The Carlyle Crenshaw Perinatal Health Initiative Of The Johns Hopkins Hospital

39 year old para 0500 referred because of her horrid obstetric history felt due, at least in part, to placental floor infarction which was found with her last placenta. She has a history of left leg and thigh phlebitis. She took INH for six months in 1991 for a PPD conversion.

Obstetric History:
'86 - 28w FDIU
'87 - 20w FDIU
'88 - 20w FDIU
'89 - 20w FDIU
'96 - 27w FDIU

LMP: xx/yy/97 -> 14 5/7w

initial visit data: ee/ff/97: 60" 173# 8w
sonogram(s):
rr/ss/97- 9 0/7w -> 14 4/7w
uu/ww/97 - 12 5/7w -> 14 3/7w

Workup to date includes an upper limit normal aPTT at 34 sec, normal creatinine clearance and uric acid, negative anti-cardiolipin IgG, negative lupus anticoagulant screen (normal aPTT, normal dilute Russell Viper Venom ratio). Thyroid function testing is normal.

Impression:
IUP 14 5/7 weeks
multiple 2nd trimester fetal losses
placental floor infarction - at least with her last pregnancy

Suggestions:
Monthly sonograms for growth.
Protein S and C and resistance to activated Protein C (Factor V Leiden), fasting homocysteine level and (though I don't know exactly how I will respond to a positive), anti-leukocyte antibodies.

I heartily endorse your plans to admit her at ~24 weeks to do daily monitoring and a weekly amniotic fluid index.

Thank you for allowing me to share in the care of this lady.


David A. Nagey, MD, PhD
pager (800) 803-8060

Subsequent Course:

I saw her at the outlying clinic about one month later and the requested labs were reviewed. This included normal Protein

C and S; normal resistance to activated Protein C; normal fasting homocysteine level and negative anti-leukocyte antibodies (whew!). Further, her creatinine clearance was 115 ml/min.

A glucose challenge test at about this time was positive, as was her 3-hour GTT (she had been tested and was not diabetic in prior pregnancies). She was well controlled on diet alone.

She was followed regularly until 24 weeks when she was admitted to The Johns Hopkins Hospital with a plan to provide close fetal surveillance and to deliver her at no later than 28 weeks. After starting her weekly betamethasone shots it became necessary to institute insulin. Her subsequent glucose values were normal without significant fluctuation. Twice daily NST's were (surprisingly) reactive from the outset and twice-weekly biophysical profiles yielded reassuring information. Weekly AFI's were normal. Fetal growth was assured by sonograms every 3 weeks.

She was begun on mini-dose heparin at 26 weeks (by one of my partners though in retrospect I think it was a good idea).

At 28 weeks we had a normally growing, reactive and healthy appearing fetus. My partners restrained me from delivering her. We continued our prior management.

At 32 weeks, with my partners out of town at the SPO, I performed a low transverse cervical cesarean because of a transverse lie and a failed external cephalic version attempt. The baby

was a 1445-gram male with Apgars 8 and 9. He required hood oxygen for 2 days then was discharged to a pediatric convalescent hospital at approximately 7 days of age. He went home at approximately one month of age and has done well since.