This is a 21 year old G3 P1 SAB2 (both at about 12 weeks, each with a D&C) who was sent to me for an ultrasound because she was bleeding. The LMP was unknown, and the pregnancy test had been positive several days before. She is Rh negative. She had a LEEP in 1994 for CIN 1 of the cervix.
This is a 21 year old G3 P1 SAB2 (both at about 12 weeks, each with a D&C) who was sent to me for an ultrasound because she was bleeding. The LMP was unknown, and the pregnancy test had been positive several days before. She is Rh negative. She had a LEEP in 1994 for CIN 1 of the cervix.
This was the first ultrasound I had done with our new ATL HDI 5000, and we had not yet had our visit from the applications specialist. For reasons that are not clear to me now, I did not videotape this exam.
I found dichorionic twins, one with a heartbeat, the other without a heartbeat. There was a large subchorionic hemorrhage (~ 35 percent of the living twin chorion separated, less from the dead twin). The living twin measured at 6w3d with the embryonic heart rate 125 to 133, normal for 45 days menstrual age.
The best way to present the chronology is to list the ultrasound exams done.
(click on each image to view larger version)
(click on image to view larger version)
(click on image to view larger version)
(On 3/1/99 a Shirodkar cervical cerclage was done using a Mersilene strip).
(click on image to view larger version)
The patient went into labor, and attempts to stop the labor were not successful. On 4/12/99 a C-Section was done. The membranes were intact at the time of the Section, and the amniotic fluid was very foul smelling. Cultures grew several organisms, including peptococcus. The Shirodkar suture was removed at the time of the Section.
At the time of the Section the gestational age, based on the first ultrasound, was 27w4d. However, the baby weighed 3 pounds 4 ounces, and was considered 31 weeks after pediatric assessment.
The baby is still in the hospital and is doing well.
Here are some quantitative HCGs (3rd IS – all done in the same lab) from the early first trimester:
11/13/98 79,560 miu/ml
11/14/98 83,812 miu/ml
11/16/98 88,938 miu/ml
Our conventional wisdom tells us the quantitative HCG should double in 3 days. "Always give the pregnancy the benefit of the doubt".
In addition to the basic theme of "Never Give Up", what are the interesting points of this case presentation?
In view of the size of the baby at delivery, could the gestational age early in the first trimester have been underestimated? Could the surviving embryo have been poorly grown because of all the stress (bleeding, subchorionic hemorrhage, and death of a twin)?
Or, does it make more sense to say the maturity of the surviving fetus was accelerated by all the stress shortly before birth (surgery, anesthesia, steroids, and chorioamnionitis)?
Or, could each factor have contributed to the final estimate of the neonatal gestational age?
How accurate is the neonatal assessment of gestational age by the pediatrician? Could our determination of gestational age by ultrasound at around 6 to 7 weeks menstrual age have underestimated the gestational age by 3 or 4 weeks? This seems very unlikely to me.
Obviously the quantitative HCG does not always double in three days, so we should be cautious about applying this "rule".
Did the chorioamnionitis (with intact membranes) come from the Shirodkar cerclage? This seems to be the most likely explanation.
I welcome comments on these questions.
S1E4: Dr. Kristina Adams-Waldorf: Pandemics, pathogens and perseverance
July 16th 2020This episode of Pap Talk by Contemporary OB/GYN features an interview with Dr. Kristina Adams-Waldorf, Professor in the Department of Obstetrics and Gynecology and Adjunct Professor in Global Health at the University of Washington (UW) School of Medicine in Seattle.
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