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Todd Fraser wrote 07-24-2010 09:56:08 am
I was pleased to find out that both mother and child are doing well. This job can be very rewarding sometimes!

Neil Orford wrote 07-29-2010 06:55:59 pm
Nice to hear good outcome. My thoughts are;

1. Treat mothers ventilation issues first, as you did - ie ventilate, PEEP, consider salvage manouvers
2. Assess if this creates adequate environment for foetus using measures available ie maternal oxygenation, foetal monitoring
3. Early collaboration with obs/paeds re "triggers" (maternal and foetal) to deliver baby, and what needs to be done to make this least harmful (ie steroids)
4. Establish and treat cause - this hasn't been mentioned but although you presumably treated for bacteria, did you give oseltamavir, send viral swabs/PCR, and are there features of other virus (eg varicella)

Kristine ESTENSEN wrote 07-18-2010 11:00:33 pm
Hi Todd,

What an interesting one. So I have a few questions issues:

1. Contracting ? -do we mean braxton hicks / or query early labour and ruptured membranes?
2. Any other antenatal history ? Chronic disease ?
3. If the mum is this sick? what do the obstetricians feel about the baby - at 29 weeks - premature but not drastically so - .

I suppose balancing risk to mum versus risk to baby. No doubt in the O&G literature that leaving babies to "gestate" for as long as possible is the ideal.....but in critical illness ?? how dose this change?

Steroids should be administered to mum to mature fetal lungs in case of delivery. Consulting with obsetricians/ obstetric physician. Are there any markers of fetal well-being in this setting ? USS/ fetal dopplers/ may help decide how well the placenta is functioning or not.Sometimes these babies have a better chance being delivered than being left intrauterine particularly if the placenta is compromised or there are other factors (maternal )- which compromise the fetal wellbeing.

I'd be really interested to read how this lady goes.

Thanks Kristine

Todd Fraser wrote 07-19-2010 09:16:49 am
Gidday Kristine,

Its a difficult one, isn't it. To some extent, the baby should be better off staying in utero a little longer, but this is traded off against the benefits to the mother in delivering. Which of these is the priority?

But I think you're right, at some point the baby is probably better off out - given it is potentially exposed to the harm of hypoxia, and possibly the cause of the mother's disease itself.

AMIT KANSAL wrote 07-21-2010 12:03:17 am
The first thought is fear! Then u start with the basics - ABC!
The question I have is, if u can maintain adequate maternal oxygention (at 100% fiO2)/ perfusion, for how long will u be game to leave the baby in?
If its infective pathology/ Amniotic fluid embolism/ Cardiac cause, will that change timing of delivery?

I will initiate referral to NICU/ give steroids to mum
Fetal monitoring (CTG)/ obstretric input will surely help.

Todd Fraser wrote 07-21-2010 06:11:34 pm
I think you're right Amit, need to get the neonatologists involved, give her steroids and monitor the baby pretty closely.

I assumed that getting the baby out would have benefits for the mum too - reduces oxygen consumption, improves chest wall compliance, allows to to ventilate prone, perhaps allows you to use prostacyclin etc etc. I assume its also beneficial for the baby - how low an O2 can the baby tolerate? Perhaps this is an unanswerable question (how would you like to try to consent the mother for a randomised trial of fetal hypoxia vrs control!) but I had assumed inability to maintain PaO2 >80mmHg on 100% was the point we would have to act.

When is a baby mature enough to force delivery?