This case involves a thirty-two-year-old pregnant female. The patient called her obstetrician at twenty-eight weeks gestation, and she complained of cramping and discomfort that was associated with a fluid discharge. The physician assured her that it was probably some urinary leakage and that she did not need to come into the office for an exam. One week later, the problem worsened, which prompted the patient to go to the hospital. The hospital staff ordered an AmnioTest but did not perform a vaginal exam with the exception of a vaginal swab. The hospital physician spoke with the patient’s Ob/Gyn who said the patient should be discharged home. The AmnioTest was not positive but was noted as suspicious for two times the accepted level of amniotic fluid. When the patient returned home, she felt an intense abdominal pressure that she assumed was an impending bowel movement. The patient went to the bathroom and felt a babies foot in the vaginal canal. The patient was rushed back to the hospital and an emergent C-section was performed. The baby had an Apgar score of one and resuscitation measures were initiated. The baby was eventually stabilized but only after a prolonged period of hypoxia. The baby was diagnosed with hypoxic encephalopathy and died from sepsis thirteen days after birth.
Question(s) For Expert Witness
- 1. What is the accepted standard of care in detecting preterm labor?
Expert Witness Response E-006011
Contractions of sufficient frequency and intensity to affect progressive effacement and dilation of the cervix at twenty four to thirty-seven weeks’ gestation are indicative of active preterm labor. If the diagnosis of preterm labor is suspected, but not confirmed, it may be prudent to first obtain a vaginal fetal fibronectin (FFN) sample before pelvic cervical examination. If the diagnosis of preterm labor becomes obvious after the pelvic examination, the FFN specimen can be subsequently discarded. However, if the diagnosis remains in doubt, the FFN specimen can be sent to the lab for analysis. Preterm labor may be difficult to diagnose and a potential exists for overtreatment of uterine irritability. Tocolytic agents, while generally safe in appropriate dosages with proper clinical monitoring, have potential morbidity and should only be used after consideration of the risks and benefits of such use. Neonatal morbidity and mortality are greatly affected by gestational age, especially when the pregnancy is less than twenty-eight weeks’ gestation. Tocolytics should be used with considerable caution in pregnant patients with cardiac disease, especially those who require medication or have a history of congestive heart failure, cardiac surgery, significant pulmonary disease, renal failure, or maternal infection (ie, pneumonia, appendicitis, pyelonephritis). In these cases, it may be prudent to consult with an MFM specialist.