight had improved slightly on following visits. Her last visit was on 37th week, Thursday, when fetal heart tones were in the 140s and fetal movements were good. Later in the evening, she began contractions and was taken to the hospital after midnight for delivery. Upon arrival, heart tones could not be found and an ultrasound showed the fetal heart had stopped. Additionally, there was no fluid at all in the amniotic sac.

Baby was delivered with no physical evidence of deformities or cord wrapped around the neck. Autopsy including chromosomal studies were normal. Path on placenta showed few areas of infarction with evidence of chorionitis. Labs were all normal with the exception of positive Abs for Ebstein Bar Virus.

Sorry this is long, but this case really bothers me. I wanted to know what your thoughts were. What do you think happened and what if anything could have been done to prevent this. Did we miss something?

Thanks.

 

[tootsweet]

Any possibility that the developed later onset gestational diabetes? Is she obese? How recent is the case? Can you do a HA1C?

 

[MJB]

I honestly don't know, so I'm asking. How often would a presentation like this lead to testing for Preterm Premature Rupture of Membranes and the testing for it? Nitrazine, Fern test, etc..

Were there any ultrasounds done after 24 weeks, but before she presented in labor where the ultrasound showed no fetal heart beat?

That's a sad case.

 

[goooooober]

This case is around 4 months old. She did not have any history of DM or gestational diabetes. Her HA1C was low 5 or high 4. Her weight was in the 150s at around 37th week and before pregnancy 125-135. Not obese at all.

The only ultrasound done was around 6 months. After that none was done.

MJB I completely agree with you. My thought is similar. I think they should have tested her "discharge" to determine if it was amniotic fluid. At least they should have done an US when she complained of weight loss and severe discharge.

I mean isn't this stuff basic OB/GYN knowledge? I think they missed a diagnosis that could of saved this baby and it is bothering the crap out of me.

 

[THP]

This case is around 4 months old. She did not have any history of DM or gestational diabetes. Her HA1C was low 5 or high 4. Her weight was in the 150s at around 37th week and before pregnancy 125-135. Not obese at all.

The only ultrasound done was around 6 months. After that none was done.

MJB I completely agree with you. My thought is similar. I think they should have tested her "discharge" to determine if it was amniotic fluid. At least they should have done an US when she complained of weight loss and severe discharge.

I mean isn't this stuff basic OB/GYN knowledge? I think they missed a diagnosis that could of saved this baby and it is bothering the crap out of me.

There is nothing in your story that makes me think they should have ruled out SROM. It is completely normal to have a leukorrhea of pregnancy, especially in the late 3rd trimester. I also assume they did a speculum exam and noted the yeast infection and treated it appropriately. I don't know how much weight she lost but rupture of membranes doesn't cause a significant weight loss. She probably lost weight because she was recently ill. There is no indication in her for another ultrasound either unless her fundal height was measuring small, and that can be difficult to detect in oligo. Diabetes doesn't cause PROM. I am not aware of EBV cause fetal problems but I don't know much about it.

She was probably ruptured but I am not sure anything would have indicated that. The vast majority of patients who rupture at term go into labor within 24hrs, especially being multiparous. Its also odd that she didn't labor. Unfortunately bad outcomes happen.

 

[goooooober]

There is nothing in your story that makes me think they should have ruled out SROM. It is completely normal to have a leukorrhea of pregnancy, especially in the late 3rd trimester. I also assume they did a speculum exam and noted the yeast infection and treated it appropriately. I don't know how much weight she lost but rupture of membranes doesn't cause a significant weight loss. She probably lost weight because she was recently ill. There is no indication in her for another ultrasound either unless her fundal height was measuring small, and that can be difficult to detect in oligo. Diabetes doesn't cause PROM. I am not aware of EBV cause fetal problems but I don't know much about it.

She was probably ruptured but I am not sure anything would have indicated that. The vast majority of patients who rupture at term go into labor within 24hrs, especially being multiparous. Its also odd that she didn't labor. Unfortunately bad outcomes happen.

Thanks for the response. Her weight loss the had been around 3-4 lbs when it was discovered 1 week prior to delivery. I should mention that at her final clinic visit several hours prior to delivery, she was dilated 2 cm and fetal heart tones were in 140s. But she was told to wait until she goes into labor before going to the hospital. she began having regular contractions that became more frequent later the same evening. When she arrived at the hospital, US showed no fluid at all in the amniotic sac around the baby. She was examined and found that her membrane was intact. It was ruptured later manually by the OB/GYN on call to help induce the still birth. This baby had died within 12 hours prior to birth.