A 32-year-old G1P0 who lived in a small, remote community presented to her family physician for her first obstetrical appointment at 11w5d. She was noted to have chronic hypertension, with a weight of 254 lb, and a body mass index of 46.45 kg/m2. Her untreated blood pressure (BP) was 130/85 mmHg. She underwent an ultrasound at 17w6d that revealed a single vertex at 17w5d, with an estimated fetal weight (EFW) of 2112 g (41st percentile), with no fetal anomalies visualized. A 1-hour glucose tolerance test (GTT) at 24w5d showed a glucose level of 191 mg/dL and a 3-hour GTT at 25w3d was abnormal, with the following results:
- Fasting blood glucose (BG) - 101 mg/dL,
- 1-hour BG - 213 mg/dL,
- 2-hour BG -169 mg/dL, and
- 3-hour BG - 141 mg/dL.
The family physician referred the patient to an obstetrician, who performed a second ultrasound which was consistent with 24w3d, and consistent with the patient dates placing her at 25w5d. The obstetrician recommended placing the patient on insulin and referred her back to the family physician for ongoing care. The family physician observed the patient and did not institute insulin over the next 7 weeks. The patient’s blood sugars obtained at various times of the day were reported to be between 110 mg/dL and 240 mg/dL. An ultrasound obtained at 32w4d was consistent with 30w6d. No estimated fetal weight was reported. The patient was referred back to the obstetrician at 33w2d, who again recommended insulin. Further recommendations included fetal testing with weekly non-stress tests (NST) and ultrasounds every 2 weeks. The obstetrician again referred the patient back to the family physician, with a recommendation to institute insulin and induce the patient at 37 to 38 weeks of gestation. Of note, the patient’s blood pressure remained relatively stable without treatment.
The family physician instituted lose-dose insulin, at 10 units of regular insulin in the morning. The patient’s BG remained between 75 mg/dL (fasting) and 120 mg/dL (post-prandial). The patient had reactive NSTs on a weekly basis. An ultrasound at 34w3d was consistent with 34w0d, with an EFW of 2434 g (32nd percentile), an amniotic fluid index (AFI) of 9.19, and an anterior placenta.
At 8:40 AM at 36w3d, the patient presented to labor and delivery with complaints of cramping, back and abdominal pain, and a small amount of vaginal bleeding. She had a reactive NST with a baseline fetal heart rate (FHR) of 130 to 140 beats per minute (bpm). The obstetrician was consulted, performed a limited ultrasound, and concluded that there was no obvious placental abruption. Approximately 30 minutes after that ultrasound, the FHR revealed an oscillatory pattern between 160 and 180 bpm, with absent variability. The FHR then dropped to the 80s and 90s for approximately 7 minutes. The patient was turned to her right and then left side, oxygen was placed, and the FHR gradually returned to the 150s. The patient continued complaining of cramping and back and abdominal pain. The FHR increased to the 170s with minimal variability and no significant decelerations (Category II). The obstetrician recommended a biophysical profile (BPP), which was done and scored at 4 out of 8. “Sluggish movement of the heart” was noted on ultrasound as was an unusual appearance of the fetal small bowel. Radiology recommended a detailed fetal ultrasound if the patient remained pregnant. While in radiology from 10:48 to 11:08 AM, the patient was unmonitored. Upon arriving back on labor and delivery, the FHR was 170 bpm with minimal variability.