Don’t Ever Give Up!

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.

• 11/16/98 6w3d, bleeding, dichorionic twins with one dead twin, subchorionic hemorrhage of both chorions, the living sac with a larger hemorrhage than the dead sac.
• 11/20/98 7w2d (7w0d by the first ultrasound), living twin doing well, subchorionic hemorrhage present.

(click on each image to view larger version)

• 11/25/98 8w2d (7w5d by the first ultrasound). The dead sac is collapsing, less subchorionic hemorrhage, the living twin is doing well.
• 12/2/98 9w1d (8w5d by the first ultrasound), patient had an acute bleeding episode. No subchorionic hemorrhage seen, the dead sac almost gone, the living twin doing well. The cervix was long and closed.

 
(click on image to view larger version)

• 12/16/98 11w6d (11w0d by the first ultrasound), dead sac gone, living twin doing well.
• 12/31/98 ultrasound done at the radiology department, Fairbanks Memorial Hospital (a visit to the emergency room because of bleeding), 14w1d (12w6d by the first sono). A myoma is seen, with a small subchorionic hemorrhage seen near the myoma. (I suspect the myoma may have been a focal myometrial contraction).
• 2/25/99 21w6d (20w6d by the first ultrasound). Normal growth and development of the fetus. Marked funneling and shortening of the cervix noted.

(click on image to view larger version)

(On 3/1/99 a Shirodkar cervical cerclage was done using a Mersilene strip).

• 4/8/99 26w6d (26w2d by first sono). The cervix looks about the same as it did on 2/25/99 except we can now see the Mersilene.

(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 (3^rd 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.

Joseph A Worrall MD RDMS
5/4/1999