11.04.2020 – 13.04.2020 Obstetric Cases over Easter

NOTE:  LONG POST AHEAD 

We currently have a number of difficult cases we have been trying to manage.   Most of these were ongoing for the Easter weekend so I will present here a little overview of the 6 challenging cases we had in our labor and delivery.  We do have normal deliveries too.  These patients usuallly leave about 2 hours after delievery.  Our midwives take care of them and I am usualy not involved for those cases as they manage them quite well on their own. Interestingly enough these were the only patients this weekend and non of them fell in this category during this time. Quick explanation for the non-medical readers.  G = number of pregnancies P= babies born A= abort  Ev= living children

#1 3G 2P A0 Ev1 (Post C-section with intrauterine death of a 6 kg baby at term in 2017) 

Diagnosis: Intrauterine death in the 32+0 week of pregnancy.  Blood group: O Rhesus positive

Procedure: External maneuver to turn the baby from a transverse position into a possible natural birth position.  Successful maneuver into breech position, cephalic position did not work.  Induction with low dose Cytotec (off label use especially after C-section!) and cervical dilation with Foley catheter. Hoping to avoid having to do another C-section.  Thankfully contractions began later that day and the patient delivered naturally but needed a manual uterine curettage as the placenta did not come on its own.  We gave her treatment with antibiotics post-partum and discharged her the following day as requested by the patient. Her first child was born naturally and is 5 years old.

#2 3G 2P A0 Ev2 (2 spontaneous deliveries)

Diagnosis: 23+2 weeks of pregnancy with a large 15 cm diameter Myoma and pain.

Procedure: The patient came in with pain in the lower left abdomen.  Ultrasound scan revealed a very large intrauterine myoma and a cervical length more than 4 cm.  Initially I hoped the pain was due to the extremely large and palpable tumor (it was bigger than the pregnancy belly more on the right). We gave her a spasmolytic and wrote a Tokogram to check for potential contractions.  Sadly that is what we saw.  We tried to stop them with the medications we had including Magnesium but were not successful.  She gave birth to a very tiny baby on Easter Monday that lived for only a few hours.

#3 4G P2 A1 Ev 2 (2 spontaneous deliveries)

Diagnosis: 38+2 with suspected gestational diabetes and a sonographic large head

Procedure: Initially an incorrect sugar test (ogTT 75) showed an elevated blood sugar.  We repeated the test and found a fasting blood sugar above normal.  A daily profile of her pre-prandial and post-prandial sugars showed values in range.  There was no longer a need for immediate delivery as had been suggested by a reference pediatrician.  Instead induction for 5 days with daily 4 doses of 50 micrograms of Cytotec followed.  No contractions and no signs of the babies head descending into the pelvis.  After 5 days of induction the decision is made for a scheduled C-section on 14.04.2020 at 38+5 weeks of pregnancy.  Blood group and a blood bag have been organized.  The patient also decided for a tubal sterilization so preparations for that surgery were also made and paperwork signed. The baby weighed 3498g and had a head circumference of 38 cm. No abnormalities just a large square head. Thankfully no trouble with hypoglycemia post partum either.

#4 G2 P1 A0 Ev1 (Post C-section 2015 for stagnated dilation)

Diagnosis: 40+0 with polyhydramnios and sonographic large baby (3700g)

Procedure: Suggestion to induce discussed with the patient.  She agreed to stay and begin induction.  Due to her last delivery via C-section we are limited how to induce as Cytotec should not be used.  Cervical dilation using a Foley catheter is done in hopes to start contractions.  After 24 hours we remove this.  There is no progress.  New evaluation the following day revealed that this patient too was open to a C-section at 40+3 weeks of pregnancy in combination with tubal sterilization.  So we scheduled for two back to back C-Sections with tubal sterilization for Tuesday 14.04.2020.

#5 G2 P1 A0  Ev1 (Spontaneous delivery 2014 with episiotomy)

Diagnosis: 38+4 with chronic hypertension on blood pressure medicine Aldomet 250 mg 1-0-1

Procedure: Induction was started according to protocol here with Cytotec.  Prior to this an oxytocin stress test (obsolete) was performed.  Afterwards Cytotec 25 micograms two times was given. This is a much lower dose but is the standard protocol here (mostly the patients are sooo tiny that this lower dose at 2 hour intervals is adequate).  The patient did give birth spontaneously after two days of induction thankfully without any complications.  We discharged her the following day while continuing her blood pressure medicine.

#6 G4 P3 A0 Ev3  (Three Spontaneous deliveries last in 2015)

Diagnosis: 35+6 with chronic hypertension on blood pressure medicine Aldomet 250 mg 2-2-2-2

Procedure: The patient presented with increased blood pressure so the medication was increased from Aldomet 500 mg 1-1-1 to 2-2-2-2.  Blood pressure spikes have been treated with Loxen 20-30mg.  They are now better under control but the only solution will be a timely delivery.  At under 36 weeks of pregnancy this is not something we really desire to do.  To exclude pre-eclampsia I ran blood work (signs of HELLP were thankfully excluded), no signs of proteinuria.  Clinically apart from some distal edema, her high blood pressure is the only thing that is way out of line.  Doppler showed no abnormalies, no notching in the uterine arteries and no brainsparing in the ACM.  Ultrasound showed no abnormalities and a normally developed baby.  Induction was started the following day at 36+0.  After two doses of Cytotec 25 micrograms the baby started showing signs of distress and presented a pathologic CTG.  Despite three spontaneous deliveries we had an indication to C-section on Easter Sunday at 36+0 weeks.

Case #16 Premature baby Noa weighing 2175g.  Though a bit early he has been adapting very well and has no problems feeding thankfully.

Surgical preparations, its starting to really have a routine after 3 months for all the local staff meaning there are also less and less of the volunteers involved.  

I had a sneak peak a week later and snapped this photo of Noa who had just finished feeding and gaining good weight.  Mom and Noa went home the next day, the blood pressure for mom is still high and we began with Metoprolol.  She is coming in for regular check-ups to make sure her blood pressure begins to normalise post-partum.