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Category Archives: Gestational Hypertension

Ooops!

I was once called for a referral. A few days old preterm baby having seizures that occurred within the first few hours of life. Baby was having seizures despite the anti-convulsant that was already given. The baby was already referred to a neurologist before I stepped into the picture. Baby was worked up and his electrolytes showed low sodium (112). (The normal level is 135 – 145; if the value is lower than 135, that’s considered hyponatremia. If value is less than 125, baby can have seizure that will not be controlled by anticonvulsant until the problem is corrected). In this case, it seems the most likely cause of seizure was identified. Thus, the immediate thing for me to do was to correct this abnormality and hope that it will eventually stop the seizures.

So after 48 hours, the sodium level was already raised to near normal. The good thing was, seizure already stopped. So I guess the baby’s urgent problem was resolved.

The question that bothered us was, why did the baby have severe hyponatremia? It is a rule of thumb that the electrolyte picture of a baby within 48hrs from birth generally reflects that of the mother. Unless that baby also has a congenital abnormality such as in cases of congenital adrenal hyperplasia (CAH). The baby in this case did not have physical signs highly suggestive of CAH, and the newborn screening eventually was normal, so this as the cause was easily ruled out. So, this made me then thought of the mother’s electrolyte status.

I interviewed the mother when she visited her baby at the NICU. I asked her if she was on prolonged intravenous fluid administration, if she was taking medications. She revealed she was on prolonged furosemide “maintenance.” This was given by an internist she consulted. BINGO! Seems I nailed the culprit with mere few questions. So I went on further with my interview. I asked why was she on prolonged furosemide intake. She said, she consulted the internist because she had edema (swelling) of both her lower legs. I further asked, “at what months of pregnancy did she notice the onset of edema, of hypertension. She did not know she was pregnant then when she had that consultation. Then my next question was, “is your menstrual cycle irregular?” And she replied YES! I was then flabbergasted and felt sorry for the mother, most especially for the baby. Why?

Let me reconstruct the story for a clearer understanding. Here was a woman with irregular menstrual cycle. She became pregnant but was not able to realize it because of her irregular schedule. Then later in the pregnancy, she developed edema of both lower extremities. She consulted an internist because of the latter, who also incidentally discovered she was hypertensive. The internist did not know the patient was pregnant; he did not do pregnancy test nor abdominal ultrasound. Pregnancy was remote from his consideration, thus he did not do these tesst… even if the woman was already showing signs of PREECLAMPSIA. So he gave furosemide. But since the edema was unresolving, she kept on taking the drugs. Few days ago, she was having abdominal pain. She saw another doctor, an OB-Gyn, who requested for an ultrasound. HALLELUJAH of all hallelujahs, she was indeed PREGNANT. And since her blood pressure remained uncontrolled, she was scheduled for emergency CS delivery. Since she was on prolonged furosemide intake, aside from it removing water from the body, furosemide also eliminates electrolytes like sodium and potassium. Since she was already hyponatremic, so was also the baby whose blood supply comes from the mother via the placenta.

The rest of the baby’s course in the neonatal ICU was unremarkable thus I signed out from the service after making sure baby was ready for discharge.

 

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When One of the Twins Die In Utero

Did you always think that when a mother conceives twins, triplets, quadruplets or more, all of the fetus will be born alive? As morbid as it maybe, some fetus/fetuses die prematurely even before being born. Some may die within the first, 2nd or 3rd trimester (3 months). And their death can bring about complication/s not only to the mother, but to the remaining twin as well.
The effect of the fetal death to the surviving twin may vary according to the timing of the death. In a data published 1994, loss of one twin at the first trimester does not impair the development of the surviving fetus. (Some are completely resorbed in a condition termed as “vanishing twin syndrome.”) In the second trimester however, this is associated with increased risk for the survivor as reflected by a high incidence of growth retardation, premature labor and perinatal mortality.
An observation of twin pregnancies where single fetal death occurred after 20 weeks of gestation, the mothers were known to have preeclampsia which may also prompt babies to be delivered prematurely. The surviving twin aside from being delivered prematurely, they are also observed to be with intrauterine growth restriction. This could be an effect of the death of the other twin, or that and the effect of preeclampsia wherein the blood flow to the fetus may become diminished. This in turn causes diminished delivery of oxygen and nutrients to the baby thus. Head MRI and ultrasound of these survivors revealed some neurologic injury. Fortunately, in these mothers, there was no detected abnormality on coagulation profile.
A similar observational study was also done among twin pregnancies where a single fetal death occurred after 20 weeks of gestation. The study showed that the main cause of the fetal death was twin-to-twin transfusion syndrome. The survivors were also delivered prematurely and later also died after birth because of the same cause. (TTTS is due to abnormal communication between the blood vessels supplying the placenta of both, leading to shunting of more blood to the other twin while deprivation of the other one. One may die immediately while still in utero, while the other may survive or end up hydropic; or both may survive with severe physical discrepancy — see my other blogs on hydrops fetalis). 
Another in depth observation was done among twin pregnancies complicated by single intrauterine fetal death after 26 weeks of gestation. Chorionicity of the twin pregnancies was noted (see illustration below on the types of twin pregnancy according to chorionicity).
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(Image courtesy of  http://www.health.sa.gov.au/ppg/Default.aspx?PageContentMode=1&tabid=75)
Often times, the surviving twin was delivered prematurely, and that baby ended up with intrauterine growth restriction. The mother on the other hand had preeclampsia and gestational diabetes, both of which may also lead to the growth restriction of the surviving twin. In cases of monochorionic pregnancies, again twin-to-twin transfusion syndrome afflicted the babies. Some of the twin eventually died as well in utero (before being delivered), while others after birth. Also, ultrasound of the baby’s head should cerebral anomalies in some.
Even if one of the twins survive after the death of the other, and gets delivered, it is not reassuring that he will live and be discharged as well baby as his outcome may be compromised by the complications of premature birth, or presence of neurologic injury.

References:

1. Prömpeler HJMadjar HKlosa Wdu Bois AZahradnik HPSchillinger HBreckwoldt M. Twin pregnancies with single fetal death. Acta Obstet Gynecol Scand. 1994 Mar;73(3):205-8.

2. Axt RMink DHendrik JErtan Kvon Blohn MSchmidt W. Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.J Perinat Med. 1999;27(3):221-7.

3. Aslan HGul ACebeci APolat ICeylan Y. The outcome of twin pregnancies complicated by single fetal death after 20 weeks of gestation. Twin Res. 2004 Feb;7(1):1-4.

4. Chelli DMethni ABoudaya FMarzouki YZouaoui BJabnoun SSfar EChennoufi MBChelli H. Twin pregnancy with single fetal death: etiology, management and outcome. J Gynecol Obstet Biol Reprod (Paris). 2009 Nov;38(7):580-7. Epub 2009 Oct 14.

 

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Aborted Abortion

Aborted Abortion.

 

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Aborted Abortion

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(Photo courtesy of http://www.ehow.com/how_2335892_manage-preeclampsia.html)

Few months ago, one baby was referred to my service because the mother was having a life-threatening, severe pre-eclampsia (if I’m not mistaken, her BP was >180/100 and can’t be controlled), on the verge of having seizure. Baby had to be delivered prematurely because she was already not faring well. Baby then was born at 28 weeks, 815 grams. She was able to survive and was discharged after nearly 2 months in the hospital.

When baby was 3 months old, she was supposed to have her injectable hormonal contraceptive but she missed it because the obstetrician was out of town at that time she had her post-natal visit. Then when baby was 5 months old, mother found out that she is 1-month pregnant again. She was very confused and alarmed because she cannot forget her traumatic experience with her first baby, when she almost had seizure due to the very high blood pressure.

On her 2nd month of gestation on the 2nd baby, she came and talked to me in a soft whisper. She was asking my opinion on her plan to have abortion. I was shocked. But at one point, I got her point, her fear of possibly dying while being pregnant again, especially that her first-born is just 5 months old. I really could sense her confusion. Do I blame her to be afraid? No. The thing she fears is a reality and not just a make-believe. I told her, personally, I would not advice abortion as it is a crime. I tried to talk to her, told her the chances of severe hypertension related with pregnancy decreases on the next pregnancies.

Gladly, she took my and her obstetrician’s advice not to go on with her plan. Now, she jokingly blames her obstetrician for being absent during that prenatal check-up that’s why she got pregnant too soon. She gave birth via a repeat cesarean section. This time, she was able to do the Unang Yakap and she was so grateful that she was able to do this at least to one of her kids. Immediately, she had ligation – she and her husband decided on this before the delivery.

Can you blame them for deciding to have ligation? My take? It was their choice. They were well aware of what the consequences of pregnancy to her health, their kids, their family. It was a well-informed, intelligent choice!

 

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When All Else Were Done…

When All Else Were Done….

 

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When All Else Were Done…

She could have been my smallest survivor…

Mother was hypertensive, first baby to have been successfully conceived after 8 years of waiting. Unfortunately, the hypertension was causing distress to the baby, so she has to be born prematurely, or the mother will seize… or die.

She was pretty 515 grams, 25 weeks, brave baby girl. As most prematures would, she was immediately in distress thus intubated, and breathing was assisted by mechanical ventilator. She was given surfactant again thus after 5 days from birth, she was already off from the ventilator and was merely on low-flow oxygen support. She was also being fed already and was tolerating the gradual progression of feeding. But the drastic event happened on the 6th day of life: she all of a sudden vomited blood.

I was called when the resident was already attempting to rescue baby. As soon as I arrived, baby was already in a very compromised state. I had to bring back the mechanical ventilator to aid her breath. She was bleeding from all over, including her lungs; good thing her brain was spared. But alas, complications upon complications set in. Respiratory failure, kidney failure, patent ductus arteriosus. Considering the long wait of the parents to have a baby, that motivated me more to try to tug baby away from the grips of death.

One week from birth, as they were that excited to successfully have a child whatever the gender is, the father went overseas to work and help finance the expenses the baby will incur no matter how much it would take.

Baby was able to pull through from those complications, but with one grave sequela, she had bronchopulmonary dysplasia. Her lungs weren’t able to resist this complication such that on x-ray, it literally looked like a sponge. As a consequence, I couldn’t take her off from the mechanical ventilator.

She later on was also having regurgitation, and the milk that regurgitated were being aspirated, thus aggravating further her respiratory condition. I tried the textbook managements to no avail. Then out of frustration as her hospital bill was already mounting up I resorted to nonconventional remedies just for her to be able to be weaned off; mechanical ventilator is the real burden on one’s financial resources. I even already tried using those asthma inhaler puffs attached to make-shift gadgets; yes, my creativity had been challenged for real by this baby. Despite her dependence on oxygen and the respirator, she was gaining weight. Though her weight is far from what was expected for her age in weeks, still it was an upward climb.

All of a sudden, the respirator got accidentally removed from her system. I was so afraid because it happened when I was out of the hospital. But… she tolerated it, she was able to tolerate just breathing low-flow oxygen delivered by a nasal cannula. Finally, the mother can cuddle baby!!!

I was already planning how to discharge baby. Mother was already trying to find oxygen tanks and gauge that they can use if ever baby goes home. From 515 grams, baby was now 1.5kgs, after 3 months on respirator! The excitement was so pent up… until one early morning.

She strained hard while defecating… until her heart beat stopped. An anethesiologist colleague was at the adjacent operating room at that time and she intubated her and initiated resuscitation. I was awakened by the distress call. Upon learning that the residents started reviving the baby, I began giving instructions through the phone. (This was then the time when I had no car, I had to commute! But at that time that the call came in, it was busy hour. No cab could be hailed and all the jeeps were full from the place where I live). I was walking to almost running hurriedly towards the main highway, phone on ears as I don’t use bluetooth headset then. Then I successfully rode a jeepney and transferred to a cab en route to the hospital. Upon arrival (it took me about 30 minutes), I took over the resuscitation command. We were able to pull baby back but with a heavy prize. The period that her heartbeat stopped and blood was not circulated to her heart and brain really was significant that baby already began to seize, she was in coma.

I immediately notified the mother with a breaking heart. How do I tell her? The day before, she had been cuddling baby on her chest, doing her motherly “job” changing her diapers, feeding her, and assisting the nurse to bathe her. And now, I am going to tell her that her daughter almost died defecating, but is now in a vegetative state? How could I do that?

She arrived, and I explained how things happened. She was sad, tough, but breaking inside. I was teary-eyed because the baby was endeared to me. I was in pain. Then I asked to be excused as I realized I looked disheveled. I went home, took a shower and prepped for work. As I was doing that, the residents still kept calling me on the updates and I giving my instructions in return.

When I arrived again later, the mother, surrounded by her relatives, gave me the blow. She decided to bring baby home, while she still has heartbeat. I was crying in front of her when I heard her say that, but it was the wisest decision a person could muster on a painful moment such as that. I hugged her tightly, and then gave instructions to the nurses to prepare baby. As she was a very dear tyanak to me, I made sure that I was with the baby when she left the hospital. When everything else was settled, it was now time. I was bag-ventilating the baby while the nurses carried her until we entered their service car. Fighting back tears, I removed the endotracheal tube… Within few seconds… she was gone.

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(Image courtesy of http://thesaltlist.wordpress.com/2011/04/15/the-great-euthanasia-debate/)

 

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A Mother’s Request

A Mother’s Request.

 

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